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City hospitals Sunderland A&E Department

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Presentation on theme: "City hospitals Sunderland A&E Department"— Presentation transcript:

1 City hospitals Sunderland A&E Department
Information Card Pack Produced by Dr Sarah Frewin Correspondence to Review date: January 2012

2 Nexus C-spine rules NICE COPD guidance Glasgow pancreatitis score NICE head CT guidance (amendment) Alvarado score NICE head CT guidance Rectal bleeding differentials Chest pain differentials Upper GI bleed differentials Breathlessness / hypoxia differentials Abdominal pain differentials Bradyarrhythmia differentials Jaundice differentials Tachyarrhythmia differentials Rockall score (GI bleed) Reversible causes of cardiac arrest ABCD2 (TIA) ECG interpretation Severe sepsis criteria New York heart failure classification Sepsis screening tool Grading of murmurs Severe sepsis 1st hour pathway Headache differentials Soft tissue antibiotic policy Dizziness differentials Curb 65 (pneumonia) AMTS LRTI antibiotic policy Timed get up and go test Meningitis antibiotic policy Stroke mimics UTI antibiotic policy falls /collapse differentials Wells criteria (PE) Pain assessment Wells criteria (DVT) Confusion differentials MRC dyspnoea scale Hypotension differentials ASA grading (anaesthetics) Stages of hypovolemic shock BTS asthma exacerbation grades CO poisoning

3 Reversible causes of cardiac arrest
Hypoxia Tamponade Hypothermia Toxins Hypovolemia Thromboembolism Hypo / hype / hypokalaemia Tension pneumothorax

4 Hypertensive encephalopathy
Stroke mimics Hypoglycaemia Seizure Complicated migraine Hypertensive encephalopathy Conversion disorder

5 CURB-65 score for pneumonia
Description 1 Age 65+ New onset confusion Urea >7mmol/l Respiratory rate >30/min SBP <90mmHg / DPB <60mmHg Additional adverse prognostic features Hypoxaemia (SaO2 <92% or PaO2 <8 kPa) regardless of FiO2 Bilateral or multilobe involvement on CXR

6 Modified Glasgow Score For Pancreatitis Parameter score age >55 1
pO2 <8.0kpa WCC >15 Ca2+ (uncorr) <2 ALT >100 LDH >600 glucose >10 score > 3 indicates severe pancreatitis

7 (Risk of re-bleeding / death after acute UGIB)
Rockall scoring system (Risk of re-bleeding / death after acute UGIB) Variable Score 0 Score 1 Score 2 Score 3 Age in years <60 60 – 79 >80 Shock None SBP >100, pulse <100 Tachycardia pulse >100, SBP >100 Hypotension SBP <100, pulse >100 Co-morbidity Nil major Cardiac failure, IHD, other major co-morbidity Renal or liver failure, disseminated malignancy Diagnosis Mallory-Weiss tear, no lesion, no stigmata of recent haemorrhage All other diagnoses Malignancy of upper GI tract



10 ABCD2 to identify patients at high risk of stroke following a TIA
Score Description 1 A - Age >=60 years B - Blood pressure at presentation >=140/90 mmHg 2 C - Clinical features of unilateral weakness C - Clinical features of speech disturbance without weakness D - Duration of symptoms >= 60 minutes D - Duration of symptoms minutes Presence of diabetes Scores range from 0 (low risk) to 7 (high risk)

11 Active cancer (treatment within last 6 months or palliative)
Wells score for DVT Score Description 1 Active cancer (treatment within last 6 months or palliative) Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity) Collateral superficial veins (non-varicose) Pitting oedema (confined to symptomatic leg) Swelling of entire leg Localized pain along distribution of deep venous system Paralysis, paresis, or recent cast immobilization of lower extremities Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 12 weeks Previously documented DVT Minus 2 Alternative diagnosis at least as likely Interpretation 2 or higher:- DVT likely (consider imaging leg veins) <2:- DVT unlikely (consider XDP to further rule out DVT)

12 MRC Dyspnoea Scale Score Symptom
1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying on walking up a slight hill 3 Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace 4 Stops for breath after walking about 100m, or after a few minutes on the level 5 Too breathless to leave the house, or breathless when dressing or undressing

13 Factors to be considered when deciding where to manage patient
COPD Guidance (NICE) Factors to be considered when deciding where to manage patient Factor Favours hospital Favours home Able to cope at home No Yes Breathlessness Severe Mild General condition Poor /deteriorating Good Level of activity Poor /confined to bed Cyanosis Worsening peripheral oedema Level of consciousness Impaired Normal Already receiving LTOT Social circumstances Living alone / not coping Acute confusion Rapid rate of onset Significant co-morbidity (IDDM / CCF) SaO2 <90% Changes on CXR Present Arterial pH <7.35 >7.35 Arterial PaO2 <7kpa >7kpa

14 Asthma Exacerbation Grades (BTS) Grading of asthma exacerbations
Moderate Acute severe Life threatening Near fatal Increasing symptoms PEF 33 – 50% best or predicted PEF <33% best or predicted Raised PaCO2 PEFR >50 – 75% best or predicted RR > 25 /min SpO2 < 92% Requiring mechanical ventilation with raised pressures No features of acute severe asthma HR > 110 /min PaO2 <8kpa Inability to complete sentences in one breath Normal PaCO2 Silent chest Cyanosis Feeble respiratory effort Bradycardia, arrhythmia, hypotension Exhaustion, confusion, coma

