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West Middlesex
University Hospital
Emergency Department
Handbook
January 2010
West Middlesex Emergency Department Handbook
1
Introduction ...................................................................................................... 14
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
Who’s who? ..........................................................................................................14
Welcome! ..............................................................................................................15
Department overview ............................................................................................15
Communication in the department ........................................................................16
Teaching ...............................................................................................................16
Working in shifts....................................................................................................16
Sick leave .............................................................................................................17
Specialist staff .......................................................................................................17
Physiotherapy .......................................................................................................18
Radiate Team .......................................................................................................18
Telephone and bleep system ................................................................................18
Note keeping .........................................................................................................18
Investigations ........................................................................................................20
Fighting MRSA ......................................................................................................20
Hand washing .......................................................................................................21
Blood Transfusion .................................................................................................21
1.16.1
1.16.2
1.17
1.18
1.19
1.20
1.21
1.22
1.23
1.24
1.25
1.26
1.27
Registrar duties .....................................................................................................24
Radiology reporting ...............................................................................................24
Prescribing ............................................................................................................25
Observation bay ....................................................................................................25
Discharging patients from A&E .............................................................................26
Ward Rounds in A&E ............................................................................................26
A&E review clinics .................................................................................................27
Domestic violence .................................................................................................27
Adverse Incidents .................................................................................................27
Do Not Attempt Resuscitation orders ....................................................................28
Death in the department........................................................................................28
1.27.1
1.27.2
1.27.3
1.27.4
1.28
1.29
2
Massive Haemorrhage.................................................................................................... 23
Haemorrhage and Warfarin ............................................................................................ 23
Death of patients under 18 years ................................................................................... 29
Organ or tissue donation ................................................................................................ 29
Summary of Organ donation pathway ............................................................................ 30
Summary of Tissue donation pathway ........................................................................... 31
Police and police statements.................................................................................32
Major Incident Plan ...............................................................................................32
Management of Acute Pain ............................................................................. 34
2.1
2.2
2.3
2.3.1
2.3.2
2.3.3
2.3.4
2.3.5
2.4
2.5
2.5.1
2.5.2
2.6
2.6.1
2.6.2
2.6.3
2.7
2.7.1
2.7.2
Misconceptions about pain ....................................................................................34
Pain assessment...................................................................................................34
Analgesics recommended by APS ........................................................................34
Paracetamol .................................................................................................................... 34
Codydramol / cocodamol ................................................................................................ 34
NSAIDs ........................................................................................................................... 35
Tramadol ......................................................................................................................... 35
Opioids ............................................................................................................................ 35
Guidelines for administration of all opioids via any route .......................................35
Guidelines for intramuscular opioid .......................................................................36
Morphine dose: age <70 years ....................................................................................... 36
Morphine dose: age >70 years ....................................................................................... 36
Guidelines for intravenous paracetamol ................................................................36
Indications for use ........................................................................................................... 36
Prescribing guidelines..................................................................................................... 36
Dose................................................................................................................................ 37
Other methods of treating acute pain ....................................................................37
Patient Controlled Analgesia (PCA) ............................................................................... 37
Inhalation analgesia ........................................................................................................ 37
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2.7.3
2.7.4
2.7.5
3
Local anaesthesia ........................................................................................................... 37
Epidural analgesia (only used in wards with specialist training) .................................... 38
Complementary therapies (to be used with analgesics) ................................................. 38
Medical Emergencies....................................................................................... 39
3.1
Adult advanced life support ...................................................................................39
3.1.1
3.1.2
3.1.3
3.1.4
3.2
Defibrillation strategy ...................................................................................................... 40
Adrenaline (epinephrine) ................................................................................................ 40
Anti-arrhythmic drugs...................................................................................................... 40
Post resuscitation care – therapeutic hypothermia ........................................................ 40
Acute management of peri-arrest arrhythmias ......................................................40
3.2.1
3.2.2
3.2.3
3.3
3.4
General management ..................................................................................................... 40
Adverse signs ................................................................................................................. 41
Treatment options ........................................................................................................... 41
Synchronised electrical cardioversion ...................................................................41
Bradyarrhythmias ..................................................................................................41
3.4.1
3.4.2
3.5
Adverse signs ................................................................................................................. 41
Management ................................................................................................................... 41
Tachyarrhythmias .................................................................................................43
3.5.1
3.5.2
3.6
Tachyarrhythmia with adverse signs .............................................................................. 43
Tachyarrhythmia without adverse signs ......................................................................... 43
AF .........................................................................................................................46
3.6.1
3.6.2
3.6.3
3.7
Treatment decision tree .................................................................................................. 46
Rhythm control of AF without adverse signs .................................................................. 47
Rate control of AF without adverse signs ....................................................................... 48
Chest pain.............................................................................................................48
3.7.1
3.7.2
3.7.3
3.7.4
3.7.5
3.7.6
3.7.7
3.7.8
3.8
Assessment of Chest pain patients ................................................................................ 48
Guidelines for use of the Biosite machine ...................................................................... 49
Interpretation of Triple marker results ............................................................................. 50
Alteration of cardiac markers in various conditions ........................................................ 51
Guide to further management ......................................................................................... 52
Summary of Chest Pain Management ............................................................................ 53
Risk Stratification for Triple test negative patients ......................................................... 55
ACS Pathway .................................................................................................................. 56
Management of severe hypertension ....................................................................57
3.8.1
3.8.2
3.8.3
3.8.4
3.8.5
3.8.6
3.9
3.10
3.11
3.12
3.13
History ............................................................................................................................. 57
Examination .................................................................................................................... 57
Investigations .................................................................................................................. 57
Overdoses associated with hypertension ....................................................................... 57
Management of emergencies ......................................................................................... 58
Management of urgencies .............................................................................................. 58
DVT / PE prophylaxis ............................................................................................59
Pulmonary embolus ..............................................................................................59
Deep venous thrombosis ......................................................................................60
Use of Oxygen ......................................................................................................62
Pneumonia............................................................................................................63
3.13.1
3.13.2
3.13.3
3.13.4
3.14
CAP project and Care Bundle at West Mid .................................................................... 63
Investigations .................................................................................................................. 64
Assessing severity of CAP.............................................................................................. 64
Management of CAP ...................................................................................................... 65
Asthma .................................................................................................................67
3.14.1
3.14.2
3.14.3
3.14.4
3.14.5
3.14.6
3.14.7
3.14.8
Initial assessment ........................................................................................................... 67
Investigations .................................................................................................................. 68
Management of acute asthma ........................................................................................ 68
Heliox in acute asthma ................................................................................................... 69
Asthma in pregnancy ...................................................................................................... 69
Patients at risk of developing near-fatal or fatal asthma ................................................ 70
Criteria for admission / discharge ................................................................................... 71
Summary of treatment in Emergency Department ......................................................... 72
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3.14.9
3.15
3.15.1
3.15.2
3.15.3
3.15.4
3.16
Risk assessment ............................................................................................................. 94
Management ................................................................................................................... 95
Cases to consider urgent brain imaging in TIA .............................................................. 96
Low risk TIA summary ...................................................... Error! Bookmark not defined.
High risk TIA summary ................................................................................................... 98
Stroke ...................................................................................................................99
3.24.1
3.24.2
3.24.3
3.24.4
3.24.5
3.24.6
3.25
Assessment .................................................................................................................... 91
Subarachnoid haemorrhage (SAH) ................................................................................ 92
Raised intracranial pressure ........................................................................................... 92
Temporal arteritis ............................................................................................................ 92
Migraine .......................................................................................................................... 93
Cluster headaches .......................................................................................................... 93
Primary angle-closure glaucoma .................................................................................... 93
Transient ischaemic attacks (TIAs) .......................................................................94
3.23.1
3.23.2
3.23.3
3.23.4
3.23.5
3.24
First fit ............................................................................................................................. 89
Status epilepticus ............................................................................................................ 89
Headache .............................................................................................................91
3.22.1
3.22.2
3.22.3
3.22.4
3.22.5
3.22.6
3.22.7
3.23
History ............................................................................................................................. 86
Examination .................................................................................................................... 86
Investigations in patients with suspected upper GI bleed .............................................. 86
The unconscious patient .......................................................................................88
Fitting ....................................................................................................................89
3.21.1
3.21.2
3.22
When to use NIV ............................................................................................................. 82
Medical optimisation prior to NIV .................................................................................... 82
How to set up NIV ........................................................................................................... 83
Ventilator Set-up ............................................................................................................. 83
Patient Parameters ......................................................................................................... 83
Reassessment of the patient .......................................................................................... 84
Signs that NIV is effective ............................................................................................... 84
Possible indications for intubation .................................................................................. 84
Failure of treatment ......................................................................................................... 84
Tuberculosis .........................................................................................................85
Upper GI Bleed .....................................................................................................86
3.19.1
3.19.2
3.19.3
3.20
3.21
Personal Protective Equipment ...................................................................................... 76
Assessment of patients................................................................................................... 77
Patients at risk of complications ..................................................................................... 78
Complications of influenza .............................................................................................. 79
Investigations .................................................................................................................. 80
Management ................................................................................................................... 81
Non-invasive ventilation ........................................................................................82
3.17.1
3.17.2
3.17.3
3.17.4
3.17.5
3.17.6
3.17.7
3.17.8
3.17.9
3.18
3.19
Differentiating between asthma and COPD.................................................................... 74
Assessing severity .......................................................................................................... 74
Criteria for admission ...................................................................................................... 74
Summary of management .............................................................................................. 75
Influenza ...............................................................................................................76
3.16.1
3.16.2
3.16.3
3.16.4
3.16.5
3.16.6
3.17
Summary of management of acute severe asthma ........................................................ 73
COPD ...................................................................................................................74
Initial assessment and diagnosis .................................................................................... 99
Imaging ......................................................................................................................... 101
Indications for thrombolysis .......................................................................................... 101
Contraindications to thrombolysis ................................................................................. 101
Drugs used in acute stroke ........................................................................................... 102
Further management .................................................................................................... 104
Diabetic ketoacidosis (DKA) ................................................................................105
3.25.1
3.25.2
3.25.3
3.25.4
3.25.5
Criteria for diagnosis ..................................................................................................... 105
Consider precipitating event ......................................................................................... 105
Initial investigations ....................................................................................................... 105
Initial treatment in the First Hour .................................................................................. 106
Treatment in Hours 2-4 ................................................................................................. 106
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West Middlesex Emergency Department Handbook
3.25.6
3.26
3.26.1
3.26.2
3.26.3
3.26.4
3.26.5
3.27
Presentation of a sickle cell crisis ................................................................................. 111
Triage / Initial assessment ............................................................................................ 111
Investigations ................................................................................................................ 112
General management of patients in sickle cell crisis .................................................... 112
Analgesia ...................................................................................................................... 112
Acute chest syndrome .................................................................................................. 113
Acute neurological symptoms ....................................................................................... 113
Acute abdomen............................................................................................................. 113
Acute priapism .............................................................................................................. 114
Acute anaemia .............................................................................................................. 114
Management of fever in neutropenic chemotherapy patients ..............................114
3.29.1
3.29.2
3.29.3
3.29.4
4
Diagnosis ...................................................................................................................... 109
Initial management ....................................................................................................... 109
Consider precipitating event ......................................................................................... 110
Sickle cell crises..................................................................................................111
3.28.1
3.28.2
3.28.3
3.28.4
3.28.5
3.28.6
3.28.7
3.28.8
3.28.9
3.28.10
3.29
Diagnosis ...................................................................................................................... 107
Consider precipitating event ......................................................................................... 107
Initial investigations ....................................................................................................... 107
Initial management ....................................................................................................... 108
Points to remember ...................................................................................................... 108
Hypoglycaemia ...................................................................................................109
3.27.1
3.27.2
3.27.3
3.28
Points to remember ...................................................................................................... 107
Hyperosmolar non-ketotic diabetic state (HONK) ................................................107
Physical examination .................................................................................................... 114
Investigations ................................................................................................................ 115
Management ................................................................................................................. 115
Antibiotic therapy .......................................................................................................... 115
Paediatrics ...................................................................................................... 116
4.1
4.2
4.3
4.3.1
4.3.2
4.3.3
4.3.4
4.3.5
4.4
4.4.1
4.4.2
4.4.3
4.4.4
4.5
4.5.1
4.5.2
4.5.3
4.5.4
4.6
4.6.1
4.6.2
4.6.3
4.6.4
4.6.5
4.6.6
4.6.7
4.7
4.7.1
4.7.2
4.7.3
4.7.4
Paediatric Red Flags ...........................................................................................116
Normal values .....................................................................................................117
Analgesia / antipyretics .......................................................................................117
Paracetamol (Calpol) .................................................................................................... 117
Ibuprofen (Nurofen) ...................................................................................................... 117
Codeine......................................................................................................................... 117
Oromorph ...................................................................................................................... 117
Intravenous morphine ................................................................................................... 118
Recognition of the seriously ill child.....................................................................118
Airway ........................................................................................................................... 118
Breathing ...................................................................................................................... 118
Circulation ..................................................................................................................... 119
Disability........................................................................................................................ 119
Intravenous fluids in children ...............................................................................119
Hyponatraemia ............................................................................................................. 119
Hypernatraemia ............................................................................................................ 119
Fluid resuscitation ......................................................................................................... 120
Ongoing fluid needs ...................................................................................................... 120
Asthma ...............................................................................................................121
Assessment of asthma in children ................................................................................ 121
Asthma in infants <2 years ........................................................................................... 122
Management points in infants <2 years ........................................................................ 122
Asthma in children aged 2-5 years ............................................................................... 123
Asthma in children over 5 ............................................................................................. 124
Heliox and other treatments in acute asthma ............................................................... 125
Discharge planning ....................................................................................................... 125
Bronchiolitis ........................................................................................................126
Assessment of disease severity ................................................................................... 126
Criteria for admission .................................................................................................... 126
Indications for high dependency / PICU consultation ................................................... 127
Treatment ..................................................................................................................... 127
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4.7.5
4.8
4.9
Advice if discharging ..................................................................................................... 127
Croup ..................................................................................................................128
Community acquired pneumonia .........................................................................129
4.9.1
4.9.2
4.9.3
4.9.4
4.9.5
4.9.6
4.9.7
4.9.8
4.9.9
4.10
Pathogens commonly involved ..................................................................................... 129
Clinical features ............................................................................................................ 129
WHO defined tachypnoea............................................................................................. 129
Indications for admission to hospital ............................................................................. 129
Investigations ................................................................................................................ 129
Treatment ..................................................................................................................... 130
Medication on discharge ............................................................................................... 130
Follow up ...................................................................................................................... 130
Complications ............................................................................................................... 131
Influenza in children ............................................................................................132
4.10.1
4.10.2
4.10.3
4.10.4
4.10.5
4.10.6
4.11
Allergic reactions.................................................................................................134
4.11.1
4.11.2
4.12
Management of Fits ...................................................................................................... 151
Febrile convulsions ....................................................................................................... 152
Abdominal pain ...................................................................................................153
4.16.1
4.16.2
4.16.3
4.16.4
4.17
Initial Assessment ......................................................................................................... 147
When to organise a CT scan ........................................................................................ 148
Associated C-spine imaging ......................................................................................... 149
Criteria for admission .................................................................................................... 150
Criteria for safe discharge............................................................................................. 150
Discharge advice .......................................................................................................... 150
Fits and febrile convulsions .................................................................................151
4.15.1
4.15.2
4.16
Symptoms and signs .................................................................................................... 143
Assessment .................................................................................................................. 143
Urine collection ............................................................................................................. 143
Urine testing, under 3 years old .................................................................................... 144
Urine testing, over 3 years old ...................................................................................... 145
Indications for urine culture .......................................................................................... 145
Localisation ................................................................................................................... 145
Risk factors for UTI / serious underlying pathology ...................................................... 146
Acute management....................................................................................................... 146
Follow up ...................................................................................................................... 147
Head injuries .......................................................................................................147
4.14.1
4.14.2
4.14.3
4.14.4
4.14.5
4.14.6
4.15
Initial Assessment ......................................................................................................... 137
Traffic light system ........................................................................................................ 138
Specific symptoms and signs ....................................................................................... 139
Management in Paeds A&E ......................................................................................... 140
Antibiotic Treatment ...................................................................................................... 141
Admission to hospital .................................................................................................... 141
Antipyretic interventions................................................................................................ 142
Discharging home ......................................................................................................... 142
Urinary tract infection ..........................................................................................143
4.13.1
4.13.2
4.13.3
4.13.4
4.13.5
4.13.6
4.13.7
4.13.8
4.13.9
4.13.10
4.14
Mild allergic reaction (no cardiorespiratory symptoms) ................................................ 134
Anaphylaxis in children ................................................................................................. 135
Fever without a focus ..........................................................................................136
4.12.1
4.12.2
4.12.3
4.12.4
4.12.5
4.12.6
4.12.7
4.12.8
4.13
Assessment of patients................................................................................................. 132
Children at risk of complications from influenza ........................................................... 132
Complications of influenza in children .......................................................................... 133
Investigations ................................................................................................................ 133
Management of children with influenza ........................................................................ 133
Antiviral dosages in children ......................................................................................... 134
History ........................................................................................................................... 154
Physical examination .................................................................................................... 155
Investigations ................................................................................................................ 155
Indications for surgical consultations in children with acute abdominal pain ............... 155
Acute gastroenteritis ...........................................................................................156
4.17.1
Assessment .................................................................................................................. 156
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4.17.2
4.17.3
4.17.4
4.17.5
4.17.6
4.17.7
4.17.8
4.17.9
4.17.10
4.18
Diabetic ketoacidosis (DKA) in children ...............................................................162
4.18.1
4.18.2
4.18.3
4.18.4
4.18.5
4.18.6
4.18.7
4.18.8
4.18.9
4.19
A&E Safeguarding Procedures ..................................................................................... 174
NICE Summary ............................................................................................................. 176
Signs which may lead to concern ................................................................................. 176
What to do if you have concerns .................................................................................. 178
Named Safeguarding Leads in the Trust ...................................................................... 178
Safeguarding sexually active children .................................................................179
4.25.1
4.25.2
4.25.3
4.25.4
4.25.5
5
Measles......................................................................................................................... 168
Chickenpox ................................................................................................................... 169
Impetigo ........................................................................................................................ 169
Erythema multiforme..................................................................................................... 169
Molluscum contagiosum ............................................................................................... 170
Fifth disease ................................................................................................................. 170
Scarlet fever .................................................................................................................. 170
Staphylococcal Scalded Skin Syndrome ...................................................................... 171
Kawasaki’s disease ...................................................................................................... 172
Safeguarding Children and Young Adults ...........................................................174
4.24.1
4.24.2
4.24.3
4.24.4
4.24.5
4.25
Petechial spots in well and afebrile child ...................................................................... 166
Petechial spots in well but febrile child ......................................................................... 167
Petechial spots in unwell child ...................................................................................... 167
Management ................................................................................................................. 167
Other rashes in children ......................................................................................168
4.23.1
4.23.2
4.23.3
4.23.4
4.23.5
4.23.6
4.23.7
4.23.8
4.23.9
4.24
Signs and symptoms of cerebral oedema .................................................................... 165
Management ................................................................................................................. 165
Paediatric Glasgow Coma Scale .........................................................................166
Petechial rash in children ....................................................................................166
4.22.1
4.22.2
4.22.3
4.22.4
4.23
Causes of hypoglycaemia............................................................................................. 164
Signs and symptoms of hypoglycaemia. ...................................................................... 164
Management ................................................................................................................. 165
Cerebral oedema ................................................................................................165
4.20.1
4.20.2
4.21
4.22
Useful formulae ............................................................................................................. 162
Diagnosis of DKA .......................................................................................................... 162
General points .............................................................................................................. 162
Emergency Management.............................................................................................. 162
Initial investigations ....................................................................................................... 163
Fluids ............................................................................................................................ 163
Bicarbonate ................................................................................................................... 163
Potassium ..................................................................................................................... 164
Insulin............................................................................................................................ 164
Management of hypoglycaemia in diabetic children ............................................164
4.19.1
4.19.2
4.19.3
4.20
Infection control ............................................................................................................ 156
Investigations ................................................................................................................ 157
Assessing dehydration.................................................................................................. 158
Fluid Management ........................................................................................................ 159
Practical points ............................................................................................................. 160
Fluid management after rehydration ............................................................................. 160
Criteria for observation / admission .............................................................................. 160
Management of feeding during gastroenteritis ............................................................. 160
Pharmacotherapy ......................................................................................................... 161
Children under 13 ......................................................................................................... 179
Children under 16 ......................................................................................................... 179
Young People 16 and 17 years .................................................................................... 179
Indicators of Harm ........................................................................................................ 180
Information sharing ....................................................................................................... 180
Major Trauma ................................................................................................. 181
5.1
5.2
5.3
5.3.1
Initial Assessment ...............................................................................................181
Preparation .........................................................................................................181
Primary Survey ...................................................................................................181
Airway maintenance with cervical spine protection ...................................................... 182
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West Middlesex Emergency Department Handbook
5.3.2
5.3.3
5.3.4
5.3.5
5.4
5.5
5.6
5.7
6
Breathing ...................................................................................................................... 182
Circulation ..................................................................................................................... 183
Disability........................................................................................................................ 183
Exposure / Environment ............................................................................................... 183
Adjuncts to Primary Survey .................................................................................184
Consider the need for transfer.............................................................................184
Secondary Survey...............................................................................................185
Records & Legal Considerations .........................................................................186
Surgical Emergencies.................................................................................... 187
6.1
Approach to surgical cases .................................................................................187
6.1.1
6.1.2
6.2
Helpful investigations .................................................................................................... 187
Indications for AXR ....................................................................................................... 187
Acute abdominal pain .........................................................................................187
6.2.1
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
6.12
6.13
6.14
6.15
6.16
Pitfalls ........................................................................................................................... 187
Acute appendicitis ...............................................................................................188
Acute pancreatitis ...............................................................................................188
Chronic pancreatitis ............................................................................................188
Acute cholecystitis ..............................................................................................189
Biliary colic ..........................................................................................................189
Obstructive jaundice ...........................................................................................189
Ascending cholangitis .........................................................................................189
Peptic ulcer disease ............................................................................................189
Other perforations ...............................................................................................190
Intestinal obstruction ...........................................................................................190
Mesenteric infarction ...........................................................................................190
Volvulus ..............................................................................................................191
Diverticulitis .........................................................................................................191
Anorectal disease ...............................................................................................191
6.16.1
6.16.2
6.16.3
6.16.4
6.16.5
6.17
6.18
Abscesses ..........................................................................................................192
Vascular problems ..............................................................................................192
6.18.1
6.18.2
6.18.3
6.18.4
6.19
7
Haemorrhoids ............................................................................................................... 191
Anal fissure ................................................................................................................... 191
Pilonidal abscess .......................................................................................................... 191
Anorectal abscess ........................................................................................................ 192
Rectal foreign bodies .................................................................................................... 192
Ruptured AAA ............................................................................................................... 192
Ischaemic limb .............................................................................................................. 193
Axillary vein thrombosis ................................................................................................ 193
Varicose veins .............................................................................................................. 193
Post-op problems ................................................................................................194
Neurosurgery ................................................................................................. 195
7.1
Head injury..........................................................................................................195
7.1.1
7.1.2
7.1.3
7.1.4
7.1.5
7.1.6
7.1.7
7.1.8
7.1.9
7.1.10
7.2
7.2.1
7.2.2
7.2.3
Assessment .................................................................................................................. 195
Investigation .................................................................................................................. 196
Organising a CT ............................................................................................................ 197
When to involve Neurosurgery ..................................................................................... 198
Guidelines for intubation prior to transfer ..................................................................... 199
Admission of head injured patients ............................................................................... 200
Reviewing head injured patients ................................................................................... 201
Discharging head injured patients ................................................................................ 202
Discharge advice .......................................................................................................... 202
Follow-up of head injured patients ................................................................................ 203
Back pain requiring Neurosurgical input ..............................................................203
History ........................................................................................................................... 203
Red Flags for back pain ................................................................................................ 204
Examination .................................................................................................................. 204
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7.2.4
7.2.5
7.3
7.4
Investigations ................................................................................................................ 204
True emergencies ......................................................................................................... 204
Cauda equina syndrome .....................................................................................204
Metastatic Spinal Cord Compression ..................................................................205
7.4.1
7.4.2
8
Diagnosis ...................................................................................................................... 205
Treatment ..................................................................................................................... 206
Orthopaedics .................................................................................................. 207
8.1
8.2
8.3
8.4
8.5
8.6
General rules ......................................................................................................207
Procedural sedation ............................................................................................207
Open fractures ....................................................................................................208
Head injuries .......................................................................................................208
C-spine injuries ...................................................................................................208
Upper limb injuries ..............................................................................................209
8.6.1
8.6.2
8.6.3
8.6.4
8.6.5
8.6.6
8.6.7
8.6.8
8.6.9
8.6.10
8.7
Lower limb injuries ..............................................................................................212
8.7.1
8.7.2
8.7.3
8.7.4
8.7.5
8.7.6
8.7.7
8.7.8
8.7.9
8.7.10
8.8
8.9
Epiphyseal plate fractures: ........................................................................................... 216
Diaphysis (shaft fractures) ............................................................................................ 217
The limping child .................................................................................................217
8.10.1
8.10.2
8.10.3
8.10.4
8.10.5
8.10.6
8.10.7
8.10.8
8.11
9
Pelvis ............................................................................................................................ 212
Neck of femur fracture .................................................................................................. 213
Hip Dislocation .............................................................................................................. 213
Trochanteric avulsion fracture ...................................................................................... 213
Shaft of femur ............................................................................................................... 213
Knee.............................................................................................................................. 213
Tibia and Fibula shaft fracture ...................................................................................... 214
Ankle ............................................................................................................................. 214
Foot ............................................................................................................................... 215
Toes .............................................................................................................................. 215
Simple mechanical back pain ..............................................................................216
Paediatric fractures .............................................................................................216
8.9.1
8.9.2
8.10
Hand fractures (closed) ................................................................................................ 209
Hand injuries ................................................................................................................. 209
Wrist fractures ............................................................................................................... 210
Forearm fractures ......................................................................................................... 210
Supracondylar fracture ................................................................................................. 210
Humeral shaft fracture .................................................................................................. 211
Neck of humerus fracture ............................................................................................. 211
Shoulder dislocation ..................................................................................................... 212
AC dislocation ............................................................................................................... 212
Clavicle fracture ............................................................................................................ 212
Questions to be asked .................................................................................................. 217
Examination .................................................................................................................. 217
Transient synovitis ........................................................................................................ 218
Septic arthritis ............................................................................................................... 218
Perthes disease ............................................................................................................ 218
Slipped upper femoral epiphysis .................................................................................. 218
Juvenile rheumatoid arthritis ......................................................................................... 219
Neoplasms .................................................................................................................... 219
Physiotherapy service in A&E .............................................................................219
Minor Injuries ................................................................................................. 220
9.1
9.2
9.3
9.3.1
9.3.2
9.3.3
9.3.4
9.3.5
Wound types .......................................................................................................220
Wound differentiation ..........................................................................................220
Wound management ...........................................................................................220
Initial cleaning and / or debridement ............................................................................. 220
Local anaesthetic .......................................................................................................... 220
Handling the wound ...................................................................................................... 221
Closure or no closure .................................................................................................... 221
Sutures.......................................................................................................................... 221
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9.3.6
9.3.7
9.3.8
9.3.9
9.3.10
9.3.11
9.4
Antibiotics or not ........................................................................................................... 221
Bites .............................................................................................................................. 221
Tetanus prophylaxis ...................................................................................................... 222
Wound dressings .......................................................................................................... 222
What the patient should know ...................................................................................... 222
Special circumstances .................................................................................................. 222
Burns ..................................................................................................................222
10 Plastics ........................................................................................................... 224
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
10.9
Principles ............................................................................................................224
Referrals to Plastics ............................................................................................224
Paediatric referrals ..............................................................................................224
Hand injuries .......................................................................................................224
Facial lacerations ................................................................................................225
Lacerations to other areas ..................................................................................225
Foreign bodies ....................................................................................................225
Tendon injuries ...................................................................................................226
Bony injuries in hand ...........................................................................................226
11 ENT .................................................................................................................. 227
11.1
The Ear ...............................................................................................................227
11.1.1
11.1.2
11.1.3
11.1.4
11.1.5
11.1.6
11.1.7
11.1.8
11.2
The Nose ............................................................................................................229
11.2.1
11.2.2
11.2.3
11.2.4
11.2.5
11.3
Foreign bodies .............................................................................................................. 229
Septal haematoma........................................................................................................ 229
Epistaxis........................................................................................................................ 229
Sinusitis......................................................................................................................... 230
Nasal Fractures ............................................................................................................ 230
The Throat ..........................................................................................................230
11.3.1
11.3.2
11.3.3
11.3.4
11.4
Otitis externa ................................................................................................................. 227
Otitis media (OM) and mastoiditis ................................................................................ 227
Wax ear......................................................................................................................... 228
Referred pain ................................................................................................................ 228
Foreign bodies in the ear .............................................................................................. 228
Trauma to external ear ................................................................................................. 228
Traumatic perforations of the tympanic membrane ...................................................... 228
Lacerations of the ear affecting the cartilage ............................................................... 229
Foreign Bodies .............................................................................................................. 230
Tonsillitis ....................................................................................................................... 230
Quinsy ........................................................................................................................... 230
Crico-thyroidotomy........................................................................................................ 231
The Face.............................................................................................................231
11.4.1
Facial Palsy .................................................................................................................. 231
12 Maxillofacial / Dental Emergencies .............................................................. 232
12.1
12.2
12.3
12.4
12.5
General principles ...............................................................................................232
Imaging ...............................................................................................................232
General management .........................................................................................232
Abscesses ..........................................................................................................232
Lacerations .........................................................................................................233
12.5.1
12.6
12.7
12.8
12.9
12.10
12.11
Head and neck lacerations ........................................................................................... 233
Stabbings of Head and Neck...............................................................................234
Fractures of Zygoma, Orbit and Midface .............................................................234
Fractures of the Mandible ...................................................................................234
Nasal Trauma .....................................................................................................235
Dentoalveolar trauma ......................................................................................235
Lumps and bumps...........................................................................................235
13 Ophthalmology ............................................................................................... 236
13.1
Important numbers ..............................................................................................236
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13.2
Examination ........................................................................................................236
13.2.1
13.2.2
13.3
13.4
13.5
13.6
13.7
13.8
13.9
13.10
13.11
13.12
13.13
13.14
13.15
13.16
13.17
13.18
13.19
13.20
13.21
13.22
13.23
Red eye examination .................................................................................................... 237
Blurred vision examination............................................................................................ 237
Primary angle closure glaucoma .........................................................................237
Giant cell (temporal) arteritis ...............................................................................238
Orbital cellulitis ....................................................................................................238
Herpes zoster ophthalmicus ................................................................................239
Infected corneal ulcer ..........................................................................................239
Ruptured globe and penetrating eye injuries .......................................................240
Chemical injury ...................................................................................................240
Sudden visual loss ..........................................................................................241
Anterior uveitis (iritis) .......................................................................................241
Scleritis ...........................................................................................................242
Dendritic ulcer (HSV keratitis) .........................................................................242
Acute dacryocystitis ........................................................................................242
Infective conjunctivitis .....................................................................................243
Allergic conjunctivitis .......................................................................................243
Episcleritis .......................................................................................................244
Corneal foreign body .......................................................................................244
Corneal abrasion .............................................................................................245
Spontaneous subconjunctival haemorrhage ....................................................245
Pingueculum / pterygium .................................................................................246
Chalazion ........................................................................................................246
When to refer ..................................................................................................247
13.23.1
13.23.2
13.23.3
13.23.4
Ophthalmic emergencies requiring IMMEDIATE referral ............................................. 247
Ophthalmic emergencies requiring URGENT referral .................................................. 247
Ophthalmic conditions requiring SEMI-URGENT referral ............................................ 247
Ophthalmic conditions not requiring referral ................................................................. 247
14 Urology ........................................................................................................... 248
14.1
Renal colic ..........................................................................................................248
14.1.1
14.1.2
14.1.3
14.2
Acute urinary retention ........................................................................................250
14.2.1
14.2.2
14.2.3
14.3
Investigations ................................................................................................................ 250
Catheterisation .............................................................................................................. 250
Follow up ...................................................................................................................... 250
Testicular pain ....................................................................................................251
14.3.1
14.3.2
14.3.3
14.3.4
14.3.5
14.4
14.5
14.6
Investigations ................................................................................................................ 248
Management ................................................................................................................. 249
Disposition .................................................................................................................... 249
History ........................................................................................................................... 251
Examination .................................................................................................................. 252
Differential Diagnoses................................................................................................... 252
Investigations and Management ................................................................................... 253
Varicocoele ................................................................................................................... 254
Priapism ..............................................................................................................254
Paraphimosis ......................................................................................................254
Genitourinary injuries ..........................................................................................254
14.6.1
14.6.2
Bladder and Urethral injuries ........................................................................................ 254
Testicular trauma .......................................................................................................... 255
15 Obstetrics and Gynaecology ........................................................................ 256
15.1
15.2
15.3
15.4
Introduction .........................................................................................................256
History ................................................................................................................256
Examination ........................................................................................................256
Vaginal pain ........................................................................................................256
15.4.1
15.4.2
15.5
Ulcers ............................................................................................................................ 256
Lumps ........................................................................................................................... 256
Vaginal discharge ...............................................................................................257
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15.6
15.7
Foreign bodies ....................................................................................................257
Contraceptive problems ......................................................................................257
15.7.1
15.7.2
15.8
Gynaecological pain ............................................................................................258
15.8.1
15.8.2
15.8.3
15.8.4
15.8.5
15.9
Missed Pills ................................................................................................................... 257
Emergency Contraception ............................................................................................ 257
Pain related to menstrual cycle .................................................................................... 258
PID ................................................................................................................................ 258
Ovarian torsion/cyst rupture.......................................................................................... 258
Fibroids ......................................................................................................................... 258
Vaginal bleeding ........................................................................................................... 258
Problems in Pregnancy .......................................................................................259
15.9.1
15.10
General considerations ................................................................................................. 259
Early pregnancy problems...............................................................................260
15.10.1 History ........................................................................................................................... 260
15.10.2 Examination .................................................................................................................. 260
15.10.3 Investigations ................................................................................................................ 261
15.10.4 Establishing a diagnosis clinically ................................................................................. 261
15.10.5 Management ................................................................................................................. 262
15.10.6 Patients suitable for Community management ............................................................. 262
15.10.7 Early Pregnancy Unit .................................................................................................... 263
15.10.8 Products of Conception ................................................................................................ 263
15.10.9 Anti D ............................................................................................................................ 263
15.10.10 Hyperemesis Gravidarum ............................................................................................. 264
15.11
Later pregnancy problems...............................................................................265
15.11.1 Pre-eclampsia / eclampsia............................................................................................ 265
15.11.2 Management of severe pre-eclampsia / eclampsia ...................................................... 267
16 Sexual Health and Genitourinary Medicine ................................................. 269
16.1
16.2
GU clinic .............................................................................................................269
Taking a sexual history .......................................................................................269
16.2.1
16.2.2
16.3
Male urethral discharge.......................................................................................271
16.3.1
16.3.2
16.3.3
16.3.4
16.4
16.5
Primary infection ........................................................................................................... 274
Management ................................................................................................................. 275
Pregnancy and HSV ..................................................................................................... 275
Syphilis ...............................................................................................................275
16.8.1
16.8.2
16.9
Symptoms ..................................................................................................................... 274
Complications ............................................................................................................... 274
Test ............................................................................................................................... 274
Management ................................................................................................................. 274
Herpes ................................................................................................................274
16.7.1
16.7.2
16.7.3
16.8
Symptoms / signs ......................................................................................................... 273
Complications ............................................................................................................... 273
Tests ............................................................................................................................. 273
Management ................................................................................................................. 273
Gonorrhoea.........................................................................................................274
16.6.1
16.6.2
16.6.3
16.6.4
16.7
Management ................................................................................................................. 271
Tests ............................................................................................................................. 271
Treatment ..................................................................................................................... 271
Advice ........................................................................................................................... 271
Abnormal vaginal discharge ................................................................................272
Chlamydia ...........................................................................................................273
16.5.1
16.5.2
16.5.3
16.5.4
16.6
Basic rules on sexual history taking ............................................................................. 269
Specific questions ......................................................................................................... 270
Investigations ................................................................................................................ 275
Symptoms and Signs .................................................................................................... 276
Sexual assault ....................................................................................................277
17 Sharps / Inoculation Injuries ......................................................................... 278
17.1
Risk assessment .................................................................................................278
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17.2
17.3
17.4
17.5
Immediate actions ...............................................................................................278
Hepatitis prevention ............................................................................................279
HIV prevention ....................................................................................................279
Summary of guidance .........................................................................................280
18 Toxicology ...................................................................................................... 281
18.1
18.2
General assessment ...........................................................................................281
General management .........................................................................................281
18.2.1
18.2.2
18.3
Initial management ....................................................................................................... 281
Specific poisons ............................................................................................................ 282
Body packers and stuffers ...................................................................................282
18.3.1
18.3.2
18.3.3
18.3.4
Police and duty of care ................................................................................................. 282
Definitions: Body packers and stuffers ........................................................................ 283
Diagnosis and management of toxicity ......................................................................... 284
Summary of guidance ................................................................................................... 285
19 Psychiatry ....................................................................................................... 286
19.1
19.2
19.3
19.4
Introduction .........................................................................................................286
General principles ...............................................................................................286
Consent issues ...................................................................................................286
Schizophrenia .....................................................................................................287
19.4.1
19.4.2
19.4.3
19.5
Deliberate self-harm (DSH) .................................................................................289
19.5.1
19.5.2
19.5.3
19.5.4
19.5.5
19.5.6
19.5.7
19.5.8
19.5.9
19.5.10
19.5.11
19.5.12
19.5.13
19.5.14
19.6
19.7
Risk stratification ........................................................................................................... 294
Special issues for older people ...........................................................................295
Acute alcohol withdrawal .....................................................................................296
19.9.1
19.9.2
19.9.3
19.10
Triage ............................................................................................................................ 289
Medical assessment ..................................................................................................... 289
GI decontamination for poisonings ............................................................................... 289
Advice on specific poisonings ....................................................................................... 290
Paracetamol overdose .................................................................................................. 290
Benzodiazepine overdose ............................................................................................ 291
Opioid overdose ............................................................................................................ 291
General treatment for self-injury ................................................................................... 292
Repeated self poisoning ............................................................................................... 292
Repeated self injury ...................................................................................................... 292
Psychiatric assessment ................................................................................................ 292
Risk assessment ........................................................................................................... 293
Patients waiting for Psychiatric assessment................................................................. 293
Threatened / actual self discharge ............................................................................... 293
Referral of Psychiatric patients............................................................................294
Special issues for children and adolescents ........................................................294
19.7.1
19.8
19.9
Medication problems..................................................................................................... 287
Psychotic crisis ............................................................................................................. 287
Rapid tranquillisation .................................................................................................... 288
Investigations ................................................................................................................ 296
Treatment ..................................................................................................................... 296
Benzodiazepines .......................................................................................................... 297
Delirium tremens .............................................................................................297
19.10.1 Investigations and Treatment ....................................................................................... 297
19.11
Wernicke’s encephalopathy (WE) / Korsakoff psychosis .................................298
19.11.1 Treatment ..................................................................................................................... 298
19.12
Patients requesting alcohol or drug detoxification............................................298
20 Appendix ......................................................................................................... 299
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1
1.1
Introduction
Who’s who?
Consultants:
Dr M Beckett
Dr Z Mirza
Miss C Smith
Dr S Ayers
Dr J Cheema
Associate Specialists:
Ihsan Kammoona
Dilip Kumar
Samik DasGupta
Middle Grades:
John Hereward
Lene Neuman
Emma Schofield
Mir Hussain
Ulrike Petri
Specialty Registrars:
We have a number of Specialty Registrars rotating through our department.
Matron of A&E:
Debbie Williams
Medical Secretary:
Julia Hardy
020 8321 5486
Associate Director, Emergency Services:
Jacqueline Hardy
Resuscitation Officers:
Sarah Jones
On mat leave
Nikki Jones
016
Annie Redwood
017
Bleep numbers:
Dr Beckett
Dr Mirza
Miss C Smith
Dr S Ayers
Dr J Cheema
205
099
477
002
607
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1.2
Welcome!
Welcome to the Emergency Department at the West Middlesex!
We have written these guidelines to help you understand the way our department works, and
give you guidance in the local management of common conditions seen here. In many
cases, you will be directed to the intranet, where many of the local policies can be found. We
are also working on a protocol folder for the department which will contain the guidelines not
currently on the intranet.
1.3
Department overview
The department currently has 5 Consultants, 3 Associate Specialists, 3 SpRs, 5 Middle
Grades, 16 SHOs and 1 HO. The on-call consultant, Middle Grade and SHO rotas can also
be found in the Registrars’ Office. Your pigeon holes are also located in this office.
Shift work can make communication in the department difficult, so check your pigeon holes
regularly (in the Registrars’ Office) and your email at least twice a week for messages
from the department.
We have a 4 bedded resus room (one paediatric), 10 bedded Majors, 8 bedded Minors and 4
bedded Paediatric area. There is also a 6 bedded Observation Bay.
The department sees approximately 105,000 patients a year, of which 20% are paediatric
patients.
We treat acute and trauma related conditions, and we see emergencies not seen by the local
GPs.
Any patient who has been assessed by their GP prior to attendance at A&E (who has a GP
letter either addressed to a specialty or a generic “Dear Dr” letter) with a condition requiring
specialty input is referred directly to that specialty without further assessment by us.
GP referrals to Medicine can be sent directly to AAU if clinically suitable, bypassing A&E
from 0900 to 2100, Monday to Friday.
Most patients you see will be discharged from the A&E without further follow-up. Those not
admitted can be follow-up by certain emergency clinics:
A&E Consultant Clinic
A&E Physio Clinic
Fracture Clinic
Hand Injuries Clinic (run by Hand OTs for conservatively managed injuries)
ENT Clinic
TIA Clinic
Rapid Access Chest Pain Clinic
Stone Clinic
TWOC (trial without catheter) Clinic
Early Pregnancy Unit
Guidelines for these clinics will be covered in later sections.
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We cannot refer to elective clinics; these patients need to be referred back to their GP to
make the referral. Similarly, patients presenting with chronic problems which have no acute
component should be managed by their GP. If a patient does not have a GP, the PALS
service in the hospital can help them register with one.
1.4
Communication in the department
Shift work presents challenges to the way we communication within the department. It is
therefore vital that you give us your mobile number and your email address accurately so
that we can contact you in both emergency and routine situations.
Look for letters in your pigeon holes each time you come on duty and check the noticeboard
in the registrars’ office for any new information. Also remember to check your email at least
twice a week for important updates and communications.
On occasion, we may also ring you on your mobile if there is something urgent to discuss. It
is important for you to contact us ASAP if there are any changes to your circumstances
which may affect your ability to work.
1.5
Teaching
Teaching sessions for the SHOs currently occurs every Tuesday at 14:30-15:30. You are
required to attend unless you are on the shift finishing at 02:00, night shift, on annual leave
or study leave. Please let Dr Mirza know in advance if you cannot attend for whatever
reason.
There will be a register taken at every teaching session. A timetable of topics will be given to
you by Dr Mirza.
Middle Grade teaching sessions occur every Thursday between 15:00 and 17:00. A
timetable of events can be found on the Registrars’ noticeboard (or you may be notified by
email). Similarly, please let the consultants know if you cannot attend for any reason.
Regular shopfloor teaching is also given by the Middle Grades and Consultants.
During your time with us, you will be encouraged to attend ALS, ATLS and EPLS courses as
appropriate to your career plans.
1.6
Working in shifts
The rotas are arranged by Miss Smith and any enquiries regarding the rota, annual leave or
study should be discussed with her well in advance. Whilst the department will aim to grant
all reasonable leave, please do not book any leave without discussing it with Miss Smith first!
It is your responsibility to double check when you are on duty. The most up-to-date version
of the rota will be on the noticeboard in the Registrars’ Office. Please check your shift times,
as very occasionally there may be some last minute changes.
Be on time for your shifts (especially if you are relieving the night shift). Persistent lateness
will not be tolerated by your peer group or your consultants.
When you arrive on duty, report to the Registrar in charge of the department for allocation to
an area. You may be asked to move to a different clinical area during your shift; please
listen to these requests and follow the instruction. The workload in A&E is fluid and we have
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to staff each area according to our patients’ needs. Pick up cards in time order (unless
instructed otherwise by a member of nursing staff or senior doctor) and work through your
patients in a timely and efficient manner.
Do not spend too long working up your patients; we have a commitment to our patients to
see and admit / discharge them within 4 hours (and to refer to a specialty within 2 hours). If
you are finding that you are spending a long time with your patient, it is often a sign that you
need to ask for senior advice regarding management. There is senior cover on the shopfloor
24 hours a day, 7 days a week.
All SHOs are allocated a registrar mentor for each shift and should communicate with
that person at regular intervals throughout the shift as well as the beginning and end
of the shift.
Ask for senior A&E help early if:
You have a sick or unstable patient
You are unsure of the diagnosis
You are unsure what investigations to do
You are unsure of the management
You need help with carrying out a treatment / procedure
You are unsure if a patient requires referral / admission
You are seeing a patient who has re-attended the department
You are having problems with other specialties / departments
It is not appropriate to ask SHOs in other specialties for advice in the first instance if you are
stuck; often they have the same level of experience as you do. Ask the seniors in A&E first!
In the last hour of your shift, aim to tie up any loose ends and either refer / discharge your
patients as appropriate. Mistakes often happen in patient handovers; please keep these to a
bear minimum. Do not start any complex cases towards the end of your shift (see
Minors cases instead if possible).
1.7
Sick leave
If you fall ill and you are due to come on duty, you must call the department at the earliest
opportunity and speak with one of the Consultants. If the Consultants are not available,
leave a message with Julia, our secretary.
It is not acceptable to leave a message with another SHO or middle grade as it is the
consultants who will make arrangements to find a replacement for you. We also
expect you ring daily during your period of sick leave to inform us of your progress.
Good communication with the consultants in the department helps us manage your return to
work appropriately and ensures that the department is adequately covered in your absence.
1.8
Specialist staff
The A&E nurses are an experienced group with a wealth of information. We have a number
of senior nurses who also have an Emergency Nurse Practitioner / Nurse Practitioner role
(including our own Cardiac Specialist Nurse, Philip Eardley) and are thus a valuable asset to
our department. Ignore their advice at your peril! The consultants regularly receive feedback
from them regarding your performance.
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1.9
Physiotherapy
The department also has two Physiotherapists who are Extended Scope Practitioners
(Sharon Pickering and Liz Ratcliffe). They are based in Minors and are extremely
knowledgeable about the diagnosis and treatment of acute soft tissue injuries. They
welcome any queries you might have regarding the treatment of these conditions and can
follow-up appropriate patients with acute injuries in their daily clinic (A&E Physio Clinic).
It is inappropriate to refer patients with chronic problems to our physiotherapists; these
patients should be referred back to their GP for appropriate management (which may or may
not involve out-patient physiotherapy). If you are unsure, they can advise you.
For more guidance, see Orthopaedic Section of the A&E Guidelines.
1.10
Radiate Team
To facilitate safe discharge, we have a specialist team of senior nurses, OTs and Physio
called the Radiate Team. They accept referrals for patients aged 16+ with social or physical
needs which will require more input prior to discharge.
Patients referred to them have to be medically fit for discharge. They can arrange home
visits, walking / other household aids and appropriate care packages for you.
Contact on Bleep 297 (0800-2000, 7 days a week).
Fill out a Radiate Referral Form (found in the filing cabinet in the Doctors’ Office and in the
Observation Bay – see Appendix.) for every patient you refer.
Always refer acutely (after 8pm admit patient to Obs Bay for referral in the morning); do not
send them a referral in the internal mail.
1.11
Telephone and bleep system
The hospital bleep system works as follows:
8 <Bleep number> <Your extension number>
For fast paging, cardiac arrests and trauma calls dial 2222. Remember to state
whether it is an adult or paediatric cardiac arrest / trauma call, and the location (e.g.
A&E Resus).
Operator is 0.
We also have a number of “tie lines” to different hospitals; see the list above the Majors’
nursing station.
1.12
Note keeping
There are a few minimum standards for note keeping which need to be adhered to in your
time in A&E. Please remember that your notes are a legal document and may be used later
in a Coroner or Law court, so accuracy and legibility are essential.
Every continuation page must additionally have the patient’s details written at the top.
Alternatively, a sticker may be used; ask our staff if you do not know how to get patient
stickers.
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In all cases, you are expected to document:
Your name, your position, the time you saw the patient
A brief history of events surrounding presentation
Important negative symptoms as well as positives
PMH, DH, allergies
Social history in the elderly / paediatric patient
Examination findings, both positive and important negatives
Accurate labelled diagrams of injuries as appropriate
Diagnosis or impression
Plan of management (treatment, medication, disposal, advice)
Investigation findings (bloods, urine, x-rays etc.)
Record of any discussions with the patient or family
After discharge and completing your notes, the card and continuation sheets should be
returned to Reception (via the discharge tray) as quickly as possible. If you need the notes
for your own reference, take a photocopy.
It is essential that the originals are returned to Reception and not left lying around on desks,
in pigeon holes or removed from the department. Our notes are often required by other
departments, the Police or the Coroner.
When notes are missing from Reception it causes enormous problems with patient
safety and also medicolegally and also wastes valuable time for all staff.
If you want original notes for audits, the following is the procedure to be followed:
1. Once you have your list of patients, speak to one of the receptionists to let them know
you intent to pull the notes.
2. Once you have pulled the notes from filing, leave a copy of your sheet with the
reception staff so that they know WHICH notes you have taken out.
3. Only pull the number of notes that you can cover in that session; pulling 50-100 notes
out of the system for weeks is unacceptable. They are a legal and confidential
document of the patient’s attendance and may be required for a complaint or court
case. We therefore have a duty to safeguard this information – do not leave the
notes lying about as they could be read / taken by people who should not have
access to them.
4. Once you have finished your session, replace all the notes you have pulled in the
correct place and let the receptionists know that you have done this.
5. If you have agreed with reception to take notes out for a few days for audit (maximum
one week) find a secure place for them to stay at the end of your day (preferably with
the receptionists) and let them know how many days you will require the notes for
(write this on the copy of the patient list that you give to reception).
Good communication with the local GPs is essential. Bear in mind that although currently we
do not have formal discharge letters for patients in A&E, we do send them a copy of their
patient’s attendance. These A&E notes can also be requested and seen by the patients
themselves.
This emphasizes the need for careful and non-judgmental documentation. Every A&E
department deals with complaints about doctors who have written poor notes or unwise
comments about the patient / their GP in the notes. Do not fall into this trap and stick to the
facts!
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Remember that the A&E notes are a legal document; you (or your colleagues) may be
asked by the Police or Coroner to compile a report at a later date based on your notes. You
are unlikely to remember details, so careful documentation at the time is essential!
It is not acceptable to leave patient’s notes unwritten and doing so will result in
disciplinary action being taken if we find this to be a recurring problem. The
consultants undertake regular spot audits of medical notes to monitor this.
1.13
Investigations
Investigations performed in A&E should be relevant to the patient’s presenting complaint.
Unnecessary investigations drain the finances of the department meaning less money is
available to spend on other aspects of patient care. Seek advice from senior doctors in the
department if you are unsure about the appropriateness of the investigation.
Only ask for X-rays if clinically indicated; no-one should be irradiated for ‘medico-legal’
reasons. You will get better quality films if you state the likely diagnosis on the request form.
