Presents with significant Eyelid oedema and erythema. (patient may not have a fever)
Look for RED FLAGS: Proptosis chemosis Ophthalmoplegia Painful eye movements Altered visual acuity or blurring Relative afferent pupillary defect Systemically unwell If post-septal cellulitis suspected (Red flags present) investigations include: bloods, blood cultures, IV abx (local guidance important), referral to ophthalmology and Paediatrics +/- urgent Contrast CT orbits . Surgical drainage may be required if the symptoms fail to respond to IV Abx Further reading: Periorbital Vs Orbital cellulitis by Don't forget the bubbles Eye infections from RCEM learning Martin Dore Jan 2022
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Tetanus is an infection caused by the anaerobic bacteria clostridium tetani which is found in soil and manure. Tetanus infection has a 90% mortality, but thankfully due to the success of vaccinations, it is rare with only 4 cases in the UK in 2019. Patients often rock up to ED because someone told them they “might need a tetanus” and the guidelines have recently changed as to who needs a booster/immunoglobulin, so hopefully this little 5 step plan should demystify it for you! STEP 1: ASSESS THE WOUND:
Tetanus-prone:
Tetanus high risk wound: is any of the above PLUS
Clean:
Note - A wound can't be tetanus high risk unless its already tetanus prone Remember that ALL wounds require thorough washout with clean water or normal saline. STEP 2: WHATS THE PATIENTS IMMUNISATION STATUS? So now you know what category the patients wound is in, the next question is whats the patient's immunisation status! Remember a full Course of tetanus vaccinations is 5 doses. A ‘priming course’ means 3 doses which is given in childhood. The table below is from the ‘green book’ on tetanus, simplified below: IN SIMPLER TERMS:
The main change in the guidance is that any adult who hasn't had a booster for 10 years with a tetanus prone wound now needs a booster! It used to be that if you'd had your full childhood immunisations then this wasn't indicated, so make sure your patient knows when their last booster was! STEP 3: WHAT DOSE DO I PRESCRIBE?: Tetanus Booster: Revaxis is the name of the tetanus booster and is a 3 in 1 diphtheria, tetanus + polio vaccine. Give one 0.5ml syringe. Immunoglobulin: For most cases 250 iu by IM injection If >24 hours have elapsed since the injury, or there is a risk of heavy contamination or burns then 500iu by IM injection. STEP 4: WHERE DO I FIND IT IN ED?: Tetanus booster- This is called ‘Revaxis’ and lives in the drugs fridge in resus. Attach a green needle directly to the syringe and its ready to be given IM! There’s a small sticker with a barcode on the side of the syringe which you should stick on the ED card next to where you sign for giving the drug. Tetanus immunoglobulin – This is technically a ‘blood product’ in the trust. Which means that you need to call blood bank and inform them that your patient needs immunoglobulin and have their details handy and the dose you require. When the tetanus is ready it will be available for the nurses to see on ‘blood track’ and they need to print a pick up slip to take to pick it up. This usually takes about 20-30 minutes. Doctors cannot pick this up, but can give the injection if you have a barcode for the blood transfusion machine. When you have the immunoglobulin you need to print the patient a wrist band and take the blood transfusion scanning machine with you to the patient – doing an ID check and scanning the square barcode on the side of the immunoglobulin (if you do not do this the lab will call up and will ask you to!) What if I need to give a booster AND Immunoglobulin? – inject IM in two different sites- i.e.:one arm each. STEP 5: ONGOING CARE:
References: The very long full government guidelines on tetanus immunisations: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/859519/Greenbook_chapter_30_Tetanus_January_2020.pdf Dr Alice Hunter |
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