Accidental adrenaline auto-injector-induced digital ischaemia: a proposed treatment algorithm.

Increased numbers of adrenaline auto-injectors (AAIs) are in circulation in the UK. The rate of accidental auto-injection injuries has increased during this time. Various treatment strategies are described in the literature. We present the case of a 32-year-old, right-hand-dominant man who sustained an unintentional AAI injury to the volar aspect of his right thumb. On presentation to the emergency department, the thumb was ischaemic. There was no improvement with simple conservative measures (warm soaks). The patient was referred to our tertiary hand surgery service and a digital block using 2% lidocaine promoted reversal of ischaemia within 2 hours with no long-term sequelae. Phentolamine rescue, on standby, was not necessary in this case. In this case report, we highlight the therapeutic challenges associated with managing AAI injury and propose an evidence-based treatment algorithm to prevent risk of severe adverse outcomes such as digital necrosis.

Cutibacterium (Propionibacterium) acnes Infection of the Native Wrist Joint.

Cutibacterium (Propionibacterium) acnes (C. acnes, previously known as P. acnes) is an anaerobic organism that commonly colonizes the human skin. After Staphylococcus spp. and Streptococcus spp., it is a common organism associated with deep prosthetic shoulder joint infections. We describe the case of rapidly progressive arthropathy of the native wrist secondary to infection with C. acnes. Diagnosis was made on prolonged enrichment cultures. The patient went on to complete a long-term course of oral sulfamethoxazole-trimethoprim with clinical improvement. To the best of our knowledge, this is the first report in the literature that C. acnes has been the main causative organism implicated in infection of the native wrist joint. It is imperative to request and wait for results of prolonged enrichment cultures to aid microbiological diagnosis in such cases.

Sudden death in patients with serious mental illness.

AIM: Sudden death is used to define a death under suspicious circumstances, where there is no clear indication of existing medical illness (natural cause) that accounts for the death or clear indication for the cause of death. This includes all deaths from suicide, unintentional poisoning, drowning, falls and violence. Sudden death contributes to the increased mortality in people with serious mental illness (premature mortality) but is far less frequently studied and understood. This study analyses data of all sudden deaths of patients who had been under the care of the Canterbury District Health Board's Specialist Mental Health Service, New Zealand's second-largest population region. The study identifies key sociodemographic, diagnostic, legal and causative factors in the study population. This study aims to identify targeted interventions to mitigate premature mortality in this population. METHOD: Data was obtained from the clinical files and the coroner's findings for all sudden death patients with established contact with Specialist Mental Health Services in the Canterbury region of New Zealand, between 2005 and 2009. RESULTS: A total of 313 patients were identified. The median age at the time of death was 42 years (IQ Range 32.5-53 years). Of these, 65% (n=203) were male. Seventy-six percent (n=239) were of European descent and 9% Maori (n=29); 68% (n=280) were under care at the time of their death and 15% (n=32) were under the Mental Health Act. The sudden death rate was 0.36% for those under voluntary care and 0.7% for those under compulsory care. The most common primary diagnoses were alcohol or other drug abuse (29%); depression (25%); psychotic disorders (18%); BPAD (9%) and personality disorder (5%). The most common cause of death was suicide (51.8%) followed by motor vehicle crashes and falls, (23.3%) medical causes (17.6%) and homicide (1.3%). Of those that died by suicide, 75% were male. Hanging was the most common method (48%) followed by carbon monoxide poisoning (9.3%); medication overdose (5.8%) and falls from a height (3.5%). CONCLUSIONS: The most common cause of sudden death was suicide, which was overwhelmingly the leading cause of sudden death in patients discharged or lost to follow up. The most potent predisposing factor appeared to be drug and alcohol problems. Mental health services should therefore advocate for comprehensive and evidence-based alcohol and drug policies, including access and availability to treatment programmes.

Improving consent in patients undergoing surgery for fractured neck of femur.