There must be adequate clinical information to allow the radiographers to decide the most
appropriate view to take. If in doubt, discuss the case with the radiographers; they can often
suggest the best view or method of imaging to show you what you need to see.
In-patient teams should not be asking you to wait for the results of blood tests prior to
referral. A referral should be made on the basis of clinical judgment; for example, a clinically
obvious appendicitis does not need a white cell count! Additionally, any blood tests
requested by specialty teams which are for in-patient management (such as iron studies,
B12, TFTs etc.) should be ordered under the specialty Consultant’s details rather than the
A&E Consultants. This ensures that the results will go back to the correct in-patient teams.
BMs and urinalysis are important simple investigations which you should not forget to
perform in the relevant patients. All female patients of child-bearing age presenting with
abdominal, GI or GU symptoms should have a urinary ßHCG performed.
As a courtesy to our colleagues in other departments, it is essential that you let them
know if you are sending them either a patient who has a potentially infectious disease
requiring isolation, or a blood sample from a High Risk patient.
1.14
Fighting MRSA
The Department of Health initiative to cut down on the spread of MRSA and other hospital
acquired pathogens has led to the “Saving Lives” care bundles. These state that all patients
receiving an IV cannula or blood culture should have the appropriate procedure followed and
this documented in the notes.
This Trust has specially packaged blood culture kits which contain instructions and all that
you need to perform this procedure safely. You will be taught in its use at the start of your
job; you will NOT be able to take blood cultures in this Trust unless you have had this
training. Please DO NOT take blood cultures with any other pieces of equipment except the
equipment in these packs.
For every cannula you insert and every blood culture you take, please apply the
appropriate sticker to the notes, with the details of the insertion / blood culture filled in.
We are audited on this practice for the DoH, so please remember to do it!
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Let one of the consultants know if you have not had your IV cannulation or blood
culture training when you start your job.
1.15
Hand washing
Another aspect of cutting down the spread of hospital acquired infections is rigorous and
regular hand washing, used in conjunction with taking standard precautions.
Please wash your hands (or gel):
On entering and leaving the clinical areas
Before and after every patient contact
Before and after aseptic procedures
Before handling food or medicines
Before and after glove usage
Before eating
After going to the toilet or toileting patients
The 6 step approach to hand washing and gelling can be found near every sink and gel
dispenser.
Note that alcohol rub is ineffective vs. C difficile, so you must wash your hands after
contact with these patients.
If you have any questions about any aspect of Infection Control in A&E, contact our
Infection Control Specialist Nurses.
Alternatively, look on the intranet under Clinical Policies & Guidelines, Infection
Prevention & Control.
1.16
Blood Transfusion
Below is a summary of Trust Transfusion Policy.
Incorrect patient details on the sample, form, or patient ID leads to 2-3 deaths from blood
transfusion in the UK every year. It is essential that these are checked for accuracy at every
stage of the process. Where possible, seek verbal informed consent for the transfusion from
the patient.
If a blood transfusion is required, request the appropriate units to be cross-matched from the
blood bank after discussion with your seniors. In an emergency, it may be appropriate to use
type specific or O negative if a patient is acutely compromised. However, these need to be
discussed with your seniors and with haematology if necessary.
Any patient requiring more than 6 units of red cells or blood products (such as platelets,
cryoprecipitate or FFP) must be discussed with the Haematologist before ordering the
products from the Blood Bank.
Once the blood is ready for issue, give the porters a Blood Collection Slip and ask them to
bring the correct blood bags from the Blood Bank Issue Fridge. On arrival in A&E, remove
the units one at a time as needed from the blood transportation box. Return the blood to the
Blood Bank immediately if they are not to be used within the next 30 minutes (they expire if
left out in this time).
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O negative blood is always available in the Blood Bank Issue Fridge. Follow the procedure
above (ask the porter to take the request for O neg and the Blood Collection Slip to the Blood
Bank). Ideally, also send a cross-match sample to the lab at the same time for analysis (if
possible).
Essential checks (by two staff members) prior to transfusion:
1. Patient details:
Surname
First name
Hospital number
Date of birth
ON THE
Prescription chart
Compatibility form
Blood bag label
2. Blood bag details:
Blood group
ON THE
Compatibility form
Unit number
Blood bag label
Expiry date and
Blood unit (i.e. the blood group label put on by the
time
Transfusion centre)
If there is any discrepancy in the details contact the transfusion laboratory
immediately.
Once the transfusion is complete, put all the used blood bags into the white plastic bag from
the Blood Bank and return to the Transfusion lab.
If blood is to go with a patient being transferred to another hospital, inform Blood Bank /
Haematology staff and return the units to them. They will then return the appropriate units to
you for transfer specially packaged and with the appropriate documentation.
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1.16.1
Massive Haemorrhage
In the event of a massive haemorrhage (50% volume loss in 3 hours or >150ml loss / min),
alert seniors and the Haematologist immediately (5515 or 5929). Send cross-match sample
(pink top), FBC (purple top) and clotting (blue top) and mark as very urgent.
Follow the flowchart below:
1.16.2
Haemorrhage and Warfarin
If a haemorrhage is secondary to over warfarinisation, alert Haematology immediately. FFP
is mostly used to reverse warfarin haemorrhage, but in life threatening haemorrhage,
Prothrombin Complex Concentrate (PCC) may be used. This can only be issued after
discussion with the Consultant Haematologist.
If the INR is raised but there is no active bleeding, Vitamin K IV or orally can be used (110mg).
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1.17
Registrar duties
Lead shifts: 0800, 1500, 2200.
If you are on the rota to begin your shifts at the above times, you will be expected to lead the
department.
Duties of lead middle grade (LMG):
1.
Take handover from LMG from previous shift of Department and Obs Bay
2.
Ensure every patient has a plan
3.
Attend Consultant Ward Rounds at 07:30 / 08:00 and at 15:00
4.
Update the staff lists for each day on the white board and where possible allocate
each SHO to a middle grade mentor (whom they will ask for advice)
5.
Be aware of patient flow through the department and allocate / reallocate staff
accordingly
6.
Find out from the SHOs their patient plans / decisions for each patient sitting
between 1:30hrs and 2:00hrs of the patient journey and to ensure that they have
referred by 2:00hrs those requiring in-patient investigation / management
7.
Ensure with all other staff that Symphony data is up to date and accurate (accurate
recording of time seen, time referred and DTAs)
8.
Input DTA (decision to admit) times on Symphony where possible on referral to inpatient specialties if the need for admission is obvious
9.
Liaise closely with the nurse in charge for decisions regarding patient management
and transfer
10. Supervise the house officer in Obs Bay (or delegate this appropriately to another
middle grade)
11. Give handover to the LMG for the next lead shift
Additionally:
It is the responsibility of the 08:00 Lead Middle Grade to check the Radiology reports every
day Monday to Friday after the 15:00 ward round and handing over the department to the
15:00 MG. See section Error! Reference source not found. below.
It is also the responsibility of the 08:00 Lead Middle Grade to supervise the completion of
Obs Bay jobs which result from the 08:00 and 15:00 Consultant Ward Rounds.
1.18
Radiology reporting
We have a joint reporting system with Radiology. For every x-ray ordered in the department,
the doctor reviewing the film must type a comment into the PACS system. This initial
impression can be entered into the system by pressing the i button found on the toolbar
when viewing a film. Please mention the disposal of the patient in your report. Press the
“Save” button after data entry is complete.
The Radiologists review all the A&E films and flag up any missed abnormalities on the
Scheduler, which appears as a grid-like icon on the PACS toolbar.
It is the responsibility of the 08:00 Lead Middle Grade to check the Radiology reports every
day Monday to Friday after the 15:00 ward round and handing over the department to the
evening MG. The LMG should check the Scheduler for the x-rays with the missed
abnormalities and document the hospital number and action taken in the Radiology diary
under the appropriate date in the Registrars’ Office.
A copy of the protocol can be found inside the Radiology Diary in the Registrars’ Office.
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1.19
Prescribing
Remember that there are a number of common drugs which are available over the counter
(and are therefore cheaper). Pharmacy will not dispense the following drugs to mobile adults
for that reason:
Piriton
Canesten cream / pessary
Hydrocortisone 1% cream
Ibuprofen
Buscopan
Lactulose
Senna
Loratidine
Paracetamol
Within Pharmacy’s opening hours, fill out a TTA form for the patient and direct them to the
outpatient pharmacy in the main atrium of the hospital. Out-of-hours, the department carries
a number of stock drugs in pre-packs, which can be given to the patient.
Fill out a TTA form, ask the patient to pay for their prescription by using the prescription
payment machine in the waiting room (if they normally pay for prescriptions), then to go to
the Minors nursing station for the pack to be dispensed.
It is important to give the patient information regarding their medications and to answer any
questions they may have; this improves their compliance with treatment. Additionally, there
is a hospital helpline which they can ring for more information (Medicines Information Line
0208 321 5880); make sure the patient knows about this number.
The Trust’s antimicrobial policy can be found on the intranet (under Clinical Policies &
Guidelines, Pharmacy, Clinical Guidelines, Antimicrobial Treatment Guidelines
section). Please refer to it (or the abbreviated version on the wall in the doctors’ room)
before prescribing any antibiotic.
Treatment options for immunosuppressed / chemotherapy patients can also be found on the
intranet under the Clinical Policies & Guidelines, Cancer & Palliative Care, Anti-infective
guidelines for Haematology and cancer patients section.
When patients bring their own medicines into the department, make sure that these stay with
the patient rather than going home with the relatives. Make sure that the patient goes to the
ward with their drugs (please avoid leaving the drugs in the Doctors’ Office in Majors!).
1.20
Observation bay
We have a 6 bedded Observation Bay with additional seating for mobile patients. If you
would like to admit a patient to the Obs Bay under the A&E team, please follow the
procedure below:
1. The patient is deemed as needing a period of observation or is waiting for results
specific to A&E which will aid disposal decision by the assessing doctor.
2. The need for Obs Bay must then be discussed with the Registrar in Charge of Obs
Bay (the morning registrar or the evening registrar) and with the Charge Nurse. This
should be done regardless of whether the assessing doctor is SHO or registrar
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and is so that the Registrar in Charge of Obs Bay is aware of all the patients within
Obs Bay and their plans.
3. The Registrar in Charge of Obs Bay must agree and be shown the plan of action
documented in the notes. The responsibility for doing this belongs to the assessing
doctor.
4. If the plan is not in the notes when the patient moves round to Obs Bay, the doctor
seeing the patient must go round to Obs bay to complete their documentation
(history / examination findings / differential diagnosis / plan / investigations pending
must all be documented) at the earliest opportunity.
5. All doctors must chase up an outstanding investigations / referrals on their own
patients in Obs Bay. During working hours, this can be delegated to the house
officer in Obs Bay if they are on duty. If there are still results outstanding after the
assessing doctor goes off duty then this must be handed over to the Registrar in
Charge of Obs Bay.
6. Each Registrar in Charge of Obs Bay will be responsible for giving a handover of
patients / plans / jobs outstanding to the next Registrar (i.e. 0800 Registrar to
1700 Registrar to 2200 Registrar to 0800 Registrar) in Charge before the end of their
shift.
Robust handovers and frequent updates with the nursing staff are essential to patient safety
and the smooth running in the Obs Bay and it is vital that every doctor follows this protocol.
1.21
Discharging patients from A&E
A few general considerations:
Beware of discharging a patient who is still in pain! Many of the cases discussed in
our morbidity and mortality meetings are the result of doctors making an incorrect
decision to send a patient in pain home
Before discharging a patient, there must be two signs of improvement – one
subjective, and one objective
If the patient has abnormal observations on arrival to A&E, they MUST have a set of
normal observations documented prior to discharge. A patient with abnormal
observations should not be discharged; always discuss with a senior doctor in the
department
Return patients must be seen by a senior doctor prior to discharge
If any doubts exist, observe the patient in Obs Bay and organise a senior review /
reassessment
Make sure patients have adequate analgesia prior to discharge
1.22
Ward Rounds in A&E
An A&E Consultant ward round occurs every morning between 7 and 8am and every
afternoon at 3pm. The lead middle grade for the shift is expected to go on this round along
with the Charge nurse for the department and the Bed Manager. The purpose of the round is
to check that patients in the department have an appropriate management plan in place.
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1.23
A&E review clinics
Currently, an A&E Consultant Review Clinic runs Monday, Tuesday, Wednesday and Friday.
There are limited slots in this review clinic, so all patients being referred there for follow-up
must be discussed with and agreed by a senior doctor. These appointments should be
reserved for follow-up of more complex wounds or soft tissue injuries (note that some of
these can also be seen in the Physio Clinic after prior discussion with the Physios).
Soft tissue injuries (especially where there has been prominent pain or swelling) should not
be brought back the clinic the next day as full assessment will still not be possible. Potential
scaphoid injuries with no x-ray abnormalities on the initial film can be seen in this clinic after
10 days. Obvious fractures should not be seen at this clinic.
1.24
Domestic violence
Many injuries due to domestic violence are originally said to be due to accidents, falls etc.
Let the patient know it is safe to talk about these issues, and encourage them to seek help
from the Community Safety Unit, police, a refuge etc. A list of phone numbers is kept in
reception; alternatively, ask the Senior Nurses for advice. If the patient is willing, we can
pass their details on to the Hounslow Community Safety Unit, who can give and co-ordinate
both practical and emotional support to victims of Domestic Violence. Their service is totally
confidential; they will not involve Police or other agencies without the permission of the client
(unless child protection issues are present, but those are treated as a separate entity – see
below).
If there are children at risk, even if they have not been bought to A&E, you must inform
social services (the Paediatric A&E nurses can help you with this). Take down details of
their names, ages and dates of birth as the information will be logged under the children’s
names and not that of the adult you are seeing.
Always refer to the hospital social work team; they will then pass the case on to the
appropriate community team as necessary. If there are particularly strong concerns,
telephone the hospital’s duty social workers and discuss the case with them directly.
1.25
Adverse Incidents
An adverse incident is any event, omission or circumstance which leads to harm or potential
harm to any patient, visitor or staff member. To learn from the incident and prevent any
future repeat of the situation, accurate information must be gathered and the situation
investigated. These reports often lead to improvements in the service so your input is vital.
If you are involved in or witness such an incident:
Escalate the situation to a senior nurse and doctor immediately.
If you are the senior staff member, assess the immediate situation to determine how
serious the incident is and if it is likely to get worse
Take prompt personal action as far as possible to correct the situation, and/or prevent
things getting worse
Reassure any persons who may be personally involved in the incident
Take careful note of the actual circumstances at the time
After the immediate situation has been dealt with, and regardless of type or
seriousness of the incident, the incident reporting arrangements need to be followed
for all adverse incidents.
“Datix” forms (incident forms) must be filled out for every incident which occurs.
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You can access Datix forms from every PC in the department:
Open Internet Explorer browser to access the Trust intranet
Go to the menu bar and click on “Favourites”
In the drop down that appears, highlight the “West Mid” folder and click on the “Datix
Incident Form” link
All Datix forms submitted are reviewed on a weekly basis and the incidents are thoroughly
investigated by senior staff in the department. More information regarding Adverse Incidents
can be found in the Trust policy (Intranet, under Non-clinical Policies & Guidelines,
General, Adverse Incident Policy).
One area where historically we have under-reported incidents is sharps injury incidents, so
please remember to fill out forms after each occasion. Refer to the Sharps Injury Section
of the A&E guidelines for more details.
1.26
Do Not Attempt Resuscitation orders
Sometimes, it is inappropriate to attempt resuscitation on a patient due to their comorbidities
and / or age. They may also have an advanced directive or have voiced their wishes to staff
or family.
Involve a senior person early if your patient fits the above criteria and discuss resuscitation
with your patient if possible. If not possible, talk to the family or patient’s representative
about the options.
Do Not Attempt Resuscitation orders can be found in the department and must be signed by
two doctors looking after the patient. (See Appendix Section).
1.27
Death in the department
We often run Cardiac Arrest calls “in-house” during the day when staffing levels are
adequate to cover the departmental needs. It is the ideal opportunity to gain experience in
resuscitation with the supervision of your senior colleagues. The Nurse-in-Charge will often
put out a call following discussion with a senior doctor.
Do not certify death in the back of an ambulance unless it is very obvious. Continue CPR in
any patient when it has been started by the ambulance crew, or if accompanied by relatives.
Please ensure that a Cardiac Arrest Call Record Form is filled out for EVERY cardiac
arrest in the department. They can be found on every arrest trolley in the Trust.
After death is certified:
Inform the relatives (take an experienced nurse with you)
Inform the Coroner (the nursing staff will help with this)
Telephone the GP if possible
Involve the hospital chaplaincy team if the relatives would like extra support
ET tubes and IV lines can be removed if there is no suggestion that the death was due to
violent or suspicious causes.
Careful documentation is essential in all these cases, as the Police or Coroner is often
involved.
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Avoid giving out news of the death over the telephone if at all possible. Involve the Police to
track down family or relatives if the patient comes to the department unaccompanied.
1.27.1
Death of patients under 18 years
Note that ALL deaths of children under 18 must be reported to the Child Protection team,
irrespective of the cause of death. Speak to the Paeds A&E team for more details.
1.27.2
Organ or tissue donation
Any patient who becomes brainstem dead and in whom the decision to withdraw treatment
has been made by ITU may be eligible for organ donation. Exclusions from this are those
with known HIV or CJD (or family history of CJD). Those in whom the manner of death
prevents organ donation may still be considered for tissue donation.
Speak to the ITU team (and Medical Team if they are involved) regarding this and if seniors
in all teams are in agreement, then the Transplant Co-ordinator should be rung (PAGER
NUMBER 07659 100103 – this is a 24 hour service).
Below is a summary of the two pathways at this Trust.
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1.27.3
Summary of Organ donation pathway
Sedation and analgesia has been
stopped, patient has fixed and dilated
pupils with NO neurosurgical
interventions indicated
Donor transplant coordinator
attends the unit, plan discussed
and agreed with the medical and
nursing staff
Normal homeostasis
maintained with fluids and
inotropes as needed
Case discussed with the on
call Donor Transplant
Coordinator DTC
Pager 07659 100103
BSD testing explained to the family
by the doctor and coordinator
BSD tests undertaken
DONATION NOT TO BE
DISCUSSED AT THIS TIME.
BSD confirmed
Relatives are informed of the
results of BSD
Family given time to accept the
diagnosis
Yes
No
Options 1 - Retest
2 - Withdraw treatment –
consider NHB donation
When it is clear that the relatives have understood that
the death has occurred the donor coordinator discuss
the possibility of organ donation
Organ Donation agreed
The DCT will organise
-
-
No Organ Donation
DCT and ICU staff to organise
Donor coordinator to work with staff for optimal
donor care
Lack of objection and patient assessment
completed with the family, hand prints and hair
locks offered
Physiological examination and bloods for virology
& tissue typing taken
Retrieval teams and theatres arranged
Organ retrieval operation
Last offices performed
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-
Family thanked for
considering donation
Hand prints and hair locks
offered
Support withdrawn
Last offices performed
West Middlesex Emergency Department Handbook
1.27.4
Summary of Tissue donation pathway
Consideration of Non–Heart Beating Donation (NHBD)
Is the patient less than 80 years old?
Does the patient have a catastrophic neurosurgical injury
or
other unsurvivable injury?
and
the decision made to withdraw treatment?
Refer to the Transplant coordinator
PAGER 07659 100103
Suitable for NHBD
Unsuitable for NHBD
Transplant Coordinator attends the department
Treatment withdrawn
Follow LCP
Staff discuss withdrawal of treatment when family
accepting end of life care, organ donation discussed
by the transplant coordinator
No Consent
Consider Tissue donation
See Tissue flow Chart
Treatment withdrawn
Follow LCP
Consent
Contact made with coroner to
gain permission for donation
Consent obtained and
donor assessment
performed
Blood taken for tissue typing and Virology
Transplant teams mobilised
Treatment withdrawn at the negotiated time – use LCP
Following asystole, there is a 5 minute
period when the family can say their
goodbyes. As per ICS guidelines.
Donation takes place
Flow chart to be used in conjunction with the LCP and
the trust policy for consideration of organ donation
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1.28
Police and police statements
The police are not entitled to medical information without the patient’s written consent. They
should never be shown the A&E cards. You may let them interview patients if there is no
medical contra-indication.
If the police want information without consent they need to approach a senior doctor. Blood
samples for legal purposes should be taken with your permission by the police surgeon.
Samples of forensic interest e.g. fragments of glass from wounds etc. should be put into a
labelled container to be given to the Coroners officer/police.
You will be asked to provide written statements for the police in cases of assault (you will find
these requests in your pigeon holes). This is for use in Court; ask a senior doctor to show
you how the first time you do this. Julia (our secretary) also has written guidelines for writing
these. You will be paid a fee, so you will not be covered for this by the hospitals insurance –
your MDU/MPS subscription will cover you.
These statements must be written and returned to Julia promptly.
1.29
Major Incident Plan
A Major Incident (MI) is any incident, either internal or external, which is expected to exceed
the normal working capacity of the emergency services / hospital. A copy of the Trust’s MI
policy can be found on the intranet under “Non-Clinical Policies & Guidelines, Major
Incident Plan”.
Declaration of a Major Incident should come from LAS via Switchboard. On occasion, LAS
may ring A&E directly through the Blue Call Phone; if this happens, redirect them to
Switchboard. Switchboard will then commence their call out procedure. We will either be
told that we have a “Major Incident Stand by” or “Major Incident Declared”.
Major Incident Standby:
Set up the Control Room (AD for A&E or on-call AD, Medical Consultant, Site
Manager, Senior Logist) – AD on call will do this.
Out-of-hours, ensure on call A&E Consultant is aware and coming in
A&E will stop seeing new patients. All non major incident patients will be triaged:
o Walking patients will be sent to Teddington Memorial Hospital
o Assess / treat new non major incident patients arriving by ambulance as
appropriate
o Start clearing Minors patients
o Assess and clear Majors patients to Specialties / discharge as appropriate
o Start calling in staff and generally prepare the area to receive casualties
Information we need from LAS:
Type of incident
Location ( if known)
Type and estimated number of casualties
Request for medical incident officer ( if needed)
Request for mobile team (if needed)
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Preparing A&E:
Immediately liaise with Nurse in Charge of A&E
Most senior A&E doctor to take the role of A&E Consultant until A&E Consultant
arrives
Unlock the MI cupboard (in the corridor opposite Obs Bay after the back door to
Minors)
Pull out the MI trolley and distribute Action Cards to appropriate staff
Start clearing the department as described above
Start preparing staff and equipment for a Walking Wounded area (P3) in OPD 3 as
per MI Plan.
Further execution of the MI Plan is not necessary unless you receive the message “Major
Incident Declared” by LAS via Switchboard.
If you receive the instruction “Major Incident Declared” immediately execute the
actions on your Action Cards.
Ending a Major Incident:
A Major Incident can only be brought to a close by the Control Room. Confirm all
external messages with them.
Be aware of the terminology:
o “Major Incident Cancelled” = Hospital can stand down and return to normal
business. This message can only come from the Control Room.
o “Major Incident Stand Down” = LAS have cleared the site of the incident;
however, the hospital CANNOT stand down until told to do so (as the
casualties may be about to arrive at the hospital) via the Control Room.
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2
Management of Acute Pain
The acute pain service (APS) is managed by Dr Kadry (Consultant Anaesthetist), an Acute
Pain Nurse and covered 24 hours by on call SHO anaesthetist. This guidance is based on a
summary of their guidelines on the intranet.
Contact numbers:
Office ext. number is 6038.
Acute pain nurse (bleep 037) or on call anaesthetist (bleep 181)
The APS can give advice on the management of acute pain and acute on chronic pain (note
that chronic pain referrals need to be sent to Charing Cross via their GP). Palliative Care
services can give advice for patients with malignant disease.
2.1
2.2
2.3
2.3.1
2.3.2
Misconceptions about pain
Staff believe that they, rather than the patient, are the authority on the patient’s pain
Pain can not be prevented
Patients will become addicted
Side effects of analgesics cannot be controlled
Opioids must not be given more than 4 hourly
The same condition produces comparable severity of pain in different people
Pain assessment
Pain must be assessed regularly by asking the patient. Pain can not be assessed
accurately by observers
Believe the patient (pain is the patient’s own experience)
Ask them to rank their pain on a scale from 0-10 and document this on the cas card
Ask the patient to assess their pain on movement (e.g. deep breathing, coughing)
Analgesics recommended by APS
Paracetamol
Use for mild pain
Dose: 1g qds
Side effects : Only hepatic damage in overdose
Codydramol / cocodamol
Use for mild to moderate pain
Dose : x2 qds
Side effects : Constipation, nausea and vomiting and drowsiness (treat with antemetics and laxatives DO NOT WITHDRAW ANALGESIA)
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2.3.3
NSAIDs
Use with compound analgesia / paracetamol. Not recommended for >65s due to the
risk of side effects
Dose DICLOFENAC 50mg tds or IBUPROFEN 400mg tds. Give regularly and review
after 3 days.
Stop immediately if patient shows signs of side effects.
NB. NSAIDs should NOT be given to patients with:
Poor renal function
History of G.I ulceration, bleeding, Crohn’s disease or gastritis
Abnormal coagulation or thrombocytopenia
Congestive heart failure
Hepatic impairment
Asthma with known sensitivity to Aspirin or any NSAIDs
Known hypersensitive reactions e.g. urticaria, angio-oedema, acute rhinitis
Pregnancy and breast feeding
Patients using concomitant medications known to increase likelihood of
gastrointestinal (GI) adverse events (e.g. corticosteroids, anticoagulants)
Note: All NSAIDs can cause side effects and they should only be prescribed when there is a
demonstrable clinical need and they should only be used for the type of conditions that they
are licensed for.
2.3.4
2.3.5
Tramadol
Use for moderate pain
Dose: 50-100mg qds with paracetamol 1g qds
Side effects: Has reduced incidence of respiratory depression and constipation. Can
cause more nausea and vomiting and may cause confusion
Opioids
Use for moderate to severe pain with NSAIDs / paracetamol
Drug of choice: Morphine IM, IV or orally (see below)
(Pethidine is no longer recommended due to short half-life, it is no safer than morphine and
risk of toxicity from metabolite norpethidine in high doses, no advantage in pancreatitis)
2.4
Guidelines for administration of all opioids via any route
All patients must have 4 hourly (if stable) pain score, sedation score, respiratory rate
and blood pressure recorded if on opioids
All patients must have an anti-emetic prescribed PRN
Patients over 60 years old must have oxygen prescribed
Do not give other sedatives with opioids
If sedation score (CNS) is 0 or 1, respiratory rate<10 or BP<90mmHg stop all
opioids and review in 15 mins
If sedation score (CNS) is >1, respiratory rate <8 or BP<90mmHg stop all opioids,
try to waken patient, administer oxygen, call for help from seniors (may need to
consider naloxone)
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2.5
2.5.1
Guidelines for intramuscular opioid
Morphine dose: age <70 years
o
o
2.5.2
Over 65kg – up to10mg
Up to 65kg – up to 7.5mg
Morphine dose: age >70 years
o
o
Over 65kg – up to 7.5mg
Up to 65kg – up to 5mg
Frequency: every 2 hours providing that:
Pain score 2 or 3
Sedation score is 0 or 1
Systolic BP >100mmHg
Resp rate >10/min
Management of pain
Pain score mild/no pain consider change to oral analgesia
Pain score moderate-severe repeat morphine dose 2 hourly for up to 3 doses and
regular NSAID/paracetamol
Pain score still remains moderate-severe call APS
Contraindications and side effects:
Liver disease and renal impairment (action of opioids is prolonged)
Causes respiratory depression which may further elevate intracranial pressure for
patients with head injury
Hypotension may be aggravated
Nausea and vomiting (treat with anti-emetics)
Urinary retention
Sedation
Dependence is not likely to occur when used appropriately for the treatment of acute
pain
Slowing of gastric emptying and GI motility
2.6
2.6.1
2.6.2
Guidelines for intravenous paracetamol
Indications for use
Acute pain problems not amenable to alternative analgesics, and where other
routes of administration are not possible (i.e. exceptional circumstances where
oral or PR route not possible / appropriate) and only as advised by the Acute Pain
Team or Consultant / Senior Staff in Anaesthetics or A&E
Hyperthermia
Prescribing guidelines
All prescriptions must be written by the Pain Team or by a Consultant / Associate
Specialist in Anaesthetics or A&E, or by a doctor advised accordingly by a Consultant
/ Associate Specialist in those specialties.
A length of treatment must be indicated e.g. STAT, 2 doses, 24 hours to a usual
MAXIMUM OF 48 HOURS.
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Patients on regular paracetamol IV must not have any other prescription for
paracetamol via another route. Paracetamol containing agents such as co-dydramol
must not be prescribed at the same time.
If multiple routes of administration are suggested by the prescriber writing ‘IV/PO/PR’
then other routes should be possible, and IV paracetamol will not be administered
against the prescription.
IV paracetamol should not be prescribed if other routes of administration are
available (i.e. oral, rectal, nasogastric, PEG) unless there are exceptional
circumstances where a consultant feels there is essential clinical need and
substantial benefit. This may on occasion include other non-surgical patient groups.
2.6.3
Dose
Adult / child >50kg:
1g in 100ml (1 vial). Maximum of FOUR times in 24 hours.
Maximum total daily dose of paracetamol by any route is 4g/24 hours.
Adult / child 25-50kg: 15mg/kg every 4-6 hours, max 60 mg/kg daily.
Infuse the calculated dose over 15 minutes.
2.7
2.7.1
Other methods of treating acute pain
Patient Controlled Analgesia (PCA)
PCAs can be set up for patients that are having regular IM injections of an opioid and NBM.
An IV loading dose needs to be given to establish analgesia before PCA is started. The
system has a lockout period built into it to allow the patient to re-assess their pain before
administering a further dose.
The safety mechanism of the pump is that the patient MUST be the only person to press the
button so if they become sedated they will not be able to press the button and overdose.
Advantages: Patients experience less anxiety and discomfort. The delay associated with
nurse administered IM analgesia does not occur
Disadvantages: Potential for malfunction and user error. Continuous training of staff is
essential. Needs patient co-operation.
2.7.2
Inhalation analgesia
Entonox (50% nitrous oxide and 50% oxygen) may be useful during short periods of pain
(e.g. during procedures or removal of drains/dressings). It cannot be used continuously
because nitrous oxide causes bone marrow depression.
2.7.3
Local anaesthesia
Action: Blocks transmission of nerve impulses
Advantages: Profound analgesia without opioid-like side effects
Disadvantages: Local anaesthetics are toxic in large quantities and short duration of action.
Some techniques are time-consuming and require specialist skills.
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2.7.4
Epidural analgesia (only used in wards with specialist training)
A catheter can be left in place in the epidural space post-operatively. A combination of
continuous local anaesthetic and opioid is used.
Advantages: Excellent analgesia allowing early mobilisation. Reduction in stress response
and post-operative complications. A reduction of opioid-like side effects has been shown.
Disadvantages: Hypotension (usually related to hypovolaemia). Risk of epidural abscess,
haematoma or nerve damage (very rare).
2.7.5
Complementary therapies (to be used with analgesics)
Reassurance
Education / Information
Relaxation
Distraction
Application of heat or cold
Massage
Exercise or Immobilisation
Transcutaneous Electrical Nerve Stimulation (T.E.N.S.)
Acupuncture
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3
3.1
Medical Emergencies
Adult advanced life support
The following is summarised from the Resus Council Guidelines (2005).
The ALS algorithm can be found at http://www.resus.org.uk/pages/als.pdf
In this Trust, the defibs are mainly BIPHASIC (all A&E ones are biphasic except for the defib
in the corridor outside Paeds A&E and the one in Obs Bay) in acute areas. This guideline
assumes a biphasic machine is being used.
The energies for defibrillation are 200J, 200J, 360J (with 360J for 4th and all subsequent
shocks) for our biphasic machines. If using a monophasic machine, use 360J for all shocks.
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3.1.1
3.1.2
Defibrillation strategy
Treat VF/ pulseless VT with a single shock (200J) followed by immediate
resumption of CPR (30 compressions to 2 ventilations).
Do not reassess the rhythm or feel for a pulse. After 2 min of CPR, check the rhythm
and give another shock (200J) if indicated.
Third and subsequent shocks are given at 360J.
If there is doubt about whether the rhythm is asystole or fine VF, do NOT attempt
defibrillation; instead, continue chest compression and ventilation.
Adrenaline (epinephrine)
VF / VT:
For VF / VT, give adrenaline 1 mg IV if VF/VT persists after a second shock.
The adrenaline should be given just prior to the third shock (drug–shock–CPR–
rhythm check sequence)
Repeat the adrenaline every 3-5 min thereafter if VF/VT persists.
Pulseless electrical activity / asystole:
For PEA / asystole, give adrenaline 1 mg IV as soon as IV access is achieved and
repeat every 3-5 min.
3.1.3
3.1.4
3.2
Anti-arrhythmic drugs
If VF/VT persists after three shocks, give amiodarone 300 mg IV bolus injection.
A further dose of 150 mg may be given for recurrent or refractory VF/VT, followed
by an infusion of 900 mg over 24 h.
If amiodarone is not available, lidocaine 1 mg/kg may be used as an alternative, but
do not give lidocaine if amiodarone has already been given. Do not exceed a
total dose of 3 mg kg-1 during the first hour.
Post resuscitation care – therapeutic hypothermia
Unconscious adult patients with spontaneous circulation after out-of-hospital VF
cardiac arrest should be cooled to 32-34°C for 12-24 h.
Mild hypothermia may also benefit unconscious patients with spontaneous circulation
after out-of-hospital cardiac arrest due to a non-shockable rhythm, or after cardiac
arrest in hospital.
Acute management of peri-arrest arrhythmias
The ALS guidance on peri-arrest arrhythmias can be found below:
http://www.resus.org.uk/pages/periarst.pdf
3.2.1
General management
For every patient presenting with an arrhythmia, the following apply:
Give oxygen
Insert IV cannula
Perform rapid 12 lead ECG to diagnose rhythm; a rhythm strip may also be useful
Look for adverse signs
Correct any reversible causes (e.g. electrolyte imbalances)
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3.2.2
Adverse signs
The presence of any of the following signs should trigger immediate treatment decisions.
The patient should be moved into resus if not already there.
Pallor, sweating, cold, clammy extremities
Impaired consciousness
Hypotension, systolic <90mmHg
Chest pain
Heart failure
3.2.3
Treatment options
Once the rhythm and the absence / presence of adverse signs have been established, the
following broad treatment options should be considered:
Anti-arrhythmic (and other) drugs
Electrical cardioversion
Cardiac pacing
In general terms, electrical cardioversion is more appropriate when adverse signs are
present and drug therapy is more appropriate when adverse signs are absent.
3.3
Synchronised electrical cardioversion
In this department, synchronised electrical cardioversions are carried out at 100J, 200J
then 360J. These energies are used for both biphasic and monophasic machines for any
tachyarrhythmia where cardioversion is appropriate, unless advised otherwise by a
Cardiologist.
3.4
Bradyarrhythmias
Absolute bradycardia is a heart rate of <40/min. However, there are also times when the
heart rate may be higher than this but is still inappropriately slow for the patient.
3.4.1
Adverse signs
Systolic blood pressure < 90 mm Hg
Heart rate < 40 beats/min
Ventricular arrhythmias requiring suppression
Heart failure
If adverse signs are absent, determine risk of asystole. The following increase risk of
asystole:
Recent asystole
Möbitz type II AV block
Complete (3rd degree) heart block (especially with broad QRS or HR <40)
Ventricular standstill > 3 sec
3.4.2
Management
If the patient has adverse signs or risk of asystole:
Atropine 500mcg every 3-5 mins up to 3mg max
Adrenaline 2-10 mcg/min
Transcutaneous pacing whilst preparing for transvenous pacing
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Consider intravenous glucagon if beta blockers or calcium channel blockers could be the
cause of the bradycardia. Complete heart block with a narrow QRS is not an absolute
indication for pacing because atrioventricular junctional ectopic pacemakers (producing a
narrow QRS) may provide a reasonable and stable heart rate.
The following diagram summarises the above guidance.
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3.5
Tachyarrhythmias
In structurally normal hearts, serious signs and symptoms are unlikely below a rate of
150bpm. However, patients with heart disease or other co-morbidities may be unstable
below this rate.
3.5.1
Tachyarrhythmia with adverse signs
Adverse signs:
Systolic blood pressure < 90 mm Hg
Chest pain
Heart failure
Reduced GCS
If adverse signs are present, attempt immediate synchronised electrical cardioversion,
with sedation if the patient is awake.
If this is unsuccessful and the patient continues to be unstable, give amiodarone 300mg IV
over 10-20mins and reattempt cardioversion following this.
3.5.2
Tachyarrhythmia without adverse signs
If adverse signs are absent, determine whether the QRS is broad or narrow and whether the
rhythm is regular or irregular.
3.5.2.1 Regular broad-complex tachycardia
Usually a VT or a supraventricular rhythm with bundle branch block.
Treat VT with amiodarone 300 mg IV over 20-60 minutes, followed by an infusion of 900
mg over 24 h.
If the rhythm is identified as an SVT with bundle branch block and the patient is stable, treat
as per narrow-complex tachycardia (below).
3.5.2.2 Irregular broad-complex tachycardia
Usually atrial fibrillation (AF) with bundle branch block, but needs careful examination of the
12-lead ECG (see AF section below for treatment).
Other possible causes are AF with ventricular preexcitation in WPW or
polymorphic VT (e.g. Torsade de Pointes), but polymorphic VT is unlikely to be present
without adverse features.
Treat Torsade de Pointes VT with magnesium sulphate 2 g IV over 10 min and stopping
all drugs known to prolong the QT interval. Correct electrolyte abnormalities, especially
hypokalaemia. Refer urgently to Cardiology as other treatment (e.g. overdrive pacing) may
be necessary.
If adverse features develop, which is common, arrange immediate synchronised DC
cardioversion. If the patient becomes pulseless, attempt defibrillation immediately (cardiac
arrest algorithm).
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3.5.2.3 Regular narrow-complex tachycardia
Regular narrow-complex tachycardias include:
Sinus tachycardia
AV nodal re-entry tachycardia (AVNRT) – the commonest type of regular narrowcomplex tachyarrhythmia
AV re-entry tachycardia (AVRT) – due to WPW syndrome
Atrial flutter with regular AV conduction (usually 2:1)
With sinus tachycardia, it is a physiological response. Treat the underlying cause.
Treatment of AVNRT and AVRT (paroxysmal SVT) without adverse features:
Vagal manoeuvres whilst recording an ECG
If unsuccessful, give adenosine 6mg rapid IV bolus. Follow this with 12mg bolus
IV if no response. A further 12mg bolus can be given following if sinus not restored.
If these measures are unsuccessful it is likely that the underlying rhythm is not an
SVT but an atrial flutter
If adenosine is contraindicated or ineffective and the rhythm is definitely an SVT,
consider a calcium channel blocker e.g. verapamil 2.5-5 mg IV over 2 min
If the patient reverts to sinus rhythm and is suitable for discharge, they should be
given a copy of their ECGs with their presenting arrhythmia and their normal rhythms
to carry in case of presentation to another hospital.
3.5.2.4 Irregular narrow-complex tachycardia
Below is a summary of ALS guidance. See also section 3.7 for further guidance.
Most likely to be AF with an uncontrolled ventricular response or, less commonly, atrial flutter
with variable AV block.
If there are no adverse features, treatment options include:
Rate control by drug therapy
Rhythm control using drugs to encourage chemical cardioversion
Rhythm control by electrical cardioversion
Treatment to prevent complications (e.g. Anticoagulation).
Seek expert help if any patient with AF is known or found to have ventricular
preexcitation (WPW syndrome). Avoid using adenosine, diltiazem, verapamil, or
digoxin in patients with pre-excited AF or atrial flutter as these drugs block the AV
node and cause a relative increase in pre-excitation.
The guidance is summarised below.
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Adult tachycardia with a pulse algorithm:
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3.6
AF
Below is a summary of the NICE guidance.
Record a 12-lead ECG to identify the rhythm if AF is suspected, especially in patients
presenting with:
Breathlessness / dyspnoea
Palpitations
Syncope / dizziness
Chest discomfort
Stroke / TIA
3.6.1
Treatment decision tree
Patients unsuitable for cardioversion include those with:
Contraindications to anticoagulation
Structural heart disease (e.g. large left atrium >5.5 cm, mitral stenosis) that precludes
maintenance of sinus rhythm
Long duration of AF (usually >12 months)
Multiple failed attempts at cardioversion and / or relapses
Ongoing but reversible cause of AF (e.g. thyrotoxicosis)
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3.6.2
Rhythm control of AF without adverse signs
If the duration of AF is <48 h:
Give flecainide 2 mg/kg over 10–30 minutes, max. 150 mg by slow IV or propafenone in
the absence of structural heart disease (coronary artery disease or LV dysfunction).
Give amiodarone 300 mg IV over 20-60 min followed by 900 mg over 24 h if structural
heart disease present.
If the duration of AF is >48h:
Consider elective electrical cardioversion as the preferred initial management.
Patient needs full anticoagulation (warfarin, INR 2-3) for at least three weeks prior, unless
transoesophageal echocardiography has shown the absence of atrial thrombus. Treatment
with sotalol or amiodarone for at least four weeks prior increases the chances of a successful
cardioversion.
A summary of the cardioversion options for AF are found below.
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3.6.3
Rate control of AF without adverse signs
Give beta-blockers orally as initial therapy in all patients.
Digoxin should only be considered as monotherapy in predominately sedentary patients or if
beta blockers are contraindicated. It may also be helpful in those with CCF; discuss with
Medical Team on-call.
3.7
Chest pain
The following is based on local agreed guidance with our Consultants in Cardiology.
3.7.1
Assessment of Chest pain patients
These patients require rapid assessment of ABC with a 12 lead ECG within 10 minutes of
arrival to the department.
If the ECG clearly demonstrates ST elevation with a history consistent with STEMI
(STEACS) follow the primary angioplasty protocol.
Contact Hammersmith with details of the patient and ECG
Contact LAS for a critical transfer
Phone numbers are on the wall in resus and the doctors’ office.
A careful history and examination is vitally important, as is accurate interpretation of the
ECG.
In the department, we use the “triple” test to help risk stratify patients with possible ACS (see
sections 3.7.5 and 3.7.7). This test uses a combination of myoglobin, CK-MB mass and
cardiac troponin I. See section 3.7.2 for further information on the use of the test and the
machine.
The test enables you to avoid admissions for 12 hour troponins in the low to low /
moderate risk group. See section 3.7.3 for a guide to interpreting the results.
The 90 minute protocol used is as sensitive as a 12 hour troponin for ruling out
myocardial necrosis for low to low moderate risk groups. Please do not perform a 12
hour troponin on these patients.
Higher risk patients should still be admitted for a 12 hour troponin and further
management (such as consideration of an in-patient ETT).
The triple marker must be used in the appropriate clinical context (i.e. in a patient where
the concern is that they are having chest pain from ischaemic heart disease) as myoglobin /
CK-MB may be raised in certain chronic conditions and in trauma etc. as so must be
interpreted carefully within these patient groups. See section 3.7.4 for further information.
However, be aware that ACS in certain types of patients may not present with “typical” chest
pain (women, diabetics, elderly etc). In the young, consider possible cocaine use.
Do not use our triple test to indiscriminately “rule out” a cardiac cause in patients with vague,
syncopal / collapse symptoms unless your history points to a cardiac cause as being most
likely. Recent audits in the department have shown that the rate of true positives is very low
at <1%.
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Remember the assessment of the chest pain patient is not easy! These guidelines will help
you decide which patients should be admitted and discharged but if in doubt always
discuss with your seniors!
3.7.2
Guidelines for use of the Biosite machine
Only use the machine if you have received training and allocated a Bar code
Allowing others to use your code will result in your code being blocked
If the blood sample is incorrectly handled and there is an incorrect reading you will be
held responsible. Be aware that rough sample handling can lead to false
positives.
Discuss the appropriateness of performing the test with a senior doctor first
Do not also send blood for lab CK-MB, myoglobin or troponin as this is
inappropriate use of resources
The patient’s ID number must be entered into machine (letter can be omitted); do not
input a random number
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3.7.3
Interpretation of Triple marker results
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3.7.4
Alteration of cardiac markers in various conditions
3.7.4.1 Myoglobin
Myoglobin may be increased in the following conditions:
AMI
Open heart surgery
Angina
Cardiomyopathy
Exhaustive exercise
Skeletal muscle damage
Patients & genetic carriers of progressive muscular dystrophy
Shock (electric)
Severe renal failure
Following intramuscular injections (variable)
Grand Mal seizures
Arterial thrombosis
Rhabdomyolysis
Congestive heart failure with AMI
Myoglobin remains normal in the following conditions:
Healthy adults
Chest pain without AMI
Cardiac catheterisation
Moderate exercise
3.7.4.2 CK-MB (creatine kinase-myocardial bands isoforms)
CK-MB may be increased in the following conditions:
AMI
Unstable angina pectoris
Inflammatory heart disease
Pericarditis
Congestive heart failure
Arrhythmia (chronic A-fib) and tachycardia
Crushing chest injuries
Defibrillation / CPR
Pulmonary emboli
Open heart surgery
Coronary artery bypass grafting
Valve replacement
Coronary angioplasty with complications
Directional atherectomy
Carbon monoxide poisoning
Malignancy
Hyperthyroidism
Malignant hyperthermia
Rocky mountain spotted fever
Normal children
Acute skeletal muscle injury (accidents, trauma, extreme exercise)
Severe burns
Chronic skeletal muscle injury
Polymyositis (inflammation of muscle tissue)
Cocaine use
Reye’s syndrome
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3.7.4.3 Troponin I
Troponin I may be increased in the following conditions:
AMI
Minor myocardial necrosis (grey zone or small positive)
Myocarditis
Myocardial contusion
Scleroderma heart disease
Coronary artery bypass grafting
Perioperative AMI
Congestive heart failure
Sometimes, Troponin I may be elevated in the following conditions:
Sepsis
Pulmonary embolism
Neoplasms
Rhabdomyolysis
Renal failure / dialysis
Drug induced
Extreme exercise (marathon runners)
In these situations, the delta rise (or lack of a delta rise) together with the clinical picture will
help you decide whether the elevated Trop I is due to a cardiac cause. However, bear in
mind that an elevated troponin I from any cause is associated in increased mortality.
3.7.5
Guide to further management
Refer to the ACS clerking proforma (see section 3.7.8) for appropriate management of all
ACS patients in the department. Give oxygen, aspirin, clopidogrel, clexane, GTN and
opiates as required.
If there is ST segment elevation on the 12 lead ECG and a history that is consistent
with acute myocardial infarction then patients should be immediately transferred to
the Hammersmith Hospital for primary angioplasty.
If there is no ST segment elevation on 12 lead ECG, the 90-120 minute protocol may be
used to rule in / rule out. Patients with positive triple tests should be immediately discussed
with the Medical team and discussed with Hammersmith Hospital if clinically appropriate.
If LBBB is present, the triple test may be used to rule in / out myocardial infarction. If test is
positive, send for primary angioplasty. If test is negative then risk stratification is required.
Only one test is required if worst symptoms were more than 12 hours ago.
If only myoglobin is raised on the first test, a further test at 120 minutes is required.
When referring patients to the on-call team, completing a TIMI score (found in the ACS
protocol and below) is helpful for risk stratification of the patient.
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Patients with a negative triple test should also undergo risk stratification as outlined in the
next section to determine the appropriate management.
If the patient is to be discharged, a minimum of TWO ECGS must be performed to ensure
no significant changes.
3.7.6
Summary of Chest Pain Management
ST-elevation myocardial infarction
Refer directly / transfer to Hammersmith hospital via A&E. The director of the “Heart Attack
Treatment Centre” has instructed his SpRs that they cannot refuse a referral of a patient who
may need urgent coronary intervention.
Non-ST elevation myocardial infarction or unstable angina
Treat as per ACS pathway. To remain an inpatient until coronary angiography can be
arranged.
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Non-ST elevation myocardial infarction or unstable angina, with continuing chest pain
and evolving ECG changes or episodes of pulmonary oedema despite treatment
Transfer to Hammersmith hospital. The director of the “Heart Attack Treatment Centre” has
instructed his SpRs that they cannot refuse a referral of a patient who may need urgent
coronary intervention.
Chest pain at rest or on minimal exertion, clinically atypical for unstable angina
Discuss all grey cases with seniors in the department. If the history is suggestive of ACS,
refer to Medicine for 12 hour troponin and further evaluation. The patient could be
discharged following a 12 hour troponin if they fit the following criteria:
Pain free since admission with negative 12 hour troponin and
Normal (or unchanging) ECG on admission and at 12 hours and
ECG during chest pain normal or with no new ST-T changes and
No signs of heart failure and
No suspicion of pulmonary embolism or of aortic dissection
These patients must be referred to Cardiology either directly (by in-patient team) or
via their GP to RACPC.
Exertional angina pectoris
Does not warrant admission. However the minimum standard of treatment should be:
Aspirin (Clopidogrel could be given in place of aspirin in case of allergy)
Statin
Initiation or escalation of anti-anginal therapy (assuming no drug intolerances)
Referral to RACPC via GP
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3.7.7
Risk Stratification for Triple test negative patients
Make sure you have thought about and excluded other causes for chest pain, such as
dissection of the aorta, pulmonary causes and cocaine usage.
The management of patients with a negative triple test is outlined below. Our referral form
for Rapid Access Chest Pain Clinic (see Appendix) uses the Duke Clinical Prediction
Score to risk stratify patients as follows:
CHEST PAIN DETAILS Is this anginal pain? (Please all that apply)
1
2
3
4
5
6
Precipitated by exercise
Brief duration (2 - 15 min)
Relieved promptly by rest or GTN
Central chest location
Radiating to jaw, neck or L arm (possibly right arm)
Other causes for chest pain excluded
If only one
If any two
If any four,
or criteria 1,2&3
Classification
Non-Anginal pain
Probability of CHD
Usually < 30%
depends on Risk Factors
Chest pain ?cause
30-70%
Typical Angina
> 70%
Low Risk of CHD (<30%) : Refer back to GP with advice and Chest Pain Standard Letter (Doctors’ Office, A&E Majors).
Medium Risk (30-70%) : Suitable for RACPC on GTN/Aspirin with advice if symptoms stable and no contraindications.
High Risk (>70%) : Refer to On-call Medical team for further evaluation / treatment. Consider ACS protocol.
RACPC contraindicated (please refer to on-call Medical team) if any of the following are present:
1. Unable to walk up 1 flight of stairs at normal pace or similar activity without pain (marked limitation of normal
activity)
2. Rest pain >15 minutes or rapidly worsening symptoms <2 weeks duration
3. Positive troponin I or dynamic ECG changes
4. CABG / angioplasty / stent in the last year with anginal pain
5. Severe heart failure
3.7.7.1 High Risk patients
If the patient is classified as high risk as above based on their clinical / ECG findings they
should be referred for admission regardless of the test being negative. This has been
fully agreed with and supported by our Consultant Cardiologists.
3.7.7.2 Medium Risk patients
Patients may be discharged with follow-up in Rapid Access Chest Pain Clinic if they have
a history suggestive of ischaemic heart disease and are medium risk if they have no
contraindications (the presence of any of these should trigger an acute referral to the on-call
medical team). If using 90-120 minute pathway for discharge ALL markers have to be taken
into consideration, not just Troponin I.
Those patients who have more atypical presentations should be sent back to their GP for
review as per the low risk patients (see below). The GP will organise a RACPC referral if
they feel on reassessment that this is appropriate.
