Key Learning Points 

The Dizzy Patient

• It is uncommon for isolated dizziness to be a symptom of a cerebrovascular event

  • Prospective chart review (2011) of 31 000 patients given the diagnosis of dizziness or vertigo found less than 1 in 500 patients developed a stroke in the first month post discharge

• Dizziness in itself can be a sign of frailty. Frailty, falls risk and social supports should be addressed if discharging home

• Concerning features of the dizzy patient: purely vertical nystagmus, down-beating nystagmus with the fast phase towards the nose, non-fatiguable nystagmus, spontaneous pure torsional nystagmus

• Hallpike test may be falsely negative if patient has received vestibular depressants (eg stemetil, benzodiazepines)

• The Epley manoeuvre may take 24 hours to be effective

• Get a Neurology consultation if:

  • Vertigo/ dizziness is accompanied by other neurological signs OR

  • If a new headache is present OR

  • Sudden onset constant vertigo with negative head impulse (suggests cerebellar pathology)

• Patients need a GP referral to be seen at the Vestibular Clinic at RVEEH (do not accept ED referrals)

Hypothermia/Hyperthermia

Frostbite

• Frostbite is uncommon in Australia – it usually occurs at temperatures less than -20 C

• It is the thawing process that causes the pathologies due to release of inflammatory mediators, vasoconstriction, ischaemia and tissue necrosia

Hypothermia

• Hypothermia is core temperature <35 C. Cardiac arrest due to hypothermia is possible at any temperature below 32 C and risk is significantly increased below 28C

• CNS disturbance occurs at temperatures <35 C

• ‘Afterdrop’ relates to continued core cooling as patients are warmed. Usually about 1 degree with minimally invasive warming. Unlikely to cause significant harm if patient is conscious, uninjured and can shiver

• Classic ECG findings: bradydcardia, Osbourne waves, shiver artefact, J waves, Q-T prolongation

• Asystole does not preclude prolonged resuscitation (CPR) while warming

• Withhold adrenaline until temperature >30 and then use at double the intervals between doses (i.e. every 4 cycles) until temp >35.

• Hypothermia-related coagulopathies can be missed as lab samples are warmed to 37 degrees prior to analysis

Hyperthermia

• Heat stroke – core temperature >40 C with altered conscious state. Any neurological abnormality may be present.

• Aim to cool to 39 C – fans, arctic sun, fluids. Body cavity lavage no longer recommended. ECMO in some centres.

• Remember to look for associated sunburn and severe dehydration 

  Burns

• This website has all the current best practice and local guidelines. vicburns.org.au

• Severe burn patients should receive a trauma assessment due to mechanism of injury

• Remember degree of injury/ tissue damage associated with electrical burns may not be apparent from the skin surface

• Speed of capillary refill is a good indicator of burn depth

• It is uncommon for the elderly to have superficial burns due to having much thinner skin. Also consider whether they may not be coping at home, possible non-accidental injury and  problems with burn healing

• If discharging home, review at 48-72 hours to reassess burn depth and monitor healing