Background Neck of femur fractures and their subsequent operative fixation are associated with high rates of perioperative morbidity and mortality. Consenting in this setting is suboptimal with the Montgomery court ruling changing the perspective of consent. This quality improvement project assessed the adequacy of consenting against British Orthopaedic Association-endorsed guidance and implemented a series of changes to improve the documentation of risks associated with surgery for fractured neck of femur. Methods Seventy consecutive patients who underwent any operative fixation of a neck of femur fracture were included over a 6-month period at a single centre. Patients unable to consent or without electronic notes were excluded. Consent forms were analysed and the documented potential risks or complications associated with surgery were compared to British Orthopaedic Association-endorsed guidance. A series of changes (using the plan, do study, act (PDSA) approach) was implemented to improve the adequacy of consent. Results Documentation of four out of 12 potential risks or complications was recorded in <50% of cases for patients with intracapsular fractures (n=35), and documentation of seven out of 12 potential risks or complications was recorded in <50% of cases for patients with extracapsular fractures (n=35). Re-audit following raising awareness and attaching consent guidance showed 100% documentation of potential risks or complications in patients with intracapsular and extracapsular fractures (n=70). A neck of femur fracture-specific consent form has been implemented which will hopefully lead to sustained improvement. Conclusions Consenting patients with fractured neck of femur for surgery in the authors' unit was suboptimal when compared to British Orthopaedic Association-endorsed consent guidance. This project has shown that ensuring such guidance is readily available has improved the adequacy of consent. The authors hope that introduction of a neck of femur fracture-specific consent form within their unit will lead to sustained adequate documentation of risks associated with surgery.

Seizure-induced unilateral posterior dislocation of the shoulder: a diagnosis not to be missed.

A man in his mid-50s with a history of bladder carcinoma presented to the Emergency Department (ED) following a witnessed tonic-clonic seizure. Computed Tomography (CT) scanning of his brain revealed an indeterminate mass lesion in the left parietal region. The patient described bilateral shoulder pain prompting plain film radiographs with axial views, but no obvious abnormality was identified by the ED staff. Staging CT scanning did not reveal any evidence of underlying malignancy but revealed dislocation of the left humeral head with a large reverse Hill-Sachs lesion and posteriorly displaced reverse Bankart lesion. Manipulation under anaesthesia and closed reduction of the left shoulder was undertaken successfully. This case report reminds the clinician to maintain a high index of suspicion for posterior dislocation of the shoulder following seizures and to perform appropriate imaging promptly.

Optimizing postoperative handover to the intensive care unit at a tertiary centre.

BACKGROUND: Comprehensive handover of patients transferred from operating theatre to the intensive care unit is crucial in ensuring ongoing quality and safety of care. Handover in this setting poses unique challenges, yet few studies have considered or tested approaches to improve the process. A quality improvement project was undertaken to assess and improve the quality of information transfer during the handover of postoperative patients to the general intensive care unit at a tertiary centre. METHODS: This quality improvement project considered all postoperative patients aged 18 years and over, using the plan-do-study-act (PDSA) approach, over a 3-month period in 2015. Baseline audit encompassing intraoperative details (allergies, grade of intubation, estimated blood loss, difficulties and complications) and the postoperative plan (analgesia, thromboprophylaxis, antibiotics and their proposed duration and nutrition) was undertaken to define the extent of the clinical problem. Changes were implemented over two cycles, centred around a novel checklist, and the transfer of information was re-audited after each cycle. RESULTS: Baseline audit (n=30) revealed a need for improvement across all domains. In PDSA cycle 1, a novel checklist was introduced which led to global improvement across all areas with performance exceeding 70% in all but three out of nine domains (n=33). Engaging key stakeholders (PDSA cycle 2) resulted in overall improvement from baseline but decreased performance in just under half of domains in comparison to PDSA cycle 1 (n=31). CONCLUSIONS: Successful implementation of a series of simple interventions resulted in more effective handover of postoperative patients admitted to an intensive care unit. Sustained long-term improvement is a major challenge and can only be achieved with the global engagement of all staff and incorporation of changes into routine clinical practice.

The impact of the Canterbury earthquakes on prescribing for mental health.

OBJECTIVE: The aim of this study is to evaluate the impact of the Canterbury earthquakes on the mental health of the local population by examining prescribing patterns of psychotropic medication. METHOD: Dispensing data from community pharmacies for antidepressants, antipsychotics, anxiolytics and sedatives/hypnotics are routinely recorded in a national database. The close relationship between prescribing and dispensing provides the opportunity to assess prescribing trends for Canterbury compared to national data and therefore examines the longitudinal impact of the earthquakes on prescribing patterns. RESULTS: Short-term increases in the use of anxiolytics and sedatives/hypnotics were observed after the most devastating February 2011 earthquake, but this effect was not sustained. There were no observable effects of the earthquakes on antidepressant or antipsychotic dispensing. CONCLUSION: Short-term increases in dispensing were only observed for the classes of anxiolytics and sedatives/hypnotics. No sustained changes in dispensing occurred. These findings suggest that long-term detrimental effects on the mental health of the Canterbury population were either not present or have not resulted in increased prescribing of psychotropic medication.