3.7.7.3 Low Risk patients
Those patients who fall into the low risk category as above can be discharged back to their
GP with the Standard Chest Pain Letter (found in the same drawer as the RACPC forms in
the Doctors’ Office in Majors) for further assessment.
They should also be advised to return urgently to A&E if they experience significant chest
pain lasting more than 15 minutes and unrelieved by rest.
The GP will organise a RACPC referral if they feel on reassessment that this is appropriate.
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3.7.8
ACS Pathway
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3.8
Management of severe hypertension
This guideline is based on agreed Acute Medicine guidelines.
There are few genuine hypertensive emergencies requiring rapid blood pressure lowering.
These include:
Hypertensive encephalopathy
Eclampsia
Severe hypertension with pulmonary oedema
Aortic dissection
These should be distinguished from hypertensive urgencies in those with a very high BP
(>220 mmHg systolic and / or >120mmHg diastolic) in the absence of acute neurological or
cardiac decompensation.
Ideally those with grade 3+ hypertensive retinopathy should be admitted for BP lowering.
3.8.1
3.8.2
3.8.3
History
Previous history of hypertension
Prior treatment of hypertension
Drug history including illicit drugs
Symptoms (CVS, CNS, visual)
In young women (where hypertension is unusual) always consider pregnancy as a
cause
Examination
Manual BP, both arms
Full cardiovascular
Full neurological (including visual acuity)
Fundoscopy
Investigations
Urinalysis (and urinary BHCG in young women of child bearing age)
ECG
CXR
FBC, U&Es, CRP
If no evidence of retinopathy and no proteinuria consider immediate secondary cause (i.e.
anxiety, pain, drug intoxication). In patients at risk or with atherosclerosis consider possible
carotid stenosis (especially in those with TIAs and severe hypertension) due to the risk of
CVA with rapid lowering of BP.
3.8.4
Overdoses associated with hypertension
“CTSCAN”
Cocaine
Thyroid supplements
Sympathomimetics
Caffeine / theophylline
Anticholinergics / amphetamines
Nicotine
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3.8.5
Management of emergencies
For immediate blood pressure lowering, patients need to be discussed with Medicine / ITU
for continuous invasive BP monitoring.
Initial agent of choice:
IV GTN (50mg in 50mls infused at 0-12mg/hr)
There are no situations in which it is absolutely contra-indicated
Eclampsia / pre-eclampsia:
Involve the Obstetrics team
Give magnesium as well as antihypertensive treatment, as this improves outcome for
both mother and child
Dissecting thoracic aneurysm
GTN and / or labetolol.
Catecholamine crisis (pheochromocytoma, cocaine or amphetamine)
GTN
Phentolamine
Avoid initial β-blockade (paradoxical worsening of hypertension due to unopposed α
effects)
NB. Treatment of tachycardia and coronary vasospasm due to cocaine: use diazepam and a
calcium channel blocker, not a β-blocker. Prolonged use of sodium nitroprusside (>24 hours)
leads to a build up of toxic cyanide ions.
3.8.6
Management of urgencies
BP should be lowered gradually over hours to days. Rapid lowering of BP risks causing
CVA, AMI or blindness. Oral treatment should be introduced step-wise; refer to the Medical
team for further management.
Do not give sublingual crushed / capsular nifedipine, standard doses of β-blockers or
ACE inhibitors in accelerated phase hypertension. These treatments may cause an
unpredictable precipitous fall in the BP.
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3.9
DVT / PE prophylaxis
This guideline is based on Trust Haematology and current NICE guidance.
In this hospital, we currently use tinzaparin 4500 IU sc od for DVT / PE prophylaxis.
3.10
Pulmonary embolus
Clinical presentation relates to degree of haemodynamic disturbance:
Sudden collapse / syncope with raised JVP and /or hypotension
Pulmonary haemorrhage with pleurisy and /or haemoptysis
Isolated dyspnoea with no cough /sputum /chest pain
If patient is pregnant, involve both Obstetrics and Haematology before proceeding
3.10.1.1 Assessment
Most patients with PE are tachypnoeic with RR>20/min. In the absence of this, pleuritic
chest pain or haemoptysis is usually due to another cause.
Use the Wells score to predict the pre-test probability of PE. A D-dimer is only useful if the
score is <4; for high risk patients, organise immediate imaging.
CLINICAL SCORING SYSTEM* (WELLS ET AL: 2000)
Present?
Clinical signs and symptoms of DVT
An alternative diagnosis is less likely than PE
Heart rate above 100bpm
Immobilisation or surgery in the previous 4 weeks
Previous DVT or PE
Active cancer undergoing treatment in last 6 months or on palliative
treatment
Haemoptysis
Score
3
3
1.5
1.5
1.5
1.0
1.0
TOTAL SCORE (RISK CATEGORY: ≥4 probability of PE likely; <4 PE unlikely)
Documentation in the notes of the clinical probability is vital. Proformas can be found
in both Majors and Minors. They are also in the Appendix.
3.10.1.2 Using D-dimers
D-dimer is only useful to rule out PE, not to rule in:
It is not a routine “screening” test for PE
Should only be considered where there is low clinical probability of PE
Only a negative result is of any value
A positive D-dimer only means that a DVT / PE cannot be ruled out
D-dimer should not be performed:
Where an alternative diagnosis is highly likely
If clinical probability is intermediate or high
In probable massive PE
If D-dimer is positive or clinical probability is intermediate or high, refer for admission and
further imaging such as CTPA.
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3.10.1.3 Management
Resuscitation
Oxygen if pO2 <8kPa
Analgesia
Tinzaparin 175iu/kg once per day
Consider thrombolysis (alteplase 50mg IV) in the presence of massive PE
3.11
Deep venous thrombosis
This guideline is based on Trust Haematology and current NICE guidance.
If a patient self-presents to ED with swollen calf and a possible DVT perform and document a
risk assessment using Wells Scoring (see below). DVT proformas can be found in both
Majors and Minors sections. They are also in the Appendix.
CLINICAL SCORING SYSTEM* (WELLS ET AL: 1995, 1997)
History:
Paralysis, paresis or recent plaster immobilisation
Bedridden for>3 days and/or major surgery in last 4/52 airline and/or flight>4
hours
Present?
Score
1
1
Active cancer undergoing treatment in last 6 months or on palliative treatment
1
Strong family history of DVT(2 or more affected first degree relatives)
On examination:
Entire leg swollen
1
Swollen calf>3cm larger than other leg measured (10cm below tibial tuberosity)
1
Tenderness along deep venous system
Pitting oedema in symptomatic leg only
Dilated superficial veins (non-varicose)
Alternative diagnosis likely
1
1
1
-2
1
TOTAL SCORE (RISK CATEGORY: ≥2 probability of DVT likely; <2 DVT unlikely)
Below is the protocol for the investigation of possible DVTs:
1. Suspected DVT clinically; record patient’s weight, calf circumferences and vital signs.
Also record the patient’s suitability for outpatient investigation and treatment.
2. Perform a D-dimer only if the Wells Score is <2. It is UNHELPFUL otherwise.
3. Document Wells Score and D-dimer result if appropriate.
4. Prescribe tinzaparin 175 iu/kg SC od and explain to patient that they will need to have
this every day until the scan is performed. They should come back to A&E for this
unless they have been referred to Medicine (who will administer this on the Medical
Day Unit).
5. Fill out a Radiology form for a Doppler USS stating the indication, the side needing
investigation and the D-dimer result / Wells Score. Also ensure that the patient’s
mobile phone number / contact telephone number is clearly documented on the form.
6. Consider with the patient and senior nurses whether special transport / Medihome or
similar arrangements need to be made.
7. Take the form to Radiology to request the scan; out of hours, the Radiographer can
help you pass it on to the ultrasonographers in the morning.
Advise the patient that they will be contacted by the ultrasonographers with a timeslot to
attend. They should NOT just turn up the next morning expecting a scan.
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Inadequately filled forms are returned to the department and the patient will not be
scanned, so take care!
Patients being investigated as out-patients must be advised to return to the department if
they have any respiratory symptoms suggestive of PE.
If the scan is positive, refer patient to the Medical Team for further investigation as
appropriate and outpatient anticoagulation.
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3.12
Use of Oxygen
The following guidance is based on current British Thoracic Society national guidance and
local guidance.
Initial algorithm for in-hospital prescription of oxygen in adult patients (based
on British Thoracic Society guidelines 2008)
Is the patient critically ill?*
No
Yes
Treat with reservoir mask at
15l/min. (use bag-valve mask
during resuscitation).
Once stable, reduce oxygen
dose and aim for 94-98% target
range.
Is the patient at risk of
hypercapnic respiratory failure?
e.g. COPD, chest wall /
neuromuscular disease
No
Yes
Yes
Aim for SpO2 88-92% or level on
‘Alert card’ pending ABG;
patients may have their own
Venturi mask.
Is SpO2 < 85%
No
Aim for SpO2 94-98%
Start with nasal cannulae (26l/min), or simple face mask (510l/min). If desired range cannot
be maintained, change to
reservoir mask at 10-15l/min
Start with 24% (2l/min) Venturi
mask & check ABG.
Consider NIV if PH<7.35,
PCO2>6.0 kPa and not
responding to medical treatment
* Critical illness is defined as cardiopulmonary arrest, shock, major trauma, head injury, near
drowning, major pulmonary haemorrhage, carbon monoxide poisoning, status epilepticus and
other life threatening emergencies. Patients with COPD and other risk factors for hypercapnia
who develop critical illness should have the same initial target saturations as other critically ill
patients pending the results of ABG measurements, after which they may need controlled
oxygen therapy or supported ventilation.
ABG - arterial blood gas; SpO2 - peripheral oxygen saturation.
Reference: Guideline for Emergency Oxygen Use in Adult Patients.
thoracic.org.uk
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3.13
Pneumonia
The following is based on current British Thoracic Society national guidance.
Follow the BTS guidelines for community acquired pneumonia (CAP), found at:
http://www.britthoracic.org.uk/ClinicalInformation/Pneumonia/PneumoniaGuidelines/tabid/136/Defaul
t.aspx
Important points:
Streptococcus pneumoniae is the most common cause of CAP
Mycoplasma and legionella infections are less frequent in the elderly
The causative pathogen cannot be accurately predicted from clinical or radiological
features
Elderly patients with CAP more frequently present with non-specific symptoms and
are less likely to have a fever than younger patients
Radiological resolution often lags behind clinical improvement from CAP
3.13.1
CAP project and Care Bundle at West Mid
Aims:
To deliver the best and most clinically effective treatment to all patients with CAP
To decrease variations in management and quality of care
Administration of appropriate antibiotics within 4 hours of arrival to A&E
Inclusions:
Patients showing symptoms and signs of lower respiratory tract infection (cough,
sputum) and confirmed by new shadowing on chest x-ray
Exclusions:
Patients under 16 years
Patients with known HIV
Interventions:
Manage oxygen requirements appropriately; document on CAP bundle
Ensure CXR confirmation
Derive and document CURB 65 score
Treat according to severity; the first dose of antibiotics should be given within 4
hours whilst in A&E
Ask for consent to review notes; this will not affect their treatment
Provide patient information sheet
Care bundle to be completed on all patients with CAP; place in CAP box regardless
of consent status
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A summary of the CAP project Care Bundle:
3.13.2
Investigations
Ill patients being considered for possible admission should have the following tests:
CXR
FBC, U&Es, LFTs, CRP
Oxygenation assessment
Microbiological tests should be performed in all patients with severe pneumonia. Also
consider in the elderly, those resistant to therapy or with significant co-morbidities:
Blood cultures
Sputum cultures
3.13.3
Assessing severity of CAP
Use the CURB-65 scoring to risk stratify. Beware of over-reliance on the CURB scoring in
young patients; they may have a low score but have a clinically severe pneumonia. Always
interpret your result with reference to the clinical picture!
If CURB 65 score is 0-1 with no changes on the CXR, consider home treatment. However,
there may be non-clinical reasons to admit the patient.
Any patient with consolidation on the CXR should be referred to Medicine for
admission and 24 hours of IV antibiotics unless young, fit and well.
Discuss with your seniors if there is any doubt.
If CURB score is 2, the patient should be referred to Medicine and considered for admission.
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If CURB score is 3 or greater, this is classified as severe CAP requiring admission and early
involvement of HDU / ITU may be required.
3.13.4
Management of CAP
Home treated, not severe
Amoxicillin 500mg tds po for 7 days
Consider Azithromycin 500mg od po if penicillin allergic or atypical infection
suspected for 3 days
Hospital treated, moderate
Amoxicillin 500mg – 1g tds po for 7 days AND
Clarithromycin 500mg bd po for 7 days
Alternatively, Benzylpenicillin 1.2g qds IV in place of Amoxicillin OR Azithromycin
500mg od po if penicillin allergic or atypical infection suspected for 3 days
Hospital treated, severe
Benzylpenicillin 1.2g qds IV
Clarithromycin 500mg bd IV OR Azithromycin 500mg od po
Alternatively, Teicoplanin 400mg bd IV for 3 doses then daily AND Azithromycin
500mg od po if penicillin allergic or atypical infection suspected
Infective exacerbation of COPD
Doxycycline 200mg stat then 100mg od po for 7 days
Aspiration pneumonia
Benzylpenicillin 1.2g qds IV AND
Clarithromycin 500mg bd IV AND
Metronidazole 500mg tds IV
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OR
Teicoplanin 400mg bd IV AND
Azithromycin 500mg od po AND
Metronidazole 500mg tds IV
Possible Staphylococcal pneumonia
Flucloxacillin 1g qds IV
OR
Teicoplanin 400mg bd IV for 3 doses then 400mg od IV
(if known or suspected MRSA e.g. prolonged hospital stay, previous hospital
admissions or admission from nursing / residential home)
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3.14
Asthma
The following is based on current British Thoracic Society national guidance.
Follow the BTS guidelines for asthma, found at:
http://www.britthoracic.org.uk/ClinicalInformation/Asthma/AsthmaGuidelines/tabid/83/Default.aspx
3.14.1
Initial assessment
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3.14.2
3.14.3
Investigations
Pulse, BP, RR, temp, sats
Peak flow pre- and post-nebs; document predicted / patient’s best
ABG if sats <92%
CXR if pneumothorax or infection suspected; also if life threatening asthma, failure to
respond to treatment or requiring ventilation
Theophylline levels if on theophylline at home and patient requiring admission
Management of acute asthma
Notify seniors immediately if you have a patient with severe or life-threatening asthma.
Also notify ITU and Medical team early in the patient’s management when dealing with
severe or life-threatening asthma.
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3.14.4
Heliox in acute asthma
3.14.5
Asthma in pregnancy
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3.14.6
Patients at risk of developing near-fatal or fatal asthma
Be aware that patients with severe asthma or one or more adverse psychosocial factors are
at risk of death. See the table below for more details.
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3.14.7
Criteria for admission / discharge
If considering discharge following nebulisers, the peak flow should be >75% of predicted /
best and stable for at least 1 hour following the last nebuliser. This is particularly important
at night, due to the diurnal variation of symptoms.
Points to note before discharge:
All patients should receive oral / inhaled steroids on discharge unless presenting with
a very mild exacerbation.
All patients should have their inhaler technique checked
All patients should have follow-up arranged with GP / Asthma Specialist Nurse
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3.14.8
Summary of treatment in Emergency Department
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3.14.9
Summary of management of acute severe asthma
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3.15
COPD
The following is based on current British Thoracic Society / NICE guidance.
NICE guidelines for COPD: http://thorax.bmj.com/cgi/reprint/59/suppl_1/i131
Speak to your seniors early if the patient has acidosis and hypercapnia, as non-invasive
ventilation may need to be considered.
3.15.1
Differentiating between asthma and COPD
3.15.2
Assessing severity
Signs of a severe exacerbation include:
Marked dyspnoea / tachypnoea
Purse lip breathing
Use of accessory muscles (sternomastoid and abdominal) at rest
Acute confusion
New onset cyanosis
New onset peripheral oedema
Marked reduction in activities of daily living
3.15.3
Criteria for admission
Many patients can be managed at home with adequate support but a few will need
admission to hospital. Consider the following to help you decide:
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3.15.4
Summary of management
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3.16
Influenza
The WHO has declared a pandemic flu outbreak with the A/H1N1 virus. The following is
based on local and national guidelines, which can be found on the intranet under Clinical
Policies & Guidelines, Pandemic Flu.
The situation and advice for healthcare professionals is rapidly changing, so please check
the current guidance when seeing any patients with suspected swine flu. Below is a
summary of guidance from local and national sources.
Further information can also be found in the following places:
World Health Organisation Website
Health Protection Agency Website
Department of Health Website
3.16.1
Personal Protective Equipment
For personal protection, appropriate PPE must be worn when assessing a patient who has
suspected or confirmed A/H1N1:
Surgical mask
Plastic apron
Gloves
Consider eye protection if eye splashes are a possibility
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If aerosol generating procedures are being performed, the appropriate PPE is:
FFP3 mask
Gown
Gloves
Eye protection
Aerosol generating procedures include:
Nebulised medication
Sputum induction
Bronchoscopy
Airway suctioning
Intubation
Please note that spontaneous coughing is NOT an aerosol generating procedure and
therefore does not require this level of PPE.
3.16.2
Assessment of patients
Clinicians are now encouraged to diagnose influenza A/H1N1v cases on the basis of
symptoms. The clinical diagnostic criteria are:
Fever (pyrexia ≥38°C) or a history of fever
AND
Influenza-like illness
(TWO OR MORE of the following symptoms: cough, sore throat, rhinorrhoea, limb or
joint pain, headache, vomiting or diarrhoea)
severe and/or life-threatening illness suggestive of an infectious process
OR
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3.16.3
Patients at risk of complications
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3.16.4
Complications of influenza
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3.16.5
Investigations
Note that patients with bilateral lung infiltrates on the CXR should be managed as a severe
pneumonia regardless of the CURB score.
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3.16.6
Management
Antivirals are most effective within 12-48 hours of onset of symptoms.
Please note that we cannot prescribe or dispense treatment for patients being
discharged. They will need to obtain a prescription from their GP / Out-of-hours
service.
Treatment drugs for influenza:
Oseltamivir (Tamiflu) 75mg bd for 5 days
Side effects include: nausea, vomiting, abdominal pain, diarrhoea, headache and
conjunctivitis. N+V can be lessened by taking with food and are more prominent for
the first few doses.
Or
Zanamivir (Relenza) x2 5mg blisters bd inhaled for 5 days
(for pregnant women or those with significant renal impairment)
Side effects (rare) include: bronchospasm, respiratory impairment, angioedema,
urticaria and rash
Current advice is found below for patients and staff with milder flu symptoms.
If you should feel unwell with flu-like symptoms the latest advice is:
Stay at home and check your symptoms online at www.nhs.uk or call the swine flu
information line on 0800 1 513 513
If you have taken these steps and are still concerned call NHS Direct on 0845 46 47 or
your GP for more advice
Please do not go to A&E unless you are seriously ill
For staff, in addition to the above, follow the normal procedures for reporting in sick to
work and keeping your line manager updated. If you believe you have been in contact
with someone with swine flu it is not necessary to stay off work unless you have
symptoms yourself. You should stay at home for as long as you do have symptoms.
Line managers should ensure that Occupational Health is informed of any staff
reporting in sick with suspected or confirmed swine flu.
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3.17
Non-invasive ventilation
Summarized below are the local guidelines for NIV written by our ITU Outreach Team.
Contact your seniors early if you have a patient who may benefit from NIV. Liaise with
Medicine and the Outreach Team to determine the suitability of your patient, and to
determine the most appropriate ward for the patient following initiation of treatment in Resus.
3.17.1
When to use NIV
Inclusion Criteria
1. pCO2 > 6.0 kPa
2. pO2 <8 kPa on air
3. pH < 7.35
4. Conventional therapy has failed
5. The patient’s quality of life supports this intervention
6. The patient wants the intervention
Absolute Contraindications
1. Type 1 respiratory failure
2. Acute severe asthma
3. Facial Trauma/burns
4. Fixed obstruction of upper airway
5. Uncontrolled vomiting (If vomiting remains a risk do not use full face mask)
6. Undrained pneumothorax
7. Impaired consciousness
Relative Contraindications (however, discuss with a senior / Outreach Team to determine
appropriateness if these are present)
1. Confused or agitated
2. Recent facial, upper airway, thoracic or GI surgery
3. Large proximal bronchial tumour may produce air tapping
4. Lung abscess or new/changing bullae
5. Unable to maintain own airway
6. Cardiovascular instability
7. CXR suggests focal consolidation
8. Bulbar insufficiency or other risk of aspiration
9. Gross sputum retention / copious respiratory secretions
10. Severe co-morbidity
11. Bowel obstruction
12. Increased intracranial pressure
13. pH < 7.25
14. Life threatening hypoxia
3.17.2
Medical optimisation prior to NIV
Treat the underlying condition with bronchodilators, corticosteroids, antibiotics,
diuretics and physiotherapy as required.
Use NIPPV observation chart
Supply oxygen to achieve a pO2 >8.0 kPa by venti-mask 28% or nasal cannula 2
l/min
Obtain Chest X-Ray
Repeat ABGs at 60 minutes
If PO2 <8 kPa but pH not falling, increase oxygen from 28% to a maximum of 35%;
accept a modest rise in pCO2 (i.e. 1-1.5 kPa). If cannot achieve pO2> 8.0 kPa without
fall in pH or unacceptable rise in CO2 consider NIPPV
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3.17.3
3.17.4
3.17.5
How to set up NIV
Decide management plan if trial of NIV fails, after discussion with seniors / Medicine
and document in the notes
Inform Outreach Team (based in ITU)
Explain NIV to the patient
Select a mask to fit the patient and hold it in place to familiarise the patient. The
nursing team / Outreach Team will help you do this.
Set up the ventilator (see 3.17.4 and 3.17.5Error! Reference source not found.).
Commence NIV, holding the mask in place for the first few minutes.
Secure the mask in place with straps/headgear.
Reassess after a few minutes.
Adjust settings if necessary (see 3.17.7).
Add oxygen if SpO2 <85%.
Clinical assessment and check arterial blood gases at 1–2 hours.
Ventilator Set-up
Install the inlet filters
Assemble and attach the patient circuit
Provide power, turn on the unit and ensure patient side ready
Set up Patient Parameters
Attach Oxygen tubing to entrain prescribed O2
Ensure alarms are turned on
Patient Parameters
Mode: spontaneous / timed
IPAP: 10 cm H2O (increase in increments of 2-4 cm H2O
EPAP (CPAP/PEEP): 4 cm H2O
Back up rate: 12/min
Ti (Time inspired): 1.6 secs
Triggers: Max sensitivity
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3.17.6
3.17.7
3.17.8
Reassessment of the patient
Chest wall movement
Coordination of respiratory effort with the ventilator
Accessory muscle recruitment
Heart rate
Respiratory rate
Patient comfort
Mental state
Repeat ABGs 1 hour after any change in NIV settings or oxygen flow rate.
Signs that NIV is effective
pH increased
PO2 increased (aim for PaO2 >8.0 kPa & SaO2 88-92%)
Accept that CO2 may not fall immediately
Respiratory Rate / effort improving
Good synchronisation
Possible indications for intubation
Always discuss this with your seniors and with the Outreach Team.
Respiratory arrest
Reduced GCS
No improvement
Heart Rate <50 bpm
Systolic BP <90 mmHg
Increased respiratory rate >30 bpm
Patient requires sedation
3.17.9
Failure of treatment
Is the treatment of the underlying condition optimal?
Check medical treatment prescribed and that it has been given
Consider physiotherapy for sputum retention
Have any complications developed?
Consider a pneumothorax, aspiration pneumonia, etc
PaCO2 remains elevated
Is the patient on too much oxygen?
o Adjust FiO2 to maintain SpO2 between 88% and 92%
Is there excessive leakage?
o Check mask fit
Is the circuit set up correctly?
o Check connections have been made correctly
o Check circuit for leaks
Is ventilation inadequate?
o Observe chest expansion
o Consider adjusting inspiratory time or respiratory rate
o Consider increasing IPAP in 2-4 cm H2O as tolerated
PaCO2 improves but PaO2 remains low
Increase inspired O2 to a maximum of 4L/min
Consider increasing EPAP to a maximum of 6 cm H2O
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Complications
Local skin damage
Eye irritation/ sinus pain or congestion
Gastric distension - NG tube if possible
Nosocomial pneumonia - much reduced compared to invasive ventilation
Barotrauma - uncommon
Adverse hemodynamic effects – less common than with invasive ventilation
Increasing agitation
3.18
Tuberculosis
TB is relatively common in our catchment area. If you suspect TB in your patient, remember
infection control measures to protect yourself and other staff (mask for patient if coughing
with possible pulmonary TB, side room etc.).
If the history and x-rays are suggestive of TB, refer to Medicine and to the TB specialist
nurse (Bleep 402), as treatment options and contact tracing need to be discussed with the
patient. They also have a support worker who can help co-ordinate discharge if the patient is
currently homeless or needs further social input.
If the patient has presented with haemoptysis, ensure that you have excluded other
significant and serious causes, such as PE.
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3.19
Upper GI Bleed
The following is based on local Gastroenterology guidelines.
3.19.1
3.19.2
3.19.3
History
Haematemesis / Melaena / Syncope
Retching
Aspirin /NSAIDs / anticoagulants
Alcohol excess
PMH of PUD / chronic liver disease
Examination
Pulse / BP / Postural Drop
Stigmata of chronic liver disease and portal hypertension
PR
Investigations in patients with suspected upper GI bleed
FBC, U&Es, LFTs, coagulation screen
Group & save (cross match if indicated - see below)
Use Rockall score to risk stratify patient (see below). Refer to Medical team if score
≥2, but always consider social circumstances prior to discharge. If in doubt discuss
with seniors.
If discharging to the GP, ensure patient has a letter to the GP requesting referral for
OP upper GI endoscopy.
Rockall Scoring System
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In cases of suspected peptic ulcer disease with bleeding
Appropriate IV fluid resuscitation / blood transfusion
Pantoprazole 40mg IV stat
In cases of variceal bleeding
Appropriate IV fluid resuscitation / blood transfusion
Keep INR < 1.3 by IV Vitamin K 20 mg and fresh frozen plasma (FFP) PRN
Keep platelet count >50 by platelet transfusion PRN
Pabrinex IV
Consider with Medical team input
o Central venous access
o Lactulose 20mls tds orally if chronic liver disease / encephalopathy
o IV Glypressin 2 mg IV 6 hourly
o Antibiotics in patients with ascites
o Elective intubation in severe bleeding with severe encephalopathy, with risk of
aspiration and hypoventilation
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3.20
The unconscious patient
Get senior help! This is a medical emergency. Patients who are comatose should be
assessed and managed in Resus.
Immediately assess ABCDEs as per ALS protocols.
AIRWAY: Ensure airway patency. Use airway opening techniques and adjuncts if
necessary to maintain a patent airway. If you have difficulty maintaining the airway,
call for immediate help.
BREATHING: Provide high flow oxygen and monitor respiratory rate and oxygen
saturations to ensure adequate oxygenation.
CIRCULATION: Establish IV access, take bloods and give IV fluids to maintain an
adequate pulse and blood pressure. Check BM.
DISABILITY: Assess AVPU, monitor GCS and check pupils. Look and test for
lateralising neurological signs. Check for signs of opiate toxicity and give Naloxone
as appropriate (400 mcg IV aliquots, can also give IM for slower release. Maximum
dose 10mg).
EXPOSURE: Look for external signs of head injury / self harm / IV drug abuse.
Measure temperature.
Further investigations:
FBC, U&E, LFTs, paracetamol and salicylate, blood cultures if pyrexia
Arterial blood gas; check pH, respiratory / metabolic status
ECG
CXR to check for aspiration
Urine for toxicology screen
Consider:
Glucose. If hypoglycaemic give 50-100mls of 10% dextrose plus IV infusion of 5-10%
glucose
IV Pabrinex: If history of chronic alcohol abuse give two pairs of Pabrinex 1 and 2 (i.e.
4 vials) over 30 minutes in 100mls of 0.9% sodium chloride or 5% glucose.
Catheterise to monitor hourly urine outputs
CT / LP
Management:
Neuro obs
If due to reversible cause (i.e. acute alcohol intoxication) and fully recovered, should
ideally be discharged into the care of a responsible adult.
Refer for admission as appropriate.
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3.21
Fitting
The following is based on current local and national NICE guidance.
3.21.1
First fit
Patients presenting with first time fits need collateral history to determine nature of the fit and
its duration. A full neurological examination as well as biochemical investigations and an
ECG are necessary. Look for a septic focus.
If the patient has no neurological deficit and electrolyte imbalance then the patient may be
sent home with a responsible adult. The patient should then be referred to their GP to be
referred to either a First Fit Clinic or Neurology OPD.
A CT is not as appropriate as an MRI is much more likely to pick up any underlying lesion
responsible for the fit. Only request a CT if the fit was trauma related (see Neurosurgery
section), if there are persisting neurological symptoms or signs, or ongoing decreased
conscious level. These patients also require admission under Medicine, as do those with
ongoing, multiple fits or presenting with status epilepticus.
3.21.2
Status epilepticus
Status epilepticus is a medical emergency in which there is either more than 30 minutes of
continuous seizure activity or there are two or more sequential seizures without recovery of
full consciousness between two seizures.
3.21.2.1 Management (NICE guidance)
Pre-hospital management (or on arrival if not done)
Secure airway and resuscitate
Administer oxygen
Assess cardiorespiratory function
Establish intravenous access
Drugs:
Diazepam 10-20 mg given rectally
Repeat once 15 minutes later if status continues, or Midazolam 10 mg given buccally
If seizures continue, treat as below
Immediate management in A&E
Regular monitoring
Consider the possibility of non-epileptic status
Emergency antiepileptic drug therapy
Emergency investigations
Administer glucose (50 ml of 10% solution) if any suggestion of hypoglycaemia and/or
intravenous thiamine (250 mg) as high potency intravenous Pabrinex if any
suggestion of alcohol abuse or impaired nutrition
Treat acidosis if severe
Drugs:
Lorazepam (IV) 0.07 mg/kg (usually a 4 mg bolus, repeated once after 10-20
minutes; rate not critical)
If seizures continue, treat as below
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Within 30 minutes
Establish aetiology
Alert anaesthetist and ITU
Identify and treat medical complications
Pressor therapy when appropriate
Drugs:
Phenytoin infusion at a dose of 15-18 mg/kg at a rate of 50 mg/minute or
fosphenytoin infusion at a dose of 15-20 mg PE/kg at a rate of 150 mg PE/minute
and/or:
Phenobarbitone bolus of 10 mg/kg at a rate of 100 mg/minute (usually 700 mg over
seven minutes in an adult)
After 30 minutes if no response to above
Transfer to intensive care
Establish intensive care and EEG monitoring
Initiate intracranial pressure monitoring where appropriate
Initiate long-term, maintenance antiepilepsy drug therapy
Drugs:
General anaesthesia, with propofol, midazolam or thiopentone.
Anaesthetic continued for 12-24 hours after the last clinical or electrographic seizure,
then dose tapered
3.21.2.2 Emergency investigations:
BM, Glucose
ABG
FBC, U&Es, LFTs, Ca and Mg, antiepilepsy drug levels
Urinalysis / toxicology
CXR
Consider CT / LP
3.21.2.3 Monitoring
Pulse, BP, temp, sats
ECG
EEG if refractory
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3.22
Headache
The following guidance is based on the guidance from the British Association for the Study of
Headache and local guidelines.
3.22.1
Assessment
3.22.1.1 History
Ask about the following:
Onset (acute, subacute, chronic)
Nature (throbbing, tight band)
Location
Duration (days, weeks, months)
Aggravating/Relieving (posture)
Associated symptoms
Effect of analgesia
Worrying characteristics
Acute onset
Progressive headache
Wakening from sleep
Worst ever
Atypical aura
New onset in >50 or <10
Postural change
PMH of cancer or HIV
Worrying associated symptoms
Photophobia
Neck stiffness
Fever
Altered mental state
New cranial / peripheral nerve symptoms
3.22.1.2 Examination
Perform front to back scalp exam, temporal arteries, eyes, ears, sinuses, TMJ, neck
Worrying examination findings
Unwell patient
Pyrexia
Meningism
Decreased level of consciousness
Confusion
Abnormal neurological finding (fundi, CNs, limbs)
Rash
3.22.1.3 Investigations
Consider if considering an underlying cause:
Bloods incl. blood cultures
CT
LP
ESR / temporal artery biopsy if ?temporal arteritis
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3.22.2
Subarachnoid haemorrhage (SAH)
Subarachnoid haemorrhage should be considered in any patient presenting with suddenonset, severe and unusual headache with or without any associated alteration in
consciousness.
Initial clinical management of subarachnoid haemorrhage (SAH) aims largely to prevent rebleeding and to reduce the rate of secondary complications such as cerebral ischaemia or
hydrocephalus.
If SAH suspected, a CT brain scan should be undertaken immediately if the patient has an
impaired level of consciousness or neurological signs. CT will pick up 90 -95% of SAH. If
the CT scan is negative or equivocal lumbar puncture should be undertaken 12 or more
hours after onset to detect xanthochromia.
3.22.2.1 Management
ABCDEs
Nurse head up 20°
Avoid hypotension / hypertension
Regular neuro obs
Oral nimodipine 60 mg 4 hourly
Adequate hydration
Adequate analgesia
Discuss with neurosurgeons at Charing Cross Hospital
3.22.3
Raised intracranial pressure
Chronic progressive headache, usually over weeks or months.
Worse on straining, coughing or bending. Early morning headache may be present. Nausea
and vomiting may be present. May present with seizure or unexplained LOC.
Papilloedema may or may not be present.
Will need contrast CT to rule out space occupying lesion. Arrange immediately if any
reduction in level of consciousness or neurological signs. Refer to Medical team for
admission.
3.22.4
Temporal arteritis
Rare under age of 55.
Gradual onset headache, scalp tenderness "when combing hair", jaw claudication (typical for
this condition), muscle aches, visual disturbance.
Thickened or nodular temporal artery on examination in 40%
Raised ESR >50, plus elevated CRP. Diagnosis unlikely if CRP normal.
Refer to Medical team as will need high dose steroids (40-60mg) and arrangements made for
temporal artery biopsy.
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3.22.5
Migraine
Usually intermittent or periodic headache associated with symptom free periods (not daily)
associated with nausea, vomiting and photophobia / phonophobia lasting 4- 72hrs.
Occasionally may be associated with cranial nerve palsies / hemiplegia but a more serious
cause should be ruled out.
70% are unilateral, pulsating, moderate-severe, aggravated by routine physical activity.
25% have an aura which gradually develops over 5-20mins and last <1hr and resolves
before headache onset. May have visual, sensory, speech or motor component e.g.
scotomata, scintillation, hemianopia, paraesthesia (rarely affects leg).
Usually resolves with sleep but lethargy common following.
3.22.5.1 Management (based on British Association for the Study of Headache Guidelines)
Analgesia e.g. aspirin 600-900mg or ibuprofen 400-600mg, initially orally but consider
PR
Little evidence for effectiveness of paracetamol alone or for opiates / codeine in
migraine
Antiemetic e.g. buccal prochlorperazine 3-6mg, domperidone10mg or
metoclopramide 10mg
If ineffective try diclofenac suppositories 100mg with domperidone suppositories 3060mg
IV fluids
Can give a triptan (e.g. sumatriptan) if initial management ineffective (note triptans
are not effective during aura i.e. do not give too early)
3.22.6
Cluster headaches
More common in young adult men. Lasts l5min to 3hrs, occurs several times a day to
several times a week, usually occurs for periods of 1-3 months and then have respite for
months or years, commonly at night. Unilateral, associated with conjunctival injection,
lacrimation, lid swelling, miosis and ptosis, rhinorrhoea.
3.22.6.1 Management (based on British Association for the Study of Headache Guidelines)
Sumatriptan 6mg sc is the treatment of choice. Aborts attack in 5-10mins
Oxygen
No evidence for the efficacy of other analgesics
GP follow-up for prophylaxis (e.g. verapamil) and neurology referral if repeated
attacks and poor control.
3.22.7
Primary angle-closure glaucoma
Consider in women, middle aged or older with headache, painful red eye and reduced visual
acuity. May have nausea and vomiting. See Ophthalmology section for more details.
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3.23
Transient ischaemic attacks (TIAs)
The following guideline is based on the current NICE guidance for TIA and stroke
http://www.nice.org.uk/Guidance/CG68 and also on local Trust policy. A summary of this
information can be found in section 3.23.4.
3.23.1
Risk assessment
The risk of developing a stroke after a TIA is about 5% within the first week. 23% of people
having a stroke had a history of at least one TIA.
The risk of stroke during the first 7 days immediately following a TIA has been associated
with several identifiable risk factors [Rothwell et al, 2005].
Age (60 years and over)
Blood pressure (140/90 mmHg and over)
Clinical features (unilateral weakness or speech disturbance)
Duration of symptoms (greatest risk with symptoms lasting over an hour). However,
other studies have suggested that short-lasting TIAs may indicate unstable disease
and be associated with a poor prognosis [Nguyen-Huynh and Johnston, 2005].
Use the ABCD2 scale below on all patients who have had a suspected TIA to assess their
risk of subsequent stroke. This can be found on the TIA Clinic forms which are in the
doctors’ room in Majors (see Appendix).
A total score of 0-7 is possible.
Patients scoring 0-3 are in a low risk category and those scoring 4-7 are in a high risk
category.
Patients with more than one TIA in a week OR on warfarin are in a high risk category
regardless of the actual ABCD2 score.
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3.23.2
Management
The following diagram summarises NICE guidance.
ABCD2 score 0-3 OR patient presenting >1 week after resolution of symptoms
Give Aspirin 300mg stat, then 75mg od
Give Clopidogrel if intolerant of aspirin
Advise patient not to drive for 1 month
Refer to TIA Clinic at WMUH (referral forms in TIA Bundle in Doctors’ Office). Fax
form to ext 5270.
Give patient information leaflets to patient
Disposal as below (see summary)
If the patient has persistent neurological signs, refer to Medicine as per stroke
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ABCD2 score 4 or 5
Give Aspirin 300mg stat, then 75mg od
Give Clopidogrel if intolerant of aspirin
Advise patient not to drive for 1 month
Refer to TIA Clinic at WMUH (referral forms in TIA Bundle in Doctors’ Office). Fax
form to ext 5270.
Give patient information leaflets to patient
Disposal as below (see summary)
If the patient has persistent neurological signs, refer to Medicine as per stroke
ABCD2 score 6 or 7 OR more than 1 TIA in 7 days OR on Warfarin
Refer to Medicine for admission, as the patient is high risk.
Within office hours, speak to Stroke Team on bleep 413 or ext 5265 for admission (or
on call Medical Team if unavailable)
Disposal as below (see summary)
3.23.3
3.23.4
Cases to consider urgent brain imaging in TIA
Carotid endarterectomy (CEA) is being considered and it is uncertain whether the
stroke is in the anterior or posterior circulation
TIA where haemorrhage needs to be excluded (e.g. long duration symptoms or on
anticoagulants)
Alternative diagnosis (for example migraine, epilepsy or tumour) is being considered
TIA Pathway Summary
As of Feb 1st, the HASU (HyperAcute Stroke Unit) at Charing Cross will become partially operational.
What this means for TIA patients:
Monday to Friday office hours, if symptoms have fully resolved:
o ABCD2 score of 1-5, fax referral to TIA Clinic and send to MDU immediately
on discharge from A&E as per patient instructions
o ABCD2 score 6-7 or >1 TIA in 7 days, discuss with Stroke Team (bleep 413)
and Med Reg on call and admit to Kew Ward WMUH as per protocol
Monday to Thursday out-of-hours, if symptoms have fully resolved:
o ABCD2 score 1-5, fax referral to TIA Clinic and send to MDU the next morning
as per patient instructions
o ABCD2 score 6-7 or >1 TIA in 7 days, refer for admission under WMUH
Medics to Kew Ward WMUH as per protocol
Friday 4pm to Monday 9am, if symptoms have resolved:
o ABCD2 score 1-3, fax referral to TIA Clinic and send to MDU on Monday
morning as per patient instructions
o ABCD2 score 4-7 or >1 TIA in 7 days, discuss on the phone with Stroke
Registrar on call at Charing Cross (for follow-up within 24hrs for score 4-5 or
admission for score 6-7)
The above is summarised in the charts following.
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3.23.5
Low Risk TIA Summary
Below is a summary of all the above guidance for this Trust.
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3.23.6
High risk TIA summary
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3.24
3.24.1
Stroke
Initial assessment and diagnosis
If patients present with a clinical syndrome that might be due to stroke, the first stage of
management is to make the correct diagnosis.
The London Ambulance Service (LAS) use the FAST (Face Arm Speech Test) tool below to
screen for stroke.
Face
Arm
Speech
New unilateral weakness
New unilateral weakness
New speech disturbance
If any of the above are present, FAST is positive. Note that some CVAs will be FAST
negative, due to the presence of mainly visual or sensory signs and symptoms.
If stroke is suggested by FAST or by symptoms / signs, a rapid assessment tool called
ROSIER (shown below) can be used to aid diagnosis. Forms can be found in the doctors’
room in Majors.
Patients still need thorough history-taking, examination and investigation. A full baseline
neurological assessment should be carried out in the ED. The assessment tool is not a
substitute for a full medical assessment but can aid diagnosis.
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3.24.2
Summary of Stroke Pathway
As of Feb 1st, the HASU (HyperAcute Stroke Unit) at Charing Cross will become partially
operational.
What this means for stroke patients:
All patients with persisting signs are a CVA until proven otherwise.
7 days a week, if stroke is suspected:
o If patient fits the criteria for thrombolysis (presents with possible acute stroke
within 3 hours), check BM and phone Stroke Registrar at Charing Cross to
discuss possible transfer
o Do NOT perform / wait for bloods, ECG, CXR or CT etc. – if patient is
accepted by HASU arrange for immediate transfer by Cat A ambulance
o If patient not accepted / does not fit criteria for transfer to HASU, follow
WMUH pathway below for stroke presentations and discuss with Stroke Team
and Med Reg on call to admit to Kew Ward.
As of April 2010, all acute strokes regardless of time of presentations or age will be accepted
by the HASU. However, from Feb to April, only the ones fitting the criteria for thrombolysis
will be accepted.
The diagram below summarises the pathway for stroke patients at this Trust.
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3.24.3
Imaging
3.24.4
Indications for thrombolysis
Thrombolysis now forms part of the recommendations from NICE. It is only appropriate if the
patient presents within 3 hours of the onset of stroke and there is no evidence of
haemorrhage on brain imaging, and if appropriately skilled specialists are available to
supervise the patient’s care.
If a patient awakes from sleep with the symptoms, these patients are assumed to be outside
the three hour window.
A local Hyper Acute Stroke Unit (HASU) service is currently in development; meantime,
patients under 80 and presenting within 3 hours should be discussed with Neurology at
Charing Cross for thrombolysis, on a case by case basis. It is currently not appropriate to
transfer any patient to Charing Cross without this discussion taking place.
Delaying transfer for CT head or lines / procedures is not appropriate, except when these
procedures are essential for the safe transfer of the patient.
This protocol has been agreed with Dr John Platt, Head of the Stroke Service at WMUH and
Dr Harri Jenkins, Consultant Neurologist and Stroke lead at Charing Cross.
3.24.5
Contraindications to thrombolysis
Patients with:
Symptoms of ischaemic attack >3 hours prior or when time of symptom onset is
unknown
Minor neurological deficit or symptoms that are rapidly improving
Severe stroke as assessed clinically and / or by appropriate imaging techniques
Seizure at onset of stroke
Evidence of intracranial haemorrhage on the CT scan
Symptoms suggestive of subarachnoid haemorrhage, even if the CT scan is normal
Anticoagulation within the previous 48 hours and abnormal clotting result
Any history of both prior stroke and concomitant diabetes
A prior stroke within the last 3 months
Platelet count below 100,000/mm3
Systolic blood pressure >185mmhg or diastolic blood pressure >110mmhg or those
on IV medication to reduce blood pressure to these limits
Blood glucose <2.8 or >22 mmol/l
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3.24.6
Drugs used in acute stroke
Antiplatelet therapy
All patients should receive aspirin 300mg as soon as possible, with PPI cover if
necessary
If the patient is genuinely aspirin allergic or aspirin intolerant, an alternative
antiplatelet drug should be used
Statins
Statins should not be introduced until 2 weeks following the acute stroke
If patients are already on statins at the time of presentation, these should be
continued
Oxygen
Oxygen should be given if the patient’s saturations <95%
Insulin
BMs should be kept between 4 and 11; if higher an insulin infusion may be required
Antihypertensive therapy
Only recommended if there is a hypertensive emergency such as:
o Hypertensive encephalopathy
o Hypertensive nephropathy
o Hypertensive cardiac failure/myocardial infarction
o Aortic dissection
o Pre-eclampsia / eclampsia
o Intracerebral haemorrhage with systolic blood pressure over 200 mmhg
Blood pressure reduction to 185/110 mmHg or lower should be considered in people
who are candidates for thrombolysis
A summary of aspirin and anticoagulation therapies is found below:
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3.24.7
Further management
Take baseline investigations:
ECG
FBC, U&Es, LFTS, coag
CXR
Refer to the Medical team for admission if thrombolysis is not appropriate. Admit to an acute
stroke bed in Kew unless medically contraindicated.
The acute management of patients with stroke is summarised below.
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3.25
Diabetic ketoacidosis (DKA)
The following is a summary of the local DKA guidelines on the intranet. This protocol can be
found on the DKA proforma in the Doctors’ office in Majors (also see A&E Appendix).
The main causes of death are preventable:
Hypokalaemia
Aspiration of gastric contents (due to gastroparesis)
Cerebral oedema (particularly in young adults and children)
Bear in mind that some adjustments may need to be made with relation to an individual’s
age, cardiac or renal function.
3.25.1
Criteria for diagnosis
1. HYPERGLYCAEMIA: blood glucose > 11 mmol/l (however, note euglycaemic DKA
can occur especially in pregnancy)
2. KETOSIS: high urinary ketones > 2+ (>7.8 on electronic meter reading). If < 2+,
consider other causes but treat as DKA if hyperglycaemic.
3. ACIDOSIS: pH < 7.3 or Bicarbonate < 18
NB: In Type 2 Diabetic patients, or insulin-treated subjects, be aware of Hyperosmolar, nonketotic diabetic coma (HONK) or lactic acidosis (very rare).
3.25.2
3.25.3
Consider precipitating event
Usually underlying infection (URTI, D&V, UTI, etc. but temp and WCC often
unhelpful)
Newly presenting patient
Alcohol / drugs
Acute abdomen (pancreatitis is often present in patients with DKA)
In older patients consider silent MI or CVA
Steroids
Trauma
Initial investigations
Initial investigations should include:
BM, blood glucose
FBC, U&E, Amylase, Mg, lactate, CRP
ABG / venous gas to look at bicarbonate / lactate / estimate glucose
Urinalysis for ketones / urinary ßHCG in females of child bearing age
CXR, blood (x2) and urine cultures to look for infection
ECG; consider cardiac enzymes
Paracetamol and salicylate levels / urine tox screen may be appropriate depending
on the history
Coagulation may be required if there are concerns regarding severe sepsis / DIC
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3.25.4
Initial treatment in the First Hour
Get senior help and alert Medical team / ITU early
Bilateral IV access
Fluid replacement:
o N/Saline 1000mls/hr (check and replace K as appropriate - see Hours 2-4)
Insulin replacement
o Fixed Rate Soluble Insulin (Actrapid): 6 iu/hr (or 0.1 iu/kg/hr) IV
o An initial IM bolus can be given if IV access is difficult initially
o Ensure K+>3.3 before starting
Monitor GCS and fluid balance
Consider central line, urinary catheter, NG tube
Fragmin prophylaxis (unless contraindicated)
Consider Antibiotics if evidence of infection
Continue usual long-acting insulin (e.g. glargine / levemir insulatard)
Stop biphasics (e.g. novomix / mixtard)
Stop oral diabetic medications
The most important aspect of management of DKA is regular examination and reassessment. Alert seniors and Medical Team early, especially if decreased conscious
level or severe acidosis.
3.25.5
Treatment in Hours 2-4
Fluid replacement:
o N/Saline 1000mls/hr for hour 2
o N/Saline 500mls/hr for hours 3 & 4 (then 150-250mls/h – aim for 5-8L in 24
hours)
Potassium replacement:
o Ensure ample Urine Output (>30 ml/h)
o 20mmols/l if 4.0 – 5.5 mmol/l. This requires continuous ECG monitoring.
o 40mmols/l if < 4.0 mmol/l. This is the MAXIMUM rate and a central line and
ECG monitoring are essential.
Insulin replacement
o Continue insulin 6 units/hr
o Aim to reduce blood glucose by less than 5mmol/hr
o Co-infuse 10% dextrose (100ml/hr) in addition to the N/Saline when blood
glucose is < 14 to maintain blood glucose 9-14 to allow resolution of ketosis
Re-assess patient including vital signs and blood glucose HOURLY in first 4 hours
Recheck K+ (main cause of mortality in DKA is Hypokalaemia due large amount
insulin)
Consider precipitating factors – e.g. ECG, CXR, MSU, Blood cultures
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3.25.6
Points to remember
Fluid replacement needs to be given judiciously (as outlined above) to avoid
complications such as cerebral oedema or respiratory distress syndrome.
If there is inadequate response to treatment, check the insulin infusion (e.g. has the
cannula tissued?).
BMs can be unreliable in the dehydrated or hypothermic patient, and laboratory
blood glucose is important as a cross reference.
Adjust fluid requirements in children and the elderly, particularly those with IHD, and
consider a CVP line.
Bicarbonate should NOT be given unless the Diabetic Team instruct you to do so.
3.26
Hyperosmolar non-ketotic diabetic state (HONK)
The following is a summary of the local HONK guidelines. HONK is associated with up to
50% mortality. The patients are usually elderly and the condition is usually secondary to an
underlying primary pathology.
The main causes of death are:
Aspiration of gastric contents (due to gastroparesis)
Cerebral oedema
Thromboembolic complications
The underlying primary pathology
3.26.1
3.26.2
3.26.3
Diagnosis
Undiagnosed Type 2 DM or known cases of Type 2 DM
Hyperglycaemia (blood glucose often > 28 mmol/l)
Usually no ketones in the urine, although may be present in patient with vomiting
(Particularly trace or 1+)
No severe acidosis (pH >7.3 and HCO3- > 15mmol/l, often normal)
Hyperosmolality (serum osmolality >350mosm/l)
50% of patients are hypernatraemic
± Decreased conscious level and mental confusion
Consider precipitating event
In elderly patients, consider MI, chest infection, etc.
Usually underlying infection (URTI, D&V, UTI, etc, but temp and WCC often
unhelpful)
Newly presenting patient
Acute abdomen
Initial investigations
BM, lab glucose, osmolality
FBC, U&Es, Bicarbonate, amylase, ketones (If available from biochemistry).
Infection screen: CXR, MSU and blood cultures
Arterial blood gases / venous gas if oxygenation is not compromised
Urinalysis
ECG, consider cardiac enzymes
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3.26.4
Initial management
IV access
Insulin regime:
o Fixed Rate Soluble Insulin (Actrapid): 6 iu/hr (or 0.1 iu/kg/hr) IV
o An initial IM bolus can be given if IV access is difficult initially
o Ensure K+>3.3 before starting
Fluid replacement:
o 1 litre N/Saline over 1 hour
o 1 litre N/Saline 2 hourly for the next 4 hours
o 1 litre N/Saline 4 hourly for the next 8 hours
o 1 litre N/Saline 6-8 hourly until rehydrated over 24-48 hours
Potassium replacement::
o Ensure ample Urine Output (>30 ml/h)
o 20mmols/l if 4.0 – 5.5 mmol/l. This requires continuous ECG monitoring.
o 40mmols/l if < 4.0 mmol/l. This is the MAXIMUM rate and a central line and
ECG monitoring are essential.
