Hi,
 
A patient was brought through with a sight-threatening injury last week, after a fall. 
 
Shortly after assessing them, I proposed that they needed a canthotomy and cantholysis - a fairly invasive and seldom performed procedure, intended to relieve pressure around the eye and save sight. 
 
“You’re just saying that because you want to do it”, one of the nurse practitioners replied.
 
This statement caught me off guard a bit.
 
Am I pushing this just because I want to do it? 
 
I was confident that it was clinically indicated, as was my consultant, but I’d be lying if I said I didn’t want to do it. 
 
I was reminded of the late Dr John Hinds’ ethic of ‘honourable intentions’ in his awesome talk, ‘Crack the Chest, Get Crucified’. 
 
As he said, ask yourself, “do I think I can salvage this, or am I doing it because it’s a cool procedure?”
 
Whilst there will often be trepidation and uncertainty performing rarer procedures, the reason we train in this speciality is because we want to do the things as best as we can. It would be odd if I had no desire to do any of these procedures.
 
But the trigger to act must be pulled only when the intentions are honourable. 
 
Regarding high acuity, low occurrence procedures, John Hinds’ takehome messages are as follows:
 
Prepare. Know the evidence.
Make your intentions honourable.
Do it.
Seek out the skeptics.
Never allow a wanker to bring you down.

Clinical Things I've Learned
  1. A patient presented with non-fatal strangulation. Multi-college UK guidelines provide excellent guidance on managing these, and the bottom line is that there is quite a low threshold for CT imaging of the neck, specifically angiography.

    Red flags are listed in detail, using an ABCD approach, and any single red flag presents as an indication to order CT imaging.

    Surprising to know 50% of victims will have no visible external injury to their neck/head as a result of the strangulation, although I’m unsure how many of these would have a clinically significant injury of CT imaging. 


  2. Came across a case of possible Hyperglycaemic Hyperosmolar State (HHS) in an 18 year old type 1 diabetic. I wasn’t quite tuned into this, as typically less than 1% of HHS is in type 1 diabetics. The patient had a normal acid-base status, ketones 2.4, but a blood glucose of 45 and impaired renal function. Their serum osmolality was calculated at around 350. This Joint British Diabetes Society guideline is worth a read, especially the executive summary (p. 9).
    1. Diagnostic criteria to fulfill for HHS: 1) severe hyperglycaemia 2) elevated plasma osmolality (>320 mOsm/kg) 3) dehydration 4) the absence of significant ketonuria. This patient had just enough insulin to stave off DKA, and fulfilled all these criteria.
    2. Higher levels of hyperosmolality can cause more severe neurological symptoms, such as depressed conscious state or coma
    3. Caution must be exercised with insulin; fluid resuscitation is the primary focus, and too aggressive lower of blood glucose can precipitate cerebral oedema, hence a lower infusion rate than in DKA
    4. Often there is a mixed HHS/DKA picture; when weighted more toward DKA, insulin should be started immediately, and often the DKA protocol.


  3. A retrospective study from two EDs in New South Wales comparing analgesia in wrist/forearm fractures, specifically procedural sedation vs bier’s block vs haematoma block, in adults >18 yo.

    It found haematoma block is associated with shorter LOS, fewer complications and the lowest staff utilisation compared with the other 2 techniques.

    I’m pretty happy about this, as I find a haematoma block +/- some oramorph or penthrox to be a very effective way to reduce these fractures, without the need for resus space or lots of faff and staff/equipment. However, it was found that successful first attempts were much higher in the procedural sedation versus other two groups, perhaps due to more muscular relaxation.

    At the end of the day, its probably still personal preference as to what technique is most comfortable, but I personally am a fan of a well executed haematoma block.
 

From Elsewhere
I tried to summarise my thinking recently about how externalised we can feel, and how easy it is to get swept along in the winds of trends and current affairs:
 
"Cultivate and learn to anchor yourself within yourself; a quiet confidence and knowledge of who you are and your own immutable value.
 
Don't seek to behave in a way so that others like you, else you will be a puppet without an anchor and unknown to yourself."

All information in the Push-Dose newsletter is strictly for educational purposes only, and does not constitute professional or medical advice.