Cardiology Clinical gems Emergency Gastroenterology

The Pink Lady is not your friend

What is a Pink Lady?

A pink lady (PL) is a commonly administered drug cocktail that has been utilised in acute medicine for years. Generally it consists of a mixture of lignocaine viscus (usually 10ml of Xylocaine™ 2% Viscous ) and 20ml of an antacid, such as Mylanta™ or Gastrogel™. It is pink due to the lignocaine.

What is a Pink Lady used for?

Lignocaine viscous is marketed specifically for the relief of oral cavity and upper GI symptoms associated with painful conditions, such as post tonsillectomy and prior to upper GI instrumentation. It is not marketed for the relief of the symptoms of gastrointestinal reflux. (MIMS).

There is widespread clinical use of the PL to manage and differentiate chest pain, especially in emergency departments. This is worth exploring further.

Does clinical response to a Pink Lady help differentiate between gastrointestinal-related chest pain and other causes of chest pain?

The short answer is NO!

There is no medical literature to support the use of the PL to differentiate gastrointestinal pain from chest pain of other aetiologies. Specifically, relief of pain with a PL does not exclude a cardiac cause of the pain.

The Australian Resuscitation Council published Guideline 14.1.2 in 2014 on the use of a gastrointestinal cocktail for the diagnosis of ACS, with the recommendation “that the GI cocktail not be used in the emergency department to assist in the diagnosis of ACS.”   Read the guideline here.

  • Patient’s description of pain is subjective. Complaints of “burning” and “indigestion” are common in patients with proven AMI.
  • Patients with proven ACS will get partial and even complete relief of their pain with a PL.
  • Relief of symptoms following a PL does not advance the diagnosis of a gastrointestinal cause, and does not exclude a cardiac cause.
  • Failure of a PL to relieve the symptoms does not make the diagnosis of a cardiac cause more likely.
  • You cannot diagnose GORD in the emergency department.
  • You can only exclude ACS by following the correct clinical pathway used in your hospital.

And also don’t forget that just because the pain is relieved with GTN does not diagnose a cardiac cause.

And let’s not get started on chest wall tenderness!!!

 

So follow the ARC recommendation. Work hard to exclude the serious stuff – ACS, pericarditis, PE, pneumonia, pneumothorax, dissection etc.

When you are happy that all these are dealt with, then you can try a PL, just before discharge. BUT do not make a discharge diagnosis of GORD or oesophagitis or gastritis because you cannot prove these. You do not want to mislabel a patient so that future treating practitioners, including the patient’s General Practitioner, are mislead and fail to reconsider a more serious cause.

And don’t forget to warn the patient not to eat or drink for at least 30 minutes until the lignocaine wears off, or they may aspirate!!

    Some further reading:

 

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