Consider antibiotics
Low molecular weight heparin
Consider nasogastric tube (mandatory if reduced conscious level: GCS <8)
Urinary catheter if no urine output in first 3 - 4 hours of treatment, or if the patient is
clinically shocked and/or has a reduced conscious level
CVP line often required, especially if IHD present
Monitor U&Es, HCO3- and Glucose after 2 hours, and then at least 4 hourly until the
patient is stable
Stop metformin
Protect pressure areas
The most important aspect of management of HONK is regular examination and reassessment. Alert seniors and Medical Team early, especially if decreased conscious
level.
3.26.5
Points to remember
Fluid deficits tend to be greater but due to increased risk of complications, fluid needs
to be replaced cautiously. A CVP line may be helpful.
Check the insulin infusion if there is any doubt (e.g. has the cannula tissued?)
BMs can be unreliable in the dehydrated or hypothermic patient, and laboratory
blood glucose is important as a cross reference
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3.27
Hypoglycaemia
The following is a summary of our local hypoglycaemia guidelines.
3.27.1
3.27.2
Diagnosis
Patients with insulin-treated DM or Type 2 DM on sulphonylureas
Autonomic symptoms: pallor, sweating, tremor, tachycardia
Neuroglycopaenic symptoms : loss of concentration, behavioural changes (e.g.,
aggression or confusion), fits, transient neurological deficits, reduced level of
consciousness
Some patients particularly with longstanding diabetes may lose their awareness of
hypoglycaemia
Symptoms maybe more nebulous in the elderly
Hypoglycaemia determined firstly by BM done accurately. ALWAYS confirm with a
laboratory glucose
The initial BM reading is <4.0mmol/l, and the laboratory random blood glucose is
usually <3.0 mmol/l
Initial management
IV access
If the patient is unconscious, give 100mls of 10% dextrose and flush well with normal
saline
Re-check BM and give further boluses of 25 - 50 mls of 50% dextrose as necessary
If the patient is un-cooperative or IV access difficult, give IM glucagon 1 mg. The
glucagon effect will wear off after 30 mins, so food is mandatory (N.B. glucagon can
take 10-15 minutes to work and maybe ineffective if there is liver disease or if the
patient is malnourished)
If patient still conscious or semi-conscious (GCS >8, and patient able to protect their
airways), Hypostop can be given (particularly useful for ambulance personnel and
relatives). Squeeze one sachet around the lips and mouth and massage inside the
cheeks afterwards.
NB: If the patient fails to respond within 20 - 30 mins despite adequate BM testing (and
confirmed by a laboratory blood glucose), look for other causes. Consider secondary
cerebral oedema or other underlying causes. Subarachnoid haemorrhage and overdoses
(particularly aspirin and insulin) can initially present with hypoglycaemia.
Further management
As soon as the patient is conscious and co-operative he/she should be given a
substantial snack, e.g. milk and sandwiches. Otherwise they are likely to have further
hypos
Patients with Type 1 DM do not usually require admission
Involve the Diabetic Team prior to discharge
Patients on long acting sulphonylureas MUST be admitted as the risk of
hypoglycaemia persists for 24 - 48 hours and a 5 or 10% dextrose infusion
commenced
NB: Aspirin may exacerbate the action of sulphonylureas. Metformin can cause
hypoglycaemia in patients with liver disease.
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3.27.3
Consider precipitating event
Undue exercise, missed meal or snack for whatever reason, alcohol, excitement or
acute stressful event, etc.
Hypos are particularly likely to occur in pregnant women and children
Beta blockers may mask symptoms of hypoglycaemia, and ACE Inhibitors and
Angiotensin receptor blockers (ARBs) have been shown to increase the prevalence of
hypoglycaemia
Look in the patient’s diabetes monitoring book if possible. It may be necessary to
suggest a reduction in the dose of insulin if there have been consistently low BMs at a
particular time of the day or night
In patients with Type 1 DM (particularly pregnant women and children), ensure that
the patient has Hypostop and glucagon at home and that relatives or friends are
instructed in their use
Consider the possibility of insulin and aspirin overdoses
Consider insulinoma in patients who are not diabetic; send pre-treatment C-peptide
and insulin levels
Deterioration of renal function
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3.28
Sickle cell crises
Below is a summary of the national guidelines, published by the Sickle Cell Society:
http://www.sicklecellsociety.org/CareBook.pdf
3.28.1
Presentation of a sickle cell crisis
Patients with sickle cell disease (HbSS, HbSC, and HbSBthal) can have a number of acute
presentations:
Acute painful crisis (most common) of long bone, limbs or axial skeleton
Infection / fever from functional hyposplensim
Acute chest syndrome
Acute neurological symptoms
Acute abdomen
Acute priapism
Acute anaemia
Common triggers:
Cold weather
Hypoxia
Infection
Dehydration
Acidosis
Alcohol intoxication
Emotional stress
Pregnancy
Worrying symptoms in patients:
Pain that will not go away with home treatment
Fever
Chest pain
Shortness of breath
Abdominal swelling
Increasing tiredness
Unusual headache
Any sudden weakness or loss of feeling
Sudden vision change
Priapism (painful erection that will not go down)
3.28.2
Triage / Initial assessment
On arrival to A&E, the patient should be urgently assessed. This triage should consist of:
Temperature
Pulse
Respiratory rate
Blood pressure
O2 saturation
Pain score
Brief history
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Medical assessment should follow. Important aspects to cover in history taking:
History of this episode
Previous admissions / pattern of admissions
Previous HDU / ITU involvement
Type of sickle disease (i.e. HbSS, HbSC, and HbSBthal)
Previous transfusions / exchange transfusions
Compliance with daily folic acid and penicillin
Are vaccinations up to date? (should have all of these)
Haemophilus influenzae B (HiB)
– Meningococcal C
– Pneumococcal C (Pneumovax)
– Influenza
– Hepatitis B
3.28.3
3.28.4
3.28.5
Investigations
Perform FBC with reticulocyte count, U&E, LFTs, G&S
Blood / other cultures, CRP, MSU if temp >38° and CXR if indicated
ABG if O2 sats <92% on room air
General management of patients in sickle cell crisis
Patients should be seen urgently. Inform Haematology early.
Rapid assessment of pain and administration of appropriate analgesia within
30mins of arrival (see below)
Oxygen if SpO2 < 95%
Keep the patient warm if necessary
Fluids: Fluid resuscitation fluid resuscitate if signs of dehydration, high fever or sepsis
then maintenance fluids (Hartmann’s 1.5ml/kg/hr). Otherwise push oral fluids
Start IV Cefuroxime 750mg tds if fever >38 or signs of sepsis
If afebrile increase Pen V to 500mg qds
DVT Prophylaxis with tinzaparin 4500iu sc od
Antiemetics may be necessary
Consider antihistamine for itch
Refer to Medical team for admission. Inform Obstetric team if the patient is pregnant.
NEVER transfuse a sickle patient without prior discussion with Haematology
Analgesia
Avoid Pethidine because of risk of seizures
Check with patient’s handheld notes for their individual needs
Morphine 0.1mg/kg IV followed by boluses of 2-3 mg every 5-10 minutes until
adequate analgesia is established (unless patient has other needs documented in
notes)
Watch for complications of the analgesia and reassess the patient frequently
Prescribe codydramol or cocodamol 30/500 2 tablets orally qds and Diclofenac
50 mg orally or PR tds unless contraindicated
Contact the Acute Pain Team as soon as possible to commence patient controlled
analgesia (PCA). Bleep 037 or 181 out of hours
Remember the importance of a supportive environment in reducing anxiety and pain
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3.28.6
Acute chest syndrome
A form of acute lung injury leading to ARDS and death. Needs high index of suspicion and
early liaison with Haematology.
Symptoms /signs include:
Chest pain / chest wall pain / thoracic pain
Respiratory symptoms
Reduced O2 sats on air
Fever
CXR shows consolidation starting at the bases (in early stages may have normal
CXR)
Management:
Urgent referral to Haematology / Medical team / ITU team
Oxygen
May need CPAP if pO2 <9.5 or intubation if pO2 <7.5 or pCO2 >6.7
May need exchange transfusion if pO2 <8.0 / transfusion
Cautious fluids iv to prevent pulmonary oedema
Antibiotic cover: cefuroxime 750mg IV tds
Admission to hospital HDU or ITU
3.28.7
Acute neurological symptoms
Be aware that sickle cell patients can present with subtle neurological symptoms and signs
(such as behavioural changes and headache in children and adults). If not diagnosed can
cause significant morbidity / mortality.
Common causes
Ischaemic stroke (children)
Haemorrhagic stroke (adults)
Subarachnoid haemorrhage from aneurysm (adults)
Management
Urgent brain imaging
Discuss patient urgently with Haematology
Urgent Neurosurgical / Neurological opinion
Admit to hospital
3.28.8
Acute abdomen
Investigation and management similar to acute abdomen presenting in non-sickle cell
patients. However, some special considerations.
Common causes
Vaso-occlusion
Constipation
Gallstones / cholangitis
Mesenteric / colonic ischaemia
Pulmonary causes
Hepatic infarction / abscess / sequestration
Intra-abdominal abscess
Splenic infarction
Renal or hepatic vein thrombosis
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Management
NBM, fluids iv
Nasogastric tube
Monitor abdominal girth
Appropriate imaging
Broad spectrum antibiotics iv
Admission to hospital under joint care of Haematology and Surgery
3.28.9
Acute priapism
Can occur in both children and adults. If not treated urgently can lead to permanent
impotence.
Management
Fluids iv
Pain relief
Urgent referral to Urologist for aspiration of blood or injection of phenylephrine from
the corpus cavernosum
Admission to hospital
3.28.10
Acute anaemia
Common causes
Parvovirus B19 infection
Splenic sequestration
Liver sequestration
Fava beans or drug precipitants in patients with co-existing G6PD deficiency
Management
Treatment of shock
Discuss top-up transfusion with Haematology
Admission to hospital
3.29
Management of fever in neutropenic chemotherapy patients
The following is based on Trust antimicrobial policy and agreed local policy.
Haematology and oncology patients may die within hours from apparently trivial infections,
especially if neutropenic (neutrophils <1.0 x 109/L). Commonest initial manifestation is fever
and therefore:
A temperature must always be investigated without delay as immunosuppressed
patients can deteriorate rapidly
A sudden deterioration in the patient’s condition with a drop in BP, even in the
absence of fever, should be managed as an infection
3.29.1
Physical examination
Pay particular attention to:
Mouth (look for ulcers, Candidal plaques etc.)
Chest
Hickman line entry site and subcutaneous track
Abdomen
Blood pressure and pulse (for septic shock)
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3.29.2
3.29.3
3.29.4
Investigations
FBC, U&Es, LFTs, CRP
Blood cultures (at least 2 sets); 1 set from Hickman catheter (to be performed by a
member of staff familiar with the care of Hickman lines), 1 set from a peripheral vein
Swabs from suspect foci of infection (e.g. Hickman entry site)
Urinalysis, urine cultures
CXR
Management
Involve Haematology / Oncology early in the process
– Haematology can be contacted on their bleep via Switchboard as they are
based on-site.
– Oncology can be contacted via Bleep 528 within office hours; out-of-hours,
either leave a voice message to inform them of the admission on ext. 6781 or
fax a referral to ext. 5249.
– For Oncology advice out-of-hours, contact the on-call Oncology Registrar at
Charing Cross Hospital via their Switchboard.
IV fluid resuscitation
Monitor input / output
If temp >38, start broad spectrum antibiotics without delay (see below). DO NOT wait
for Medical Team review first.
Discuss platelet / blood transfusion with Haematology if Hb / Plt counts low
Give paracetamol for fever
Refer to Medicine for admission to a side room
Antibiotic therapy
For Haematology patients:
Tazocin: 4.5g IV tds
PLUS
Amikacin: 15mg/kg/day IV (infusion) od
For Oncology patients:
Tazocin: 4.5g IV tds
PLUS
Gentamicin: 5mg/kg/day IV (infusion) once daily
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4
Paediatrics
This guide is designed to give you a basic outline of common Paediatric conditions.
Remember to ask – senior ED doctors, paediatricians, paediatric nurses if you need advice
or have doubts about your patient.
4.1
Paediatric Red Flags
This guidance has been developed with our Paediatric department.
This is for the attention of all staff working with children. It outlines agreed “red flag” features,
which if present require immediate referral to Paediatrics (usually from Triage). These
patients do not require further workup in A&E and your referral should not be refused or
deferred awaiting blood test results.
History:
Focal seizures
Headache in child under 5 years of age
Non-blanching rash & fever
Police or social work presentation of a child with child protection concerns, or
disclosure of harm by child at triage
Genital injury of any cause
Status epilepticus
Bile-stained vomiting
Clinical examination:
Colour:
o Pale, mottled, ashen blue
Activity:
o No response to social clues
o Ill appearance
o Unable to rouse, or if roused, does not stay awake
o Weak, high pitched or continuous cry
Respiratory:
o Grunting, tachypnoea, respiratory rate > 60/min
o Moderate to severe chest wall in-drawing
Hydration:
o Reduced skin turgor
Others:
o Non-blanching rash
o Neck stiffness
o Focal neurological signs
Additionally, discussion with Paediatric Team following triage if:
2nd or subsequent presentation for same illness
Vomiting post-head injury (NICE guidelines)
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4.2
Normal values
Age
Newborn (term)
3 months
6 months
12 months
2 years
3-5 years
6-12 years
13+ years
Weight (kg)
3-4 kg (~ 3.5)
6
8
10
12
14-18
20-42
>50
HR
120-160
110-150
110-150
100-150
100-150
95-120
70-110
55-105
RR
40-60
30-40
30-40
25-35
25-35
20-30
20-30
12-20
Min Sys BP
50
50
60
65
65
80
80
110
REMEMBER:
The patient's normal range should always be taken into consideration.
Heart rate, BP & respiratory rate are expected to increase during times of fever or stress.
Respiratory rate on infants should be counted for a full 60 seconds.
One Other Useful Formula:
W- Weight: (Age +4) x 2 = weight in kilograms
4.3
Analgesia / antipyretics
Simple things work the best.
4.3.1
Paracetamol (Calpol)
Loading Dose: 20mg/kg
Maintenance dose: 15 mg/kg qds
Remember:
Paracetamol suppositories are very useful - prescribe the closest size to the correct oral
dose. However oral route is preferable, as time to peak concentration is sooner (30-60mins
vs. 2-3hrs).
4.3.2
Ibuprofen (Nurofen)
Loading dose: 10mg/kg
Maintenance dose: 5-10mg/kg tds
Remember:
Diclofenac suppositories can be used, but the doses are much smaller
4.3.3
Codeine
Dose: 0.5mg/kg tds
After oral administration, peak concentration is at 60mins.
4.3.4
Oromorph
10-20kg
21-30k
31-50kg
51-65kg
>65kg
2.5mg
7.5mg
10mg
15mg
20mg
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4.3.5
Intravenous morphine
Dose: 0.05 - 0.1mg/kg
Remember, you do not need to give antiemetics in children.
4.4
Recognition of the seriously ill child
Early recognition and management of developing respiratory distress or circulatory
impairment or changed level of alertness/consciousness in a child will allow further urgent
assessment and treatment.
Where adults tend to suffer sudden cardiac arrest whilst fairly well perfused, a child is more
likely to have a cardiac arrest because of hypoxia and is therefore much more difficult to
resuscitate.
Recognition of the seriously ill or injured child involved the identification of a number of key
signs affecting airway, breathing, circulation or neurological systems.
4.4.1
4.4.2
Airway
Assess for airway obstruction – check for stridor
Foreign body?
Epiglottitis?
Breathing
Tachypnoea in a child at rest indicates that increased ventilation is due to A, B, or C
problem
Intercostal / Subcostal / Sternal recession is seen when the child is struggling to
breathe
The degree of recession indicates the severity of respiratory difficulty. Younger children with
more flexible chests show recession more easily. If seen in older children (>6-7 years old),
this suggests severe respiratory problems.
Accessory muscle use: in children, this may present as head bobbing, when the SCM muscle
is used as an accessory muscle.
Flaring of the Nostrils: seen in infants.
Added noises:
Stridor – upper airway obstruction
Wheeze – lower small airway narrowing, heard more on expiration. Beware a
monophonic wheeze, heard in foreign body inhalation
Grunting – produced by exhalation against a partially closed glottis. Seen in severe
respiratory distress in infants
Effect on other systems:
Tachycardia
Bradycardia – pre-terminal sign
Skin Pallor/Mottling – secondary to vasoconstriction.
Mental Status – assess conscious level
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4.4.3
Circulation
Heart Rate – increases as a result of autonomic compensatory response
Pulse Volume – absent peripheral pulses and weak central pulses are signs of
advanced shock
Capillary Refill time – Normal CRT <2 seconds. Raised CRT may indicate poor
perfusion
Effects on other systems:
Tachypnoea without recession is due to the body trying to compensate for acidosis
resulting from circulatory failure
Skin – mottling, cold, pale skin indicates poor perfusion
Mental Status – initial presentation will be agitation, progressing to drowsiness
4.4.4
Disability
Use AVPU scale
A Alert
V responds to Voice
P responds to Pain
U Unresponsive
Glasgow Coma Scale can also be used in older children
Posture: Sick children are often floppy.
Effects on other systems:
Hyperventilation, Cheyne-stokes breathing
Bradycardia may be due to raised intracranial pressure and is a pre-terminal sign
Frequent reassessment of ABCDE is necessary to monitor progress or deterioration.
The recognition of a serious illness is a child is of greater importance than establishing a
specific diagnosis.
4.5
Intravenous fluids in children
Below is a summary of the local Paediatric guidance on our intranet. It applies to all children
up to the age of 16 but excludes conditions such as acute burns, DKA and patients with renal
or cardiac disease.
4.5.1
Hyponatraemia
Hyponatraemia can develop with any fluid regime. In children, symptomatic hyponatraemia
is a medical emergency. Features suggestive of hyponatraemia include nausea, vomiting,
headache, irritability, altered level of consciousness, seizure and apnoea.
4.5.2
Hypernatraemia
Children with a plasma sodium in excess of 160mmol/L should receive isotonic solutions to
reduce the risk of neurological injury associated with a rapid fall in plasma sodium.
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4.5.3
Fluid resuscitation
If the child is shocked, administer a 20ml/kg bolus of 0.9% sodium chloride (in trauma, use
10ml/kg). Call for senior help immediately and repeat as necessary. Check plasma
electrolytes.
4.5.4
Ongoing fluid needs
The following need to be considered:
Pre-existing fluid deficit (fluid resuscitation plus post resuscitation care)
Maintenance requirement (post resuscitation care)
Ongoing losses (fluid resuscitation plus post resuscitation care)
Once the child is haemodynamically stable, any further fluid deficit or ongoing losses need to
be replaced over a minimum of 24 hours (use sodium chloride 0.9% with 5% dextrose, or
sodium chloride 0.9%). Weigh the child and document this in the notes.
If fluids are required for maintenance and ongoing losses, use one of the above fluid types
(sodium chloride 0.9% with 5% dextrose, or sodium chloride 0.9%).
The Paediatric nurses and doctors can help you calculate maintenance fluids. If only
maintenance fluids are required, it is safe to use sodium chloride 0.45% with glucose 5% or
sodium chloride with glucose 2.5%. Exceptions to this are:
Hyponatraemic on blood results and definitely if less than 135mmol/L
Hypovolaemia / hypotensive
Peri- and post-operative patients
CNS infection
Head injury
Bronchiolitis
Sepsis
Excessive gastric or diarrhoeal losses
Salt-wasting syndromes & chronic conditions such as diabetes, cystic fibrosis &
pituitary deficits, & those requiring replacement of ongoing losses
In the above mentioned cases, use sodium chloride 0.9% with 5% dextrose, or sodium
chloride 0.9% or Hartmann’s solution as appropriate to the patient’s needs.
Calculating Maintenance Fluids
< 10kg:
10-20kg: 1000ml plus 50ml/kg/day for each kg over 10kg
or 40ml/hour plus 2ml/kg/hr for each kg over 10kg
>20kg:
100ml/kg/day or 4ml/kg/hour
1500ml plus 20ml/kg/day for each kg over 20kg
or 60ml/hour plus 1ml/kg/hour for each kg over 20kg
Maximum of 2500ml/day in males and 2000ml/day in females.
Consider adding potassium chloride, up to 40mmol/L, to maintenance fluids once
plasma potassium concentration is known.
Some acutely ill children with increased ADH secretion may benefit from restriction of
maintenance fluids to two-thirds of normal recommended volume.
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4.6
Asthma
This guidance is based on current British Thoracic Society guidelines for the treatment of
asthma in children.
4.6.1
Assessment of asthma in children
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4.6.2
Asthma in infants <2 years
4.6.3
Management points in infants <2 years
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4.6.4
Asthma in children aged 2-5 years
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4.6.5
Asthma in children over 5
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4.6.6
Heliox and other treatments in acute asthma
4.6.7
Discharge planning
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4.7
Bronchiolitis
The following is based on local Paediatric guidance.
The diagnosis of bronchiolitis is a clinical one based on typical history and findings on
physical examination. Bronchiolitis is a seasonal viral illness characterised by fever, nasal
discharge and dry, wheezy cough. On examination, there are fine inspiratory crackles and/or
high pitched expiratory wheeze.
Bronchiolitis typically has a coryzal phase for 2-3 days which precedes the onset of other
symptoms. In the first 72 hours of the illness, infants may deteriorate before improving; in
other words, infants with bronchiolitis will probably deteriorate until at least day 3 of the
illness.
Bronchiolitis mainly affects infants under 2 years old, with peak incidence at 3-6 months.
Many infants with bronchiolitis have feeding difficulties due to dyspnoea and this is often the
reason for hospital admission.
4.7.1
Assessment of disease severity
Assess the following:
RR, HR, colour, O2 saturation
Use of accessory muscles,
Head bobbing, recession
Feeding difficulties / vomiting
Presence of any of the following signs indicates severe disease:
Poor feeding (<50% of usual fluid intake in preceding 24 hours)
Lethargy
History of apnoeic episodes
Respiratory rate >70/min
Presence of nasal flaring/grunting etc
Severe chest wall recession
Cyanosis
Oxygen Saturations <94%
You also should also take account of whether the illness is at an early (and therefore
perhaps worsening) stage or at a later stage.
4.7.2
Criteria for admission
<6/52 old
Fatigue / Pallor
Marked recession, accessory muscle use
Parental concern
RR>60
O2 sats <93% in air
Feeding less than 50% normal amount
Low threshold if ex-prem, chronic disease
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4.7.3
4.7.4
4.7.5
Indications for high dependency / PICU consultation
Failure to maintain O2 sats of >92% with increasing oxygen therapy
Deteriorating respiratory status with signs of increasing respiratory distress and / or
exhaustion
Recurrent apnoea
Treatment
Oxygen as required to maintain saturation >92% via nasal cannula
NGT feeds if severe attack or not tolerating oral feeds (use iv fluids if NGT not
tolerated)
Nasal suction should be used to clear secretions in infants with acute bronchiolitis
who exhibit respiratory distress due to nasal blockage
Advice if discharging
Advise parents they MUST NOT SMOKE around the chid
Illness can recur, so parents must have low threshold for return to hospital
Breathing may be helped by sitting child up a little
No follow-up needed if recovery uneventful
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4.8
Croup
The following is based on local Paediatric guidance.
CONSIDER: 1. Epiglottitis:
Toxic, Drooling.
2. Bacterial Tracheitis: High fever, Toxic, Drooling.
3. Foreign Body:
Sudden onset, no h/o URTI/ temperature.
4. Angioedema:
Swelling of face / tongue / Wheeze. Associated rash.
Stridor:
0 = None.
1 = when upset.
2 = At rest.
Recession:
0 = None.
1 = Mild recession.
2 = Moderate recession.
3 = Severe recession.
WESTLEY CROUP SCORE
Cyanosis:
0 = None.
4 = When upset.
5 = At rest.
Level of Consciousness:
0 = Normal.
5 = Altered Mental state.
Air Entry:
0 = Normal.
1 = Decreased.
2 = Markedly Decreased.
Croup score 0-2: Mild.
Croup score 3-7: Moderate.
Croup score >/= 8: Severe.
Leave child in comfortable position.
Do not insert tongue depressor.
Do not take bloods or insert IV lines.
Do not x-ray.
MILD
0-2
Reassurance.
Consider
Dexamethasone
0.15mg/kg orally (Stat
dose).
MODERATE
3-7
Dexamethasone 0.15mg/kg
orally (max 2 mg)
or
Budesonide 2 mg nebulised
if not tolerating oral or
vomiting.
SEVERE
>/= 8
Call for senior help
including Anaesthetist.
Dexamethasone 0.6 mg/kg
orally if tolerated.
Adrenaline 0.5ml/kg of
1:1000 solution nebulised up
to max of 5 mls.
Can be repeated.
If no improvement or worsening, re-score and act accordingly
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Child may require urgent
intubation and transfer to
PICU (call CATS)
West Middlesex Emergency Department Handbook
4.9
Community acquired pneumonia
The following is based on British Thoracic Society and local Paediatric guidance.
Acute respiratory infections make up 50% of all illnesses in children < 5yrs. Most are upper
respiratory tract infections; only 5% involve the lower tract. Pneumonia is more common in
children < 5yrs. Incidence for children <5yrs is 36/1000/yr and for children 5-14 yrs is
16/1000/yr.
4.9.1
4.9.2
4.9.3
4.9.4
4.9.5
Pathogens commonly involved
Neonates – Group B Strep, E coli, Resp viruses, enteroviruses
<5yrs – Strep pneumoniae, Resp viruses, (occasionally invasive Haem influenza)
>5yrs – Mycoplasma pneumoniae, Strep Pneumoniae, Resp viruses
Clinical features
Fever >38.5°C (bacterial pneumonia to be considered if <3yrs with chest recession,
resp rate > 50)
Cough, tachypnoea, grunting
Breathing difficulties (in older children is more helpful than other clinical signs)
Accessory muscles of respiration use; nasal flaring, in-drawing of chest
Cyanosis, saturations in air <92% (this is a good indicator of lower resp tract
involvement)
Wheeze (if present in pre-school child, primary bacterial pneumonia unlikely)
Crepitations and decrease in breath sounds
Other features: Abdominal pain, chest pain, asthma not responding to treatment
WHO defined tachypnoea
<2 months > 60 breaths/min
12 months > 50 breaths/min
>12 months > 40 breaths/min
Indications for admission to hospital
Oxygen saturations < 92% in air
RR > 70/min in infants, > 50 /min in older children
Signs of severe breathing difficulty; chest wall in-drawing, nasal flaring, grunting,
apnoea
Vomiting or feeding less than half of normal intake
Signs of dehydration
Family unable to provide appropriate observation or supervision
Investigations
There is no indication for routine blood tests for child with uncomplicated CAP.
A child > 2 months old, presenting with clinical signs consistent with pneumonia does not
require any microbiological or radiological investigation before starting treatment.
CRP, ESR, and WBC do not help distinguish between viral and bacterial pneumonia and
should not be measured routinely.
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Useful investigations in hospital:
FBC – WBC, absolute neutrophil count, CRP, + ESR
Blood cultures, paired serology for Mycoplasma (2wks apart)
Nasopharyngeal aspirate in children < 18 months
If significant pleural fluid present, pleural aspiration
CXR – should not be performed routinely in children with mild uncomplicated acute
lower respiratory tract infection
Indications for CXR in either primary care or hospital:
For diagnosis of child < 5yrs with fever of 39°C of unknown origin
If complication (for example, pleural effusion) suspected
Atypical symptoms or unresponsive to treatment
For follow up of children with lobar collapse or ongoing symptoms
4.9.6
Treatment
Oxygen, fluids and other symptomatic management should be given according to
need
Oral Antibiotics (mild cases)
Clarithromycin
<8kg – 7.5mg/kg 12hrly po 7-10 days
1-2yr – 62.5mg 12hrly po
3-6yr – 125mg 12hrly po
7-9yr – 187.5mg 12hrly po
10-12yr – 250mg 12hrly po
>12yr – 500mg 12hrly po
Intravenous antibiotics (moderate to severe cases)
Ceftriaxone
50mg/kg 24hrly IV 7-10 days
Plus
Clarithromycin
Lobar pneumonia
Benzylpenicillin
<8kg – 7.5mg/kg 12hrly po 7-10 days
1-2yr – 62.5mg 12hrly po
3-6yr – 125mg 12hrly po
7-9yr – 187.5mg 12hrly po
10-12yr – 250mg 12hrly po
>12yr – 500mg 12hrly po
25-50mg/kg 4-6hrly IV 7-10 days
Discuss complicated cases i.e. underlying disorders, secondary complications, suspected
aspiration pneumonia, suspected staphylococcal pneumonia.
If a child remains pyrexial or unwell 48 hours after commencing treatment re-evaluate and
consider possible complications or alternative diagnosis.
4.9.7
Medication on discharge
Clarithromycin as above
Duration of antibiotics in total – 7 to 10 days
4.9.8
Follow up
No routine follow up required
Follow up in clinic with repeat CXR in 6-8wks for children with lobar collapse, round
pneumonia, middle lobe involvement or complications
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4.9.9
Complications
Treatment failure caused by antibiotic resistance
Pleural effusion and empyema
Lung abscess
Septicaemia
Metastatic infection – for example, osteomyelitis or septic arthritis
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4.10
Influenza in children
The following is based on both local and national guidance.
The WHO has declared a pandemic flu outbreak with the A/H1N1 virus. Local guidelines can
be found on the intranet under Clinical Policies & Guidelines, Pandemic Flu.
The situation and advice for healthcare professionals is rapidly changing, so please check
the current guidance when seeing any patients with suspected swine flu. Below is a
summary of guidance from local and national sources.
Further information can also be found in the following places:
World Health Organisation Website
Health Protection Agency Website
Department of Health Website
Please also see the Section 3.16 (Influenza in Adults) of the ED Handbook for guidance on
PPE and related issues.
4.10.1
Assessment of patients
Clinicians are now encouraged to diagnose influenza A/H1N1v cases on the basis of
symptoms. The clinical diagnostic criteria are:
Fever (pyrexia ≥38°C) or a history of fever
AND
Influenza-like illness
(TWO OR MORE of the following symptoms: cough, sore throat, rhinorrhoea, limb or
joint pain, headache, vomiting, diarrhoea, poor feeding or poor responsiveness)
severe and/or life-threatening illness suggestive of an infectious process
OR
4.10.2
Children at risk of complications from influenza
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4.10.3
Complications of influenza in children
4.10.4
Investigations
4.10.5
FBC, U&Es, LFTs and blood / sputum cultures should be done in all severely ill
children
CXR if hypoxic, severe illness or who are deteriorating despite treatment
Pulse oximetry should be performed on every child being assessed for admission
No virology is required as pandemic has been declared unless the patient is being
admitted to hospital
Management of children with influenza
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4.10.6
Antiviral dosages in children
Please note that we cannot prescribe or dispense treatment for patients being
discharged. They will need to obtain a prescription from their GP / Out-of-hours
service.
If the child is well enough for discharge, prescribe the appropriate dosage of Clarithromycin
(see section 4.9.6) as well to cover possible community-acquired pneumonia. Additionally,
they should receive Oseltamivir as follows:
Oseltamivir in children under 6 months:
2mg per kg body weight twice daily for 5 days
Oseltamivir in children 6 – 12 months:
3mg per kg body weight twice daily for 5 days
Oseltamivir in children 1 - 3 years (<15kg in weight):
30mg twice daily for 5 days
Oseltamivir in children 3 – 7 years (15 – 23kg in weight):
45mg twice daily for 5 days
Oseltamivir in children 7 – 13 years (23-40kg in weight):
60mg twice daily for 5 days
Oseltamivir in children over 13 years (over 40kg in weight):
75mg twice daily for 5 days
These dosages are also used for any child requiring admission to hospital.
4.11
Allergic reactions
The following is based on the Resus Council guidelines on anaphylaxis and local Paediatric
policy.
Always assess A, B, C and call for help.
4.11.1
Mild allergic reaction (no cardiorespiratory symptoms)
Give Chlorphenamine orally:
<2 years
2-6 years
6-12 years
>12 years
=1mg bd
=1mg 4-6hrly
=2mg 4-6hrly
=4mg 4-6hrly
Observe the patient, reassess and treat further symptoms as appropriate.
Consider giving Prednisolone 2mg/kg orally, up to a maximum of 40mg in a single dose.
Oral Chlorphenamine is well absorbed from the gut; therefore IV treatment offers no
advantage in most children. However, in a small minority of patients where there is concern
regarding swallowing or vomiting, IV Chlorphenamine can be used.
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4.11.2
Anaphylaxis in children
Severe Anaphylaxis – Get immediate help!
Cardiorespiratory symptoms present (wheeze, stridor, noisy
breathing, shortness of breath, pale/grey, unwell, collapse)
Adrenaline IM
> 12yrs:
500mcg (0.5mL)
6-12 years: 300mcg (0.3mL)
>6 years:
150mcg (0.15mL)
High flow oxygen
Call Anaesthetists
Wheeze
Nebulised Salbutamol
0-4yr: 2.5mg, 5yr+: 5mg
Adult or child >12years
Child 6-12 years
Child 6 mo to 6 years
Child < 6 months
Stridor
Nebulised Adrenaline
5ml of 1 in 1000
Chlorphenamine
(IM or slow IV)
10mg
5mg
2.5mg
250mcg/kg
Hypotension / collapse
Normal Saline
20ml/kg IV/IO
Hydrocortisone
(IM or slow IV)
200mg
100mg
50mg
25mg
If no response within 5 minutes or only slight response within 10 minutes
Repeat Adrenaline IM (even if iv access obtained)
Wheeze
Repeat Nebulised Salbutamol
Follow severe/ life-threatening
asthma protocol
Stridor
Repeat Nebulised Adrenaline
Follow severe/ life- threatening
upper airways obstruction protocol
Hypotension / collapse
Further colloid or normal saline
Consider elective intubation if no
response
If no response after 5 minutes or only slight response after 10 minutes
Adrenaline IV / IO given only by experienced specialists
Adrenaline IV Dose: 0.05 - 0.1mL/kg of 1 in 10 000
Inform CATS
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4.12
Fever without a focus
The following guideline is a summary of NICE and local Paediatric guidelines.
Key points:
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4.12.1
Initial Assessment
The key management decision is to admit or elect for out patient management. Consider
admission if parents are anxious & / or social reasons indicate.
Check ABCDE for life threatening features. Alert seniors / Paeds immediately if
these are present
Measure and record temp, HR, RR, cap refill time
Risk assess using traffic light system
Check for dehydration
o If shock present immediately give a bolus of 0.9% saline IV, 20ml/kg
o Give further boluses as necessary
Look for a source with reference to specific symptoms and signs. Remember to
ask about infectious contacts and travel abroad.
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4.12.2
Traffic light system
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4.12.3
Specific symptoms and signs
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4.12.4
Management in Paeds A&E
In summary:
Green features only
Fever less than 38.50C on arrival without antipyretics and no identifiable focus and ’Green’
features only:
No lab tests or antibiotics are necessary in this group apart from Urinalysis
Instruct parents to return to A&E if fever persists more than 2-3 days or condition
deteriorates
Consider antibiotics if urinalysis positive
Amber features
Perform FBC, blood culture, CRP and a urinalysis
Consider CXR if Fever >39°C or WBC >20
Refer to Paeds for consideration of admission / follow-up; antibiotics may be needed
if WCC <5 or >15 or if urinalysis positive
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Red features
Investigate as per Amber patients but also include blood gas and electrolytes
Consider LP in all ages
Start antibiotics immediately
4.12.5
Antibiotic Treatment
See Trust antimicrobial guidelines for children (on the intranet under Pharmacy section,
Clinical Guidelines, Paediatric Antimicrobial Treatment Guidelines).
In general, the following applies:
4.12.6
Admission to hospital
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4.12.7
Antipyretic interventions
4.12.8
Discharging home
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4.13
Urinary tract infection
The following is a summary of NICE guidance and local policies.
4.13.1
Symptoms and signs
4.13.2
Assessment
Assess severity as per “Fever without a Focus” above.
Test urine in children with
Symptoms and signs of UTI (see table above)
Unexplained fever of 38°C or higher (test urine after 24 hours at the latest)
An alternative site of infection but who remain unwell (consider urine test after 24
hours at the latest)
4.13.3
Urine collection
A clean catch urine sample is the recommended method for urine collection.
If a clean catch urine sample is not possible:
If urine bags or cotton balls are used to exclude infection, do not send these samples
to the lab
If other non-invasive methods are not possible:
Use a catheter sample or suprapubic aspiration (SPA)
Do not delay treatment if the sample cannot be obtained and the infant or child is at high risk
of serious illness.
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4.13.4
Urine testing, under 3 years old
In infants and children aged 3 months to 3 years if clinically suspect UTI send two urine
samples for microscopy and culture and sensitivity (MC&S) regardless of dipstick result.
If specific urinary symptoms: start antibiotics.
If symptoms are non-specific: only start antibiotics without waiting for culture result if clinically
indicated.
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4.13.5
Urine testing, over 3 years old
In children aged three years and older dipstick is diagnostically as useful as microscopy
and culture. If mixed growth need to repeat with clean catch sample.
4.13.6
4.13.7
Indications for urine culture
Diagnosis of acute pyelonephritis/upper urinary tract infection
High to intermediate risk of serious illness
Under 3 years
A single positive result for leukocyte esterase or nitrite
Recurrent UTI
Infection that does not respond to treatment within 24–48 hours
Clinical symptoms and dipstick tests do not correlate.
Localisation
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4.13.8
Risk factors for UTI / serious underlying pathology
4.13.9
Acute management
For children >3 months with upper urinary tract infection / pyelonephritis:
Oral cephalosporin or co-amoxiclav for 7-10 days
Erythromycin if penicillin-allergic
If not tolerated (e.g. vomiting) or more severe infection:
Refer to Paeds for IV ceftriaxone for 2-4 days then oral for total 10 days
Consider gentamicin if penicillin-allergic
For children over 3 months with lower urinary tract infection
Oral antibiotics for 3-5 days: cephalexin or co-amoxiclav
If receiving prophylaxis treat any infection with different antibiotic. Asymptomatic bacteriuria
should not be treated.
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4.13.10
4.14
Follow up
Children who do not require imaging should not routinely be followed up
Children with minor unilateral renal parenchymal defect do not require long term FU
unless they have recurrent UTI or family history
Children with bilateral renal abnormalities, impaired kidney function, hypertension or
proteinuria require referral to paediatric nephrologist
The urine does not need to be retested to confirm eradication of infection if the child
is asymptomatic
Head injuries
In this department, head injuries are managed according to NICE guidelines. In paediatric
patients, the same criteria are used to determine the further management of a head injured
patient.
If you feel that a patient requires further investigation or observation, discuss this either with
a senior ED doc, or with the Paediatricians. Head CT scans are requested in trauma
situations by the most senior A&E or Paediatric doctor available; most radiologists prefer to
speak to a middle Grade or SpR, so to avoid any problems, let them make any out of hours
phone calls.
If you are worried about a patient, remember you can always ask a senior to come and
review; never send a patient home if you are unhappy about the discharge.
Early imaging, rather than admission and observation for neurological deterioration, will
reduce the time to detection of life-threatening complications and is associated with better
outcomes. Remember to consider C-spine injuries and NAI.
4.14.1
Initial Assessment
Any child where CT scan is being considered should be discussed at an early stage with
Paediatrics.
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Any child returning to the department within 48 hours of an acute head injury with persistent
symptoms must be reassessed by a senior clinician and discussed with Paeds for
consideration of a CT scan.
4.14.2
When to organise a CT scan
Discuss these cases with Paediatrics early. Anaesthetics need to be involved early (even if
the GCS is above 8) in cases where sedation is required.
Organise a CT scan if any of the following:
Witnessed loss of consciousness lasting > 5 minutes
Amnesia (antegrade or retrograde) lasting > 5 minutes
Abnormal drowsiness
3 or more discrete episodes of vomiting
Clinical suspicion of non-accidental injury
Post-traumatic seizure but no history of epilepsy
Age > 1 year: GCS < 14 on assessment in the emergency department
Age < 1 year: GCS (paediatric) < 15 on assessment in the emergency department
Suspicion of open or depressed skull injury or tense fontanelle
Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid
leakage from ears or nose, Battle’s sign)
Focal neurological deficit
Age < 1 year: presence of bruise, swelling or laceration > 5 cm on the head
Dangerous mechanism of injury (high-speed road traffic accident either as
pedestrian, cyclist or vehicle occupant, fall from > 3 m, high-speed injury from a
projectile or an object)
The Paediatricians must be involved in any suspected case of non-accidental injury in a
child. Consider:
Skull X-ray as part of a skeletal survey
Fundoscopic examination for retinal haemorrhage
Examination for pallor, anaemia, tense fontanelle and other suggestive features
Imaging such as CT and magnetic resonance imaging (MRI) may be required to define
injuries.
Additionally, the social work team and Child Protection Nurse for the Trust may need to be
alerted. Discuss this with Paediatrics on a case by case basis. See the Safeguarding
Children section for more information.
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4.14.3
Associated C-spine imaging
In most circumstances, plain radiographs are the initial investigation of choice to
detect cervical spine injuries – three views of sufficient quality for reliable
interpretation (two views for children under 10 years of age).
Children under 10 have increased risk from irradiation, so restrict CT imaging of cervical
spine to children with indicators of more serious injury, in circumstances such as:
o Severe head injury (GCS ≤ 8)
o Strong suspicion of injury despite normal plain films
o Plain films are inadequate
As a minimum, CT imaging should cover any areas of concern or uncertainty on plain film or
clinical grounds.
If imaging is indicated: imaging within 1 hour of request being received by the radiology
department or when patient sufficiently stable.
Children under 10 with GCS ≤ 8: CT imaging of the cervical spine within 1 hour of
presentation or when sufficiently stable.
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4.14.4
Criteria for admission
The following patients meet criteria for admission to hospital following head injury and should
be discussed with Paediatric Registrar:
Patients with new, clinically significant abnormalities on CT scan
Patients who have not returned to GCS 15 after imaging, regardless of imaging
results
Patient meets criteria for CT scan but this is not performed
o CT not available
o Patient not sufficiently cooperative to facilitate scanning
o Clinical decision to delay scanning in favour of admission for period of
neurological observations
Persistent symptoms of concern to clinician, despite normal imaging
Vomiting, headache not controlled with simple analgesia
Suspicion of NAI
Inappropriate support/supervision on discharge
4.14.5
Criteria for safe discharge
The child can be safely discharged if the following points are met:
If CT not indicated, above criteria not met and no concerns following history and
examination
No suspicion of NAI
Appropriate structures in place for safe discharge and subsequent care, for example
supervision
Following normal CT scan of head, risk of clinically important brain injury is low and
patient can be discharged as long as:
o GCS is 15
o No other factors warranting admission are present e.g. Alcohol/drug
intoxication, shock, meningism, other injuries
o No suspicion of NAI
o Appropriate support structures in place for safe discharge and subsequent
care, e.g. Supervision at home.
4.14.6
Discharge advice
All parents should receive verbal advice and a written head injury advice card (and this
should be documented in the notes); these can be found in Paeds A&E. Ask the nursing
staff for help if you cannot find one.
A communication letter should be generated for all patients who have attended A&E with a
head injury and sent to the patient’s GP within 1 week, including details of clinical history and
examination.
Every patient who has undergone imaging of the head and/or has been admitted to hospital
should routinely be referred to their GP for follow up within one week of discharge.
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4.15
Fits and febrile convulsions
The following is based on current APLS and local Paediatric guidance.
4.15.1
Management of Fits
Note: Dilute the Paraldehyde in the same volume of olive oil prior to PR administration.
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4.15.2
Febrile convulsions
4.15.2.1 Simple febrile seizure
Seen together with fever in a child aged 6 months to 5 years
Seizure is generalized and lasts less than 15 minutes
Child is otherwise neurologically normal by examination or by developmental history
Fever (and seizure) is not caused by meningitis, encephalitis, or other illness affecting
the brain
4.15.2.2 Complex febrile seizure
Age, neurological status before the illness, and fever are the same as for simple
febrile seizure
Seizure is either focal or prolonged (i.e., >15 min), or multiple seizures occur in close
succession
4.15.2.3 Symptomatic febrile seizure
Age and fever are the same as for simple febrile seizure
The child has a pre-existing neurological abnormality or acute illness
Children with a previous simple febrile seizure are at increased risk of recurrent febrile
seizures; this occurs in approximately one third of cases.
Children younger than 12 months at the time of their first simple febrile seizure have a 50%
probability of having a second seizure. After 12 months, the probability decreases to 30%.
Children who have simple febrile seizures are at an increased risk for epilepsy. The rate of
epilepsy by age 25 years is approximately 2.4%, which is about twice the risk in the general
population.
The literature does not support the hypothesis that simple febrile seizures lower intelligence
(i.e., cause a learning disability) or are associated with increased mortality.
Children with relatives, especially brothers and sisters, who have had febrile seizures are
more likely to have a similar episode. Children who are developmentally delayed or who
have spent more than 28 days in a neonatal intensive care unit are also more likely to have a
febrile seizure.
Children who have had febrile convulsions and have recovered completely often do not need
admission, if the parents are happy to take the child home. In some cases, admission is
required for parental reassurance.
If the child is discharged, the parents need to be given detailed instructions about fever
management, and when to bring the child back to the ED.
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4.16
Abdominal pain
The following is based on local Surgical guidance.
The table below lists many causes of acute abdominal pain in children. Information on rare
entities can be found in any standard paediatric surgery textbook.
Causes of Acute Abdominal Pain in Children
Gastrointestinal causes
Genitourinary causes
Gastroenteritis
Urinary tract infection
Appendicitis
Urinary calculi
Mesenteric lymphadenitis
Dysmenorrhoea
Constipation
Mittleschmertz
Abdominal trauma
Pelvic inflammatory disease
Intestinal obstruction
Threatened abortion
Peritonitis
Ectopic pregnancy
Food poisoning
Ovarian/testicular torsion
Peptic ulcer
Endometriosis
Meckel's diverticulum
Haematocolpos
Inflammatory bowel disease
Metabolic disorders
Lactose intolerance
Diabetic ketoacidosis
Liver, spleen, and biliary tract Hypoglycaemia
disorders
Porphyria
Hepatitis
Acute adrenal insufficiency
Cholecystitis
Haematological disorders
Cholelithiasis
Sickle cell anaemia
Splenic infarction
Henoch-Schönlein purpura
Rupture of the spleen
Haemolytic uraemic
Pancreatitis
syndrome
Drugs and toxins
Erythromycin
Salicylates
Lead poisoning
Venoms
Pulmonary causes
Pneumonia
Diaphragmatic pleurisy
Miscellaneous
Infantile colic
Functional pain
Pharyngitis
Angioneurotic oedema
Familial Mediterranean fever
Age is also key factor in the evaluation of abdominal pain.
Differential Diagnosis of Acute Abdominal Pain by Predominant Age
0 to 1 year
2 to 5 years
6 to 11 years
12 to 18 years
Infantile colic
Gastroenteritis
Gastroenteritis
Appendicitis
Gastroenteritis
Appendicitis
Appendicitis
Gastroenteritis
Constipation
Constipation
Constipation
Constipation
Urinary tract infection Urinary tract infection Functional pain
Dysmenorrhoea
Intussusception
Intussusception
Urinary tract infection Mittleschmertz
Volvulus
Volvulus
Trauma
Pelvic inflammatory
Incarcerated hernia
Trauma
Pharyngitis
disease
Hirschsprung's
Pharyngitis
Pneumonia
Threatened abortion
disease
Sickle cell crisis
Sickle cell crisis
Ectopic pregnancy
Henoch-Schönlein
Henoch-Schönlein
Ovarian/testicular
purpura
purpura
torsion
Mesenteric
Mesenteric
lymphadenitis
lymphadenitis
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4.16.1
History
In evaluating children with abdominal pain, a thorough history is required. An algorithm to
aid diagnosis is presented below.
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4.16.2
4.16.3
4.16.4
Physical examination
General appearance including hydration, rashes, jaundice, pallor
Vital signs
Abdominal examination including Rovsing’s sign, rigidity and rebound tenderness
Masses and organomegaly
Testicles / hernial orifices
Investigations
BM
FBC, U&Es, LFTs, CRP
Urinalysis including pregnancy test in girls post-menarche
Imaging as appropriate
Indications for surgical consultations in children with acute abdominal pain
Severe or increasing abdominal pain with progressive signs of deterioration
Bile-stained or feculent vomitus
Involuntary abdominal guarding / rigidity
Rebound abdominal tenderness
Marked abdominal distension with diffuse tympany
Signs of acute fluid or blood loss into the abdomen
Significant abdominal trauma
Suspected surgical cause for the pain
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4.17
Acute gastroenteritis
The following is a summary of current NICE guidance, CG84.
1 in 10 under 5s present to healthcare services every year with this complaint. It accounts
for about 16% of presentations to A&E. Vast majority have an infective cause, of which 80%
is viral, commonest being rotavirus.
4.17.1
Assessment
Suspect gastroenteritis if there is a sudden:
Change to loose watery stool
Onset of vomiting
If you suspect gastroenteritis, ask about:
Recent contact with someone with acute diarrhoea and/or vomiting and
Exposure to a known source of enteric infection and
Recent travel abroad
However, remember not every case of diarrhoea and vomiting is gastroenteritis.
Notify and act on the advice of the microbiology and public health authorities if you
suspect an outbreak of gastroenteritis.
4.17.2
Infection control
Usual infection control measures apply. Hand washing is very important and parents need to
be educated on this aspect, especially after nappy change. Isolation of cases also will be
required.
Bacterial gastroenteritis, food poisoning and dysentery are Notifiable diseases.
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4.17.3
Investigations
Do not routinely perform blood tests. Measure FBC, U&Es and glucose
concentrations if:
o Intravenous fluid therapy (IVT) is required or
o Symptoms or signs suggesting hypernatraemia (see below)
o Signs of sepsis / shock
Take a venous gas to look at chloride and lactate if shock is suspected or confirmed
Blood cultures should be taken if antibiotics are to be given
Urinalysis / cultures
Suspect hypernatraemic dehydration if there are any of the following:
Jittery movements
Increased muscle tone
Hyperreflexia
Convulsions
Drowsiness or coma
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4.17.4
Assessing dehydration
More numerous and more pronounced symptoms and/or signs of clinical dehydration
indicate greater severity. For clinical shock, one or more symptoms or signs would be
present. Interpret symptoms and signs more cautiously in those at risk of dehydration (see
below).
Red flag ( ) symptoms and signs may help to identify children at increased risk of
progression to shock. If in doubt, manage as if there are red flag symptoms or signs.
Dashes (–) indicate that these clinical features do not specifically indicate shock.
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4.17.5
Fluid Management
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4.17.6
Practical points
Children who are dehydrated are thirsty and do not normally refuse oral rehydration
solution
Give fluid little and often, if vomiting decrease volume & increase frequency (every 510 min)
Where carers / child are not willing / able rehydrate under supervision, consider
rehydration by NGT. Discuss with seniors / Paeds team, as oral route is safest
and most effective
Give IV normal saline 20ml / kg bolus x1-2 in severe dehydration if there is circulatory
compromise. Alert seniors / Paeds team
Once hydration complete, start on normal diet including full strength formula or milk
Do not give:
Water alone as this contains no electrolytes or sugar which are needed to promote
absorption and may also cause hyponatraemia
Inappropriate solutions such as juices and coca-cola as these contain very little
sodium and are hyperosmolar and may lead to worsening of diarrhoea, dehydration
and metabolic upset
4.17.7
4.17.8
4.17.9
Fluid management after rehydration
Encourage breastfeeding, other milk feeds and fluid intake.
