The role of lactate to guide resuscitation

’Doctor, this patient’s lactate is raised at 4mmol/l, do you want to prescribe some fluid?’’. There have been many a time where we as clinicians have had similar encounters in our clinical journey. The reaction would be to prescribe intravenous crystalloids, however with time and recent emphasis on the importance of damage control/source control resuscitation this has been realised to be fraught with errors. The approach differs if the resuscitation is a medical or trauma based. The aim of this article is to explore some of the concerns that the emergency and critical care clinicians have from a raised lactate

The Effects of the COVID-19 pandemic in the UK- at a Local, National and International level perspective from the Emergency Department

Context: There is a significant burden on all emergency services in the management and prevention of the novel COVID-19 transmission. The effects are felt right across the World with certain geographical areas being most affected, it has affected all countries irrespective of their healthcare infrastructure. It has been suggested that certain parts of World that are prone to natural disasters are better prepared for pandemics. However, this is completely unfound as major economies are overwhelmed with the effects of the COVID-19 and it becomes completely irrelevant of any past experiences as these have been in never seen before scale. Evidence acquisition: The national fight against COVID-19 has been dubbed as the greatest fight for the National Health Service (NHS) with the entire United Kingdom under lockdown and the unfamiliar situation not seen before in peacetime. The general understanding of the disease process is that it has profound effects on the elderly and those with significant underlying health conditions such as cardiovascular, respiratory amongst others. However, it has surfaced from time to time that the very young are being affected and at times unfortunately been fatal. Results/Measures: The United Kingdom has been in a lockdown just like several nations across the globe in a desperate measure to limit the spread of the virus. There have been weeks of planning at every level for all possible eventualities with regards to the ongoing COVID-19 pandemic. All routine operations and procedures have been cancelled only procedures that emergency life and limb saving and cancer surgery continue to take place in hospitals all across the hospitals in the NHS. Widespread measures such as social distancing, calling a dedicated helpline for information and advice rather than attending the nearest Emergency Department have led to a significant number of presentations to the Emergency Department. Conclusions: The main concerns that remains for the NHS and other countries that have been affected is that once the lockdown restrictions are slowly eased will lead to a significant resurgence of cases that will overwhelm their respective healthcare infrastructures. From a clinician perspective, the main concern is the potential late presentations of the acutely unwell patients. This is the sentiment that is likely to be felt by many of my critical care colleagues working across NHS hospitals

A Case Report of Subacute Degeneration of the Spinal Cord due to Chronic Nitrous Oxide Use with Review of the Literature

Subacute degeneration of the spinal cord (SACD) is an acute medical emergency that requires early detection and management to limit worsening neurological deficit. With the increase in the usage of recreational drugs including nitrous oxide whippets, the incidence of the condition is noted to be rising. Currently it is the second most commonly used recreational drug used in the United Kingdom amongst 18–24-year-olds. Here we present a young gentleman with weakness and numbness following chronic usage of nitrous oxygen whippets

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

An Increase in Incidence of ED Presentations in the United Kingdom with Complete Heart Block- COVID-19 Effect?

There seems to an increase in the presentations to our Emergency Department with patients with complete heart block. The important question is whether this is an apparent increase in numbers or a true increase in numbers of presentations remains to be seen. It has been well recognised that across the Emergency Departments in the United Kingdom, there has been a fall in the number of attendances. In some estimates, this has been as low as a 30% reduction in the number of ED attendances when compared with figures in the previous years.</jats:p

Quality Improvement Project in the introduction of Major Trauma and Major Haemorrhage Protocol

Introduction: We recognised there was a need for a set criterion for the activation of MHP andMTTA at our Trust. The main aim is to streamline the trauma care that our patients would receivearound the clock. Ours is a large Major Trauma Unit regularly receiving a large volume of traumapatients of varying severity of injury Objective: The use of a checklist for the initial management of MTTA and MHP to ensure the process is streamlined and led by the trauma team leader. This wouldhelp reduce the cognitive load that is often presented to the team leader. This would also help directjunior team members with limited experience in the initial management of major trauma. Method/Intervention: An initial survey about MTTA and MHP from senior clinicians was carriedout. Several teaching sessions were undertaken. In addition to this, an algorithm for the initialmanagement in terms of transfer protocol was also introduced. Results: From the clinicians’perspective, 89% of the respondents felt that the use of MHP and MTTA protocol would reduce thecognitive load whilst managing major trauma. There was an improvement in the level of confidenceof clinicians in the initial management of major trauma from 52.9 % to 89%. Conclusion: Throughthis project, we hope that there is a better understanding of the need to have pre-defined criteria foractivation for MTTA and MTP for several reasons as highlighted in the article. The eventual aim of theproject is to streamline the initial management of the majorly injured patient and undertake thenecessary practical steps

To assess the outcomes associated with the use of tranexamic acid in the open fixation of pelvic and acetabular fractures- A systematic review

Abstract Background There is a growing knowledge base for the use of antifibrinolytic therapy in trauma and orthopaedic surgery. The mechanism of action of tranexamic acid is through the inhibition of fibrinolysis. The role of TXA in hip fractures has been researched extensively. However, the research has been limited in the realms of pelvic and acetabular fractures. Aim This systematic review aimed to examine the effect of TXA on patients undergoing open pelvic and acetabular fracture surgery. The primary aim of the study was to examine the estimated blood loss and blood transfusion rates in patients who received TXA versus those who did not receive TXA. The secondary aim was to examine the rates of deep venous thrombosis. Method A literature search was carried out using PubMed, Medline and the Cochrane database. The selection criteria for the systematic review were studies investigating intravenous TXA in the form of RCTs, as well as cohort studies. Results Five studies were included in the systematic review with 625 total patients. The estimated blood loss between the two groups was noted to be 661 ml in the control group and 850 ml in the TXA (p = 0.49). There was a marginally lower number of units transfused in the control group vs the TXA group (1.9 vs 2.2) (p = 0.27). The rates of transfusion in the TXA group were 29% TXA whilst in the control group, it was 31%(p = 0.13). The overall incidence of deep venous thrombosis was 2.8% in the TXA group and 1.7% in the control group(p = 0.097). Conclusion The results of this systematic review highlight that with the use of TXA the estimated blood loss and rates of DVT are not statistically significantly lower when compared to the groups that did not receive TXA. There is a greater need for larger adequately powered trials to further evaluate the results of this review.</jats:p

An interesting case of an atraumatic painful swollen limb in a pregnant woman

Phlegmasia cerulea dolens is an uncommon complication of deep venous thrombosis. This is associated with high rates of morbidity if not treated effectively. We present a young lady 13 weeks pregnant with one-day history of left lower limb swelling with pain and discolouration. Bedside ultrasonography revealed thrombosis occluding the common femoral vein and collateral femoral vein. She had history of neonatal alloimmune thrombocytopaenia (NAIT), and had immunotherapy previously. The safest option was to give low molecular weight heparin (LMWH) on an inpatient basis. Anticoagulation with LMWH has been well established as thromboprophylaxis during pregnancy, however, the safety profile of systemic anticoagulation is matter of debate. As highlighted in this scenario the management needs to be tailored on an individual basis. The cause for the extensive deep vein thrombosis could be possibly due to the recent immunoglobulin therapy, undiagnosed prothrombotic state (outwith pregnancy) or the procoagulant state associated with pregnancy.</jats:p