Consider giving 5 ml/kg ORS solution after each large watery stool to:
o Children younger than 1 year (especially those younger than 6 months)
o Infants who were of low birth weight
o Children who have passed six or more diarrhoeal stools in the past 24 hours
o Children who have vomited three times or more in the past 24 hours
If dehydration recurs, start ORT again.
Criteria for observation / admission
Severe dehydration to be admitted
Mild-mod dehydration – observe for 4-6hrs (4hrs for rehydration & 2hrs for
maintenance of rehydration)
Children whose parents or carers are thought to be unable to manage at home
successfully should be admitted
Uncommon presentation / worrying signs / diagnostic uncertainty should be admitted
Management of feeding during gastroenteritis
Breast fed: Continue breast feeding throughout rehydration and maintenance phases
Formula fed: Rehydrate in 4hrs then restart feeds at full strength.
Weaned Children: Rehydrate in 4hrs then restart child’s normal diet avoiding fatty foods or
foods high in simple sugars. It is also advisable to avoid high fibre foods for a few days.
Starchy foods like dry toast or biscuit, boiled potato, rice and pasta are good weaning foods
in acute gastroenteritis.
Persistent Diarrhoea: If diarrhoea persist for >2 wks and after reintroduction of feeds,
consider lactose intolerance.
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4.17.10
Pharmacotherapy
Infants and children with gastroenteritis should not be treated with anti-diarrhoeal
agents
Most bacterial GE does not require or benefit from antibiotic treatment
Antibiotic treatment may be indicated in infants <6months with salmonellas, in
immunocompromised patients, and in those with proven Salmonella, Shigella,
amoebiasis and Giardiasis
See antibiotic policy on intranet for above
If in doubt please discuss with Microbiology.
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4.18
Diabetic ketoacidosis (DKA) in children
The following is based on local Paediatric guidance.
4.18.1
4.18.2
4.18.3
Useful formulae
Osmolality = (2 [Na + K] + glucose) normally 285-295 mosm / kg but in DKA it can be
300-350 mosm/kg
Anion gap = [Na+] – ([Cl-] + [HCO3-]) Normally 12 + 2 mmol/L [10-14]
Diagnosis of DKA
Known history of IDDM or first presentation of IDDM
Hyperglycaemia (blood glucose >11mmol/L) and venous pH <7.3 & or HCO3
<15mmol/L
Mild DKA: pH <7.30, HCO3 <15mmol/L
Moderate DKA: pH <7.2, HCO3 <10mmol/L
Severe DKA: pH <7.1, HCO3 <5mmol/L
General points
Alert your seniors / Paeds team immediately
Always refer children in DKA
Remember children can die from DKA and causes of death (hypokalaemia and
cerebral oedema) are preventable
Document level of dehydration and conscious level
These guidelines are intended for the management of the sick diabetic child, i.e.
>5% dehydrated
and / or drowsy
and / or clinically acidotic
Children who are 5% dehydrated or less and not clinically unwell usually tolerate oral
rehydration and subcutaneous insulin.
4.18.4
Emergency Management
AIRWAY: Ensure that the airway is patent; use airway adjuncts as required
BREATHING: Give 100% oxygen
CIRCULATION: Insert IV cannula and take blood samples.
If shocked give 10-20ml/kg of 0.9% saline with 20mmol KCl (500ml bags).
Maximum 30ml/kg for resuscitation. This is regardless of initial potassium
level, unless anuria is suspected or there are peaked T waves on the ECG.
Consider N/G tube and urinary catheter
Careful documentation of fluid balance
If comatose, or >10% dehydration with shock, patient will need transfer to PICU
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4.18.5
Initial investigations
Weigh the child or use estimated weight
BM, lab glucose
FBC, U&Es, bicarbonate, osmolality
ABG if unwell
Blood cultures
Urinalysis and urine cultures
Cardiac monitoring
Consider CXR, Throat swab, LP etc.
DKA may be precipitated by sepsis but fever is not a part of DKA.
4.18.6
Fluids
Requirement = Maintenance + Deficit (subtract Initial boluses given)
Deficit (litres) = % dehydration X body weight (kg)
To avoid overzealous fluid replacement, which may be a risk factor for cerebral oedema,
calculate the deficit as if the patient is no more than 10% dehydrated.
Mild DKA correct deficit in 24 hrs
Moderate DKA correct deficit in 48 hrs
Severe DKA correct deficit in 72 hrs
Maintenance fluid formula:
0 –10 kg =100ml / kg
10 – 20k = 50ml / kg
Over 20kg = 20 ml / kg
Example: Body wt. (on admission) = 25kg
The patient is assumed to be 10% dehydrated and moderate DKA
Deficit = 10 / 100 x 25kg = 2.5kg = 2.5litres
Maintenance fluid:
1st 10 kg = 10 x 100 =1000ml
2nd 10kg = 10 x 50 = 500ml
Last 5 kg = 5 x 20 = 100ml
Maintenance fluid for 24hr = 1600ml i.e. 3200ml for 48 hrs
Rate of replacement: 5700 ÷ 48 = 118ml/hr for 48 hours.
Initially use 0.9% saline with 20mmol KCl in 500ml bags.
Switch to 0.9% saline with 5% dextrose and 20mmol KCl in 500ml bags once the blood
glucose has fallen to 14 - 17 mmol / L. If the BM falls further, increase the glucose
concentration in the fluids infused but maintain insulin at 0.1units / kg /hr as this switches off
ketone production.
4.18.7
Bicarbonate
Bicarbonate should only be considered in children who are profoundly acidotic (pH < 6.9) and
shocked with circulatory failure. Its only purpose is to improve cardiac contractility in severe
shock. Always discuss with the Paeds team, who should discuss with the Consultant
in charge.
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4.18.8
Potassium
Potassium should be commenced immediately unless anuria is suspected or there are
peaked T waves on the ECG. 20 mmol of KCl should be present in every 500ml bag of fluid
used.
Check U&Es 2 hours after resuscitation is begun and then at least 4 hourly, and alter
potassium replacement accordingly. Maintain cardiac monitor and observe frequently for T
waves changes.
4.18.9
Insulin
Insulin should not be commenced until 1 hour after fluid resuscitation is commenced.
This reduces the risk of cerebral oedema from over-rapid correction of
hypoglycaemia.
Insulin infusion dose: 0.1 units/ kg/ hr.
The dose of insulin should remain at 0.1 iu/ kg/ hr at least until resolution of ketoacidosis
(pH >7.30, HCO3 > 15mmol/L and / or closure of anion gap). iu= international units
Ideally blood glucose should fall at 5mmol / hr and if this rate is exceeded keep the rate of
insulin infusion same and add more dextrose to the fluid infusion.
4.18.9.1 Insulin regimen
Calculate insulin infusion as follows:
Take 50ml syringe and draw 2.4 units / kg of soluble insulin.
Inject into 50ml syringe and then dilute with 48ml of normal saline.
Mix the insulin and normal saline in the syringe and then set up an infusion pump via
a 3-way tap.
Run solution at 2ml / hr. This rate will infuse 0.1units / kg / hr.
4.19
Management of hypoglycaemia in diabetic children
The following is based on local Paediatric guidance.
Please inform your seniors and the Paediatric team immediately.
4.19.1
4.19.2
Causes of hypoglycaemia
Delayed or missed meal.
Increased level of activity or strenuous exercise.
Increased insulin dosage.
Poor overall control leading to swinging of blood sugar.
OVERDOSE of insulin – deliberate or accidental.
Signs and symptoms of hypoglycaemia.
Feeling faint, sweaty, cold, nauseated or irritable
Abdominal pain, headache or blurred vision
Altered behaviour
Severe hypoglycaemia leads to loss of consciousness and convulsions
Children with diabetes may have signs & symptoms of hypoglycaemia at a
slightly higher level (<5mmol/L) than adult population (<2mmol/L)
Confirm by checking BM
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4.19.3
Management
Child is conscious:
Give sugar or food containing sugar immediately
o Glucose tablets (3 tablets in >5yr, 2 tablets in <5yr)
o Sweet drink (such as 50ml lucozade or other drink containing sugar – not diet
versions)
o 1 heaped tablespoon of sugar dissolved in water
Follow with complex carbohydrate such as biscuits, sandwiches, yoghurts
Child semiconscious or unable to swallow:
Hypostop (40% Dextrose gel), 1/3 of the plastic dispenser bottle
Liquid honey, 2 teaspoons
Both these solutions can either be swallowed or placed between the gum and the
cheek and then massaged in via the outer cheek
Repeat the dose after 10 mins if no response
Child unconscious
Glucagon 0.5mg IM (or SC or IV) if <12yr or 1.0mg IM if >12yr if IV access
unavailable or difficult
5ml/kg of 10% glucose IV followed by an infusion of 5–10% dextrose until the child
is awake if access is available
4.20
Cerebral oedema
This is a major cause of death (accounts for 60- 80% of all deaths in DKA) in diabetic
children and can occur at any time up to 24 hours after the start of resuscitation.
One of the most important principals of management is a slow correction of biochemical
abnormalities with the aim of preventing cerebral oedema.
Cerebral oedema is most likely to occur in the new diabetics and younger child e.g. < 5 yr. of
age and should be suspected if there is deterioration in the patient’s condition during the
treatment of ketoacidosis.
4.20.1
4.20.2
Signs and symptoms of cerebral oedema
Headache, impaired conscious level, increasing BP& slowing pulse ( ↑ ICP)
Confusion, convulsions, papilloedema
Irritability, small pupils, possible respiratory impairment
Management
Exclude hypoglycaemia
Inform Paediatric team / Paeds consultant immediately
Give Mannitol 0.5g / kg stat (2.5 ml/kg of 20% Mannitol over 15 minutes)
Restrict IV fluids to 2/3 maintenance and replace deficit over 72 hrs
Arrange for child to be intubated and transferred to PICU
CT scan to exclude other causes e.g. thrombosis, haemorrhage or infarction
Intracerebral pressure monitoring may be required
Repeated doses of Mannitol (above dose every 6 hrs.) may be necessary
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4.21
Paediatric Glasgow Coma Scale
Best eye response: (E)
4 Eyes opening spontaneously
3 Eye opening to speech
2 Eye opening to pain
1 No eye opening
Best verbal response: (V)
5 Infant coos or babbles (normal activity)
4 Infant is irritable and continually cries
3 Infant cries to pain
2 Infant moans to pain
1 No verbal response
Best motor responses: (M)
6 Infant moves spontaneously or purposefully
5 Infant withdraws from touch
4 Infant withdraws from pain
3 Abnormal flexion to pain for an infant (decorticate response)
2 Extension to pain (decerebrate response)
1 No motor response
4.22
Petechial rash in children
The following is based on local Paediatric guidance.
Petechial spots are non-blanching haemorrhagic spots <2mm in diameter, whereas purpura
are non-blanching haemorrhagic spots >2mm in diameter.
NOT all non-blanching spots are meningococcal disease. Consider other diagnoses i.e. ITP,
HSP, coagulation and other blood disorders, child abuse etc.
Common infective causes of petechiae:
Meningococcus
Group a beta-haemolytic streptococcus
Pneumococcus
Enterovirus
Adenovirus
Petechiae in the superior venal cava (SVC) distribution are usually due to a mechanical
cause – vomiting, coughing, crying, tight clothing, secondary to trauma. Rash confined to the
SVC area is unlikely to be due to meningococcal infection.
4.22.1
Petechial spots in well and afebrile child
Local distribution:
If mechanical cause i.e. SVC distribution after coughing or vomiting - then treat underlying
cause. If there is no mechanical explanation treat as extensive distribution.
Extensive distribution:
Discuss with Paediatrics and perform FBC, CRP and clotting screen. If normal, Paeds likely
to discharge with plan to review in 24-48hrs.
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4.22.2
Petechial spots in well but febrile child
Discuss with Paediatrics and perform FBC, CRP, clotting screen and blood cultures.
Paeds will observe child and discharge if bloods normal and patient well with plans for
review.
If abnormal lab criteria or spreading rash, treat as meningococcal disease.
4.22.3
Petechial spots in unwell child
Unwell / ill child with purpura, increased capillary refill time, or hypotension should be
admitted and treated for meningococcal infection without delay. Refer immediately.
If there is any doubt about the diagnosis discuss urgently with the Paediatric Registrar and
treat.
Give Ceftriaxone 80mg/kg IV twice daily.
Investigations for suspected meningococcal disease
FBC, U&E, Ca, Mg, PO4, LFTs, glucose, clotting screen, FDPs
Blood cultures (ideally before antibiotics)
Blood (EDTA) for meningococcal PCR
Blood (clotted) for acute meningococcal serology
Blood (clotted) for convalescent meningococcal serology (10-14 d)
Throat swab (specify for Meningococcus)
CSF for MC+S (if applicable)
Smear of skin aspiration for gram stain
Venous gas
4.22.4
Management
Treatment in meningococcal disease / suspected meningococcal disease is IV Ceftriaxone
80mg/kg twice a day for 24 –48hrs and then once a day to complete the course.
For children who are sent home, parents must be advised to bring the child back immediately
if they are unwell, irritable or the rash is spreading.
In ALL cases treated as suspected meningococcal disease inform Public Health and
Microbiology.
During office hours
Phone numbers for Public Health on the front of the Notifiable Diseases book in the
Registrars’ Office
Microbiology can be contacted via extensions 5858 or 5784 or Bleep 316
Out of hours
Contact Public Health via Hillingdon Hospital Switchboard on 01895 238282 and ask
for the Public Health Duty Doctor
Microbiology can be contacted via Switchboard
Organise Rifampicin /Ciprofloxacin for household contacts after discussing with Public Health
and Microbiologist.
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4.23
Other rashes in children
Below is an algorithm that can help to decide what kind of rash the patient has
4.23.1
Measles
The incubation period from exposure to onset of symptoms ranges from 8-12 days.
Prodromal phase: malaise, fever, anorexia, conjunctivitis, cough, and coryza.
Course of uncomplicated measles 7-10 days
Signs:
Fever >38°C
Koplik spots on the buccal mucosa prior to appearance of rash
Erythematous and maculopapular rash that becomes confluent beginning on the face
and spreading to the trunk, extremities, palms, and soles lasting about 5 days
Desquamation sparing the palms and soles may occur after 1 week
Generalized lymphadenopathy
Mild hepatomegaly
Management is supportive.
Measles is a Notifiable disease. Contact Public Health and Microbiology.
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4.23.2
Chickenpox
Characteristic rash with successive crops of lesions of different ages of development. May
have had exposure to an infected contact within the incubation period of 10-21 days.
Chickenpox in adults and adolescents may be preceded by a prodrome of nausea, myalgia,
anorexia, and headache but in children there may not be a prodromal illness.
The typical patient is infectious for 1-2 days prior to the development of rash and for 4-5 days
afterwards, which is usually the time at which the last crop of vesicles has crusted over.
Signs:
Malaise
Low-grade fever
Small, erythematous macules with rapid progression to papules, clear vesicles, and
pustules followed by crusting
Spreads from trunk and face peripherally
Pruritus
Clinical variants of chickenpox:
Hemorrhagic lesions (seen in immunocompromised or immunosuppressed)
Bullous chickenpox (needs further investigation)
Complications:
Bacterial superinfection
Encephalitis
Disseminated Varicella infection (rare in children)
4.23.3
Signs:
Impetigo
Tender red rash; may be non-bullous or bullous and usually on face
Honey-coloured crusts
Pruritus
Poorly healing wound / site of trauma
May have systemic upset
Causes:
S. aureus and group A beta haemolytic streptococci
Treat with Flucloxacillin for 7 days. A child with impetigo should be kept out of school or
other activities, usually until 24 hours after treatment has begun.
4.23.4
Erythema multiforme
Associated with many viral / bacterial infections and use of prescription and over-the-counter
medications.
Signs:
Rapidly progressive, symmetrical, cutaneous and/or mucocutaneous lesions (target
lesions)
Centripetal spread
Burning sensation in affected areas
Pruritus generally absent
Lesions may coalesce and become generalised
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Most cases need no treatment, as the lesions will clear up by themselves within 2-4 weeks.
Refer to Paediatrics if systemically unwell and involvement of mucous membranes (StevensJohnson syndrome)
4.23.5
Molluscum contagiosum
It is a cutaneous infection caused by a large DNA poxvirus that affects both children and
adults. Transmission is by direct skin contacts well as auto-inoculation
Most patients are asymptomatic; some complain of pruritus, tenderness, and pain. Some
develop eczema around lesions (10% in series of 95 and 200 cases). The incubation period
ranges from weeks to months (14-50 d).
Primary lesions are firm, smooth, umbilicated papules, usually 2-6 mm in diameter. The
lesions can be flesh-coloured, white, translucent, or even yellow in colour.
Lesions generally are self-limited but can persist for several years. In children, papules are
mainly found on the trunk and extremities.
4.23.6
Fifth disease
Common childhood exanthem caused by human parvovirus B19 (PV-B19).
Incubation period of 4-14 days with a mild prodrome which may include headache, coryza,
low-grade fever, pharyngitis, and malaise. Infrequently, nausea, diarrhoea, arthralgias, and
abdominal pain may occur.
The exanthem begins with the classic slapped-cheek appearance. The bright red erythema
appears abruptly over the cheeks and is marked by nasal, perioral, and periorbital sparing.
The exanthem may appear like sunburn, occasionally is oedematous, and typically fades
over 2-4 days.
Within 1-4 days of the malar rash, an erythematous macular-to-morbilliform eruption occurs
primarily on the extremities. Can involve the palms and soles. Pruritus is rare.
After several days, most of the second stage eruption fades into a lacy pattern, with
particular emphasis on the proximal extremities. Lasts from 3 days to 3 weeks.
Benign self-limited disease requiring reassurance of the parents only. For patients with
arthralgias or pruritus, symptomatic relief can be obtained using oral analgesics and
antihistamines or topical antipruritic lotions.
4.23.7
Scarlet fever
Exotoxin-mediated from group A beta-haemolytic streptococcal infection. Often from a
tonsillar / pharyngeal focus, although the rash develops in fewer than 10% of cases of "strep
throat."
Scarlet fever generally has a 1 to 4 day incubation period. Abrupt onset common with
sudden fever associated with sore throat, headache, nausea, vomiting, abdominal pain,
myalgia, and malaise.
The characteristic rash appears 12-48 hours after onset of fever.
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Signs:
Exudative tonsillitis
Erythematous oral mucous membranes
Petechiae and punctate red macules on the hard and soft palate and uvula
White coating covers the dorsum of the tongue with reddened papillae projecting
through (white strawberry tongue); white coating then disappears leaving raspberry
tongue
Circumoral pallor.
Erythematous patches below the ears, chest, and axilla which develop into scarlet
macules over generalized erythema (boiled lobster appearance).
Skin has a rough “sandpaper” like texture
Desquamation begins 7-10 days after resolution of the rash and may continue up to 6
weeks
Treatment
Phenoxymethylpenicillin or erythromycin for 10 days
4.23.8
Staphylococcal Scalded Skin Syndrome
Acute exfoliation of the skin following an erythematous cellulitis. SSSS is caused by an
exotoxin from a staphylococcal infection.
Presents as a red rash followed by diffuse epidermal exfoliation. Prodrome from S aureus
infection of the skin, throat, nose, mouth, umbilicus, or GI tract occurs but is often not
clinically apparent before the SSSS rash appears.
Signs:
General malaise
Fever
Irritability
Skin tenderness
Fever
Diffuse erythematous rash
Nikolsky sign (gentle stroking of the skin causes the skin to separate at the
epidermis)
Exfoliation of skin, which may be patchy or sheet like in nature
Facial oedema
Perioral crusting
Dehydration may be present and significant.
Refer to Paediatrics for further management.
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4.23.9
Kawasaki’s disease
The following is based on local Paediatric guidance.
Kawasaki disease (KD) is an acute febrile vasculitic syndrome of early childhood.
Kawasaki disease (KD) has 3 stages, as follows.
4.23.9.1 Acute stage (1-11 d)
High fever
Irritability
Non-exudative bilateral conjunctivitis (90%)
Anterior uveitis (70%)
Perianal erythema (70%)
Acral erythema and oedema
Strawberry tongue and lip fissures
Hepatic, renal, and GI dysfunction
Myocarditis and pericarditis
Lymphadenopathy (75%), generally a single, enlarged, non-suppurative cervical node
measuring approximately 1.5 cm
4.23.9.2 Subacute stage (11-30 d)
Persistent irritability, anorexia, and conjunctival injection
Decreased temperature
Thrombocytosis
Acral desquamation
Aneurysm forms
4.23.9.3 Convalescent or chronic phase (>30 d)
Expansion of aneurysm
Possible MI
A tendency for smaller aneurysms to resolve on their own (60% of cases)
Patients with classic KD must have 5 of the following symptoms (fever is an absolute
criterion):
Fever, lasting more than 5 days and refractory to appropriate antibiotic therapy
Polymorphous erythematous rash
Non-purulent bilateral conjunctival injection
Oropharyngeal changes, including diffuse hyperaemia, strawberry tongue, and lip
changes (e.g., swelling, fissuring, erythema, bleeding)
Peripheral extremity changes, including erythema, oedema, induration, and
desquamation
Non-purulent cervical lymphadenopathy
Other findings may include the following:
General - Irritability
Cardiac - Coronary aneurysms, pericardial effusion, myocarditis, CHF
Neurological - Stiff neck secondary to aseptic meningitis, facial palsy, cerebral
infarction
Renal - Sterile pyuria, proteinuria, nephritis, acute renal failure
Musculoskeletal - Joint involvement
Pulmonary - Pleural effusion, infiltrates
GI - abdominal pain, diarrhoea, hepatitis, obstructive jaundice, hydrops, pancreatitis
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Tissues - Meatitis, vulvitis, urethritis
Ophthalmological - Conjunctivitis, uveitis
Up to 10-45% of published cases have incomplete or atypical clinical presentations. The 2
most commonly missing findings include cervical lymphadenopathy and polymorphous rash.
Mucous-membrane changes are the most common manifestations of KD, occurring in more
than 90% of patients with either typical or atypical forms of the disease.
The main goal of treatment is to prevent coronary artery disease and to relieve
symptoms. Involve Paediatricians early if you suspect this diagnosis.
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4.24
Safeguarding Children and Young Adults
The following is based on current local and national NICE guidance.
Safeguarding children and young people (up to the age of 18) is the responsibility of all
healthcare professionals. Any child that presents to the ED with an injury is potentially a
victim of NAI. There are many forms of NAI including physical abuse, emotional abuse,
neglect, sexual abuse (see Section 4.25 for more information) and bullying.
4.24.1
A&E Safeguarding Procedures
The following Safeguarding procedures should be followed for ALL children and young
persons (0-17 year olds) attending our department.
4.24.1.1 Booking in / checking details
All under 18s will have their details checked by reception including GP and NOK
detailed
These details will be checked against the Register of Children with a Child
Protection Plan
Additionally, the number of previous attendances will be noted on the A&E Cas Card
(in the top right hand corner)
This information will be cross checked by the Paediatric Nurse / Doctor seeing
the patient to ensure accuracy
All children and young people should have the name of the person accompanying
them, the Child’s NOK and who has parental responsibility clearly recorded. This
also applies to all 16 and 17 year olds seen in the adult section.
If the doctor or nurse assessing the child is concerned that the child has suffered or is
likely to suffer significant harm then they must consult all the child’s previous notes
and those for any known siblings prior to discharge. Check next working day if out
of hours.
In reviewing previous notes staff should be vigilant to potential patterns of injuries, or
frequent attendances.
For children and young people who are presenting from out-of-area ask why they
have come to WMUH. Record any local address they are visiting.
4.24.1.2 Involving the Paediatricians
All children under 1 year of age with a medical condition.
All children under 2 years of age with a fracture, head injury, cuts/laceration, bruises
and trauma. These patients must be discussed with a middle grade doctor
(Paediatric) prior to discharge.
For all children under 5 years of age, x-rays must be viewed on a high-resolution
screen. Seek advice from the A+E middle grade doctor on duty to read child x-rays.
Any child attending the department suffering or likely to suffer significant harm. The
Paediatric Registrar should consider admitting the child, and must contact the
Consultant Paediatrician on-call regarding management of the care.
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4.24.1.3 In cases where NAI is suspected
The Local Authority is the lead agency for the protection of children. Involve the
Hospital Social Work Team early (during office hours) or the out of hours the
Emergency Duty Social Work Team via the numbers in Section 4.24.5.
In an emergency situation call the Police to prevent the removal of a child considered
to be at risk of harm (Paediatrics will help you with this if you are unsure). A written
referral must be sent to social services within 48 hours of the original verbal referral.
All referrals to the Social Work Team must be documented on the A&E Social Work
Referral Database on the intranet and on Symphony.
4.24.1.4 Children of Vulnerable adults
All staff should be aware of the harm suffered by children when exposed to Domestic
Violence.
Children may also become vulnerable in the homes of vulnerable adults such as
those with an alcohol or drug addiction, or those with unstable mental health issues
When seeing these adults, always check if there are any children at home, and the
details of these children.
All mothers, including those who are pregnant at the time, who attend the department
and are suspected of being victims of Domestic Violence, should be referred to the
Hospital Social Work Team.
If you have concerns regarding any children of a vulnerable adult, always discuss
these issues with the Hospital Social Work Team.
In emergency situations out of office hours the Police and the Emergency Duty Social
Work Team should be consulted.
4.24.1.5 Interagency working
A&E staff must report any child welfare concerns to the Hospital Social Work Team
(or Duty Team out of hours).
Our Liaison Health Visitor is informed of all attendances by children and young
people under 18 years where concerns exist and Community team referrals are made
according to agreed criteria.
However, A&E staff should not rely upon the Liaison Health Visitor to make referrals
for them where concerns exist.
Our Alcohol Liaison Worker and Emergency Psychiatry Teams also feed into this
system if they pick up concerns on their assessment of patients in the department.
There are fortnightly psycho-social meetings between the A+E consultant, Hospital
Social Work Team, Paediatric nurse, Liaison Health Visitor and consultant
Paediatrician to review and monitor the application of these procedures.
4.24.1.6 Unclear social situations
Any child attending A&E who is apparently living within a private fostering
arrangement (i.e. child living with an aunt, friend of the family, etc which has not been
arranged through Social Services) must be referred to Social Services.
Any child who is of school age but not attending school or who does not have a
named school should have this clarified with the parent / guardian. If the situation
remains unclear, discuss the child with the Liaison Health Visitor and Social Work
Teams as appropriate.
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4.24.2
NICE Summary
An approach to safeguarding children is outlined by NICE guidance below:
4.24.3
Signs which may lead to concern
Worrying signs in the history
Inconsistency between the carer and the child’s history
An injury that is not consistent with the history given
An injury that is not consistent with the developmental stage of the child
A changing history
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Physical abuse may present with
Delayed presentation
Unexplained recurrent injuries or burns
Improbable excuses or refusal to explain injuries
Fear of medical help or examination
Aggression towards others
Fear of physical contact
Emotional abuse may present with
Delayed physical, mental and emotional development
Sudden speech disorders
Continual self-deprecation
Overreaction to mistakes
Extreme fear of any new situation
Neurotic behaviour
Extremes of passivity or aggression
Neglect may present with
Constant hunger
Poor personal hygiene
Constant tiredness
Poor state of clothing
Emaciation
Untreated medical problems
No social relationships
Destructive tendencies
Parental behaviour may include
Delay in seeking advice
Minimisation or denial of symptoms
Refusal tallow admission or proper treatment
Aggression
Age appropriateness
Any bruising to a young baby is unacceptable
It is unusual for a child who is not walking to sustain a fracture accidentally
Rib fractures in a young child are suggestive of NAI
Spiral fractures of the long bones are suggestive of NAI
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4.24.4
What to do if you have concerns
If you think that a child may be a victim of NAI, do not work in isolation
Discuss with the Paediatric Nurses
Alert your seniors
Discuss with the Paeds team
If you are concerned about the child’s situation, you can
Discuss with Paeds team regarding possible admission
Discuss with our specialist nurse in charge of Child Protection (Daisy Dholoo)
Discuss with the duty Social Worker and make a Social Services referral
Discuss with our Liaison Health Visitor and make a Health Visitor referral
Make a School Nurse referral
Inform the GP
If at any time you are unsure what to do, discuss with your seniors, the Paediatric
nurses or the Paeds team.
4.24.5
Named Safeguarding Leads in the Trust
Named Doctor, Dr Anne Davies (Consultant Paediatrician) - ext 5743
Named Nurse, Judy Preston - ext 5468
Named Midwife, Tonie Neville - ext 2580
Named Nurse/ Child Death Review coordinator, Daisy Dholoo - ext 5361/ 5362
Liaison Health Visitor, Kathy Godwin - ext 5379
WMUH Children’s Social Work Team - ext 5620
Out-of-Hours:
Contact Paediatric Registrar via switchboard
Hounslow Emergency Duty Social Worker after 5pm - 0208 583 2222
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4.25
Safeguarding sexually active children
The following is based on current local and national NICE guidance.
All the general Safeguarding procedures mentioned in Section 4.24 apply. In addition:
Staff must be aware of the procedure for dealing with children and young people
attending the department where sexual abuse is suspected.
Staff should refer to Hounslow Child Protection Policy and London Protocol Working
with sexually active young people under 18 years (accessed via hospital Intranet –
under Clinical Guidelines, Paediatrics).
4.25.1
Children under 13
A child under 13 is not legally capable of consenting to sexual activity. Any incident
involving a child under 13 is very serious and indicates risk of significant harm to the child.
Always discuss with the Paeds Registrar.
Under the Sexual Offences Act, penetrative sex with a child under 13 is classed as
rape.
If there is concern that a child is involved with penetrative sex or other intimate sexual
activity, suspect that the child, whether girl or boy, is suffering or is likely to suffer
significant harm
Always refer to The Hospital Social Work Team or the Duty Team out-of-hours
Paediatrics and Social Work Teams will involve other agencies such as the Police
Sapphire or CAIT (Child Abuse Investigation Team) teams.
4.25.2
Children under 16
Sexual activity with a child under 16 is also an offence. Where it is consensual it may be
less serious than if the child were under 13, but may still have serious consequences for the
welfare of the young person.
Discuss with the Paediatric Registrar
Consider in every case whether there should be a discussion with other agencies
Except in exceptional circumstances, a referral should be made to the Social Work
Team
The younger the child, the stronger the presumption that the sexual activity should be
a cause for concern
Where confidentiality needs to be preserved, a discussion can still take place without
identifying the child.
Document your discussions and decisions carefully
4.25.3
Young People 16 and 17 years
Sexual activity involving a 16 or 17 year old, though unlikely to involve an offence, may still
involve harm or the risk of harm.
Professionals should still bear in mind the considerations and processes outlined in this
section in assessing that risk, and should share information as appropriate.
It is an offence for a person to have a sexual relationship with a 16 or 17 year old if they hold
a position of trust or authority in relation to them.
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4.25.4
Indicators of Harm
Consider the factors below:
Is the young person competent to understand and consent to the sexual activity they
are involved in (NB. children under 13 cannot legally consent to sexual activity)?
Social circumstances of the young person:
o Who is at home?
o Schooling?
o Already known / under the care of Social services?
Nature of the relationship, particularly if there are age or power imbalances?
Use of aggression, coercion or bribery (either by the sexual partner or peer group),
including the misuse of alcohol or other substances as a disinhibitor?
Is the young person’s own behaviour, for example through misuse of alcohol or other
substances, placing him/her in a position where he/she is unable to make an
informed choice about the activity?
Any attempts to secure secrecy by the sexual partner beyond what would be
considered usual in a teenage relationship?
Are the methods used to secure the young person’s compliance and trust and/or
secrecy by the sexual partner are consistent with grooming for sexual exploitation?
o Grooming is likely to involve efforts by a sexual predator (usually older than
the child or young person)
o Behaviour may include befriending the young person with gifts, treats, money,
drugs, developing a trusting relationship with the child/young person’s family,
developing a relationship with the child or young person through the internet
etc. in order to abuse the child/young person.
Is the sexual partner is known by one of the agencies as having or having had other
concerning relationships with young people (requires Police to be involved to check
this)?
Any additional vulnerability because the young person has a physical dependency or
learning disability?
4.25.5
Information sharing
The child’s best interests must always be at the heart of any decision to share
information
Children are entitled to the same duty of confidentiality as adults.
o However, make it clear to children and young people at the earliest
opportunity and throughout any working relationship that the duty of
confidentiality is not absolute.
o There will be some circumstances where the needs of the child or young
person, or other children and young people, can only be safeguarded by
sharing information with others.
o This discussion with the child or young person should include asking them
their thoughts, feelings and wishes.
o The discussion can be useful as a means of emphasising the gravity of some
situations.
According to current Government guidance, although the age of consent remains at
16, the law should not be used to prosecute mutually agreed teenage sexual activity
between two young people of similar age, unless it involves abuse or exploitation.
Always ask for advice from Seniors, Paediatrics or our named Safeguarding Leads if
you are unsure.
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5
Major Trauma
Below is a summary of current ATLS (8th Ed) guidelines. If you intend to pursue a career in
Emergency Medicine, you will be strongly encouraged to go on an ATLS course.
Aims of ATLS:
Identify the correct priorities in assessing a multiply injured patient
Apply guidelines and techniques to resuscitate and treat a multiply injured patient
Identify how the history and mechanism of injury can identify potential injuries
Anticipate possible pitfalls
5.1
Initial Assessment
The initial assessment consists of:
Rapid primary survey
Resuscitation
Adjuncts to primary survey / resuscitation
Consider the need for patient transfer
Detailed secondary survey
Adjuncts to secondary survey
Re-evaluation
Definitive care
5.2
Preparation
After receiving a pre-alert by ambulance crew
Get help
Decide with senior nurses / senior doctors if a Trauma Call is required, based on skill
mix / numbers available
Check equipment and services required
Ensure standard precautions (gloves, aprons, goggles if necessary) are taken
Check transfer agreements
Patients can be triaged on arrival in a number of different ways depending on the
situation and the resources available
5.3
Primary Survey
Identify and manage problems simultaneously. Use the same priorities for all patients,
regardless of age, gender or situation:
A - Airway maintenance with cervical spine control
B - Breathing with oxygenation
C - Circulation with haemorrhage control
D - Disability or brief neurological assessment
E - Exposure and environment
It is vitally important that all patients are continually assessed and reassessed, especially if a
change occurs in the patient’s clinical state. Always begin that reassessment at “A”.
These priorities are the same regardless of the age or condition of the patient you are
treating.
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5.3.1
Airway maintenance with cervical spine protection
Potential problems with the airway include:
Altered consciousness
Apnoea or inadequate ventilation
Vomiting and other aspiration risk
Maxillofacial trauma
Neck trauma
Laryngeal trauma
Burns patients
Foreign body
Consider if a definitive airway is required and get help from senior doctors in the department
or Anaesthetics. A number of senior doctors in the department have advanced airway skills.
Priorities:
Establish a patent airway
Always suspect C-spine injury and protect the C-spine with collar, blocks and tape or
manual in-line immobilisation
Pitfalls:
Equipment failure
Inability to intubate
Occult airway injury
Progressive loss of airway
Spinal protection
5.3.2
Breathing
Potential problems with the breathing include:
Airway injury
Tension pneumothorax
Open pneumothorax
Flail chest
Massive haemothorax
Always examine the posterior chest as a significant injury may not be apparent from looking
at the front only.
Priorities:
Assessment of chest with inspection, palpation, percussion and auscultation
Oxygenate with high flow oxygen
Ventilate if necessary
Pitfalls:
Airway vs. ventilation problem?
Iatrogenic pneumothorax / tension pneumothorax through positive pressure
ventilation
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5.3.3
Circulation
Potential problems with the circulation include:
Massive haemorrhage
Cardiac tamponade
Blunt cardiac injury
Traumatic aortic disruption
Mediastinal traversing wounds
Priorities:
Get large bore IV access x2
Take blood for FBC, U&Es, BM and Cross-match as appropriate
Control any obvious haemorrhage using pressure, splinting etc.
Restore blood volume with fluids and then blood depending on response
Reassess
Definitive haemorrhage control
Pitfalls:
Aggressive and continued volume resuscitation is not a substitute for definitive
haemorrhage control
Elderly patients have little physiological reserve so may decompensate faster
Athletes and children have greater reserve so may not exhibit signs of tachycardia or
hypotension until late
Medications may mask clinical signs
5.3.4
Disability
Potential problems with disability include:
Extradural haematoma
Subdural haematoma
Contusion
Diffuse axonal injury
Associated spinal injuries
Priorities
Baseline neurological evaluation with GCS scoring or AVPU
A GCS of 8 or less (or an AVPU score of P or U) should prompt definitive airway
management due to lack of protective airway reflexes
Document pupillary responses
Pitfalls:
Observe for changes in neurological status
Alcohol / drugs can alter response
5.3.5
Exposure / Environment
Priorities:
Completely undress patient to visualise injuries
Log roll to expose injuries on posterior chest / back
Avoid hypothermia
Watch for hyperthermia
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5.4
Adjuncts to Primary Survey
During the primary survey, monitoring should be applied to the patient. Other simple tests
and procedures should also be carried out:
Always remember to do a BM
Vital signs monitoring
Pulse oximeter
CO2 monitoring
Urinary / gastric catheters
Urinary output
12 lead ECG
ABGs
Remember adequate pain relief given IV with careful monitoring
Imaging should also be carried out if the patient is stabilised and if it does not delay definitive
treatment
Lateral C-spine
CXR
Pelvic XR
Also consider if appropriate to the clinical situation:
DPL (should be done by the surgical team)
USS / FAST
Early transfer if unable to provide definitive care locally
o Do not delay transfer for diagnostic tests
o Use time before transfer to resuscitate
5.5
Consider the need for transfer
During the Primary Survey and Resuscitation phase, there is often enough information to
decide if the patient needs to be transferred to another facility. This is usually the case if the
patient requires a team / specialist opinion which is not provided by the receiving hospital.
At this hospital, we have to transfer out any cases requiring Cardiovascular, Neurosurgical,
Vascular (Imperial Trust) or Burns (Chelsea & Westminster Trust) expertise. We may also
need to transfer out any complex pelvic fractures (this is organised via on-site Orthopaedics).
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5.6
Secondary Survey
Proceed to the secondary survey only AFTER the primary survey has been completed and
ABCDEs are reassessed. Vital functions should be returning to normal and stabilised.
Priorities:
Detailed history of events / mechanism leading to accident, including “AMPLE”
Physical examination – “head to toe”
“Tubes and fingers in every orifice”
Complete neurological exam
Special diagnostic tests such as CT
Re-evaluation minimises missed injuries; needs high index of suspicion
Reassess frequently, including the need for analgesia
Pitfalls:
Head, Neck and Spine
Eye examinations can be difficult if the patient has massive facial injury and oedema
but must take place in order to exclude significant ocular injury
Some maxillofacial fractures can be missed early in the process; therefore, frequent
reassessment is vital
Blunt trauma to the neck can produce injuries where the symptoms and signs only
present late (e.g. injury to the intima of the carotids)
Cervical root or brachial plexus injury may not be apparent in a patient with reduced
consciousness
Pressure ulcers can develop quickly from immobilisation (e.g. from collar or spinal
board)
Chest and Abdomen
Elderly patients may not tolerate even minor chest injuries and can deteriorate quickly
Children can suffer significant injuries without outward signs, so a high index of
suspicion is required
Injuries to retroperitoneal organs can be very difficult to detect, even with the use of
CT (examples of this are duodenal and pancreatic injuries)
Pelvis and Perineum
Excessive manipulation of the pelvis must be avoided as it can precipitate further
haemorrhage. The pelvis should be examined by gentle palpation only, rather than
“springing” (as previously taught in ATLS)
Blood loss from pelvic injuries which increase the volume of the pelvis can be difficult
to control. Immediate splinting (from a pelvic binder or similar) should be performed
followed by rapid arrangements for definitive treatment such as embolisation or
surgical fixation
Urethral / bladder injury must be suspected when pelvic fractures or straddle injuries
are present. This applies to both males and females, though it is less common in
females (but also more difficult to detect)
Musculoskeletal
Fracture involving bones of the hands, wrists or feet are often missed
Injuries to the soft tissues around joints are frequently missed, thus the need for
frequent re-evaluation
A high level of suspicion must be maintained to prevent the development of
compartment syndrome
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AMPLE History:
A – Allergies
M – Medications
P – Past illness / Pregnancy
L – Last meal
E – Events / Environment
5.7
Records & Legal Considerations
Documentation should be concise and chronological. Diagrams may be helpful, especially
for documentation of lacerations, abrasions and haematomas. Remember that your notes
may later be required for court proceedings, so be thorough.
Seek the patient’s consent whenever possible for necessary procedures. In life-threatening
situations such consent may not be possible; it is acceptable to proceed without it but
document this thoroughly in the patient’s notes.
In cases where a crime may have been committed, you have a duty to preserve any
evidence (for example, clothing, personal belongings, bullets, drugs etc.). Nothing can be
discarded unless the Police have given their permission to do so.
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6
Surgical Emergencies
The following sections are based on local Surgical guidelines.
6.1
6.1.1
6.1.2
Approach to surgical cases
Helpful investigations
FBC, U&E, Amylase, Glu
Urinary ßHCG / urine dip
LFTs in patients with pancreatitis or obstructive jaundice
Indications for AXR
Suspicion of intestinal obstruction
Inflammatory bowel disease
Perform an erect CXR if any suspicion of GI perforation.
AXR not indicated in
Appendicitis
UTI
Gastroenteritis
GI bleed
Acute pancreatitis
6.2
Acute abdominal pain
You will see lots of patients presenting with abdominal pain everyday in A&E. There are
numerous causes of such pain so a detailed history is essential. It is important not to miss
serious causes of pain, e.g. ectopic pregnancy, AAA rupture.
All surgical patients with abdominal pain have pancreatitis until proven otherwise.
All women of child bearing age are pregnant until proven otherwise.
Non urgent causes with no indication for admission should be referred back to GP for further
follow up/specialist referral.
6.2.1
Pitfalls
Steroids / obesity (mask symptoms)
No fever (old / very ill / immunosuppressed)
Disproportionate pain (?infarction / aortic rupture / acute pancreatitis)
Glandular fever => risk splenic rupture with minor trauma
Normal WCC possible in established peritonitis/sepsis
Normal amylase possible in even acute pancreatitis
Moderate increase in amylase possible in acute cholecystitis, perforated PU,
mesenteric infarction
Consider Gynae causes – ectopic / torsion ovarian cyst
Consider Medical causes – MI / pneumonia / PE / DKA
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6.3
Acute appendicitis
Classically presents with colicky central abdominal pain later localising to RIF pain.
Atypical presentations very common depending on position of tip of appendix, e.g. urinary
frequency, altered bowel habit. Urine may be positive to leucocytes so be cautious not to
dismiss as a UTI.
The diagnosis may be difficult in children as they can present with vague abdominal
symptoms and signs without the classic localisation into the RIF as described above.
In women of child bearing age, exclude an ectopic with a ßHCG.
Check testicles in males and hernial orifices in all patients; testicular torsion and strangulated
hernias can present similarly.
Appendicitis is a clinical diagnosis. It cannot be established with blood tests, therefore do
not wait for a WCC or CRP before referring the patient. This has been agreed with the
Surgical Consultants.
Rx:
6.4
IV access & resuscitate
IV opioid & anti-emetic
NBM, refer to surgeons
If pyrexial / peritonitic – IV Cefuroxime & Metronidazole
Acute pancreatitis
ALWAYS send blood for amylase in abdominal pain. The condition has significant mortality.
Most commonly due to gallstones or alcohol
Patient may need urgently resuscitating with IV fluids due to 3rd space fluid shifts.
Investigations: Glu, Sats, amylase, FBC, U&E, Ca, LFT, LDH and ABGs
Amylase usually raised; may be >x5 normal.
However, pancreatitis can be seen with a normal amylase.
Rx: O2, IV access, resuscitate, analgesia, NG tube, catheterise & monitor UO
Measure Glasgow Score, found on SAU admission sheet. Risk of death is predicted by
Glasgow score.
If severe may need input from ITU / HDU.
Complications: ARF, DIC, hypocalcaemia, ARDS. Later risks include pancreatic abscess,
pseudocyst.
6.5
Chronic pancreatitis
These are patients with permanent pancreatic damage usually secondary to long term
alcohol abuse. Patients may present with severe epigastric pain, normal amylase and
requesting morphine / pethidine. Previous notes should be requested on arrival as some
patients may develop drug seeking behaviour.
In this trust, these patients are admitted under the Medical team for pain management with
input from the acute pain service (APS).
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6.6
Acute cholecystitis
RUQ pain +/- radiation to R shoulder blade. Patient usually pyrexial and may be vomiting.
O/E: RUQ tenderness, worse on inspiration (Murphy’s sign).
If a mass is palpable, a mucocoele or empyema may be present and the patient at risk of
sepsis.
Inv: FBC, U&E, Glu, amylase, LFT, CXR, ECG (may be atypical presentation MI).
Refer to surgeons for IV Cefuroxime and USS to confirm presence of stones. Metronidazole
is only required if the patient is jaundiced.
Differential diagnoses: PUD, pancreatitis
6.7
Biliary colic
In patients with RUQ pain that is controlled with simple analgesia and who have normal
WCC, LFTs and amylase.
Refer back to GP for USS if not known to have gallstones and subsequent referral to surgical
out patients.
6.8
Obstructive jaundice
Jaundice, pale stools, dark urine, itching.
Differential diagnoses: hepatitis, cholangiocarcinoma, pancreatic carcinoma.
Remember Courvoisier’s law; ‘in the presence of jaundice, if the gallbladder is palpable, the
cause is unlikely to be a stone’, i.e. Ca pancreas more likely.
Arrange an USS and refer to surgeons.
6.9
Ascending cholangitis
Biliary stasis and subsequent infection.
Charcot’s triad = abdominal pain, jaundice, fever.
The patient may become very unwell and develop septic shock.
Give IV Cefuroxime and Metronidazole and refer to surgeons.
6.10
Peptic ulcer disease
PUD is managed by the Medical team (see Medical section). Very few cases require
surgical input.
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6.11
Other perforations
Pain becomes generalised as peritonitis develops. Abdominal tenderness and guarding are
usually present with absent bowel sounds ± shock and fever.
Perform an erect CXR, but be aware that 25% of perforations have a normal CXR.
Inv: FBC, U&Es, glu, amylase, ABGs, ECG.
Rx: O2, IV access, opioid and antiemetic, IV fluids, NBM, NGT, IV Cefuroxime and
Metronidazole.
Refer to Surgeons; may need a CT to clarify.
Common causes include trauma, diverticular disease, colonic carcinoma and stercoral
perforations in the elderly.
6.12
Intestinal obstruction
Abdominal pain, distension, vomiting, constipation.
Upper GI obstruction – less distension, more vomiting (possibly faeculent)
Lower GI obstruction – more distension, less vomiting.
Mechanical Causes:
Adhesions from previous surgery
Obstructed hernia
Tumours
Volvulus
Inflammatory mass
PUD
Gallstone ileus
Intussusception
Non-mechanical causes (paralytic): post op, due to electrolyte disturbance and pseudoobstruction.
O/E: Check for temperature, dehydration, shock. Check hernial orifices. Scars. Distended
abdomen +/- tenderness. Tinkling/absent bowel sounds. Empty rectum.
Inv: routine bloods, G&S, CXR, AXR, ECG, ABG (if shocked), request old notes. CT
abdomen is the gold standard investigation.
Rx: NBM, IV fluids, analgesia, anti-emetic, NG tube (if vomiting + or very distended), if
shocked – catheterise, give 02, consider central line.
Refer to surgeons.
6.13
Mesenteric infarction
Early recognition essential, as infarction quickly results in irreversible gangrene of a section
of bowel. Presents with sudden severe diffuse abdominal pain, usually in elderly or middle
aged (AF, aortic valve disease, prosthetic valve and hypotension post MI are risk factors).
Patients may give a history of pains after eating, weight loss and other evidence of vascular
disease, e.g. intermittent claudication.
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Inv: Routine bloods, G&S, ABG (often severe metabolic acidosis), AXR, ECG.
Rx: Refer to surgeons ASAP. IV access, IV fluids, NBM, analgesia, anti-emetic, IV
Cefuroxime and Metronidazole.
6.14
Volvulus
Caecal or sigmoid. AXR shows large single dilated loop of bowel. Often spontaneously
relieved with passage of flatus / watery stool.
Refer to surgical team.
6.15
Diverticulitis
Inflammation of diverticulae, with pain and tenderness in LIF. May progress to perforation.
Inv: Routine bloods, CRP, G&S. Blood cultures if sepsis clinically. AXR (mainly to exclude
obstruction/perforation), erect CXR.
Rx: analgesia, IV fluids, NBM, IV Cefuroxime & Metronidazole
Refer to surgeons.
Complications: Perforation, obstruction, massive PR bleed, fistulae (to bowel, bladder,
uterus, vagina), stricture.
6.16
6.16.1
Anorectal disease
Haemorrhoids
Bleeding on defecation (GP to refer to surgical OPD if not excessive bleeding and no
thrombosed piles).
Prolapsed reducible piles – analgesia, stool softeners, GP referral.
Perianal haematoma – Refer to surgeons for I&D
6.16.2
Anal fissure
Severe pain on defecation and often some fresh PR bleeding.
Rx: Rectogesic ointment bd for 6/52 and stool softeners. Warn patients that they will
experience headache in the first few days of using Rectogesic. GP can continue treatment
after first week for a total of 6/52 if appropriate.
If atypical appearance or fails to resolve; GP to refer to surgical OPD to exclude IBD, anal
carcinoma, rectal Ca invading anal canal.
6.16.3
Pilonidal abscess
Infected pit in natal cleft; refer to surgeons for I&D
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6.16.4
Anorectal abscess
80% perianal or ischiorectal. Persistent rectal pain worse on walking/sitting/defecation.
Rx: analgesia, Refer to surgeons.
**If children present with any ano-rectal lesions, ensure possibility of NAI taken in to
account and discuss with Paediatric Registrar. For more information see section on
Safeguarding in Children (on the intranet under Clinical Guidelines, Accident &
Emergency, Paediatric Emergencies)**
6.16.5
Rectal foreign bodies
Exclude perforation with erect CXR. Also perform AXR to locate object. Refer to surgeons
for removal.
6.17
Abscesses
Localised collection of pus. Some may be suitable for drainage in A & E – discuss with your
seniors if unsure.
Most need referral to surgical team, especially if:
Systemically unwell, immunocompromised
Abscess secondary to IV drug abuse
Axillary, groin and perineal abscess should be referred to General Surgery
Breast abscesses can be treated during office hours in Breast Clinic if a clinic is
running. Contact surgical team for more details.
Facial and retropharyngeal abscesses should be referred to ENT
6.18
Vascular problems
All vascular referrals are managed by the Surgical on-call team, who liaise with the Vascular
Service at Charing Cross. If you see a patient with a vascular problem, they should all be
referred to the on-call team who will discuss with Charing Cross regarding further
management.
6.18.1
Ruptured AAA
Can present in a variety of ways
Abdo pain in patient with known AAA
Collapse following back pain
Loin pain in the elderly
Have a high index of suspicion for this diagnosis. Move patient to Resus if not being
managed there already. USS in resus is often the most convenient and rapid investigation to
establish diagnosis if there is any clinical doubt.
Ensure there are 2 large bore cannulae, give O2 and send blood for routine tests, coag and
cross match of at least 10 units and 2 units of platelets and 2 units of FFP.
Give IV analgesia and anti-emetic.
Give IV fluids cautiously as aggressive fluid resuscitation can exacerbate their
condition.
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Catheterise and involve anaesthetist early, who is likely to insert an arterial line / CVP line.
If you suspect a ruptured AAA, fast page the on-call Surgical Registrar.
The Surgical Registrar will discuss with the Vascular Team to determine whether local
management or transfer to Charing Cross is appropriate.
6.18.2
Ischaemic limb
6 P’s of acute limb ischaemia:
Pain
Paraesthesia
Pallor
Pulselessness
Paralysis
Perishingly cold
Commonest cause is embolism or thrombosis.
Risk factors – DM, smoking, hypertension, hypercholesterolaemia, PMH of TIA / CVA / MI.
Rx: Analgesia, correct hypovolaemia, refer to surgeons ASAP (revascularisation required
within 6 hours to prevent muscle necrosis, need for amputation, rhabdomyolysis or ARF).
6.18.3
Axillary vein thrombosis
Upper limb DVT
Primary (Paget-von Schroetter syndrome)
Secondary (related to malignancy, hypercoagulable states, OCP use, pacemaker
wires or CVP line)
Usually presents with swelling, heaviness and pain in affected arm
O/E: dusky swollen arm with localised tenderness and distended collateral veins. May
present with features of a PE.
Inv: ascending contrast venography, or Doppler USS if unavailable.
Rx: Refer to surgeons for anticoagulation with IV heparin prior to warfarinisation.
Treat underlying cause.
6.18.4
Varicose veins
Complications include:
Bleeding – typically in people with longstanding chronic venous hypertension from
thin walled dilated veins at the ankle. Can be a profuse bleed causing hypovolaemic
shock. Rx: elevate leg, apply direct pressure, bandage (cautiously if co-existent
arterial disease). If bleeding continues or shocked, refer to surgeons. All should be
followed up.
Superficial thrombophlebitis – bed rest, elevation, analgesia. Exclude DVT if
suspicious.
Venous ulcers – typically medial aspect of ankle. Clean and dress, elevate. Treat
any surrounding cellulites. Check for Marjolin’s ulcers (areas of malignant change).
GP to arrange district nurse regular review and surgical OPD follow up.
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6.19
Post-op problems
Recent post-op problems such as post-operative wound infections should always be
discussed with the on-call team, who will liaise with the team responsible for the operation.
Some of these will be managed as an Outpatient, whereas others will require admission.
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7
Neurosurgery
The following sections are based on national NICE and local guidance.
7.1
Head injury
Many patients present to the emergency department with head injury. It is important to be
able to recognise which patients require urgent investigations and intervention.
http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11836#summary
7.1.1
Assessment
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7.1.2
Investigation
Skull x-rays are not indicated for head injury.
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Always consider whether there is an associated neck / spinal injury. The following flowchart
will help you decide if imaging is appropriate.
7.1.3
Organising a CT
During 9 - 5 discuss with CT suite radiographer to organise a CT; bring a request form. They
may ask you to discuss with a Radiologist.
After 5pm, CT heads are organised with on-call radiographer. Treat weekends as out of
hours.
Fill out the proforma and an ICE request form and give the completed forms to the
Radiographer, who will perform the scan.
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7.1.4
When to involve Neurosurgery
Discuss any significant abnormalities (on CT or clinically) with the Neurosurgeons at Charing
Cross. They can be contacted on their mobiles via the Charing Cross switchboard. The
following flowchart offers guidance.
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7.1.5
Guidelines for intubation prior to transfer
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7.1.6
Admission of head injured patients
Minor head injuries can be cared for in the A&E observation bay if discharge within hours is
likely. Always discuss these with your seniors before admitting them to the observation bay.
For more complex head injuries requiring more prolonged admission, refer to Orthopaedics.
If a lesion / bleed is seen on the CT, discuss the patient first with Neurosurgery at Charing
Cross. Multiply injured patients should be admitted under the joint care of Surgery and
Orthopaedics.
Patients not immediately transferred to neurosurgical centres are to be admitted under the
care of Orthopaedics for neurological observations.
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7.1.7
Reviewing head injured patients
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7.1.8
Discharging head injured patients
7.1.9
Discharge advice
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7.1.10
7.2
Follow-up of head injured patients
Back pain requiring Neurosurgical input
The following is based on NICE and agreed local guidance.
Back pain is one of the commonest presentations to A&E.
60-80% of people will have low back pain sometime in their lives
30% are referred; 3% admitted; 0.5% operated
90% LBP resolves in 6 weeks, 75% may experience symptoms & disability one year
after initial consultation
Although most will be simple mechanical back pain (see Orthopaedic Section 8.8 of A&E
Handbook), it is important to exclude serious pathology. Remember back pain may be
referred; you must exclude (especially in the elderly) AAA, intestinal perforation,
pyelonephritis, renal colic etc.
7.2.1
History
Pain exacerbated by movement or by prolonged sitting or standing?
Duration of pain?
Pain sudden in onset or gradual over days or months?
Precipitating event?
Systemic symptoms such as fever, weight loss, dysuria, cough, and bowel or bladder
problems?
Current medications?
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7.2.2
Red Flags for back pain
Look for the Red Flags of back pain; these indicate possible serious underlying spinal
pathology (e.g. cauda equina, infection, neoplasm, fracture). These patients need further
investigation (bloods / imaging):
Age under 20 or over 50
Non-mechanical pain / violent trauma
History of cancer
Weight loss or fever
Recent infection, IV drug abuse or immunosuppression
Pain worse on lying flat or severe night time pain
Thoracic back pain or spinal deformity
Progressive neurological deficit
Disturbed gait, sphincter disturbance or saddle anaesthesia
7.2.3
7.2.4
7.2.5
Examination
Examine the whole spine, including an assessment of the range of movement.
Assess the hips and sacroiliac joints
Perform a full neurological examination of the lower limbs
Perform an abdominal examination in all elderly patients to exclude AAA etc.
PR any elderly patient or those with possible cauda equina symptoms
Investigations
Urinalysis
Routine bloods if systemic symptoms or fever
XR only if history of trauma or infection / malignancy suspected
True emergencies
Patients with a history of malignancy / systemic illness and bilateral neurological
deficits
Patients with back pain associated with paralysis or gross muscle weakness
Patients with bilateral neurological deficits associated with bowel or bladder function
loss
These patients (with cord compression secondary to neoplasm, trauma, infection or cauda
equina syndrome) need urgent referral to Orthopaedics for an MRI and further investigations.
7.3
Cauda equina syndrome
Many patients attend the emergency department with complaints of back pain. It is important
to identify those that may have cauda equine syndrome which is a medical emergency.
Red flag symptoms include (see section above 7.2.2):
Urinary and faecal incontinence
Sensory numbness of the buttocks and the backs of the thighs
Lower motor neurone weakness
The LMN weakness depends upon the level at which the cauda equina is compressed.
Commonly, the foot becomes flail with loss of dorsiflexion of the foot (L4) and toes (L4, 5),
and of eversion and plantar flexion (S1). The ankle jerks are usually absent on both sides.
Involve Orthopaedics immediately. Discuss with Radiology regarding urgent MRI.
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7.4
Metastatic Spinal Cord Compression
The following is based on NICE (CG 75) and locally agreed guidance.
Metastatic Spinal Cord Compression (MSCC) is a true emergency. It is defined as spinal
cord or cauda equina compression by direct pressure and/or vertebral collapse or instability
due to metastatic spread or direct extension of malignancy.
Delays in diagnosis, treatment and care can lead to the development of avoidable disability
and premature death.
7.4.1
Diagnosis
Patients with known cancer and new signs / symptoms suggestive of MSCC should be
referred immediately to Oncology / Orthopaedics for further investigation and MRI within 24
hours. The Cancer Network in NW London is in the process of developing a new service
where a co-ordinator at Charing Cross Hospital will accept these patients directly; however,
this is not currently in place.
Patients with new symptoms suggestive of spinal metastases but without neurological
symptoms / signs should be referred to the next available urgent Oncology slot with the
Consultant supervising their care. Fax a referral to the Oncology Office (020 8321 5249)
marked “urgent”.
Do not use plain x-rays to diagnose or exclude spinal metastases or MSCC. Discuss with
Oncology (within hours bleep 528 or out-of-hours via Charing Cross switchboard) and
Radiology if MRI is contra-indicated as repeated plain films increase the risk of spinal
metastases.
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7.4.2
Treatment
7.4.2.1 Handling / Mobilisation
7.4.2.2 Corticosteroids
7.4.2.3 Pain relief
Use the standard analgesic ladder (see A&E Handbook section 2 on the Treatment of Acute
Pain) and call the Pain Team for further advice if this is inadequate to control the patient’s
pain. Also involve the patient’s Oncology team / Palliative Care Team as appropriate.
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8
Orthopaedics
The following sections are based on locally agreed Orthopaedic guidelines.
8.1
General rules
Describe the fracture properly for your documentation and referral.
Remember to include the following information:
Site of the fracture
Type of the fracture: simple, oblique, spiral, comminuted, open and closed
Deformity: displacement, angulation and rotation
Intra-articular involvement
Neurovascular complication
If in doubt discuss with a senior doctor first and then with on call Orthopaedics SHO
BLEEP 114.
Also:
8.2
Pain relief is the first treatment line for all of fractures and dislocation.
Don’t forget to splint the fracture site which is as helpful as pain relief.
Don’t forget for Trauma patients, follow ATLS protocol. Concentrate on ABCDE
priorities first!
If you cannot find a fracture on the X-ray but you are clinically worried discuss X-ray
with a senior doctor. You may need to further discuss the film with the Radiologists.
Any fracture with distal Neurovascular impairment is an emergency.
It is helpful if you learn how to apply POPs, as a loose plaster can not support
fracture site properly.
Consider compartment syndrome for patients with a tight plaster and fractures in
bones associated with a large muscle group. Don’t forget it can also happen in soft
tissue crush injuries.
For paediatric long bone fractures always consider NAI and discuss the case with
your seniors.
Procedural sedation
Procedural sedation is giving inhalational agents (e.g. Entonox) or intravenous agents (e.g.
Midazolam and Fentanyl) to produce sedation in a patient for a painful procedure.
Inform your seniors if you want to sedate a patient. All sedations in the department must
be performed by two doctors, one to oversee the sedation and the other to perform the
manipulation or procedure.
A full risk assessment must be performed to assess the suitability of the patient (comorbidities, drug history, allergies, last meal, and previous reactions to anaesthetic agents).
Procedural sedation in A&E should not be performed on patients who are not fasted (at least
4 hours) or who have significant co-morbidities.
Verbal consent for the sedation and the procedure must be obtained prior to sedation. This
must be carefully documented in the notes.
Patients should be fully monitored in Resus during the sedation. Aim for “awake sedation”
with a GCS of ≥10 where verbal response is maintained at all times. Sedation deeper than
this is a GA and is not safe in A&E. Document observations before and after sedation.
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Following the procedure, the patient must be observed until the effects of the sedation have
worn off. The patient must be given post discharge advice regarding the sedation (no driving
/ drinking alcohol / working heavy machinery in the next 24 hours, should be supervised for
the first 12 hours and to return to A&E if any persisting adverse effects following sedation).
8.3
Open fractures
Open fractures occur when the fracture is open to the air (beware of the small
puncture wound close to the fracture site – does this actually represent an open
fracture?)
Treat life–threatening injuries before limb threatening
Give analgesia
Correct obvious severe deformities with gentle traction following analgesia and
sedation if necessary and splint the fracture site. Always get senior help!
Check distal neurovascular status frequently
Take a photo for the notes if possible
Remove obvious contaminants, irrigate with saline and cover with saline soaked pads
Give IV antibiotics
Check tetanus status and take appropriate action
Refer all open fractures.
Some open distal phalangeal fractures of the toes can be treated with wound toilet,
debridement and closure under LA, but seek advice from your seniors.
Open distal phalangeal fractures of the fingers are referred to Plastics at Chelsea. If in doubt
because the nail bed is not involved, discuss the case with a senior doctor. (See Plastics
Section)
If discharging a patient with an open fracture for review with another service, advise elevation
and prescribe antibiotics and analgesia.
8.4
Head injuries
See Neurosurgery section 7 of the A&E handbook for more information.
If a patient has a mild head injury and no indications for CT, they can be observed in the Obs
Bay prior to discharge (always discuss these with a senior before admitting them under
A&E).
If the patient has an abnormal CT, it should always be discussed with Neurosurgery at
Charing Cross. If they have an abnormal CT but no Neurosurgery is required, they are
admitted under Orthopaedics.
8.5
C-spine injuries
Follow ATLS protocol and fully immobilize the neck with a hard collar and blocks on sides.
If you find any abnormality on the X-ray or any neurology in examination refer the
patient immediately.
Always remember that C-spine injuries are often associated with head injuries or
injuries to the rest of the spine
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8.6
8.6.1
Upper limb injuries
Hand fractures (closed)
Always note down hand dominance and patient’s occupation in your documentation. Some
cases can be referred to Orthopaedics / Fracture clinic but more complex cases should be
considered for referral to the Plastics Team at Chelsea. Always discuss the case with a
senior doctor before referring your patient to Chelsea.
Distal phalangeal fractures: if it is not grossly displaced treat them with analgesia and
elevation and refer them to Fracture Clinic after discussion with your seniors (Also see
Plastics section).
Middle and proximal phalangeal fractures: treat them with neighbour strapping and
analgesia.
If angulated will need manipulation under LA (ring block). Discuss with your seniors; if
unstable may need referral to Plastics or Orthopaedic SHO!
If your reduction is unsatisfactory, refer the patient after discussion.
2nd, 3rd, 4th and 5th metacarpal fractures: look for rotational deformity. If present, refer.
Otherwise consider volar slab and/or neighbour strapping if undisplaced and refer to Fracture
Clinic, or Plastics SHO at Chelsea if more complex.
Tip: If displaced check with seniors as internal fixation might be necessary. Refer to Plastics
SHO at Chelsea or Orthopaedics.
Thumb metacarpal fractures: refer these if displaced otherwise POP and Fracture Clinic.
Always check collateral ligaments.
Always refer fractures through the base of first metacarpal with radial subluxation of MC
(Bennett’s fracture).
8.6.2
Hand injuries
Remove rings ASAP
X-ray if any concerns about a foreign body
Check neurovascular status very carefully
Don’t forget to check Radial, Ulnar and Median motor and sensory functions in hand
Don’t give LA until you are sure sensation is intact
Refer all nerve and tendon injuries to Plastics SHO at Chelsea
Avoid subcutaneous sutures (if you think you need them, you are dealing with an
extensive wound which should be closed in theatre under GA)
Check tetanus status
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8.6.3
Wrist fractures
8.6.3.1 Scaphoid fracture
Important not to miss due to risks of malunion, delayed union and non-union
Always check for tenderness over anatomical snuff box, over tubercle of scaphoid
(palmar surface) and compress longitudinally over thumb
Flexion and ulnar deviation of wrist cause pain
If displaced fracture discuss with Orthopaedics; otherwise scaphoid plaster and
fracture clinic
If X-ray is normal but clinically suspicious give the patient a wrist splint and bring the
patient back in 10 days to A&E clinic
8.6.3.2 Lunate dislocation
Rare but often missed
Median nerve paraesthesia may give a clue to the diagnosis
Lateral wrist X-ray is characteristic
Refer to Orthopaedics
8.6.3.3 Colles fracture
Distal radius fracture within 2.5cm of wrist with dorsal angulation
Reduce under haematoma block, then apply back slab and repeat x-ray
Refer if comminuted, grossly displaced, intra-articular or unable to reduce to an
acceptable position in A&E
Always seek advice from Orthopaedics for young active patients with Colles fracture
If position acceptable after reduction, discharge with sling and adequate analgesia to
Fracture Clinic
8.6.3.4 Smith’s fracture:
Unstable distal radius fracture with volar (anterior) displacement
Immobilize in back slab and refer to Orthopaedics
8.6.3.5 Barton’s fracture
Intra-articular fracture of the volar portion of the distal radius
Unstable; refer to Orthopaedics for ORIF
8.6.4
Forearm fractures
Golden rule here is not missing the second fracture (paired bones). If there is any fracture in
shaft of radius or ulna there is often another fracture / dislocation in the other bone.
X-ray one joint above and below the fracture.
If undisplaced and just one bone fractured treat in an above elbow backslab and refer to
Fracture Clinic.
8.6.5
Supracondylar fracture
Common in Paediatric patients
Immobilise ASAP with backslab / splint prior to x-ray
Always check and document distal neurovascular status
Always discuss the management with your seniors and Orthopaedics on call as most
patients need MUA or ORIF
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Remember ossification centres at the elbow in children. They appear from six months up to
twelve years old:
Capitellum (1 year)
Radial head (3 years)
Internal (medial) epicondyle (5 years)
Trochlea (7 years)
Olecranon (9 years)
External (lateral) epicondyle (11 years)
Visualisation of these in your patient’s age group will help distinguish between a fracture and
an ossification centre.
8.6.6
Humeral shaft fracture
X-ray usually looks displaced / angulated; however after applying U-slab it often realigns
well. Discuss with Ortho for further management if still angulated; otherwise discharge with
adequate analgesia and refer to Fracture Clinic.
Always check radial nerve function.
8.6.7
Neck of humerus fracture
Discuss if significantly displaced with Orthopaedics otherwise manage in a collar and cuff
sling. Refer to Fracture Clinic.
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8.6.8
Shoulder dislocation
Usually anterior and obvious clinically. If “light bulb” sign is present on the x-ray, think of a
posterior dislocation.
Reduce the dislocation with adequate sedation and analgesia. Always alert your seniors
prior to sedation, as this needs to be performed by two doctors. In patients with recurrent
shoulder dislocation, Entonox is often adequate to reduce the shoulder.
First time dislocations should be referred to Fracture Clinic for follow-up. Recurrent
dislocations should be referred back to the GP for OP physiotherapy or Orthopaedic OPD as
appropriate. Sharon or Liz our Physios can give advice on staged exercises prior to the
patient’s discharge.
Don’t forget:
Sensory check before and after manipulation and document it (Axillary nerve)
8.6.9
AC dislocation
Very common and easily missed. Most require rest in a broad arm sling and analgesia,
followed by Physiotherapy. Refer to Sharon, our A&E Physio. Refer to Ortho if it is grade 3
or 4 or the skin is under pressure.
8.6.10
Clavicle fracture
Very few require surgical intervention. Refer to Orthopaedics if there is tenting of the skin.
Otherwise, rest in a broad arm sling, give analgesia and refer to Fracture Clinic.
8.7
8.7.1
Lower limb injuries
Pelvis
Follow the rule of rings.
For trauma patients don’t forget to check SI joints and sacrum. Any injury which increases
the volume of the pelvis must be reduced immediately using a pelvic binder or similar to
reduce haemorrhage as it is a life-threatening injury.
Acetabular fractures can be seen as part of high velocity trauma and are serious if missed,
as they are often associated with other life-threatening injuries. Additionally, if left untreated,
it can lead to disabling arthritis of the hip joint. It requires reduction and stabilisation
operatively. Have a high index of suspicion if there is abnormal positioning of the hip at rest,
severe pain on movement but no fracture seen on x-ray of the hip. Special acetabular views
or additional imaging may be required; discuss with Radiology.
In significant pelvic injuries, have a high index of suspicion for bladder and urethral injury.
Gross haematuria with an anterior pelvic injury signifies bladder rupture until proven
otherwise. See Urology section 14.6 for more information.
In the elderly, pubic ramus fractures can occur with a minor fall. These should be mobilised
and discharged if this successful (refer to Radiate team for support). If unable to mobilise,
refer to Medicine for in-patient rehab.
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8.7.2
Neck of femur fracture
Please follow the NOF pathway.
Prescribe adequate analgesia, IV fluids, perform ECG, CXR and standard blood tests.
Refer to Orthopaedics.
Don’t forget to think about the cause of the fall in your patient (e.g. MI excluded?).
Pitfall: Sub-capital fractures can be missed so if clinically fractured but you cannot see it on
the x-ray, discuss with your seniors.
8.7.3
Hip Dislocation
If a hip prosthesis is dislocated you can reduce it under sedation if appropriate (often this is
unsuccessful in A&E). Refer to Orthopaedics.
If the patient has a traumatic dislocation of the hip (i.e. not a prosthesis), remember to follow
ATLS protocols (resuscitate ABCDEs before attempting to reduce the hip).
8.7.4
Trochanteric avulsion fracture
Treatment is usually conservative with early mobilisation, if in doubt discuss with your seniors
or the Physios.
8.7.5
Shaft of femur
Remember ABCDEs, as the patient can lose a considerable volume of blood with this
fracture.
The fracture needs to be reduced and skin traction applied to prevent further blood loss. The
patient will require adequate analgesia / sedation or a femoral nerve block to achieve this.
Do not attempt this on your own! Always speak to a senior about nerve blocks.
Document neurovascular status of the leg prior to nerve block if attempting.
8.7.6
Knee
A knee x-ray is only required for knee injury patients with any of these findings (Ottawa Knee
Rules):
Age 55 or over
Isolated tenderness of the patella (no bone tenderness of the knee other than the
patella)
Tenderness at the head of the fibula
Inability to flex to 90 degrees
Inability to weight bear both immediately and in the casualty department (4 steps unable to transfer weight twice onto each lower limb regardless of limping)
Document range of movement and stability of the knee following injury by examining the
collaterals, cruciates, patellar ligaments and menisci. If the knee is stable and no fracture is
seen on the x-ray, refer to Sharon or Liz the A&E Physios.
“Locked” knees due to meniscal “bucket handle” tears should be referred to Fracture Clinic
for review. Discharge with crutches and analgesia.
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Traumatic knee effusions are usually due to significant injuries to the knee (ACL tear,
significant meniscal tear or fracture) and therefore should be referred to Fracture Clinic for
review.
Tibial plateau fractures are easy to miss as they are often impacted rather than being
displaced. If you are clinically suspicious (traumatic knee effusion, unable to weight bear,
joint line tenderness on palpation) but cannot see a fracture on the x-ray, discuss the x-rays
with your seniors. Tibial plateau fractures should be referred to Orthopaedics.
Patients with patellar fractures must have their ability to straight leg raise documented. If the
fracture is unstable / transverse, they lose the ability to do this. Discuss with Orthopaedics if
concerned but most can be sent to Fracture Clinic.
Patella dislocations (usually lateral) usually can be reduced under Entonox sedation. For
first time dislocations, immobilise in a cylindrical cast, give crutches and refer to Fracture
Clinic. In recurrent dislocations, refer back to GP for physiotherapy and referral to
Orthopaedic OPD if appropriate.
8.7.7
Tibia and Fibula shaft fracture
Golden rule is if there is one fracture look for the second one (paired bones).
Beware of compartment syndrome in these patients.
Always check neurovascular function in the leg and document common peroneal nerve
function if fracture is at the neck of fibula.
Treatment depends on degree of displacement and presence of rotational deformity; always
discuss these injuries with Orthopaedics.
8.7.8
Ankle
For any ankle / foot injury, always examine:
Neck of fibula
Medial malleolus
Lateral malleolus
Achilles tendon
Talus
Calcaneum
Midfoot
Base of 5th metatarsal
Ankle sprains should be mobilised early following RICE; refer to Sharon our Physio if you are
having difficulty mobilising the patient.
X-rays are only required if there is any pain in the malleolar or midfoot area, and any one of
the following (Ottawa ankle rules):
Bony tenderness along the distal 6 cm of the posterior aspect of the tibia or tip of the
medial malleolus
Bony tenderness along the distal 6 cm of the posterior aspect of the fibula or tip of the
lateral malleolus
Bony tenderness of the base of the fifth metatarsal
Bony tenderness of the navicular bone
Inability to bear weight both immediately and in the emergency department for four
steps
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Certain groups are excluded, in particular children (under the age of 18), pregnant women,
and those with diminished ability to follow the test (for example due to head injury or
intoxication).
Simple, stable isolated lateral malleolar fractures can be treated in a below knee backslab,
crutches and sent to Fracture Clinic.
The following fractures should be referred to Orthopaedics:
Displaced medial, lateral, or posterior malleolar fractures
Medial malleolar fracture with lateral ligament damage
Lateral malleolar fracture with deltoid ligament damage
Fibula fracture above the syndesmosis (Weber C)
All bimalleolar fractures
All trimalleolar fractures
All intraarticular fractures
All open fractures
All pilon fractures
An ankle dislocation is an emergency.
The patient should be quickly assessed, given adequate analgesia / sedation and the ankle
reduced, especially if the skin or neurovascular status is compromised. Do not wait for an xray; it should be clinically obvious.
Document neurovascular status before and after the reduction and apply a backslab
following reduction and prior to sending for post-reduction films. Refer to Orthopaedics once
the ankle has been reduced.
8.7.9
Foot
Talar fractures involving the neck of the talus can compromise the blood supply to the talus
and lead to avascular necrosis. Arthritis and chronic pain can also frequently result from
talar fractures. Refer these injuries to Orthopaedics for further management.
Calcaneal fractures are often sustained from a fall from height, therefore spinal and other
long bone fractures must be excluded. Refer to Orthopaedics for further management.
Navicular fractures can often be difficult to see on X-ray but if clinically suspicious discuss
with your seniors, as there is a risk of avascular necrosis. Any displaced fractures should be
referred to Orthopaedics, otherwise apply POP and refer to Fracture Clinic.
Multiple metatarsal fractures can be associated with tarso-metatarsal dislocation (Lisfranc
fracture dislocation) which is an Orthopaedic emergency. If there is one fracture in the base
of MT look carefully for the others and for dislocation.
Fractures through the base of the 5th metatarsal from an ankle inversion injury can be put into
a POP and referred to Fracture Clinic.
8.7.10
Toes
If not open or not deformed do not perform an X-ray. Apply neighbour strapping, give
adequate analgesia and reassure. Toe fractures do not need referral to Fracture Clinic.
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8.8
Simple mechanical back pain
Firstly, exclude RED FLAGS for back pain. See Neurosurgical section 7.2.2 of the A&E
Handbook for more details.
If the red flag symptoms have been excluded, consider simple mechanical back pain. In
simple mechanical back pain, encourage mobilisation. They should not be referred to
Orthopaedics (unless this is for pain control which cannot be managed in the A&E setting) or
Fracture Clinic. Refer to Sharon our Physio for exercises prior to discharge. In those with
nerve root symptoms but no worrying neurological signs, refer back to the GP for follow-up.
8.9
Paediatric fractures
There are a few differences between paediatric bony injuries and adult fractures.
Remember
Children’s bones are still growing, always consider the growth plate
Children’s bones often bend, not break
Terminology
Diaphysis: shaft of long bone
Metaphysis: widened area of the shaft adjacent to the growth plate
Epiphysis: area of cartilage / bone where the growth plate is attached
Physis: the growth plate
If you are not sure about an x ray, ask a senior to review it – paediatric x rays are difficult to
interpret.
8.9.1
Epiphyseal plate fractures:
30% of children fractures involve the growth plate (physeal plate).
Salter-Harris Classification:
Salter I: Transverse fractures of the growth plate without injury to metaphysis or epiphysis
Salter II: Transverse fractures of growth plate which split obliquely into the metaphysis
Salter III: Transverse fractures of growth plate which split obliquely into the epiphysis
Salter IV: Extend through bony epiphysis across the growth plate and into the metaphysis
Salter V: Crushed growth plate
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Refer all patients with displaced fractures through the growth plate and any patient with
Salter Harris III, IV or V injuries. Salter Harris I is difficult to diagnose as the x-rays are
normal but have a benign course. Salter Harris II injuries are often managed can be
managed in a POP with referral to Fracture Clinic if not displaced.
8.9.2
Diaphysis (shaft fractures)
Buckle (torus) fractures – caused by compression failure of bones. It occurs usually near
the metaphysis. These are normally managed conservatively as the majority heal well with
no sequelae.
Greenstick fractures – occurs when bone is angulated beyond limit of bending. If the limb
appears clinically straight, the position is usually acceptable (i.e. it will be less than 20
degrees angulation). However, if the limb looks deformed, refer to Orthopaedics for
manipulation and reduction.
8.10
8.10.1
8.10.2
The limping child
Questions to be asked
Duration and progression of limp
Recent trauma and mechanism – beware limitations of paediatric history and
possibility of unintentional trauma
Associated pain and its characteristics
Accompanying weakness
Time of day when limp is worst
Can the child walk or weight bear
Has the limp interfered with normal activities
Presence of systemic symptoms like fever, weight loss
Generalised medical history – including birth, immunisation, nutritional and
developmental
Examination
The gait of a child is different from that of an adult for the first three years of life. Children
typically take a lot more steps per minute at a slower speed than adults to compensate for
their immature balance. Toddlers tend to flex their hips, knees and ankles more than adults
in order to lower their centre of gravity and improve their balance.
The examination should follow the usual Look, Feel, Move system.
Problems at the hip are often the cause of the limp and are frequently associated with hip
pain on examination. However, remember that knee pain can be referred from the hip and
can also indicate a problem with the hip. Always examine and x-ray the hip in children
presenting with knee pain.
Common causes of a limping child are listed below:
Age 1-5 years old
Trauma
Transient synovitis
Osteomyelitis or septic arthritis
Developmental dysplasia of the hip
Juvenile rheumatoid arthritis
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Age 5-10 years old
Trauma
Transient synovitis
Osteomyelitis or septic arthritis
Perthes disease
Age 10-15 years old
Trauma
Osteomyelitis or septic arthritis
Slipped upper femoral epiphysis
Chondromalacia
Neoplasm
8.10.3
Transient synovitis
Commonly occurs after a respiratory illness.
FBC and ESR are normal or slightly raised.
X Rays may be normal. USS may show an effusion.
Treatment is rest and physiotherapy.
NSAID are useful and can shorten the duration of the symptoms.
8.10.4
Septic arthritis
Emergency orthopaedic consultation with further management is required, with antibiotics
given together with aspiration, arthroscopy, drainage and debridement.
The child may be unwell, pyrexial, in pain and refusing to move the affected limb.
WCC is raised, together with CRP. Blood Cultures are normally positive.
X ray images show delayed changes.
Acute osteomyelitis is suggested by overlying soft tissue oedema at 3-5 days after infection.
Bony changes are not evident for 14-21 days and initially present as periosteal elevation
followed by cortical or medullary lucencies. By 28 days, 90% of patients show some
abnormality.
Joint aspiration is the definitive diagnostic procedure, and the most common pathogen is S.
Aureus.
8.10.5
Perthes disease
X ray images show a widened joint space between the ossified femoral head and the
acetabulum. This needs orthopaedic referral and further management.
8.10.6
Slipped upper femoral epiphysis
Most common in obese or rapidly growing boys between 12 to15 years old. 25% have
bilateral involvement. Note that many will present with knee pain.
X ray shows widening and irregularity of the plate of the femoral epiphysis. The
displacement of the epiphyseal plate is medial and superior.
Surgical treatment is required. Refer to Orthopaedics.
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8.10.7
Juvenile rheumatoid arthritis
Autoimmune disorder; may present affecting a single ankle or knee.
Presence of associated systemic findings, such as high fever, salmon pink rash and eye
inflammation may aid diagnosis.
Refer to Paeds and Orthopaedics for further investigation.
8.10.8
Neoplasms
Osteogenic sarcoma causes an acute unremitting limp or limb pain, and often involved the
distal femur and proximal tibia. Leukaemia can cause ill defined migratory bone or joint pain
and generalised weakness. Neuroblastoma can produce nerve impingement.
8.11
Physiotherapy service in A&E
Currently run by our Physio Sharon, Monday to Friday 8:30 -16:30.
You can refer patients to the clinic after discussion with either Sharon (Bleep 347) or with a
senior out of hours. The reception staff can help you give the patient a time.
Appropriate patients:
Acute soft tissue injuries
Acute back pain (require appointment in 7 days)
Acute knee injuries
Acute whiplash (appointment in 7 days)
Acute shoulder or neck injuries
Do not refer the following:
Patients with a fracture clinic appointment
Chronic back pain (refer back to GP)
Patients with chronic injuries (refer back to GP)
Patients who require multi-disciplinary needs (usually elderly; these patients should
be discussed with the Radiate Team)
Patients who require hand therapy (refer directly to Hand Management Unit at
WMUH)
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9
Minor Injuries
The following sections are based on local guidelines.
9.1
Wound types
Definition of wound types:
Cut
Incision of the skin by sharp edged object, e.g. knife
Laceration
Tearing or splitting of skin, e.g. blunt trauma, bite, rugged sharp object
Abrasion, graze
Surface area of skin is worn by friction, superficial to full thickness
Stab, penetrating wound
Are deeper than long, e.g. knife, bite, any sharp long object
Crush wound
Break in skin with additional contusing force to the surrounding tissues
9.2
9.3
9.3.1
Wound differentiation
Clean
Clean contaminated: a wound involving normal but colonized tissue (e.g.. wound
open >6hrs)
Contaminated: a wound containing foreign or infected material
Infected: a wound with pus present
Wound management
Initial cleaning and / or debridement
All wounds need thorough cleansing with 0.9 % Saline. If it is a large area use a fluids giving
set, 1L Normal Saline run at a steady flow and get the patient to hold it over the wound.
The wound needs inspection for material of contamination, e.g. dirt, potential foreign bodies
(if suspected an x-ray should be requested). Foreign bodies need to be removed to minimise
risk of infection and any devitalised tissue should be debrided (however see note under
Special circumstances section 9.3.11 below).
Aim: to convert a contaminated wound into a clean wound!
9.3.2
Local anaesthetic
Use local anaesthetic / ring block (unless large area or vascular involvement) as this will help
you explore the area whilst keeping the patient comfortable. Use 1% lignocaine (use up to
15mL max).
You can use lignocaine with adrenaline (xylocaine) as it allows you to use more except on
digits (fingers/toes) and anything with an end arterial supply (ear/nose/penis etc).
Wherever possible it is great to do ‘ring’ blocks or a nerve block as this avoids disruption of
the anatomy. Ring blocks offer excellent analgesia / anaesthesia for fingers and toes.
Please ask a senior to show you these techniques if you are unfamiliar.
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9.3.3
Handling the wound
Good wound healing depends primarily on good tissue management, so try to handle the
tissue as little as possible – use ‘toothed’ forceps if possible.
9.3.4
Closure or no closure
Closure of clean wounds less than 6 hours old can be achieved by sutures, steristrips /
leucostrips, and glue.
Discuss clean contaminated and contaminated wounds with your seniors. Some should be
referred for debridement / surgical washout and others should be given a thorough wound
toilet and brought back after 48 hours of antibiotics for delayed primary closure.
Do not close any human or animal bite. They should be left to heal by secondary intention.
If deep and extensive, they will need referral to Plastics for exploration, washout and closure
in theatre. After human bites, remember to consider Hepatitis and HIV prophylaxis.
9.3.5
Sutures
As suture is a foreign body, use the minimal size and amount of suture material required to
close the wound:
Face 5/0 or 6/0
Scalp 3/0 or 4/0
Upper limbs 4/0
Lower limbs 3/0
In children, reduce the gauge of the suture material by 1. Use non-absorbable sutures in the
skin.
Removal of sutures
Facial wounds = 5 days
Scalp wounds = 7 days
Arm / hand wounds = 7-10 days
Lower limb / joint wounds = 10-14 days
If appearance is important and suture marks unacceptable as in the face, sutures can be
removed as early as 3 days. In this case, re-enforce the wound with steristrips or
leucostrips.
Close deep wounds in layers, using absorbable sutures for the deep layers.
Do not suture any pretibial laceration. These wounds should be steristripped only.
9.3.6
Antibiotics or not
A clean wound should not need antibiotics.
Otherwise give Flucloxacillin 500mg qds 5 days; if allergic to Penicillin use Erythromycin.
9.3.7
Bites
For Animal and Human bites use Augmentin, if allergic to Penicillin, use Erythromycin and
Metronidazole.
For Human bites remember to assess risk of Hep B / C or HIV infection, and prescribe
appropriate prophylaxis.
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9.3.8
Tetanus prophylaxis
Full course and booster within 10 years: no booster required
Full course but no booster in last 10 years: give toxoid booster
Status unknown: check with GP. Should have a booster within 72 hours if none in last 10
years
If no previous cover: start course and also give Human tetanus immunoglobulin
9.3.9
Wound dressings
Clean wounds: non adhesive dressing
If infection risk: Inadine or similar
Burns: Mepitel
9.3.10
What the patient should know
Watch for:
infection
wound breakdown
other complications structural injuries, nerves, tendon vessels
If any of the above, should return to the department for assessment.
9.3.11
Special circumstances
Nailbed injuries
Needs inspection and repair. Discuss with your seniors as may need referral to
specialist unit i.e. Plastics at Chelsea
Face, eyelids, lip, mouth
Should all be discussed with your seniors as some will need referral to Plastics at
Chelsea, Ophthalmology at Ashford or Maxillofacial at Northwick Park
Perineal wounds
All Paediatric perineal wounds should be discussed with a senior and with Paeds and
the possibility of NAI considered.
Foreign bodies
If a foreign body is seen on x-ray and can be seen / palpated from the surface, an
attempt can be made to remove it under LA. However, any significant impalpable (or
multiple) foreign body / bodies should be referred to Orthopaedics for formal
exploration / debridement in theatre under GA.
This has been fully agreed with the Orthopaedic Consultants.
9.4
Burns
Remember that the airway can be affected through inhalation of hot gases, so these patients
need an ABCDE approach as per ATLS guidelines. They may also have associated injuries
or smoke inhalation if they have had to escape from a burning building.
Document carefully time and mechanism of burn along with type, size, depth and location of
burn. Include a diagram in the notes if possible.
In Paeds patients, a thorough history is always required to clarify the circumstances
surrounding the burn; the possibility of NAI should always be considered.
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Use Wallace’s Rule of Nines or Lund and Browder charts to estimate size of burn. In the
early stages of a burn, this is an estimate only as it is not always possible to distinguish
erythema from true burn. Once you have calculated the TBSA, you can calculate the volume
of fluid you need to resuscitate the patient.
Parkland formula:
2-4 mls per %TBSA per Kg body weight.
This volume is given over the 24 hours following injury with half the volume being given over
the first 8 hours from the injury.
If superficial and small area:
Cool if not already done, Mepitel dressing, check Tetanus status
If full thickness or larger area:
Cool if not already done, Clingfilm, check Tetanus status and refer to Chelsea
If discharging from the department, ensure the patient has adequate follow-up (either with
GP or in A&E clinic) at 24-48 hours. They do not need routine prophylactic antibiotics.
Burns which should be referred immediately:
Burns (with dermal or full-thickness loss) covering more than 5% TBSA (children) or
10% TBSA (adults)
Burns (with dermal or full-thickness loss) to the face, hands, feet, perineum, or any
flexure (particularly the neck or axilla)
Circumferential dermal or full-thickness burns of the limbs, torso, or neck
Any significant infection, septic episode, or suggestion of toxic-shock-like illness
Any significant inhalation injury
Any electrical burn injury
Chemical burn injury (>5% TBSA)
Suspicion of non-accidental injury (see Non-accidental injury)
The following patients should also be considered for referral (discuss these with a senior):
Children under 5 years or adults over 60 years
People who have coexisting medical problems, e.g. cardiac, respiratory, or hepatic
disease or diabetes, or people who are immunosuppressed or who are pregnant
Burns associated with other injuries e.g. crush injuries, fractures, head injury,
penetrating injury
Always give good pain relief (often need IV analgesia)! Burns are very painful.
Cooling the area provides some analgesic effect.
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10 Plastics
The following sections are agreed with the Plastics Team at Chelsea & Westminster Hospital
(our receiving tertiary centre for Plastic Surgery) and also reflect local policy.
10.1
Principles
If patients are sent to OP clinic at Chelsea & Westminster Hospital after discussion with the
Plastics on-call, you MUST make sure that you send a copy of notes / x rays and a referral
letter with the patient.
Patients from WMUH cannot be seen in Plastics Dressings clinic at C&W even if the on call
person advises this. All patients must be referred to our own dressing clinic.
Patients with open wounds are not suitable for OP clinic; they need to be discussed with
Plastics on-call, and an appropriate decision taken. They will often ask for them to attend the
Plastics ward, where they will be reviewed.
Certain types of injuries e.g. deep hand or midface lacerations require the involvement of the
plastic surgeons. This is desirable not just to ensure optimum cosmetic effect, but also to
exclude underlying tissue injury, which if unrecognized, could lead to long-term disability.
However remember that an excellent outcome for many lacerations e.g. forehead, can be
achieved with simply gluing or steristrips if the edges oppose well.
10.2
Referrals to Plastics
There is an outline below of the type of injuries, which may need Plastic Surgery. Please
discuss these patients with a senior before referring them to Chelsea.
10.3
Paediatric referrals
In general, most children wriggle so often it is physically impossible to close wounds in A&E
and so intervention is best done in theatre with the child fully anaesthetised. We do not
hold down children in A&E to suture them!
However older children may well co-operate with local infiltration ± sedation (try Entonox;
remember oral intranasal midazolam has unpredictable effects and can cause agitation
rather than sedation) within A&E, assuming the injury is appropriate for repair without the
magnifying lens.
If a child attends in the evening with an injury which will need GA, the surgery can usually
wait until the next day, save life-threatening injury.
10.4
Hand injuries
Fingertip injuries involving the nail bed (minor distal injuries with the nail bed intact
can be managed conservatively)
Crush injuries of fingers (again if only involving the tip and the nail is intact, this can
often be managed conservatively)
Lacerations which are deep (hidden perils of missed tendon injury)
Displaced or open fractures of fingers, metacarpals or carpal bones (discuss with
your seniors, as often Orthopaedics at West Mid are happy to manage these)
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10.5
Facial lacerations
Lacerations which are:
Jagged or extensive
Crossing eyebrow or upper and lower eyelids* (but horizontal lacerations of eyebrow
or upper eyelid can be steristripped in dept)
Involving inner and outer canthus of eye, alar margin, vermilion border
Within the area as defined from outer canthus of eye down to lateral aspect of corner
or mouth across to tragus of ear (risk of injuries to facial nerve etc)
*If severe, these may also need to be referred to Ophthalmology. Some facial lacerations
may also be suitable for closure by Maxillofacial (see section 12.5)
10.6
Lacerations to other areas
Most scalp or forehead lacerations unless extensive can be treated by gluing, steristrips or
suturing in the dept.
Distal volar and pulp injuries of fingertips without bone or nail involvement have a very good
outcome without surgical intervention. The tip should be wrapped in a betadine ointment and
tegaderm dressing and reassessed if severe in the A&E clinic.
Any injury exposing bone must be referred to Plastics.
For finger amputations, the amputated remnant must be placed in a saline soaked gauze
wrap, placed in a plastic bag and this should be placed into ice water slush (not ice alone)
prior to referral to Plastics.
Lacerations of non-cosmetic areas may be referred to surgeons if not suitable for suturing in
A&E.
10.7
Foreign bodies
The removal of foreign bodies from wounds should be performed under GA unless:
Foreign body is clean and unlikely to leave fragments (this excludes glass and most
wooden objects)
The track that it follows should be superficial and in no way endangers significant
anatomical structures
It is a child and they are able to both tolerate and co-operate with the procedure
If there is any doubt please discuss the situation with a senior for foreign bodies in face or
hand. Removal of superficial splinters can be attempted in some cases; discuss with a
senior.
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10.8
Tendon injuries
Any patient with a laceration as a result of a cut from glass MUST have an x-ray to rule out
any glass in the wound.
Always assume that ANY cuts from glass or a knife (on the hand especially) will have caused
a tendon damage until proven otherwise.
Check flexor / extensor tendon movements – if they can’t do it, it is likely the tendon
has been cut – refer to Plastics.
If they can do movements but it is painful with resistance, then they may have a
partial tendon tear / cut; this will need referral.
It is best to anaesthetise the area and examine directly for any tendon damage (will look like
nice white shiny strands – if you are not sure ask a senior, once seen never forgotten!)
10.9
Bony injuries in hand
Discuss these with your seniors. Most bony injuries of the hand are dealt with by the
Orthopaedic service here at West Mid. However, on occasion (usually with more complex
cases involving both bone and soft tissue) they will advise referring to the Hand service at
Chelsea.
See Orthopaedic section 8 for more advice.
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11 ENT
The following sections are based on local ENT guidelines.
ENT SHO – Bleep 091
If it is an ENT Emergency ask switchboard to fast bleep or phone the Reg or Consultant on
call; if you do not specify this, you will only get the ENT SHO!
11.1
The Ear
Earache is a common ENT complaint and many patients can be diagnosed and treated in the
Emergency department. However it is important that conditions requiring urgent ENT referral
are recognised. The following diagnoses need to be considered.
11.1.1
Otitis externa
This is an inflammation or infection of the external ear. The external ear includes the pinna
and the external auditory canal and it is the latter that is usually involved.
There is pain with scanty discharge initially. The discharge may increase later but is never
plentiful.
Traction on pinna is painful, a useful test to differentiate from otitis media.
Gentle otoscopy will show inflammation and swelling in the external canal but a normal
eardrum. Mastoid is not tender.
The presence of normal eardrum and lack of tenderness over the mastoid are important
signs in differentiating otitis externa from middle ear infection.
Treat with Sofradex eardrops and no water in ear followed by GP review. If very severe refer
to ENT for suction of infected debris with microscope and insert an antibiotic wick.
11.1.2
Otitis media (OM) and mastoiditis
OM is infection of the middle ear and mastoiditis is the extension of the infection into the
adjacent mastoid bone.
The former can be treated by oral antibiotics and referred back to the GP; the later needs to
be referred to ENT urgently.
The first attack of OM is referred to as ‘Acute’ while repeated attacks may be referred to as
‘Chronic’. Acute OM may present as pain, malaise and fever as suppuration develops in the
middle ear. This is followed by rupture of the eardrum and discharge.
There is no swelling, redness or tenderness in the external auditory canal. The eardrum will
be congested and/or bulging and later on found to be ruptured.
Chronic OM is easier to diagnose as there is past history. Each exacerbation is associated
with increased discharge, loss of hearing but minimal if any pain.
Treatment of acute OM or exacerbation of chronic OM is oral amoxicillin. In contrast if the
infection spreads to the mastoid, the condition becomes osteomyelitis and requires
admission & IV antibiotics.
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Mastoiditis only develops in association with otitis media. In acute otitis media it should be
suspected if there is increasing pain and temperature and/or mastoid tenderness.
In chronic otitis media it should be suspected if there is any pain at all, as usually there is no
pain in uncomplicated chronic otitis media. The development of pain in chronic otitis media
is an ominous sign as it may suggest spread of infection to mastoid or in a cranial direction.
11.1.3
Wax ear
The primary complaint is sudden onset of deafness; patient may have had water getting in
the ear before. Wax imbibes water and swells to occlude the meatus causing deafness and
discomfort.
Otoscopy reveals complete occlusion.
Ear drops to soften the wax can be prescribed tallow syringing by GP in a few days time.
11.1.4
Referred pain
This is a common cause of earache. Diagnosis is easy as there may be other symptoms of
sore throat or dental carries/abscess.
Treatment with appropriate analgesia (NSAIDs tend to work better)
11.1.5
Foreign bodies in the ear
All foreign bodies should be removed. Ask one of the seniors to show you how. If you are
unable to remove it do not cause added trauma and refer to ENT.
Cotton buds can be removed by first straightening the canal by pulling up the Pinna and then
grabbing under direct vision with fine forceps.
For beads, you can try gentle suction, but they often require removal by ENT.
Live insects will often crawl onto a blunt probe. Alternatively, pour 1% Lignocaine into
external canal to float it out. Try gentle flushing with a green venflon (without the needle)
mounted on a syringe (fluid must be warm). The books recommend olive oil but this is very
greasy.
11.1.6
Trauma to external ear
Trauma to the pinna is a common injury. The development of “Cauliflower ear” is caused by
blood stripping off the skin from the underlying cartilage and the cartilage later necroses due
to loss of blood supply.
If you see a significant haematoma ask for advice from one of the seniors. It may need to be
discussed with ENT / Plastics. Do not attempt to drain it yourself.
11.1.7
Traumatic perforations of the tympanic membrane
Commonly occur as a result of a patient being slapped or “boxed on the ear”.
Once a gentle auroscopic examination has been performed, advise the patient not to swim or
to put cotton buds or drops in the ear. We sometimes prescribe oral amoxicillin but not
routine. GP follow up in 4 weeks; for ENT if hasn’t healed.
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11.1.8
Lacerations of the ear affecting the cartilage
Major lacerations of the pinna should be referred directly to Plastics at Chelsea and
Westminster (bleep 0278); more minor lacerations can be closed in the department. Discuss
these with your seniors.
11.2
11.2.1
The Nose
Foreign bodies
All foreign bodies in the nose should be removed. Beware of pushing the object in further.
We have nasal speculums which improve vision. We don’t have a head light so use an
auroscope and ask someone else to hold it.
If you block the other nostril sometimes the patient can blow the object anteriorly. Try using
forceps gently or passing a blunt hook past and then pulling the object back out.
11.2.2
Septal haematoma
Always look at the septum in a patient with nasal trauma.
A septal haematoma is swollen and purple and needs to be drained as otherwise the
cartilage is destroyed leaving a hole. Although uncommon, it is important to make the
diagnosis; ask a senior for advice if you think you have seen one.
If present refer to ENT.
11.2.3
Epistaxis
Don’t forget ABCD (especially in the elderly) as large volumes of blood can be lost. Consider
FBC, clotting and Group and Save depending on history.
Most nose bleeds stop on pressing the fleshy end of the nose between finger and thumb so
that the nostrils are occluded. An ice pack over the bridge may vasoconstrict. Many patients
attempt to press the bony bridge which does nothing.
Look at Little’s area on the anterior septum for the source of bleeding.
If you see an active vessel bleed, then spray with xylocaine nasal spray and then cauterise
with silver nitrate.
If cautery fails, pack with a merocel tampon. If this fails then either there is a posterior bleed
or else the merocel hasn’t filled the anterior nose well. Try repacking the anterior nose with
BIPP ribbon gauze instead of the merocel.
A posterior bleed is controlled with a Foley catheter passed into the nose, then inflated and
pulled forward to block the posterior nose. Pack the anterior with BIPP. Avoid pressure on
the alar from the catheter as it can erode.
All patients with packs should be admitted under ENT.
Even if the bleeding has stopped it is worth looking for a vessel to cauterise as the bleeding
may start again as soon as the patient goes home.
If the bleeding mucosa looks dry, treat with naseptin cream (or just Vaseline) to try to stop
further bleeding but this is not proven to work.
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11.2.4
Sinusitis
A cause of facial pain associated with a blocked feeling and tenderness over the frontal or
maxillary sinus.
No need for sinus x-rays.
Treat with decongestants such as olbas oil or oxymetolazone nasal spray from the chemist.
Often need strong analgesia. Amoxicillin is a suitable antibiotic.
Discharge with GP review.
11.2.5
Nasal Fractures
The diagnosis of nasal fractures is clinical so do not x-ray.
Check for a septal haematoma.
The treatment is for cosmetic purposes. Often the patient is happy with the shape once the
swelling has gone down.
If you think the nose will need straightening, refer to ENT SHO who will book them into a
clinic. The best time to straighten a nose is about 7 days after injury.
11.3
11.3.1
The Throat
Foreign Bodies
Fish bones can be problematic. Can do lateral neck x-ray; some types of fish bone are more
easily seen than others.
A bone in the tonsillar bed is easily removed but unfortunately most bones are too far down
to be seen. A bone should not be left too long (i.e. not more than 24hrs) as there is a danger
of retropharyngeal abscess.
However, often the bone has just scratched the throat so the patient feels the bone is still
present but it is not. If clinically you think there is a bone then refer to ENT for laryngoscopy.
11.3.2
Tonsillitis
Tonsillitis is quite common reason for ENT admission. Most people can manage at home
with oral antibiotics but if the patient cannot swallow they need admission.
Use Penicillin rather than Amoxicillin in case the diagnosis is glandular fever. Glandular
fever patients given Amoxicillin develop a widespread maculopapular rash.
11.3.3
Quinsy
This presents as a unilateral swelling in the tonsillar region. Often cannot swallow and have
trismus.
It is a peritonsillar abscess and the appearance is of a mass pushing the tonsil area forward
and across.
These should be referred to ENT for drainage. Do not be tempted to drain these yourself,
due to the proximity of important structures including the carotid artery.
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11.3.4
Crico-thyroidotomy
The indications for an immediate crico-throidotomy are rare. However if you cannot ventilate
and cannot intubate then respiratory / cardiac arrest may be imminent unless a surgical
airway is performed.
The ALS and ATLS manuals explain the procedure.
Always alert your seniors, anaesthetics and ENT immediately if you have a patient
who may need this procedure.
11.4
11.4.1
The Face
Facial Palsy
Facial palsy presents commonly to the Emergency Department.
It is usually “Bell’s Palsy”, which is a unilateral lower motor neuron (LMN) facial palsy that
develops suddenly and is not associated with any other cranial nerve palsies. Bell’s is
caused by reactivation of Herpes Simplex virus in the facial nerve.
As it is a LMN seventh nerve palsy, the forehead is not spared. Bells phenomenon is also
present (upward diversion of the eye on attempted closure of the lid). Hyperacusis and
disturbed taste sensation on the anterior 2/3 of the tongue can also occur (as facial nerve
supplies stapedius and taste sensation from the anterior 2/3 of the tongue).
Bells palsy must be differentiated from an UMN 7th Palsy which spares the forehead.
Mild ear, retroauricular or face pain may precede the palsy. Reactivation of Herpes Zoster in
the facial nerve is called Ramsay Hunt syndrome and presents with a LMN facial palsy and
associated vesicles in the ear or mouth. Severe pain without vesicles also suggests Herpes
Zoster.
Exclude:
Cholesteatoma
Malignant otitis externa
Acoustic neuroma
Head and neck tumours
Parotid tumour (look for asymmetry in the oropharynx)
Trauma with facial nerve palsy from fractured base of skull
Treatment for Bells palsy and Ramsay Hunt:
Still controversial
Prednisolone 40mg od 7 days with oral aciclovir 400mg 5x a day for a week
Consider IV aciclovir if immunocompromised or severe Ramsay Hunt
If can’t close eye discuss with ophthalmology for eye drops during the day and
ointment at night
Refer to ENT SHO for clinic follow up or back to GP if out of area
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12 Maxillofacial / Dental Emergencies
We obtain our Maxillofacial service from Northwick Park Hospital. The following
sections are based on their guidelines.
Northwick Park offers a full Paediatric service (including <2 years) and will therefore also
accept this patient group for trauma and abscess management.
12.1
General principles
All patients should have all other injuries documented and cleared prior to referral to
Maxillofacial Surgery.
Multiply injured patients should have their life threatening / limb threatening injuries treated
first. Once stabilised, contact the Maxillofacial SHO to transfer to Northwick Park. Liaise
with the senior doctors in the department and Surgical, Orthopaedic and Neurosurgical
teams as appropriate to establish the order in which injuries should be treated.
12.2
Imaging
Patients with Maxillofacial injuries often have associated head injuries. If a patient presents
with both head and maxillofacial injury and fulfils the criteria for a CT head, please request a
facial CT at the same time (from frontal sinuses to mandible).
12.3
General management
All maxillofacial patients should have the following:
ATLS protocols with primary and secondary surveys to exclude significant head injury
and other injuries
Basic observations including neuro obs
Young trauma patients with no medical problems and no other injuries do not need
blood tests, unless there is persistent or significant haemorrhage
Discuss with Maxillofacial SHO to determine if patient needs to be kept nil by mouth
(NBM)
If to remain NBM, start IV fluids at a maintenance rate
Adequate analgesia should be prescribed
12.4
Abscesses
Most abscesses of the face, mouth and neck have an odontogenic origin.
Patients with superficial infections may complain of localized pain, oedema, and sensitivity to
temperature and air. They are usually associated with dental caries and if not affecting
surrounding tissues and not systemically unwell, they can be treated by the patient’s dentist.
Prescribe:
Adequate analgesia; NSAIDs such as ibuprofen are best, with paracetamol as
required. Codeine preparations can also be added
Metronidazole 400mg tds OR amoxicillin 500mg tds 5/7 if signs of systemic upset
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Advise:
Avoid foods that are either too hot or too cold
Take regular analgesia, sticking to prescribed limits
See dentist ASAP for debridement
Patients should be considered for admission to hospital if they have a dental abscess and:
Are unwell with a high temperature and cardio-respiratory compromise (rapid pulse
rate or low blood pressure, high respiratory rate)
Early signs of dysphagia or a significant 'floor of mouth' swelling
Are in severe pain despite analgesia (maximum tolerated) prescribed in primary care
Have a spreading facial infection
Have a history of being immunocompromised
Patients with deep infections or abscesses that spread along the fascial planes may
complain of fever and difficulty swallowing, breathing, and opening the mouth. These
patients should also be admitted to hospital.
Patients requiring admission with abscesses of the face, mouth and neck should have the
following:
URGENT airway assessment
Routine observations
History and physical examination
FBC, U&Es, CRP, BM and blood cultures as appropriate
IV fluids
Adequate analgesia
OPG
Penicillin and Metronidazole IV if to be admitted
If airway compromise is predicted or imminent, alert your seniors and Anaesthetics
IMMEDIATELY.
12.5
12.5.1
Lacerations
Head and neck lacerations
If injuries to deeper structures have been excluded, lacerations around the eye, eyelids and
eyebrows, nose and ears can be referred to Maxillofacial Surgery for repair. Discuss with
Maxillofacial for the relevant transfer details.
Points to note:
Always exclude underlying damage to vital structures such as eyes, eyelids (refer to
Ophthalmology) and the facial nerve (refer to Plastics).
Always check Tetanus status
Always debride thoroughly prior to suturing
Always administer systemic antibiotic therapy if wounds are contaminated. Consider
delayed closure – speak to Maxillofacial Surgery.
Maxillofacial Surgery run a clinic for wound and scar management at Northwick Park.
Patients with complex wounds closed in A&E should be considered for follow-up by this
clinic. Contact the Maxillofacial SHO on call for arrangement of such clinics.
Intra-oral lacerations: Contact Maxillofacial Surgery.
Neck lacerations: Never close without referral or senior opinion.
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12.6
Stabbings of Head and Neck
Maxillofacial accept all these patients. ATLS protocols must be followed prior to transfer.
12.7
Fractures of Zygoma, Orbit and Midface
The most common facial fractures we see are fractures of the orbital margin, particularly the
orbital floor.
In the history, remember to ask about the mechanism, any LOC, visual symptoms /
disturbance, occlusion of teeth / bite and areas of numbness / tingling on face.
Check for asymmetry on inspection of the face, both from the front and from above the
patient. Palpate for bony tenderness. Check facial stability by looking for movement when
the hard palate is grasped and gently pushed backwards and forwards.
Symptoms / signs suggesting orbital floor fracture:
History of blunt trauma to the face / orbit
Diplopia
Limitation of eye movement
Enophthalmos / hypoglobus
Paraesthesia in the infraorbital nerve or supraorbital nerve distribution can also be present in
a fracture of the orbit, but is less specific.
Always document visual acuity, ocular movements and check anterior and posterior
chambers for haemorrhage.
Any injury to the globe must be referred immediately to Ophthalmology (see
Ophthalmology section for further information).
Imaging
15 and 30 degree occipitomental views
CT of face if head CT is also required for the patient’s management
Look for the tear drop sign on x-ray and an air fluid level in the maxillary sinus. Look for loss
of symmetry between the two sides.
Refer to Maxillofacial SHO at Northwick Park. Make sure you give hard copies of the X-rays
and a copy of the notes to the patient before you discharge home. Advise the patient not to
blow nose and give antibiotics if advised.
12.8
Fractures of the Mandible
90% of these require admission. Contact Maxillofacial SHO to decide, depending on pattern
of injury. Needs appropriate analgesia and antimicrobial therapy with Penicillin and
Metronidazole i.v.
Imaging:
PA Mandible and an OPG
If OPG not available, get a left and right oblique view of the mandible
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12.9
Nasal Trauma
Patients with nasal trauma are also accepted by the Maxillofacial Service at Northwick Park.
Always exclude a septal haematoma as part of the secondary trauma survey.
Admission/Discharge will depend on pattern of injury. Contact the Maxillofacial SHO.
12.10 Dentoalveolar trauma
Call Maxillofacial directly, but adhere to ATLS guidelines, and assess for any other injuries in
parallel to a Maxillofacial referral.
If missing teeth, a Chest XR is necessary to exclude aspiration of the tooth / teeth.
Maxillofacial team will advise on management.
12.11 Lumps and bumps
Infections, swellings, lumps and lymphadenopathy of the neck, face, salivary glands, throat
and mouth that present to A&E can be referred to the Maxillofacial team at Northwick Park
for further management.
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13 Ophthalmology
The following is based on local policy. Note that we do not currently have an agreed service
provider for Ophthalmology. This has been raised at the highest level in the Trust and is
currently under negotiation with several potential providers.
13.1
Important numbers
To call on-call Ophthalmology: via Switchboard (located at Ashford Hospital 01784 884488).
Note that the Heart of Hounslow and Ashford Eye Services are appointment only and
not a walk-in service.
You can organise these appointments by speaking to the on-call person via Ashford
Switchboard. Overnight, you may need to wait for the morning to make this referral. If it
cannot wait for the morning, discuss with your senior and consider an emergency referral to
one of our adjacent Ophthalmology centres such as Moorfields or Western Eye.
Many patients attending A&E will have eye problems.
History is important:
What symptoms?
Any previous episodes?
Vision affected?
Any other medical conditions?
Any preceding injury?
13.2
Examination
All patients with eye problems need to have their visual acuity measured and
documented.
Use our standard Snellen chart at 6 metres with their normal glasses or pinhole. Record the
acuity as the smallest line of text they can accurately read. An example is given below,
where 6/60 means that they can read at 6 metres what a person with normal sight can read
from 60 metres.
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If the patient has a painful eye and cannot open the eye due to pain / watering of the eye,
instill some local anaesthetic drops prior to testing their visual acuity.
13.2.1
Red eye examination
Eyelids and Anterior segment (with magnifier)
Lid swelling?
Conjunctivitis?
Ciliary injection? (injection around the cornea)
Corneal ulcers or foreign body?
Cloudy cornea?
Check corneal epithelium by instilling fluorescein
Defects show up green when examined with a blue light
Always check under both upper and lower eyelids for a retained foreign body!
To check under upper lid ask patient to look down and relax
Evert the lid against a cotton bud and make a gentle sweep across the epithelium
with a cotton bud. A black speck on your cotton bud may represent a foreign body
13.2.2
Blurred vision examination
Check visual fields by confrontation
Pupillary reaction to light directly and consensually
Swinging light test (?Relative afferent pupillary defect)
RAPD suggests significant retinal or optic nerve dysfunction
Examine fundi; may need to dilate pupil
Remember to look for a red reflex
13.3
Primary angle closure glaucoma
Symptoms
Severely painful red eye, impaired vision, vomiting
Signs
Decreased VA
Red eye
Cloudy cornea
Shallow anterior chamber
Fixed mid dilated pupil
Greatly raised intraocular pressure ( globe hard on palpation)
Management
Refer IMMEDIATELY to ophthalmology. This is an ophthalmic emergency.
Rx. Options include
Timolol 0.5%
Pilocarpine 2%
Acetazolamide IV
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13.4
Giant cell (temporal) arteritis
Symptoms
Sudden visual loss / impaired vision, new persistent headache, jaw claudication /
trismus, scalp tenderness
Signs
May have decreased VA
Age over 50
Clinically abnormal temporal artery
ESR >50
RAPD
Pale swollen optic disc
Visual field defect
Management
Refer IMMEDIATELY to ophthalmology if vision is affected. This is an ophthalmic
emergency.
13.5
Requires high dose steroids (this may be sight saving) and temporal artery biopsy.
Refer to Medical / Rheumatologist if no visual disturbance.
Orbital cellulitis
Symptoms
Severely painful red orbit and red eye, fever, double vision / impaired vision
Signs
May have decreased VA
Pyrexia / systemic upset
Tense red orbit
Red, injected eye
Proptosis
Chemosis
Diplopia / limitation of eye movements / pain on eye movements
May have abnormal pupillary reactions / optic disc swelling
Management
Refer IMMEDIATELY to ophthalmology. This is an ophthalmic emergency.
Will need admission for IV antibiotics and urgent CT of orbits / head to exclude
extension into cavernous sinus. Other complications include meningitis /
encephalitis.
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13.6
Herpes zoster ophthalmicus
Symptoms
Painful vesicular / crusting rash around one eye (often involving forehead and may
involve nose)
May have associated painful, gritty red eye with photophobia
May have impaired vision
Signs
May have decreased VA
Vesicles in the distribution of the Ophthalmic nerve
Lesions at the tip of the nose predict likely corneal involvement
Red, injected eye
Oedema of eyelid
Infiltrative lesions (rather than ulcerative) of the cornea may be seen on slit lamp
examination
Management
Refer IMMEDIATELY to ophthalmology if patient has corneal involvement. This is an
ophthalmic emergency.
13.7
Refer to ophthalmology within 24 hrs if no immediate corneal involvement.
Oral acyclovir (or equivalent) 800 mg 5 times a day 7-10 days. May need artificial
tears and adequate analgesia.
Infected corneal ulcer
Symptoms
Painful red eye with discharge, photophobia, impaired vision
Often a contact lens wearer
Signs
May have decreased VA
Corneal opacity with overlying epithelial defect and pus in anterior chamber /
mucopurulent discharge
May have associated iritis
Management
Refer IMMEDIATELY to ophthalmology. This is an ophthalmic emergency.
Discuss antibiotics with ophthalmology as they may wish to send corneal scrapings
prior to antibiotic treatment.
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13.8
Ruptured globe and penetrating eye injuries
Symptoms
History compatible with penetrating eye injury or damage to the globe
Pain (may not be immediately severe), loss of vision / impaired vision
Signs
Decreased VA
Disrupted cornea or anterior segment
Prolapse of anterior chamber contents
Extensive subconjunctival haemorrhage may be present
Irregular / “tear-drop” shaped pupil
Restricted eye movements / diplopia
Enophthalmos / exophthalmos both possible
May have associated eyelid laceration
Hyphaema (blood in anterior chamber) or vitreous haemorrhage (if massive will
appear as a loss of the red reflex i.e. is black) may be present
Management
Refer IMMEDIATELY to ophthalmology. This is an ophthalmic emergency.
13.9
Tetanus
Orbital x-rays / CT may be required
IV/IM analgesia +/- antiemetic (NBM if needs surgery)
Eye shield to avoid pressure on orbit (e.g. paper cup); no eye patching for this
reason.
Manage any coexisting injuries
Chemical injury
Symptoms
History of acid or alkali splash into the eye
Red, painful photophobic eye
Signs
Decreased VA may be present
Injected cornea / conjunctiva
Look for corneal defect / ulceration / perforation with slit lamp examination following
irrigation
Management
Assess pH
Instill LA drops into eye
Immediate irrigation (with 1L bag of normal saline), including everting lids & removing
solid particles, UNTIL pH NEUTRAL
Treat any coexisting injuries
Refer IMMEDIATELY to ophthalmology if there is any corneal injury. This is an
ophthalmic emergency.
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13.10 Sudden visual loss
Symptoms
Can be described in various ways (e.g. “grey curtain”, blurring, fogging or dimming of
vision)
Ask for associated headache, photophobia, history of trauma, co-morbidities
Signs
Decreased VA
May have visual field loss / RAPD
May have corneal pathology
May have anterior chamber abnormalities
May have fundal changes
Check for extraocular signs (e.g. changes to temporal artery, neurological deficits,
Possible diagnoses
Cardiovascular disease (emboli, carotid stenosis etc.)
Hypercoagulable states
Acute glaucoma
Optic nerve compression / swelling / ischaemia
Foreign body
Central / branch retinal artery occlusion
Central / branch retinal vein occlusion
Globe rupture
Retinal detachment
Vitreous haemorrhage
Management
Refer immediately if sudden visual loss is less than 6 hours old, as surgical
intervention may be possible in some cases
Refer to ophthalmology for urgent review to be seen within 24 hours if >6 hours old
13.11 Anterior uveitis (iritis)
Symptoms
Red, painful, photophobic eye
Often sudden onset pain
Worsened by pressure on globe
No tearing or discharge
Mildly impaired vision
Note association with HLA-B27
Signs
Normal or slightly decreased VA
Injected area around iris / cornea (ciliary flush / perilimbal injection)
Clumps of cells on the cornea (keratic precipitates)
May have cells / hypopyon in the anterior chamber
Pupil may be irregular, constricted or reacting poorly to light
Management
Refer to ophthalmology for urgent review within 24 hours. May require topical steroid
and mydriatic to dilate pupil and prevent iris sticking to the cornea causing glaucoma
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13.12 Scleritis
Symptoms
Painful red eye with tearing, photophobia and impaired vision
Pain often wakens patient from sleep and is exacerbated by touch / pressure
Association with systemic connective tissue or vasculitic diseases
Signs
Decreased VA
Intense blue-red inflammation of an area of sclera (note no white sclera visible
between injected vessels) which gradually becomes necrotic
Scleral vessels do not move with a cotton bud
Management
Refer to ophthalmology for urgent review within 24 hours if scleritis is suspected
Important to differentiate between scleritis and episcleritis, as scleritis can lead to loss
of vision and episcleritis is self-limiting and benign
13.13 Dendritic ulcer (HSV keratitis)
Symptoms
Painful red eye with photophobia and blurred vision
Diagnosis
May have slight decrease in VA
Initially have small vesicles on cornea which become dendritic ulcers
Dendrites stain green with fluorescein
May have previous history of herpes simplex keratitis or cold sores
Management
Refer to ophthalmology for urgent review within 24 hours
Topical acyclovir 3% 5 times / day for 7-14 days
May also require topical steroids; discuss with ophthalmology
13.14 Acute dacryocystitis
Symptoms
Painful red lump at medial canthus
May have fever and purulent discharge
May have history of recent conjunctivitis or URTI
Signs
Normal VA
Swelling, tenderness and erythema at medial canthus
May have associated lid oedema
Management
Refer to ophthalmology for urgent review within 24 hours
High dose oral or IV antibiotics may be required
Do not incise swelling as fistula may form
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13.15 Infective conjunctivitis
Symptoms
Red, itchy eye with FB sensation and grittiness
May have purulent or watery discharge
May have had recent URTI
Signs
Normal VA
Conjunctival injection
Thickened, boggy conjunctiva
Follicles / papilla on lid eversion; lid may be mildly oedematous
Preauricular adenopathy may be present
Management
Topical chloramphenicol qds 5 days and discharge to GP
Advice on hygiene / contagious nature / minimising risk of spread
No contact lenses until fully resolved
Always ask patient to return to A&E if any impaired vision, increasing redness / pain in
eye or not resolving after 3-5 days of topical treatment.
Refer to ophthalmology for urgent review within 24 hours if
Reduced VA
Corneal infiltrates
Evidence of spreading cellulitis(distinguish from oedematous lids)
Chlamydia suspected / infection worsening or not resolving despite topical medication
13.16 Allergic conjunctivitis
Symptoms
Itchy red eye of acute / subacute onset
Tearing
Signs
Normal VA
Conjunctival injection , papillae
Eyelid oedema
History of atopy
Management
Avoidance of stimulus
Oral antihistamines
Sodium cromoglycate drops / antihistamine drops
Discharge to GP
Refer to ophthalmology to be seen in the same week if condition is slow to resolve
despite topical treatment
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13.17 Episcleritis
Symptoms
Discomfort in eye with localised area of redness on sclera
May have photophobia and watery discharge
Signs
Normal VA
Localised injection of conjunctival and episcleral vessels (areas of white sclera visible
between injected vessels)
Note that may have associated signs of a systemic disease (e.g. Rheumatoid
arthritis, SLE, PAN, seronegative spondyloarthropathies)
Management
Reassure patient
Self limiting condition requiring no treatment; typically lasts 7-10 days
Can take NSAIDs for discomfort
Refer to ophthalmology to be seen in the same week if patient has marked discomfort
or the condition is slow to resolve.
13.18 Corneal foreign body
Symptoms
Red painful photophobic eye with foreign body sensation
History of working with metal etc. and inadequate eye protection
Tearing
Signs
Normal VA
Consider penetrating eye injury if decreased VA noted
FB or abrasions seen under slit lamp with fluorescein staining
Residual rust ring may be present
Management
Instill topical LA eye drops to assist examination (tetracaine)
Always evert both eyelids to check for retained but dislodged FBs
Use small blue or orange needle to remove FB (can be mounted on the end of a
cotton bud for better balance /reach) side on
Topical Chloramphenicol qds 5 days
No eye pads
No contact lenses until fully resolved
Discharge to GP if FB & rust ring removed
Refer to ophthalmology to be seen in the same week if patient has residual rust ring.
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13.19 Corneal abrasion
Symptoms
Red painful photophobic eye with foreign body sensation
Usually a history of trauma to the eye but may occur spontaneously
Tearing
Signs
Normal VA
Stains green with fluorescein when viewed with slit lamp and blue light
Cornea should be clear with no underlying opacities
Management
Instill topical LA eye drops to assist examination (tetracaine)
Always evert both eyelids to check for retained but dislodged FBs
Topical Chloramphenicol qds 5 days
No eye pads
No contact lenses until fully resolved
Discharge to GP if FB & rust ring removed
Refer to ophthalmology to be seen in the same week if patient has recurrent
spontaneous corneal abrasion (erosion).
13.20 Spontaneous subconjunctival haemorrhage
Symptoms
Painless or mildly uncomfortable red eye, sudden onset
Signs
Normal VA
Usually no cause found but ask about hypertension and medications
Excluded trauma as a cause
Stain with fluorescein to exclude corneal defect
Management
Check BP
Reassure
Discharge to GP
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13.21 Pingueculum / pterygium
Symptoms
Raised white or pink lump conjunctiva (pingueculum) which can extend onto cornea
(pterygium)
May be asymptomatic or associated with minor grittiness / discomfort
Signs
Normal VA
White or pink triangular or nodular fibrovascular growth near corneal limbus
Classically occurs in people exposed to dry/ hot climates
Management
Consider artificial tears for grittiness
Discharge to GP
Refer back to GP for routine referral to ophthalmology if approaching visual axis,
causing significant discomfort or cosmetically unsatisfactory.
13.22 Chalazion
Symptoms
Slowly enlarging nodule in eyelid
May be red and painful in the acute stages
Signs
Normal VA
Localised lid swelling
Check inferior surface of eyelid
Ocular surface should be normal
Management
Warm compress for 15 minutes qds
Daily lid hygiene
Usually spontaneously resolve after several months
Antibiotics are usually not required. Consider topical chloramphenicol qds 5-7 days if
associated purulent discharge
Discharge to GP
Refer back to GP for routine referral to ophthalmology for incision and drainage if not
resolving.
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13.23 When to refer
13.23.1
Ophthalmic emergencies requiring IMMEDIATE referral
Needs to be seen immediately:
Acute glaucoma
Giant cell arteritis
Orbital cellulitis
Herpes zoster ophthalmicus
Infected corneal ulcer
Painful eye post cataract operation
Ruptured globe and penetrating eye injuries
Significant chemical injury
Retinal artery occlusion < 6 hours old
Unexplained sudden visual loss < 6 hours old
13.23.2
Ophthalmic emergencies requiring URGENT referral
Needs to be seen within 24 hours:
Unexplained sudden visual loss > 6 hours old
Vitreous haemorrhage
Retinal detachment
Sudden onset floaters
Anterior uveitis (iritis)
Scleritis
Dendritic ulcer
Acute dacryocystitis
13.23.3
Ophthalmic conditions requiring SEMI-URGENT referral
Refer for appointment the same week:
Persistent conjunctivitis
Episcleritis
Facial nerve palsy
Retained rust ring following removal of metallic FB
Recurrent corneal erosions
13.23.4
Ophthalmic conditions not requiring referral
Discharge back to GP:
Uncomplicated corneal abrasion
Spontaneous subconjunctival haemorrhage
Sticky eye of < 24 hours without visual disturbance
Pingueculum / pterygium
Chalazion
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14 Urology
The following sections are based on agreed local Urology guidance.
14.1
Renal colic
This is a common problem presenting to A&E. The typical presentation is a sudden onset of
sharp pain anywhere from the loin to the testes / labia majora, depending on site of stone
within the renal tract. Patients find it hard to stay still and are often pacing around. Ask
about previous stones, haematuria or passing any gravel in their urine.
It is very important to exclude the following differentials:
Aortic and iliac aneurysms
Pyelonephritis
Peritonitis, including appendicitis and diverticulitis
Biliary colic
Reno-vascular compromise, including renal artery or vein thrombosis
Cancer, especially renal
Endometriosis
Ovarian torsion
Always do a pregnancy test in females of child bearing age to exclude ectopic
pregnancy.
14.1.1
Investigations
Urine dipstick / MSU
Haematuria is only present 85% of the time, so the history is key
Remember that the presence of haematuria is not specific for stones
The presence of leucocytes and nitrites on dipstick or bacteria on microscopy
suggests an infected stone
Urinary βhCG
On all females of child bearing age
FBC
Should only be requested if the temp >38, suggesting the presence of infection
The WCC can be raised even in the absence of infection, so FBC should not be done
routinely on uncomplicated renal colic
U&Es
To be performed in the elderly, those with impaired renal function, diabetics and
those who are hypovolaemic
The young and previously healthy do not need routine U&Es
If the patient is not septic and pain reasonably well controlled with analgesia; book a CT KUB
for the following day.
There are allocated slots each morning for A&E patients with probable renal colic. Print out a
CT KUB request form and give to the patient along with information sheet about attending for
scan and results (see Appendix). Patients should report to x-ray department at 8am the
following morning (Monday for all Friday and weekend attendances) with forms and return to
A & E at 2pm for results.
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This investigation should be used judiciously, as a large amount of radiation is involved in a
CT KUB. Discuss with a senior before you arrange this for your patient (have you
considered other diagnoses?).
14.1.2
Management
14.1.2.1 Pain control
The pain from renal colic can be very severe. Aim to give the patient adequate analgesia
quickly.
Give IV morphine for severe pain, along with PR diclofenac. NSAIDs have been shown to be
effective in the treatment of renal colic and can be used in conjunction with opiates if the
patient is able to tolerate them and you do not suspect renal impairment. Do not give
diclofenac IM, due to the risk of abscess formation / tissue necrosis.
Codydramol can be given for moderate pain, again with PR / oral diclofenac if the patient has
no contra-indications.
Buscopan is no more effective than placebo; do not use it!
If the pain cannot be controlled by the above measures, refer to Urology for admission.
14.1.2.2 Fluids
Hydrate with 0.9% normal saline.
14.1.2.3 Antibiotics
Give Gentamicin 5 - 7mg/kg IV daily (caution in renal impairment – seek advice) or
Cefuroxime 750mg IV tds if co-existing urosepsis is suspected.
14.1.3
Disposition
Admit the following patients:
1. Fever > 38 degrees, or septic as may require a nephrostomy
2. Severe ongoing pain that does not settle with IV narcotic and NSAIDS
3. Recurrent attacks of colic with repeated visits to the emergency department
4. Ureteric stone more than 6 mm in diameter. These are unlikely to pass. (If pain
controllable can be referred to urgent stone clinic)
5. Any stone in a solitary kidney
6. Creatinine > 200
Discharge:
Everyone else
Send a referral to the urology outpatients clinic. The patient will be seen in 4 weeks
with an updated KUB film unless the stone is radiolucent when a limited IVU will be
done
Advise patient to increase oral fluid intake to 3L per day
Give the patient a script for voltarol unless there is a contraindication to the drug
The patient should return promptly if they develop a fever
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14.2
Acute urinary retention
Often in severe pain on presentation – patient should be transferred to cubicle and
catheterised ASAP.
Record pain score and give analgesia appropriately if any delay with catheterisation:
0
1-3
4-6
7-10
No pain
Mild pain
Mod pain
Severe
Nil
Paracetamol / Ibuprofen po
Codydramol / cocodamol + PR Diclofenac
IV opiates + PR Diclofenac
Full examination should include PR to assess size of prostate & nature. Consider other
causes of AUR, e.g. UTI, constipation, post operative pain.
14.2.1
14.2.2
Investigations
U&E, PSA
Urinalysis, CSU
Catheterisation
Aseptic technique.
1st presentation – use 14-16 gauge catheter. Always check that you have the
appropriate length of catheter as a female catheter inserted into a male urethral can
cause traumatic injury.
Record time or catheterisation, size, complications and residual volume (volume drained in
the first 15 minutes). Always ensure foreskin is replaced to avoid paraphimosis developing.
Record urine output for first 2 hours post catheterisation.
Patients with UO>200ml/hr post catheterisation and a residual of >1000ml are at risk of postobstructive diuresis and should be referred for admission under Urology.
If evidence UTI treat with cephalexin 500mg bd 7/7 or nitrofurantoin MR 100mg bd 7/7.
Also give antibiotics if patient high risk, e.g. prosthetic valves, even if no sign of infection.
14.2.3
Follow up
8 to 5: Discuss with Urology re: OPD clinic
Out of hours: Discuss with surgical on call team, write referral for urology TWOC clinic (Trail
WithOut Catheter), ensure patient can manage leg bag and write to GP to arrange district
nurse to manage catheter until TWOC.
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14.3
Testicular pain
The commonest causes of testicular pain presenting to A&E are:
Epididymitis
Torsion of testicular appendage
Testicular torsion
Testicular torsion occurs in less than 1/3 of the cases but is the presumptive diagnosis until
proven otherwise. Note that testicular function unlikely to be recoverable after 12 hours of
untreated torsion.
The key to an accurate diagnosis is a careful history and thorough examination.
14.3.1
History
Take a careful history. Be aware that there are no pathognomonic features and
presentations can be misleading. Use the following table as a guide.
Testicular Torsion
Testicular
Appendage
Torsion
Epididymitis
Age
First few days, 13 – 15
<10
Younger – STD
Older – UTI
organisms
Previous similar episodes
with pain free episodes
Strongly suggestive or
intermittent or recurrent
torsion
No
Not self resolving
Pain
Usually severe, cant
touch or walk
Sudden,
moderate
gradual
Nausea, vomiting,
anorexia
30 – 80%
Rare
Rare
Time of presentation
Sudden onset
Usually within 6 hours
Often nocturnal
Often a few
days
Often later >24
hours
Insidious onset
History of trauma or
physical exertion
10 – 20%
Dysuria, frequency or
urethral discharge
No
No
50%
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14.3.2
Examination
Always do a THOROUGH PHYSICAL EXAMINATION. Generally, the patient with torsion
of the testis will appear uncomfortable whereas the patient with appendage torsion or
epididymitis will appear relatively comfortable.
Additionally:
Examine the parotids for mumps
Local inspection should rule out a hernia
Inspect the penis for discharge
Inspect the scrotum for swelling, redness and tenderness. Swelling to the entire
scrotum is common to all three conditions. With torsion swelling comes on typically
later, usually after 12 hours.
Try to elicit the cremasteric reflex. If present testicular torsion is very unlikely.
Examine the testis for abnormal elevation and lie
Palpate the testis for tenderness
Transilluminate for hydrocoele
Examine the abdomen for pathology causing referred pain
Testicular torsion is suggested by:
An abnormal elevation (high-riding testis) with a palpable twist in the spermatic cord.
Abnormal axis with the patient standing up.
Abnormal position of the epididymis within the scrotum.
An abnormal axis in the contralateral testis. E.g. Horizontal lie = bell clapper
deformity or the epididymis is palpated at the inferior pole.
Torsion of a testicular appendage:
Palpable 3 to 5 mm tender nodule or mass in the groove between the testis and the
epididymis.
The blue dot sign - where a blue dot is present in the superior portion of the scrotum
through stretched scrotal skin, is not as common.
Epididymitis:
Superior pole is tender. However, note that in 10 % of cases of torsion, the patient
will initially present with tenderness in a similar position.
Scrotal elevation to relieve pain is unreliable as a differentiating feature from torsion
of the testis.
14.3.3
Differential Diagnoses
Emergencies
Torsion of the testis
Traumatic testicular rupture
Fournier's gangrene
Peritonitis with patent
processus vaginalis
Abdominal aortic aneurysm
Non-emergencies
Torsion of appendix testis, epididymitis or
acute epididymo-orchitis
Idiopathic scrotal oedema
Traumatic haematoma
Scrotal abscess
Acute haemorrhage into testicular neoplasm
Renal colic
Hydrocoele
Varicocoele
Henoch-Schonlein Purpura
Insect bite
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14.3.4
Investigations and Management
14.3.4.1 General principals
Urinalysis: About 50 % of patients with epididymitis will have leucocytes on urinalysis
but its absence does not rule out epididymitis or nor does its presence rule out
torsion.
Serum WBC count is not useful on its own, as it is raised in 30 to 50 % of
patients with either condition, epididymitis or testicular torsion.
14.3.4.2 Suspected torsion of testis
Analgesia
Refer to the urgently to the Urology Registrar
Obtain an urgent ultrasound
If operated on within the first 6 hours, there is an 80-100% success rate
14.3.4.3 Epididymo-orchitis
If in any doubt, refer as a suspected testicular torsion.
The aetiology depends on age. In the young male it is most commonly an STD, the
organisms being Chlamydia, Neisseria gonorrhoea and Ureaplasma urealyticum. In the
older male it is most commonly a gram negative rod, such as E.coli and Klebsiella and rarely
Pseudomonas.
Patient febrile and toxic
Admit for IV antibiotics and imaging studies to rule out abscess.
Patient non toxic
Discharge on antibiotics, bed rest, scrotal elevation with folded towel, ice for 10
minutes 3 to 4 times a day and advise to ambulate when pain free.
Prescribe NSAIDs and paracetamol
Suspected STD: Refer to GUM clinic for swabs, contact tracing and further treatment.
If STDs suspected:
Appropriate swabs or GUM review
Ciprofloxacin 500 mg po stat only (alternatively Ceftriaxone 250 mg IV stat only),
and/or Doxycycline 100mg bd for 10 days (alternatively erythromycin)
If STD not suspected:
IV Gentamycin 5-7mg/kg daily
or Trimethoprim 300mg daily 10 days
or Nitrofurantoin 50mg QDS for 10 days
At discharge refer all patients to their GP for follow up. If concerned, refer to Urology Clinic
as 10% of testicular tumours present with an acute painful episode.
14.3.4.4 Torsion of testicular appendage
Bed rest, NSAIDS, analgesia, and ice.
The affected appendage will necrose in 14 days and become asymptomatic. Refer to
Urology Clinic.
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14.3.5
Varicocoele
Affects 10-15% of the population. Caused by dilatation of veins of the pampiniform plexus.
Can cause vague, “dragging” discomfort. On examination, has “bag of worms” appearance
surrounding the testis; should be confirmed on USS.
This is an important diagnosis to make as it can be the cause of infertility if untreated, as it
causes progressive testicular atrophy. Speak to Urology to arrange follow-up.
14.4
Priapism
Persistent painful erection greater than 4 hours. This is a true Urological emergency.
Causes:
Iatrogenic: post intracavernosal injection for impotence
Drugs (phenothiazines, cannabis, cocaine)
Renal dialysis
Prostate Ca or metastases
Haematological: leukaemia, myeloma, sickle cell disease
Spinal injury (rare)
Refer to Urology urgently, as it can result in later impotence if prolonged. May require
aspiration of blood from corpus cavernosum (lateral approach), usually performed by
Urology.
14.5
Paraphimosis
Occurs when foreskin is left retracted, glans subsequently swells and foreskin becomes
unretractable. Tissue necrosis may develop if not reduced.
Attempt to manually decompress swelling ± ice. Once decompressed (or if unable to) refer
to Urology for circumcision.
14.6
14.6.1
Genitourinary injuries
Bladder and Urethral injuries
Anterior pelvic fractures are associated with a high rate of bladder and urethral injuries.
Gross haematuria with anterior pelvic fractures is likely to be due to bladder rupture until
proven otherwise.
A CT cystogram can be arranged to confirm this. Views of the bladder during a standard
trauma CT are not sufficiently sensitive or specific for bladder injury.
Other signs suggestive of genitourinary injury:
Blood at the urethral meatus
Scrotal bruising
High-riding prostate on PR
Patient with multiple grossly displaced superior and inferior pubic rami fractures
All these require urgent referral to Urology for further investigation.
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14.6.2
Testicular trauma
These are uncommon due to the positioning and mobility of the testes. However, it should
be suspected when the patient gives a compatible history of direct trauma and there are
signs of an acute scrotum (pain, oedema and bruising).
Testicular rupture is an acute Urological emergency; the 80% of ruptured testes can be
saved if surgery is performed within 72 hours.
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15 Obstetrics and Gynaecology
The following sections are based on agreed local O&G guidelines.
15.1
Introduction
We have 2 specific Gynae rooms in majors, 9 and 10, which have all the equipment in the
cupboards. When the department is very busy you may have to use the eye room or other
Majors rooms. However you must consider privacy at all times.
15.2
History
Take a general history and a Gynae history.
Include: LMP, cycle length and duration, menorrhagia, dysmenorrhoea, IMB, post coital
bleeding, PMB, parity, contraception, smear history, vaginal discharge, abdominal pain, PID
If the patient is pregnant, remember task about fertility problems and problems prior to this
episode. Remember task about: previous USS, drug history, folic acid, ETOH and smoking.
15.3
Examination
Include: General examination, temp, pulse, BP, (lying and standing) abdominal examination
and vaginal examination, (digital and speculum).
Swabs if appropriate, e.g.: HVS- for Candida, B Haem strep etc.
Chlamydia: urine sample for NAAT (see GU section)
Chaperones: consider carefully whether to have a chaperone present, especially when
performing vaginal examinations.
15.4
15.4.1
Vaginal pain
Ulcers
Most common is Herpes Simplex. Primary infection is extremely painful and needs
appropriate analgesia.
Start on oral Acyclovir, 200mg x5 daily for 7 days. Needs referral to GU clinic.
Complications: urinary retention. Ref Gynae SHO.
If patient is pregnant: refer to Gynae SHO - don’t start Rx
Other ulcers: refer to GU clinic
15.4.2
Lumps
Bartholins cyst or abscess: arises from inside the vagina posterolaterally. Needs Gynae
referral.
Sebaceous cyst: if large may require I&D, otherwise antibiotics and GP follow-up.
Urethral caruncle: at external urethral meatus, a small red swelling which may bleed. Needs
GP referral to Gynae.
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15.5
Vaginal discharge
Can be physiological.
Atrophic: post menopausal and can cause PMB. Needs GP follow-up with Gynae referral to
PMB clinic if appropriate
Candida: creamy white discharge which is intensely itchy. Check BM.
Rx: Canesten, available over the counter
Other Discharge: take swabs, including Chlamydia and refer to GU Clinic
IMB/PCB: Consider Chlamydia. Visualise cervix, check smear history
PMB: If stable, needs GP ref to PMB clinic
15.6
Foreign bodies
Commonly tampons, condoms. Digital examination to feel FB, then speculum with forceps
Toxic Shock: usually due to Staph. aureus toxin from retained tampon
Patient is septic and may be extremely unwell. Menstrual history and use of tampons may
prompt suspicion.
Be aware that the foreign body may be due to assault.
15.7
15.7.1
Contraceptive problems
Missed Pills
COCP: refer to BNF.
Missing first few or last few pills so that the pill free week is extended is the most risky.
Remember 7 day rule
POP: 48 hr rule
Antibiotics: if you prescribe antibiotics you must ask re. COCP use. The patient needs to use
condoms whilst on the antibiotics and for 7 days following. Refer to BNF. This must be
documented.
15.7.2
Emergency Contraception
Levenorgestrel: To take within 72 hrs of unprotected SI. Refer to BNF.
Need drug history e.g. enzyme inducers, menstrual history to work out where she is in cycle.
Consider STDs and refer to GU clinic
IUD: If unprotected SI was more than 72 hrs ago and less than 5 days.
Ref GP, Family Planning Clinic (phone book) or GU clinic
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15.8
Gynaecological pain
Always consider pregnancy and ectopic.
15.8.1
Pain related to menstrual cycle
Dysmenorrhoea: Rx NSAIDs e.g. Mefenamic Acid (effective but needs to be taken before
onset of symptoms for maximum benefit). Refer back to GP
Mid Cycle: Consider Mittleschmertz pain. Rx NSAIDs
15.8.2
PID
May be acutely unwell with bilateral low abdominal pain, temp and vaginal discharge.
Resuscitate as required. Most commonly due to Chlamydia.
Needs urine for NAAT. Refer to Gynae / GUM clinic
15.8.3
Ovarian torsion/cyst rupture
Consider with Hx of low abdominal pain. May present as peritonitis; note differential Dx
15.8.4
Fibroids
May undergo degeneration / torsion especially in pregnancy. Refer to Gynae
15.8.5
Vaginal bleeding
See Vaginal bleeding protocol on intranet.
Always ask could the patient be pregnant?
In Hx: try and establish amount of bleeding ?related to menstrual cycle, smear history,
Exam: Visualise cervix. ?Polyp ?Cervicitis ?Ca
If in doubt discuss with Gynae SHO.
Rx Provera 30mg daily to stop bleeding. Also available, Mefenamic Acid and Tranexamic
Acid.
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15.9
Problems in Pregnancy
15.9.1
General considerations
The safety of mother and baby is paramount.
The well being of the mother takes precedence over that of the fetus.
Some acute medical / surgical conditions cannot be safely managed in QMMU.
Up to 12 weeks’ gestation
Women presenting with pregnancy complications up to 12 weeks’ gestation, including women
with excessive vomiting, should be assessed in A&E. Women suitable to be managed in the
community can be discharged from A&E and followed up in the Early Pregnancy Unit (EPU). The
EPU referral form should be faxed to EPU.
Women with more complex problems who are likely to be admitted are referred to the Gynae
SHO for assessment who consults with the Gynae Registrar.
12 - 18 weeks’ gestation
Women should be assessed in A&E by the A&E team and a referral made to the obstetric SHO
(bleep 493) / SpR (bleep 530) to determine the appropriateness of admission to either QMMU or
to a bed on a general ward.
>18 weeks
These women should be cared for in QMMU. They should be first assessed in the A&E
department by the A&E team or the Obstetric SHO / SpR. The Delivery Suite should be
consulted / informed before the woman is transferred from A&E (x 5946 / 5947).
Non-pregnancy related conditions in pregnant women
Women with non-pregnancy related conditions may be admitted to a general ward or QMMU
depending on clinical need.
Pregnant women who require admission to a general ward must be discussed with an
experienced obstetrician prior to a decision being made, to allow optimal care and
communication. Women with medical conditions should be referred to the obstetric medicine
and endocrinology teams early in the discussion so that they can be involved in their
management.
Fetal monitoring may be undertaken by midwifery staff.
Postnatal complications
Women with postnatal complications who are still under the care of the midwife (usually <10
days) should be (re)admitted direct to QMMU via Triage if their medical condition permits.
Women who have delivered within the last four weeks but who have been discharged from
the Maternity Service must be reassessed in A&E. Admission into QMMU may not be
appropriate. The A&E team will liaise directly with the on call obstetric SpR (bleep 530) to
decide appropriate management.
Women who delivered more than 4 weeks ago are beyond the remit of midwifery care.
Admission of mothers to general wards
Staff on general wards are requested to notify the Delivery Suite (x 5946) of any mother
admitted to the ward who has delivered within the past 28 days.
A midwife will be available to provide support and advice particularly to breast feeding
mothers, and can supply a breast pump if required.
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15.10 Early pregnancy problems
Always consider ectopic pregnancy!
Early pregnancy problems that present to the Emergency Department include:
Threatened miscarriage
Miscarriage- inevitable, incomplete, complete, delayed
Septic miscarriage
Abdominal Pain in early intrauterine pregnancy
Retained products of conception after termination of pregnancy
Ectopic pregnancy
Ruptured ectopic pregnancy
Hyperemesis gravidarum
15.10.1
History
General
Age
Previous pregnancies
LMP and frequency of menstrual cycle to establish the gestation.
Have they had a scan in this pregnancy establishing the site of the pregnancy?
Last smear – particularly if bleeding
Ectopic risk factors
Previous ectopic pregnancies
History of female factor subfertility, assisted conception,
Maternal age > 40 years
Previous STD or PID
Symptoms
Onset
Bleeding and amount
Pain, location, type i.e. dysmenorrhoea type, sharp etc
Associated symptoms – faintness, pain with defecation, shoulder tip pain, dysuria and
frequency.
15.10.2
Examination
Pulse, temperature, blood pressure
Abdominal palpation
Bimanual examination: Is the uterus bulky consistent with dates, is there cervical excitation,
are there any masses, is there unilateral tenderness, is the internal os open?
Are there products in the os?
Speculum examination: looking at the cervix, is the blood coming through the os?
If products were felt in an open os these should be removed with sponge holders and sent
for histology. The patient needs to sign consent form for histology / sensitive disposal
(Gynaecology doctors will arrange this, as they have been trained to take the appropriate
consent).
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15.10.3
Investigations
All patients should have had a positive urine pregnancy test. However, there can be false
negatives in very early pregnancies or at low levels of BHCG, so send a serum sample if any
doubt exists.
Full blood count and group and save
All patients with significant bleeding in early pregnancy should have these performed.
However, FBC / G&S are unnecessary in fit women who have had minor bleeding / spotting
only.
Serum BHCG
This should be performed on all suspected ectopic pregnancies and those 5 weeks pregnant
or less. At the weekend you need to speak to the biochemist to perform the sample urgently.
Progesterone
This should not be performed on patients in A&E unless requested by the Gynae Registrar.
Transvaginal ultrasound scans
These can be organized through the Early Pregnancy Unit. There are emergency slots each
weekday. Patients must be stable for transfer to EPU.
15.10.4
Establishing a diagnosis clinically
Diagnosis
Threatened miscarriage suitable
to be managed as an outpatient
Findings
Light bleeding, Uterus bulky consistent with pregnancy,
cervical os closed, no unilateral tenderness or cervical
excitation, pulse, blood pressure and temperature normal.
(these patient may experience some dysmenorrhoea type
pain)
Incomplete/ complete
miscarriage that can be
managed as an outpatient
Heavy bleeding with a history of having passed products
and a closed cervical os. The bleeding must have settled
to light bleeding and pain to just a dull ache.
Suspected retained products
after ERPC or termination of
pregnancy suitable for outpatient
management
Continued bleeding (not heavy) and pain after procedure,
cervical os closed, apyrexial, haemodynamically stable
with a normal Hb.
(Always consider perforation if onset of pain immediately
post surgical procedure)
Threatened miscarriage that
requires admission for further
investigation
Heavy bleeding with a closed os and no unilateral pain
with normal pulse, blood pressure and temperature.
Probable ectopic pregnancy
requiring admission and
investigation to establish a
diagnosis
Any patient with unilateral pain, a closed os and
tenderness on bimanual examination.
Incomplete / inevitable
miscarriage requiring immediate
treatment or admission and
ERPC
Heavy bleeding with an open external os or products
within the os. (Haemodynamically compromised patients
will need immediate treatment-remove products from the
os if they are present)
Any patient with a past history of ectopic pregnancy or
assisted conception pregnancy with abdominal pain even
if not tender on bimanual examination.
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Suspected retained products
after ERPC or TOP requiring
admission
Continued bleeding and pain after procedure with an
open cervical os, or temperature or heavy bleeding.
Probable ectopic pregnancy
requiring immediate treatment
Collapsed patient with abdominal pain and vaginal
bleeding, a closed cervix and tender on bimanual
examination.
A patient without collapse but low blood pressure,
tachycardia or HB<10 g/dl with symptoms as above.
A patient with severe abdominal pain and marked
tenderness on bimanual examination (unusual for an
ectopic to rupture without vaginal bleeding, but lack of
bleeding does not exclude an ectopic).
15.10.5
Management
General rules
Management depends on the presumed clinical diagnosis and suitability for community
management and investigation (see above table).
Patients suitable for community management should be assessed by the A&E Team.
Women with more complex problems who are likely to be admitted should be referred
to the Gynae SHO for assessment in consultation with the Gynae Registrar.
All patients requiring a surgical procedure should be seen by the Gynae Registrar.
All patients with haemodynamic compromise should be seen by the Gynae Registrar.
Any patient with bleeding in early pregnancy and a raised temperature should be
admitted, septic miscarriage must be excluded and intravenous antibiotics considered.
15.10.6
Patients suitable for Community management
Patients suitable to be managed in the community can be discharged from the Emergency
Department and follow up arranged in the Early Pregnancy Unit. Remember to take a
contact telephone number for the patient.
Fill in the EPU referral form and fax to EPU (see below)
If Rhesus negative: All women with an estimated gestation of 12 week or more must receive
anti-D as soon as possible after the sensitising event, but always within 72 hours.
Before 12 weeks gestation, where vaginal bleeding has been heavy or repeated, associated
with abdominal pain, and the pregnancy apparently remains viable, it may be prudent to
administer anti-D particularly if approaching 12 weeks gestation.
All non-immunised rhesus negative women with an ectopic pregnancy must receive Anti D
500 IU.
Give patient a “Vaginal Bleeding in Early Pregnancy” information leaflet (found in the
Doctors’ Room in Majors; you can also print this from the A&E Appendix 20 section) and
advise them to re-attend if worsening of symptoms or concerned.
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15.10.7
Early Pregnancy Unit
On First Floor of the Woman’s Day Unit. Open Daily Mon-Friday either mornings or
afternoons.
Referrals by fax from A&E, using form in doctors’ office. The unit will contact the patient
directly with an appointment time therefore form must have a contact telephone number.
Not all patients will get an USS as this will depend on the clinical picture. Do not
promise patients that they will receive a scan; they will be assessed by the
Gynaecology team, and if required, they will be scanned.
Nurse practitioners:
15.10.8
Heather Hall;
Jan Meloni:
ext 5796
ext 5005
bleep: 256
bleep: 249
Products of Conception
Following new guidelines, if you remove POC from the cervix/vagina this needs to be
documented and sent to Histology. If patients bring in POC they are treated similarly.
The patient needs to sign a special consent form to agree to Histology and to indicate their
choice for Sensitive Disposal. This is part of Trust Policy and is mandatory under the
Human Tissue Act 2004.
If there is an identifiable foetus, however small, this must be sent to the Mortuary, not to
Histopathology.
There are separate forms for this, including certificate of miscarriage and hospital funeral
arrangements. Usually, the Gynaecology Team will arrange this as they have received
training in obtaining the appropriate consent.
15.10.9
Anti D
Please see guidelines on intranet (Clinical guidelines / maternity / antenatal / A13).
Consider anti D in all pregnancies over 12 weeks with PV bleeding and in all ectopic
pregnancies if Rhesus –ve.
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15.10.10 Hyperemesis Gravidarum
Gynae are running an outpatient management service for suitable hyperemesis patients.
However, all hyperemesis patients still need to be referred to the Gynae SHO prior to leaving
A&E for the designated outpatient area.
See Clinical guidelines / maternity / antenatal / A2 on the intranet for more information.
Inclusion criteria
Urinalysis: 2+ ketones
Inability to maintain adequate hydration at home
Vomiting >5 times per day, or unable to keep down more than 500mls fluid/ 24hrs
Weight loss
Clinical hypovolaemia: reduced skin turgor (sternum, back of hand, dry tongue)
In return patients, criteria for continuing outpatient management
Normal LFTs
Normal TFTs
Normal calcium
Normal blood glucose
Negative urinalysis for UTI (no proteinuria or blood)
Ultrasound scan confirms a viable intrauterine pregnancy (not molar)
Exclusion criteria
Failed outpatient management
No improvement over 3 consecutive days
Remains hypovolaemic (pulse>100; systolic BP<80 mmHg) following 2L of fluid
Threatened miscarriage
Client unable to walk / make own way home
Abnormal U&Es
Abnormal LFTs or TFTs- both are associated with increased severity of HG
Significant medical comorbidites e.g. diabetes, thyrotoxicosis, heart disease, active
IBD, epilepsy, severe anaemia (diagnosis of HE may be difficult or consequences of
HE may be more serious).
Management
At least a green cannula
Bloods for FBC, U&E, LFTs, Ca, TFTs (if not done recently)
BM
Urinalysis
1L of 0.9% saline with 20mmol/L KCl over 2 hours followed by a second bag over 2-4
hours. Dextrose containing fluids must not be given because of the risk of
central pontine myelinolysis.
Give cyclizine 50mg IV or prochlorperazine 12.5mg IM
If oculogyric crisis occurs related to metoclopramide, stemetil or cyclizine use
Procyclidine 5mg IV
Oral antiemetics useful on discharge: Cyclizine 50mg tds po (alternatives metoclopramide
10mg or domperidone suppositories 30-60mg tds).
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15.11 Later pregnancy problems
Over 18 weeks women should be seen in maternity unit for pregnancy related problems. If
they have presented to A&E, they should first be assessed to ensure that they are stable for
transfer to QMMU. However if the problems are not pregnancy related, e.g. RTA, suspected
DVT/PE they will be seen and assessed by the A&E Team. You may need input from the
Obstetric Team.
15.11.1
Pre-eclampsia / eclampsia
This guidance is based on local policy on pre-eclampsia, A23.
Risk factors for pre-eclampsia:
Prior history of pre-eclampsia
Diabetes, renal disease, chronic hypertension, autoimmune disease present
Nulliparous
Aged 40 or older, or teenage pregnancy
Family history of pre-eclampsia (for example, preeclampsia in a mother or sister)
Body mass index (BMI) at or above 35 at first contact
Booking BP >130/80
Multiple pregnancy
Symptoms:
None in mild cases
Headache
Visual disturbance such as blurring or flashing lights
Epigastric abdominal pain
Vomiting
Sudden, new swelling of the face, hands or feet
Seizure activity
Diagnosis
Always do BP and urinalysis, looking for proteinuria.
Don’t forget that BP should be lower in pregnancy, and always compare it to the booking
blood pressure (if significantly raised may be a sign of pre-eclampsia). The presence of the
following should prompt referral to Obstetrics:
Diastolic blood pressure of at least 90 mmHg or a systolic blood pressure of at
least140mmHg
A rise in diastolic pressure of at least 15mmHg or in systolic pressure of at least
30mmHg from the baseline measurement
Proteinuria of at least 1+ on dipstick in the absence of UTI.
Get large bore IV access and send blood for FBC, U&E, LFT, coag and uric acid. Look for
HELLP syndrome (haemolysis, elevated liver enzymes, low platelets).
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Complications
Cerebral haemorrhage
Eclamptic convulsions (can occur without preceding signs of pre-eclampsia)
Pulmonary oedema
Hepatic and renal impairment
DIC
HELLP
IUGR / prematurity
Placental abruption
Maternal / Foetal death
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15.11.2
Management of severe pre-eclampsia / eclampsia
Severe hypertension is defined as sustained systolic ≥160mmHg or diastolic
≥110mmHg. This requires treatment. This guideline is based on local policy on severe
pre-eclampsia and eclampsia, B17.
Get help! Put out a call through the emergency operator (2222) stating an “Obstetric
Emergency in A&E Resus”. You should have the Obstetric Team, Paediatricians and
Anaesthetists attending.
If the patient presents with uncontrolled hypertension and fitting:
ABCDE resuscitation; secure airway early
For acute management of severe hypertension use either Nifedipine orally or Labetalol
orally or IV, or Hydralazine IV:
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Magnesium sulphate is the drug of choice for controlling seizures:
Careful fluid balance and fluid restriction is required to prevent iatrogenic pulmonary
oedema
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16 Sexual Health and Genitourinary Medicine
The following guidance is summarised from the guidelines of the British Association for
Sexual Health and HIV.
16.1
GU clinic
Situated on right hand side by the road entrance to the hospital.
Opening times:
These vary, but walk-in clinics on most days from Mon to Fri. Reception has a list of the
times of these clinics.
Men: walk in clinic
Women: walk in clinic and appointment only clinics
Tel ext. 5718
16.2
Taking a sexual history
History taking is essential for making any diagnosis and management plan, and sexual
history taking is no exception.
Important points:
Think about the possibility of an STI
Discuss this gently with the patient
Test for suspected STI
16.2.1
Basic rules on sexual history taking
Privacy and the assurance of confidentiality are essential
Many STIs can be asymptomatic, but when symptoms are present the patient may
not link them to an STI, so you may have to raise the subject sensitively
Do not make assumptions about
o sexual orientation (a married man may still have sex with other men)
o age (sexual liberation is not exclusive to the young)
o anything!
Sometimes you will need to ask direct questions when the patient doesn’t volunteer
information
o explain why you need to ask something, but only ask what is relevant
Embarrassment can be infectious – try not to let your own feelings / opinions
interfere. Have a non-judgemental attitude.
Clarify terms: “sex” doesn’t always mean peno-vaginal penetration, and many STIs
are spread easily from oral or anal sex
Be aware that condoms are often put on after some penetration has already taken
place (and condoms also split / come off).
Be alert to non-consensual sex (child protection issues)
Alcohol and drug use can lead to risk-taking sexual behaviour, and financial
difficulties may lead to prostitution.
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16.2.2
Specific questions
1. Symptom history
Men
Urethritis can present as
o Vague urethral discomfort or itch
o Dysuria
o Urethral discharge
o Epididymo-orchitis
o Reactive arthritis
o Conjunctivitis (autoinoculation)
Women
Cervicitis / endometritis
o Intermenstrual bleeding,
o Post coital bleeding,
o Deep dyspareunia,
o Lower abdo pain,
o Ophthamlia neonatorum
Salpingitis / PID
o As above plus RUQ (perihepatitis) and shoulder tip (referred) pain
o Ectopic pregnancy
Vaginal infections
o PV discharge
o Itch
o Soreness
2. Medical History
Past medical history (including previous STIs)
Medication (including OTC or illicit drugs)
Allergies
Obs / Gynae Hx for women
3. Partner history
When was the last sexual encounter?
Who with? (Traceable or not? male or female? Abroad?)
What sort of sex (oral, vaginal, anal?)
Was barrier contraception used for all contact?
Go back through all partners for last 3 months (to cover most incubation periods).
Do not assume gender each time.
NB: Such detailed sexual history taking may not always be appropriate in A&E and depends
on the individual clinical scenario. A detailed sexual history may be more appropriate in the
context of the GUM clinic by trained staff.
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16.3
Male urethral discharge
Urethral discharge is a result of urethritis which is usually due to a sexually transmitted
infection.
Urethritis can produce the following symptoms (not all may be present):
Urethral discharge – (ranges from mildly mucoid to purulent+++ )
Urethral “itch” / discomfort
Dysuria – do NOT assume dysuria in a male is always a UTI!
A sexually active man c/o dysuria must have STIs excluded
Infective causes (you cannot reliably distinguish these clinically):
Chlamydia
Gonorrhoea (also known as “gonococcus” or “GC” for short)
NSU – a diagnosis of exclusion after GC and Chlamydia have been ruled out.
Caused by many different organisms.
16.3.1
Management
Refer to GU urgently
If an urgent (< 48 hrs) appt is not possible then consider:
Taking tests for STIs and then treating empirically (see below)
16.3.2
Tests
1st pass urine (NAAT test – nucleic acid amplification test)
16.3.3
Treatment
Chlamydia and NSU:
AZITHROMYCIN 1 g po stat
or
DOXYCYCLINE 100 mg po bd 7/7
Uncomplicated urethral gonorrhoea:
CEFIXIME 400 mg po stat
If very purulent discharge, suspect GC, especially if recent SI abroad. Treat for both GC and
Chlamydia / NSU.
If mild symptoms only, treat for Chlamydia / NSU and await results of urine testing for GC at
GUM clinic.
16.3.4
Advice
Advise patient and partner(s) to attend GUM clinic for Rx.
Advise pt NO sexual encounters at all, until given all clear
Advise no sex until 7 days after Rx finishes and symptoms resolved and partner
successfully treated. Document this in notes.
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16.4
Abnormal vaginal discharge
In pre-menopausal women:
1/3 due to Candida
1/3 due to bacterial vaginosis
1/3 due to STIs or physiological
The history and characteristics of the discharge can give you clues to the diagnosis.
Refer to GUM clinic if:
You suspect Trichomonas vaginalis
The diagnosis is in doubt
Symptoms are persistent
Otherwise refer back to GP for treatment.
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16.5
Chlamydia
Estimated prevalence at about 10% women and 13% in men under 25. Note that the
highest rates are in 16-19 year old women.
Risk factors for acquisition:
Age < 25 (highest rates are in women aged 16 to 19 )
New sexual partner or > 1 partner recently
Lack of barrier contraception, top
16.5.1
Symptoms / signs
Women
Asymptomatic in 80%
Vaginal discharge
Post coital or intermenstrual bleeding
Dysuria (beware sterile pyuria – it may be Chlamydia)
Lower abdo pain
Deep dyspareunia
Cervicitis
Men
16.5.2
16.5.3
Asymptomatic in 50%
Dysuria
Discharge
Urethral discomfort
Epididymo-orchitis
Sexually acquired reactive arthritis (SARA)
Complications
PID, ectopic pregnancy, chronic pelvic pain
Peri-hepatitis (and peri-appendicitis)
Epididymo-orchitis
Adult conjunctivitis
Neonatal conjunctivitis
Sexually acquired reactive arthritis “SARA” (men > women)
Tests
NAAT – nucleic acid amplification tests
A very sensitive way of detecting DNA
o Urine: Send 15 to 20 ml of first void urine (not mid stream). Label specimen
“first void”
o We do not stock the endocervical swabs in A&E. A HVS will not be adequate.
Although very accurate, they are not 100% sensitive or specific
16.5.4
Management
Refer all cases to GUM clinic for follow up, who will arrange treatment and screening.
Advise the patient to abstain from sexual encounters until they and their partner(s) have
been given treatment and all clear by GUM clinic.
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16.6
Gonorrhoea
Spread by sexual contact. No evidence that it can be transmitted from use of toilets or other
shared facilities.
16.6.1
Men
Symptoms
Urethral infection will produce symptoms most of the time but can be asymptomatic
10% of the time
Pharyngeal and rectal infections are usually asymptomatic
Women
50% have no symptoms and 50% have vaginal discharge
Urethral infection is usually asymptomatic but may cause dysuria
16.6.2
16.6.3
Complications
Endometritis < 10%
Epididymitis < 1%
Systemic spread < 1%
Test
Culture from affected area and send for NAAT.
16.6.4
Management
Refer to GUM clinic
Advise abstinence from sexual encounters until they and their partners have been treated
Screening for other STIs should take place
16.7
Herpes
Herpes usually presents as multiple painful ulcers; beware the lone painless ulcer – think
about primary syphilis. HSV is transmitted by close physical contact and shedding of the
virus occurs sporadically, not just when symptoms are present.
16.7.1
Primary infection
This is the first time the virus is acquired, but it may not necessarily result in symptoms. If it
does cause symptoms, this first “attack” tends to be longer and more severe than future
recurrences.
Symptoms of primary genital infection
Febrile flu-like illness (prodrome) lasting 5 to 7 days
Tingling / neuropathic pain in genital area, buttocks or legs
Extensive bilateral* crops of genital blisters, ulcers or fissures
Tender lymphadenitis
May get local oedema
Untreated, a first episode may last 3 weeks or so
Diff Dx: Candida ( painful fissures), shingles
*cf the lesions of recurrent genital herpes, which, like those of herpes zoster, are almost
always unilateral.
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16.7.2
16.7.3
Management
Refer to GU same day – ring to arrange
Saline bathing (1 tsp salt in 1 pint warm water)
Consider topical LIGNOCAINE 5% ointment if very painful
Adequate analgesia
No role for topical anti-virals
If any delay to being seen, give oral anti-herpesvirus Rx (such as ACICLOVIR 200
mg po 5 x day for 5/7 or oral VALACICLOVIR 500 mg po bd 5/7) if within 5/7 of onset
of Sx, or if new lesions still forming
To prevent urinary retention, tell the patient to micturate whilst sitting in a warm bath
Pregnancy and HSV
Danger! – Risk of neonatal infection
Neonatal HSV is usually acquired during delivery from maternal viral shedding,
although rarely it may be acquired in utero
Most likely to occur with new maternal acquisition of HSV in the final trimester
Rare but can be catastrophic
First episode or a recurrence?
Neonatal infection
Symptoms 2 to 28 days after delivery: vesicles, jaundice, encephalitis, DIC
Management
Refer / talk to GU if uncertain as to what to do
Discuss case with Obstetric team ?Elective section required
Treat according to clinical need (i.e.: give Aciclovir orally for 5/7 if needed. Although
not licensed for pregnancy, there is substantial clinical evidence over many years to
support its use - informed consent)
Consider Aciclovir for mother now (and baby afterwards)
16.8
Syphilis
A rare infection which is now becoming more common in London. It is a complicated illness;
refer to GUM clinic.
The highest rates are in:
Men who have sex with other men* (however, your patient may not volunteer this
unless asked directly)
The over 25s
Certain urban areas (e.g. London, Brighton, Manchester)
Many patients are HIV+ as well (and may not be aware of this). Transmission can occur
easily through oral sex. If untreated, it can remain infectious for up to 2 years.
Always consider syphilis if you see a single painless ulcer (a primary chancre).
16.8.1
Investigations
Send blood for syphilis serology
Strongly consider testing for HIV as well
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16.8.2
Symptoms and Signs
If the primary chancre was unnoticed, the patient may present with secondary syphilis. Most
commonly, this is in the form of a maculopapular rash, which can affect the palms and the
soles. It tends not to be itchy.
However, it can mimic may other conditions and present as:
Generalised malaise
Lymphadenopathy, hepatosplenomegaly
Oral mucous patches (“snail track” ulcers)
Moist warty lesions (“condylomata lata”) at sites of skin friction (perineal, vulval, under
breasts, axillae)
Patchy alopecia
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The oral ulcers and condylomata lata are highly infectious, leading to easy transmission to
intimate contacts.
Tertiary syphilis (late syphilis) is rare because in the course of a lifetime, a patient may
receive treponemocidal antibiotics for other conditions by chance.
Symptoms and signs:
Cardiovascular system
Aortic incompetence with aortic regurgitation
Aortic aneurysms
Nervous system
General paralysis of the insane
Tabes dorsalis
Skin and bones
Gummatous (localised vascular granulation tissue) lesions with nodule formation and
destructive ulceration
16.9
Sexual assault
This is defined as any non-consensual sexual act. Keep careful notes and record
information verbatim. The patient needs first aid for any injuries. Then ask the patient if they
want to provide forensic evidence.
If so, refer the patient to a specialist counselling centre e.g. Haven Trust. If the patient is
agreeable, this can be done by the Police, who can accompany the patient to the centre.
They can also self refer if they do not want to involve the Police.
See website www.thehavens.co.uk. These are specialist centres linked to the police,
where swabs etc are taken. They can then be used at a later date if required. The Havens
provide a 24 hour service.
Fax referral to GU clinic for follow up: 020 8321 2568.
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17 Sharps / Inoculation Injuries
Every effort must be taken by all staff to prevent and avoid sharps injuries. The guidance
below summarises Trust policy on Sharps.
Use common sense to prevent injuries:
Learn to avoid any action which directs a used sharp instrument towards the hand.
Dispose of used Sharps straight away.
Do not leave Sharps for others to clear up.
Do not use a receiver to carry used Sharps after phlebotomy but carry a Sharps tray
with a Sharps bin to the bedside.
Discard Sharps bins when ¾ full.
Keep them away from children.
Do not put needles in plastic bags.
Never resheath or bend used needles.
Obtain help when taking blood from or putting up a drip on uncooperative patients.
17.1
Risk assessment
An occupational injury is considered significant if the source is HIV positive and the injury is:
A percutaneous injuries (from needles, instruments, bone fragments, significant bites
which break the skin)
An exposure of broken skin (abrasions, cuts, eczema, etc) to high risk fluid*
An exposure of mucous membranes, including the eye, to high risk fluid*
*High risk body fluids include blood, amniotic fluid, vaginal secretions, semen, breast milk,
CSF, peritoneal fluid, pleural fluid, pericardial fluid, synovial fluid, saliva in association with
dentistry (that is blood contaminated).
Usually, a member of staff suffering the injury is the recipient and a patient is the source.
(Sometimes the patient may be the recipient of an injury).
17.2
Immediate actions
The recipient is responsible for making sure that the following action is taken:
Wash wound under running copious water and encourage bleeding
Do not suck the wound
If the eye is involved wash with copious amounts of saline or water
Report to immediate superior or senior members of staff present
Fill out Datix form
The senior member of staff is then responsible for the next steps:
Check from the notes whether the hepatitis B, hepatitis C or HIV status of the source
patient is known
If the source is HIV positive or is at high risk of being HIV- positive immediate action
is required
Telephone Occupational Health Department (xt. 5044) to arrange for immediate
assessment or, if out of working hours, advise the recipient to attend A&E
immediately and ask for the nurse in charge.
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Occupational health staff or A&E staff:
Will take details and where appropriate, advise and administer first aid, hepatitis B
vaccination and / or HIV post-exposure prophylaxis (see proforma in Doctors’ Room
and in A&E Appendix section 20 on intranet)
Fill out the Proforma / ask patient to sign declaration
Give out Patient Information sheet (also in Appendix section)
Arrange for the source patient to be approached so that a request for the source to be
tested for hepatitis B, hepatitis C and HIV be made
5ml clotted blood must be taken (arrange in A&E or Occupational Health) from the
recipient and sent to Microbiology for hepatitis B surface antibodies and save serum.
This sample should not be tested for hepatitis C or HIV antibodies.
Check that a Datix form has been completed.
Ensure that the patient has the appropriate follow-up with Occupational Health plus
GU Clinic if appropriate. Fax over completed proforma to appropriate numbers as
stated on the form.
17.3
Hepatitis prevention
Ask the affected healthcare worker when they last had a Hepatitis B booster. If it has been
over a year, give them a booster.
If they have never been immunised or never developed immunity and the patient is high risk,
a course of Hep B immunoglobulin may be required. Discuss this with the on call
Microbiologist or GU Consultant.
There is no immunisation or preventative treatment available for Hepatitis C.
17.4
HIV prevention
Recommendations for PEP:
If there is any doubt, discuss this with the Microbiologist or GU Consultant on call. Document
the advice you are given by them.
If the decision is made to delay treatment until the results of the HIV test on the source are
known, then discuss with the medical Microbiologist to perform this test urgently.
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During working hours, refer the recipient to the GUM clinic immediately to start PEP.
Out of hours, starter packs are kept in A&E (Truvada 1 tablet bd and Kaletra 2 tablets
bd). It is also good practice to prescribe anti-emetics to treat the side effects of the
tablets. This increases compliance with the medications.
If the source is unable to give consent to HIV testing (refuses consent, medical condition
preventing patient from giving informed consent) please discuss the case with GUM
Consultants / Microbiology Consultants.
17.5
Summary of guidance
Make sure an incident form has been completed by the recipient, give the recipient the
advice sheet found on the Intranet under Sharps Policy if receiving PEP, and advise recipient
to attend Occupational Health ASAP (and GUM clinic if PEP commenced out-of-hours).
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18 Toxicology
The guidance in this section is drawn from locally agreed guidelines used in NW Thames.
18.1
General assessment
Prior to approaching the patient, always consider the risk to yourself, your staff and
other patients in the department / hospital from contamination, especially if there is
more than one casualty.
Hazmat procedure may apply.
Important points in assessment:
Ascertain the nature and time of poisoning if known
If more than one patient is affected, immediately escalate this to seniors in the
department and isolate the affected patients. Consider what decontamination or PPE
may be required.
Always contact the National Poisons Information Service (Tel 0844 892 0111) for
advice regarding more complex cases. Advice can be obtained from their website
http://www.spib.axl.co.uk but this is not sufficient for more complex cases.
18.2
18.2.1
General management
Initial management
Follow an ABCDE approach
Secure airway if necessary
Give high flow 02
Heart rate, respiratory rate and respiratory pattern may give clues as to the nature of
the poisoning and should be accurately recorded.
Treat shock with fluid boluses. Inotropes should be used with caution, as they may be
pro-arrhythmic in combination with poisons.
Assess conscious level. Commence frequent neurological observations
Look for associated injury from attempted self harm
Emesis is no longer recommended and is contraindicated with volatile
substances.
Consider gut decontamination. Carefully follow Poisons Centre advice with regard to
charcoal administration.
Helpful investigations
An ECG should be performed for all cases of known tricyclic antidepressant (TCA)
overdose and where the full history of poisoning is uncertain. QRS prolongation is an
early sign of cardiovascular involvement.
Urine must be sent as soon as possible for toxicology.
The possibility of more than one poison should always be considered.
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Blood tests
Draw blood for FCB, U&Es, coag, salicylate and paracetamol levels at 4 hours from
time of poisoning.
Blood gas analysis and anion gap {(Na+ + K+) – (Cl- + HCO3-)} should be performed.
o Elevated anion gap (>16) is seen with methanol, ethanol, ethyl alcohol,
salicylates, ketones and iron poisoning (secondary to increased lactate).
Measuring the osmolar gap can also be useful.
o Osmolar gap = (2 Na + Urea + Glucose) – measured osmolar gap.
o Gap >20 is significant. This is seen with methanol and ethylene glycol.
18.2.2
Specific poisons
Opiates
Naloxone should be considered if opiate poisoning is likely.
A naloxone infusion may be required if a bolus improves conscious level or
cardiorespiratory status.
Salicylate (aspirin) / TCA
Alkalinisation with bicarbonate (1mmol/kg boluses) should be considered for salicylate
or tricyclic overdose.
Specific antidotes (
Paracetamol = N-acetylcysteine
Iron = Desferrioxamine
Organophosphates = Pralidoxime and atropine
Give after discussion with the poisons centre.
18.3
Body packers and stuffers
This is a brief guide to the problems which may occur when detainees are brought to the
Accident and Emergency Department by the police because they are believed either to have
swallowed drugs or to be a drug smuggler.
18.3.1
Police and duty of care
1. Individuals who have been brought by the police for examination on suspicion of having
consumed or concealed drugs are there for medical care, which includes diagnosis
and treatment. For example, we have no duty to detain a patient until they pass
ingested packets – customs and police have facilities for this.
2. We have no legal obligation to assist the police in the pursuit of their duties. Our
primary responsibility is to exercise our duty of care to the patient – to prevent harm
to the patient. However, this may include discharging the patient as soon as they are
deemed to be medically fit to leave.
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18.3.2
Definitions: Body packers and stuffers
1. Body packers (“drug couriers”) is the term commonly used to describe people who
swallow packets of illicit drugs or put them into body orifices in order to escape
detection as they pass through customs checks. The packets are intended to retain
their contents as the individual crosses frontiers.
Rupture or leakage of packets is the commonest reason why these individuals attend
an A&E department.
2. Body stuffers is the term commonly used to describe people who swallow illicit drugs
(usually in a hurry) in order to avoid being found with the drugs in their possession.
These individuals are then arrested and brought to an A&E department in case of
deterioration or because they have developed symptoms. The substance may be
swallowed loose or wrapped in cling film, but the packet is usually not secure and leaks
drug from the time it is swallowed.
3. The substances involved are most typically cocaine or heroin.
Body stuffers may also consume ecstasy, amphetamine, ketamine, LSD or other drugs.
These cause characteristic signs of toxicity and will not be dealt with in detail here.
Body Packers
1. Body packers swallow packets (which may be condoms or other containers, often
purpose designed) of drugs before travelling. The packets may leak or rupture at any
stage, with the risk of severe and potentially fatal toxicity.
2. Drug smugglers aim to convey the ingested drugs across national boundaries without
any adverse effects, passing the packets in the country of arrival. However, some of
these individuals come to medical care, either because they have been suspected of
swallowing packets or because they have become ill while travelling or after arrival.
3. Diagnosis is based on the presence of symptoms and on clinical examination. Signs of
toxicity may be apparent, and packages may sometimes be felt through the abdominal
wall or on rectal examination.
A near-patient urine test can be helpful to confirm the presence of drugs. If positive for
cocaine, it is very likely that cocaine is responsible. If positive for opioids the packages
may contain heroin, but opioids such as codeine are frequently taken in order to slow
the bowel during a long flight. Thus a positive test for opioids does not confirm that
heroin has been taken.
4. Other investigations include abdominal x-ray, abdominal ultrasound or CT scanning,
which can show up the presence of packages.
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Body Stuffers
1. Because of the mode of swallowing, the drug is not securely wrapped. Even if
wrapped in cling-film does not significantly delay the development of toxicity.
2. If the urine test for drugs is not positive by two hours after ingestion, drug consumption
is unlikely, and the patient can be discharged.
3. If no symptoms or signs develop within four hours of ingestion, the patient can be
safely returned to police custody.
4. Symptoms of toxicity from cocaine and heroin are dealt with in this guide.
18.3.3
Amphetamine ingestion including MDMA (“ecstasy”) may lead to agitation,
tremor, tachycardia and hypertension.
Ketamine causes mild tachycardia and hypertension with agitation and
confusion.
Gamma hydroxybutyrate (GHB) causes nausea followed by drowsiness and
deep coma, often with muscle twitching.
LSD typically causes behavioural disturbances. Near-patient tests are not
available for the latter three substances.
Diagnosis and management of toxicity
1. The commonest drugs involved are cocaine and heroin, and signs of toxicity are
usually typical for these drugs. The flowchart gives a general guide to management.
2. Heroin toxicity causes impaired consciousness or coma, pinpoint pupils and slowing of
respiration. Bowel sounds may be absent. Vomiting may occur. Convulsions are
uncommon. Death in these circumstances is usually due to respiratory arrest.
3. Management of opioid toxicity includes respiratory support and liberal use of naloxone.
In severe cases, mechanical ventilation will be indicated.
4. Cocaine toxicity may typically lead to agitation, disorientation, hallucinations, violence,
twitching, hypertension, chest pain, collapse and convulsions. In severe cases, the
patient may be hypotensive due to the negative inotropic effect of high levels of
cocaine. Pupils are dilated and the patient may be sweating and possibly
hyperthermic.
5. Crack cocaine ingestion is a very serious emergency and as little as 1 gram can be
fatal if swallowed. Close observation is essential, and it is worth administering
relatively large doses of diazepam as soon as any signs of toxicity start to become
apparent. Further management is as for cocaine.
6. Management of cocaine toxicity includes close observation, administration of diazepam
in large doses, and nitrates for hypertension. If the patient is profoundly hypotensive,
sodium bicarbonate may help to reverse the negative inotropic effect of cocaine, and
nitroprusside may also paradoxically restore blood pressure by reversing
vasoconstriction.
7. Once the patient’s condition has been stabilised, there are three approaches for
removal; endoscopy, operation (laparotomy) and the use of isotonic solutions given
orally or by nasogastric tube. The solution must be isotonic (e.g. Klean-Prep prepared
as used for radiological examinations). A hypertonic solution (e.g. Lactulose) could be
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counter-productive as it might make damaged packages leak more. The use of
isotonic solutions is preferred for individuals who have minimal or no signs of toxicity.
8. There is no indication to keep the patient in an accident and emergency environment
until the drugs are passed. Recovery of drug packets for evidence is the responsibility
of the Customs and Police.
18.3.4
Summary of guidance
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19 Psychiatry
This section is based on national NICE and local guidance.
19.1
Introduction
Patient with mental health problems who present to the ED include those who have harmed
themselves, those who are behaving bizarrely, those who are anxious and /or depressed
patients and those with drug +/ alcohol problems. Much of this section relates to patients
who self harm as this is the largest group in the ED but many of the principles relating to this
apply to the management of patients with mental health problems in general.
19.2
General principles
When dealing with patients with mental health problems or who have self-harmed:
Always treat patients with care and respect and ensure their privacy. Whenever possible,
use the Psychiatric interview room when assessing these patients (third assessment room in
the corridor between Majors and Minors).
Ask the patient to explain in their own words the why they have come to the ED. Bear in mind
that patients may be very distressed when you see them. For patients who attend
repeatedly, the reason for each presentation may be different on each occasion; don’t
assume the same reasons each time.
Involve the patient regarding treatment decisions and give as much information as possible
about treatment options. Ask the patient if they want relatives / carers to be involved in their
assessment / treatment
Bear in mind that the relatives /carers may be upset as well. They may need support too.
Even if the patient doesn’t want to see a psychiatrist, always offer whatever physical
treatments which are necessary (i.e. activated charcoal within 1 hour). Don’t assume that
they don’t want this either.
Specifically, if a patient has injured themselves, always use proper anaesthesia and /or
analgesia. Treat them as you would any other patient who has an injury.
19.3
Consent issues
When dealing with patients with mental health issues or who have self-harmed, there may be
issues about consent. Therefore:
Always assess the patient’s mental capacity and interview relatives /friends to help in
this assessment.
Assume mental capacity, unless there is evidence to the contrary. Obtain fully
informed consent before each treatment or procedure is started. Capacity may
change over time.
If the patient is mentally incapable, always act in their best interests even if against their
wishes. If you are unsure, seek help from the senior doctors in the department. You may
also need to seek help from the Emergency Psychiatry (Home Treatment Team) Service;
discuss with your Middle Grades.
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19.4
Schizophrenia
Schizophrenia is a term used to describe a major psychiatric disorder (or cluster of
disorders) that alters an individual’s perception, thoughts, affect and behaviour.
Positive symptoms include:
Hallucinations
Delusions
Disorganised speech and behaviour
Negative symptoms include:
Emotional apathy
Lack of drive
Poverty of speech
Social withdrawal
Self-neglect
Common presentations to A&E:
Complication of treatment / medication problems
Socioeconomic crisis
Psychotic crisis
It is essential in the emergency department not to confuse the thought and behavioural
disturbances of organically based acute delirium with any of the psychotic disorders.
19.4.1
Medication problems
A problem with antipsychotic medications commonly is the chief complaint:
Acute dystonia (muscle rigidity and spasm), oculogyric crisis (bizarre and frightening
upward gaze paralysis and contortion of facial and neck musculature), akathisia
(dysphoric sense of motor restlessness)
Parkinsonian symptoms of stiffness, resting tremor, difficulty with gait, and feeling
slowed-down
Orthostatic hypotension caused by alpha-adrenergic blockade
Dry mouth, fatigue, sedation, visual disturbance, inhibited urination, and sexual
dysfunction, which can be adverse reactions to antipsychotic medication or to
anticholinergic drugs taken for prophylaxis of dystonia
Acute dystonia can be treated by administering procyclidine 5-10mg IV as a bolus.
Resolution of symptoms usually occurs within 5-10 mins. Other medication problems should
be discussed with Psychiatry.
19.4.2
Psychotic crisis
Obtain the following information when an acutely psychotic patient presents to the ED
Potential danger the patient presents to self or others
o A paranoid schizophrenic, in response to delusions and command
hallucinations, can be extremely dangerous and unpredictable
o Find out about threats made to others, expressions of suicidal intent, and
possession of weapons at home or on the person
Prior medical and psychiatric records, including past hospitalizations and medication
therapy
Baseline level of functioning
Current or recent substance abuse
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Current use of prescribed, over-the-counter (OTC), and herbal medications
Compliance with current psychiatric medications
Examine the patient carefully for signs of an organic illness
Fever, tachycardia (with rigidity may be a sign of neuroleptic malignant syndrome)
Systemic upset
Signs of dystonia, tremor or muscle rigidity
Mental status testing should typically reveal clear sensorium and orientation to
person, place, and time. Altered sensorium suggests an acute delirium
Always check BM.
Blood tests should be performed if there is concern regarding the presence of an acute
delirium or drug intoxication.
If medical causes / acute delirium are excluded, refer to Psychiatry for further management.
19.4.3
Rapid tranquillisation
This guidance is based on the NICE guidance:
http://www.nice.org.uk/guidance/index.jsp?action=byID&o=10916
During an acute illness, some patients can become behaviourally disturbed and may need
help to calm down. For the majority of patients rapid tranquillisation is unnecessary and
should not be resorted to routinely.
Involve your seniors and the Psychiatric team EARLY.
Use non-pharmacological methods first:
Environmental and communication factors
De-escalation techniques
Call Security for back up
Staff using rapid tranquillisation techniques should be trained in the assessment and
management of the risks involved, and should be familiar with the dose limits of the agents
and the usages of flumazenil. They should also be up-to-date with the current ALS
protocols.
The minimum effective dose should be used. The BNF recommendations for the maximum
doses should be adhered to, except in exceptional circumstances. Use single agents rather
than cocktails of drugs.
First line:
Oral lorazepam, olanzapine or haloperidol
Second line
Intramuscular injection is preferred to intravenous injection (IV only in exceptional
circumstances)
Use lorazepam or haloperidol or olanzapine
If urgent rapid tranquillisation is needed, consider lorazepam and haloperidol
If haloperidol is used, anticholinergics should be administered
Monitor the patient’s vital signs closely and look for side-effects. Avoid over-sedation.
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19.5
Deliberate self-harm (DSH)
Majority relate to poisoning, a minority relate to self injury. Psychiatric symptoms are
common but usually transient and relate to social, psychological or emotional factors.
Psychiatric illness is uncommon. The aim of ED assessment is to identify those with
underlying psychiatric illness or true suicidal intent.
These guidelines are based on the NICE guidance:
http://www.nice.org.uk/Guidance/CG16/
19.5.1
Triage
All patients with DSH should be triaged immediately to establish physical risk and mental
state. To give you an understanding of the triage process, the following is a guide for nursing
staff:
1. Immediate
Patient is violent, aggressive, suicidal, a danger to self and /or others, has /may have a
police escort
2. Very Urgent
Patient is very distressed or psychotic, likely to become aggressive and is a danger to self
and /or others, patient is experiencing a situational crisis and is very distressed
3. Urgent
Patient has a long standing semi-urgent mental disorder /problem. May have a supporting
agent with them (e.g. community mental health nurse)
4. Standard
Patient has a long standing non acute mental disorder /problem. No supportive agency
present
We are currently working with the Psychiatry Unit to implement a tool for initial assessment of
Psychiatric patients. This tool will also guide your further management.
19.5.2
Medical assessment
Always look for and treat life-threatening conditions first!
A&E staff have role in ruling out any acute medical illness which needs treatment prior to
Psychiatric assessment. This though, should not delay the Psychiatric assessment, except
when the patient needs life-saving treatment, is unconscious or is incapable of assessment
(e.g. intoxicated). Therefore, contact the Psychiatry team EARLY.
19.5.3
GI decontamination for poisonings
Consider gastrointestinal decontamination only if
the patient presents early
is fully conscious
has a protected airway
is at risk of significant harm from the ingested substance
Offer activated charcoal, unless contraindicated, as early as possible, and within 1 hour.
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Activated charcoal may also be considered between 1 and 2 hours for certain substances for
reducing absorption if the ingested substance delays gastric emptying such as tricyclic
antidepressants.
Unless specifically recommended by TOXBASE or following consultation with the National
Poisons Information Service (NPIS):
don’t offer multiple doses of activated charcoal
don’t use emetics, including ipecac
don’t use cathartics
don’t use gastric lavage
don’t use whole bowel irrigation
19.5.4
Advice on specific poisonings
Consult the NPIS website http://www.spib.axl.co.uk for further information on specific
poisonings and telephone for more complex cases (0844 892 0111) as required.
19.5.5
Paracetamol overdose
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19.5.6
Benzodiazepine overdose
19.5.7
Opioid overdose
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19.5.8
General treatment for self-injury
Don’t delay treatment because it is self-inflicted
Take account of the distress involved in self-harm and in seeking treatment
Explain the treatment options to the service user and discuss fully his or her
treatment preferences
Always use anaesthesia and/or analgesia if treatment may be painful
For superficial uncomplicated injuries of 5 cm or less in length:
o offer tissue adhesive as the first-line treatment, or
o offer skin closure strips if the service user prefers this
For superficial uncomplicated injuries greater than 5 cm in length, or deeper injuries
of any length, assess and explore the wound and follow good surgical practice
19.5.9
Repeated self poisoning
Don’t offer harm minimisation advice regarding self-poisoning – there are no safe
limits
Consider discussing the risks of self-poisoning with service users (and carers, where
appropriate) who are likely to use this method of self-harm again
19.5.10
Repeated self injury
Discuss with a mental health worker which patients should be offered the following
advice (voluntary organisations may have suitable materials)
Consider giving advice and instructions on
o Self-management of superficial injuries, including providing tissue adhesive
o Harm minimisation issues and techniques
o Appropriate alternative coping strategies dealing with scar tissue
19.5.11
Psychiatric assessment
Take a detailed history
Events (including prior preparation and attempts at concealment) relating to the
episode of self-harm.
Suicidal intent at the time and currently (including the patient’s perceived outcome
and their thoughts about the actual outcome).
Current stressors which may have contributed to this episode.
Past self-harm, psychiatric and medical history.
Perform a brief Mental State Examination. Note the following:
Appearance and Behaviour (are they sitting smiling at you or are they tearful, are they
smart or dishevelled and unkempt, are they acting in a bizarre manner?)
Mood (ask them to describe their mood (subjective), how would you describe their
mood (objective)
Speech (describe the form, flow and content of their speech)
Thoughts (is there a normal thought pattern, is there evidence of thought insertion,
withdrawal or broadcast, do they appear distracted?)
Hallucinations (do they see or hear things that others do not hear or see?)
Insight (do they think they are well or unwell?)
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19.5.12
Risk assessment
Currently, we are using the modified SAD PERSONS risk assessment form (see Appendix)
Sex: male =1
Age: < 19 or > 45 =1
Depression or hopelessness =1
Previous suicide attempts or psychiatric care =1
Ethanol or drug use (excessive or changing) =1
Rational thinking loss (psychotic or organic illness) =2
Social isolation: Lives alone or no friends =1
Organized plan /serious attempt / =2
No partner or social support: Separated, widowed, divorced =1
Stated future intent: plans to repeat /ambivalent =2
Score <6 – low risk, requiring psychosocial assessment but likely safe for OP follow-up
Score ≥6 – high risk, possibly requiring hospital admission
All patients who have self-harmed should be offered a psychosocial assessment
regardless of perceived risk. Those who are deemed very low risk may have this in
the community (ask Home Treatment Team for advice).
If you are at all unsure, discuss the case with the Home Treatment Team (Emergency
Psychiatry) team (0900-1700) or on-call psychiatrist out of hours (inform the patient that you
are doing this).
19.5.13
Patients waiting for Psychiatric assessment
Whilst the patient is waiting for their Psychiatric assessment, give them as much verbal and
written information about what is happening.
Provide a safe and supportive environment where people can wait, and provide supervision
to ensure safety if appropriate with a named member of staff.
19.5.14
Threatened / actual self discharge
If the patient refuses a psychiatric assessment:
Alert a Senior
Assess for mental capacity / mental illness and record in the medical notes
Pass patient’s details and assessment to the GP and the appropriate Mental Health
team to enable rapid follow-up
If mental capacity is diminished and/or the patient has significant mental illness,
prevent the patient from leaving the department (engage patient verbally, call security
for back up) and call Psychiatric Home Treatment Team / Emergency Psychiatry
urgently
Do not physically restrain the patient
If the patient leaves the department despite these measures and you are concerned
that the patient has significant mental illness or reduced capacity, inform the Police to
bring the patient back to the department
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19.6
Referral of Psychiatric patients
The Emergency Psychiatric Team at Lakeside Hospital (which serves WMUH) comprises:
Home Treatment Team: Bleep 385 Mon-Friday (0800hrs -1700hrs)
On-call Psychiatry SHO: Bleep 274 (1700hrs - 0800hrs and weekends)
Children: For initial assessment of <18 years old CAMHS service (0900-1700 or on-call
Psychiatry SHO out of hours)
19.7
Special issues for children and adolescents
For all children and adolescents consider:
Confidentiality
Young person’s consent (including Gillick competence)
Parental consent
Child protection issues
Use of the Mental Health Act and the Children Act
Currently, all under 18s are assessed as Paediatric cases and must be discussed with the
Child and Adolescent Mental Health Service (CAMHS) and the Paediatric Social Workers
within office hours.
Out of hours, all cases need to be referred to the on-call Psychiatry team, as CAMHS do not
have cover beyond 5pm.
19.7.1
Risk stratification
There is a DSH protocol which can help determine the level of risk of the patient. See the
Paeds A&E nurses for help:
Low Risk Presentations
There is no need to admit this group (e.g. stress, mild anxiety, simple alcohol
intoxication without other social issues)
Consider referral to GP, School Nurse, Alcohol / Substance Misuse Teams
Medium Risk Presentations
May require admission but not a 1:1 Mental Health Nurse (e.g. overdose, depression,
anxiety, eating disorders)
Following a physical assessment for medical problems, refer to CAMHS in hours or to
Psychiatry out-of-hours for Psychiatric assessment
Liaise with Paediatrics if admission is required. For 16-17 year olds, admission
should be to the adult service rather than Paeds unless parents / Paediatrics
specifically specify this
High Risk Presentations
Requires admission and will need 1:1 Mental Health Nursing (e.g. psychosis,
aggression, significant suicidal intent / risk to others)
Following a physical assessment for medical problems, refer to CAMHS in hours or to
Psychiatry out-of-hours for Psychiatric assessment
Liaise with Paeds and CAMHS within hours for admission, or with Lakeside Team
out-of-hours
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Also:
Bear in mind that assessing mental capacity in children of different ages differs from the
assessment in adults and that the issues of capacity and consent also differ.
Seek advice from senior A&E staff or the Paediatric team if you are unsure (issues include
confidentiality issues, young person’s consent including Gillick competence, parental
consent, child protection, use of the Mental Health Act and the Children Act).
16-17 year olds are currently assessed by A&E in the adult section. Within working hours,
the case should be discussed with CAMHS and Paediatric Social workers. Out of hours, the
patient should be referred to the adult psychiatry team, who will assess acutely and admit to
Lakeside if a place of safety is required. In the morning, the case must still be handed over
to CAMHS and Paediatric social workers for further assessment and follow-up.
19.8
Special issues for older people
All acts of self-harm in people over the age of 65 years should be taken as evidence of
suicidal intent until proven otherwise.
Note the possible presence of depression, cognitive impairment, physical ill health (see
below), and document the person’s social and home situation.
These patients have a thorough physical assessment prior to referral to the Older People’s
Mental Health Service. If there is any doubt regarding the physical health of an older person
with DSH (or any other psychiatric presentation), discuss with senior doctors in the
department.
Specialist assessment by the Older People’s Mental Health Service should take place before
discharge (contact the Specialist Nurse for Older People MHS via Switchboard). If they are
unable to assess the patient in a timely manner, they should be admitted (particularly
overnight) to obs bay (if physically well, or to Medicine if physically unwell) to await
assessment.
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19.9
Acute alcohol withdrawal
Alcohol can also be a factor in patients who present with injuries (either accidental or nonaccidental as in domestic violence) or those with panic attacks, deliberate self harm or in
those who present to the ED frequently.
We have an Alcohol Nurse Specialist (David Singh) who can take referrals from A&E for
patients with alcohol problems seeking help. Contact him via his mobile on 07947 641010;
switchboard can put your through.
Severe alcohol withdrawal states include delirium tremens, alcohol withdrawal seizures,
alcoholic hallucinations and blackouts. Complications such as liver failure, hypoglycaemia
and subarachnoid haemorrhage can occur. Refer to the Medical team.
If acute alcoholic hepatitis is suspected (features: jaundice, palpable tender hepatomegaly,
fever, WCC>12 – neutrophilia, hepatic encephalopathy) please refer immediately to the
Medical Team.
Severe withdrawal may be predicted if patients have had:
High levels of alcohol intake
Previous history of severe withdrawal
Previous history of seizures or delirium
Concomitant use of psychoactive drugs
Poor physical health
High levels of anxiety or other psychiatric disorders
Signs of severe withdrawal
Acute confusion / hallucinations
Decreased conscious level
Ataxia
Ophthalmoplegia
Memory disturbance
Hyperthermia with hypertension / tachycardia / tachypnoea / sweating or
cardiovascular collapse
Delirium tremens (can start from a few hours post stopping alcohol with peak at
48-72 hours)
19.9.1
19.9.2
Investigations
FBC, U&Es, LFTs, coag, amylase if abdo pain / vomiting
BM (NB. Always give Pabrinex prior to correcting hypoglycaemia as this may
precipitate Wernicke’s encephalopathy)
Blood cultures if suspicion of infection
CXR if respiratory symptoms
Treatment
Oxygen
IV normal saline resuscitation
Thiamine and Pabrinex IV (TWO pairs tds if symptoms are severe or you suspect
Wernicke’s)
Benzodiazepines (such as chlordiazepoxide)
Glucose if BM is low (always give after Pabrinex to avoid WE)
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19.9.3
Benzodiazepines
Mainstay of in-patient treatment of alcohol withdrawal is chlordiazepoxide. Slowly absorbed,
has long half-life and low potency. Also has lower abuse potential than diazepam because of
slower onset of action. Adequate doses prevent withdrawal fits.
Chlordiazepoxide prescribing
Initial starting dose 30mg QDS (moderate withdrawal) or 40mg QDS (severe
withdrawal) plus 10-20mg PRN doses up to every 2 hours. 250mg as a maximum
dose in 24 hours (total includes regular plus prn doses). Does above 250mg
should be prescribed by a Consultant only.
In mild cases of withdrawal, only PRN doses may be required to control symptoms.
Where the patient has regular breakout symptoms, consider more frequent regular
doses rather than higher single doses – especially where over-sedation may occur.
If the patient has required more than three doses PRN in a 24 hour period, review of
medication and consider increasing the frequency of regular doses.
Do not reduce the dose within the first 48 hours. NOTE: in severe cases, prolonged
stabilization at the initial dose may be needed for up to 3 days (usually reduce within
48 hours).
PRN benzodiazepines (to be prescribed on patient’s drug chart):
If there is a history of seizures, lorazepam 2-4mg QDS PRN can be added to the
chart. Use Phenytoin carefully and consider only as a second line agent if seizures
are frequent / prolonged.
Cautious use of haloperidol 2.5-5mg prn (maximum 10mg in 24 hours) can be used
for agitation and hallucinations. Discuss with Alcohol Nurse Specialist (8 to 5, MonFri) or on-call Psychiatrist at other times.
If patient is already on benzodiazepines, please contact Alcohol Nurse Specialist (8-5
Mon-Fri) for advice or on-call Psychiatrist at other times.
19.10 Delirium tremens
Delirium tremens is a potentially fatal form of alcohol withdrawal. Symptoms may begin a
few hours after the cessation of ethanol but may not peak until 48-72 hours. Early
recognition and therapy are necessary to prevent significant morbidity and death.
Signs:
Tremors
Irritability
Insomnia
Nausea/vomiting (frequently secondary to gastritis or pancreatitis)
Hallucinations (auditory, visual, or olfactory)
Confusion
Delusions
Severe agitation
Seizures - Begin 6-48 hours after the last drink (Status epilepticus is uncommon in
patients with ethanol withdrawal, but ethanol withdrawal is still one of more common
causes of status epilepticus.)
19.10.1
Investigations and Treatment
As per acute alcohol withdrawal
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19.11 Wernicke’s encephalopathy (WE) / Korsakoff psychosis
This is a relatively common and potentially lethal condition resulting from thiamine deficiency.
It can lead to permanent anterograde / retrograde amnesia (Korsakoff psychosis).
Preventable or reversible if treated early. Commonest in heavy drinkers who have a poor
diet.
Common signs of WE
Ophthalmoplegia (lateral rectus palsies and gaze palsies) /nystagmus / papillary
abnormalities
Confusion
Ataxia
Impaired consciousness
Hypothermia
Hypotension
19.11.1
Treatment
Treat empirically with IV Pabrinex.
DOSE: Two pairs of Pabrinex 1 and 2 (i.e. 4 vials) given initially in the ED over 30 minutes in
100mls of 0.9% sodium chloride or 5% glucose. This should be prescribed TDS for 3 days.
Always administer Pabrinex prior to giving glucose containing infusions.
Observe patients for anaphylactic reactions throughout infusion. Resuscitation facilities
should be readily available. If has signs of WE, refer to medical team for admission for
continued IV treatment.
19.12 Patients requesting alcohol or drug detoxification
Patients may present to the ED having stopped drinking alcohol +/- requesting alcohol or
drug detoxification.
Assess for signs of severe alcohol or drug withdrawal.
If these are present, refer to the on-call Medical team for admission. If they have mild to
moderate symptoms, patients with alcohol misuse can be referred to our ANS, David Singh
for further management. Patients with drug misuse can be referred to the Joint Substance
Misuse Agency via their referral form (see Appendix).
Chlordiazepoxide as a TTA should NOT be considered without discussion with our ANS or
A&E senior. Our ANS sees patients on a daily attendance basis at A&E for treatment and
monitoring of the reduction regime of Chlordiazepoxide medication.
NB. If advising patients about continued drinking on discharge, give clear information on
reducing consumption rather than stopping abruptly because of risk of withdrawals.
All patients should receive 14 days prescription of thiamine and Vitamin B strong on
discharge with advice to contact their GP for continuation.
If a patient has moderate withdrawal symptoms, they may be given a single dose of a
benzodiazepine in the department after which they must access the relevant services as
outlined above.
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20 Appendix
Radiate referral form
Radiate.pdf
DNR form
DNR.pdf
Rapid access chest pain clinic form
RACPC.pdf
Standard GP letter for chest pain
GP Letter.pdf
Wells score DVT sheets
DVT.pdf
Wells score PE sheets
PE.pdf
ROSIER stroke assessment form
ROSIER.pdf
DKA proforma
DKA Final 09.pdf
CT KUB form
C:\Documents and
Settings\relliott\Desktop\CT KUB form.pdf
CT scan out-of-hours request form
CT out of hours
09.pdf
Children’s Social Work referral form
SW form.pdf
Vaginal Bleeding in Early Pregnancy Leaflet
Vaginal bleeding in
Early Pregnanacy 09.pdf
EPU referral form
EPU.pdf
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Sharps Proforma
Sharps injury
Proforma 09.pdf
Sharps Patient Information Leaflet
Sharps injury patient
information sheet 09.pdf
Modified SAD PERSONS scale
SAD.pdf
Paddington Alcohol test
PAT.pdf
Joint Substance Misuse Agencies referral
form
Notification of Infectious Disease or
Contamination
Substance.pdf
C:\Documents and
Settings\relliott\Desktop\Notification.doc
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