15 Grading of murmurs Grade Description 1 Very faint, heard only after listener has "tuned in" may not be heard in all positions 2 Quiet, but heard immediately after placing the stethoscope on the chest 3 Moderately loud 4 Loud, with palpable thrill (ie, a tremor or vibration felt on palpation) 5 Very loud, with thrill. May be heard when stethoscope is partly off the chest 6 Very loud, with thrill. May be heard with stethoscope entirely off the chest

16 New York Association Heart Failure Classification
Description 1 No Limitation. Ordinary activity does not cause undue fatigue, dyspnoea, or palpitations 2 Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in heart symptoms 3 Marked limitation of physical activities. Comfortable at rest, but less than ordinary activity causes heart failure symptoms 4 Symptoms of heart failure are present at rest. If any physical activity is undertaken, discomfort is increased

17 Modified Alvarado score for appendicitis Score Description 1
Migratory right iliac fossa pain Anorexia / acetone urine Nausea/vomiting 2 Tenderness right lower quadrant Rebound tenderness right iliac fossa Pyrexia greater than or equal to 37.5° Leucocytosis Score <5 is not likely appendicitis 5 or 6 is equivocal 7 or 8 is probably appendicitis 9 means patient is highly likely to have appendicitis

18 ASA Grading (assessment of fitness for anaesthesia and surgery) Grade
Definition   I Normal healthy individual II Mild systemic disease that does not limit activity   III Severe systemic disease that limits activity but is not incapacitating   IV Incapacitating systemic disease which is constantly life-threatening   V Moribund, not expected to survive 24 hours with or without surgery

19 Temperature > 38°C or < 36°C Heart rate > 90 beats/minute
Sepsis Screening Tool Score Criteria 1 Temperature > 38°C or < 36°C Heart rate > 90 beats/minute Respiration > 20/min WCC >12 or <4 Hyperglycaemia in absence of diabetes >6.6 Acutely altered mental state Ask patient about history suggestive of new infection Sepsis present in patients presenting with 2 or more criteria PTO for severe sepsis criteria

20 Severe Sepsis Criteria
SBP <90 or MAP <65 Urine output <30mls/hr for 2 consecutive hours Unexplained metabolic acidosis pH<7.35 Acute change in mental state New need for O2 to keep SPO2 >90 Plasma lactate >2 Platelets <100 Creatinine >177

21 Severe Sepsis First Hour Pathway
Oxygen Target SPO2 >94% / COPD target 88-92% Blood cultures Also consider other microbiology samples (urine / sputum /swabs) IV antibiotics As per trust guidelines (contact microbiology for advice) Fluid Bolus of Hartman’s / Further Lactate / FBC Also ensure Hb >7 / do other bloods as appropriate Catheterise Commence 1 hourly urine output Discuss with senior to asses if escalation in care is needed

22 Antibiotic policy for soft tissue infection
Less severe More severe notes 1st line Flucloxacillin PO 500mg – 1g QDS Flucloxacillin IV 1-2g QDS Treat for 5,7, 10 days according to response Penicillin allergy Clindamycin PO 300 – 600mg QDS Clindamycin IV 600mg QDS Caution in elderly due to risk of C-diff MRSA suspected Doxycline PO 100mg BD Plus either Sodium fusidate PO 500mg TDS Or Rifampicin PO 300mg BD Contact microbiology

23 Antibiotic policy for acute meningitis infection
Notes Standard Cefotaxome IV 2g QDS Or Ceftriaxone IV 2g BD Add amoxicillin IV 2gQDS if aged > 55to cover listeria Additional Acyclovir IV 10mg/kg TDS For suspected HSV

24 Antibiotic policy for UTI (non catheterised)
Patient condition Treatment Asymptomatic Needs no treatment Symptomatic Trimethoprim PO 200mg BD for 5-7 days Or Cefalexin PO 500mg TDS for 5 – 7 days Clinically unwell Co-amoxiclav IV 1000/200mg TDS for 5 – 7 days Cefuroxime IV 750mg – 1.5g TDS for 5 – 7 days Aztreonam IV 1g TDS for 5 – 7 days Septic Single dose of IV gentamicin 5mg/kg (await culture)

25 Antibiotic policy for LRTI
Condition 1st line 2nd line 3rd line Bronchitis / COPD Doxycycline PO 200mg loading dose then 100mg OD for 5 days Amoxicillin 500mg – 1g TDS for 5 days (IV or PO) Moxifloxacin PO 400mg OD for 5 days Systemic Sepsis Cefuroxime 750mg – 1.5g IV TDS (switch to co-amoxiclav PO 625mg TDs to complete 5 days ASAP) Contact microbiology CAP CURB-65 ≤ 2 Amoxicillin 1g TDS (initially IV) Plus either Clarithromycin IV 500mg BD Or Erythromycin PO 500mg QDS Clarithtomycin PO 250 – 500mg BD All for 5 – 7 days In penicillin allergy For 5 – 7 days Moxifloxacin PO 400mg OD for 5 days (up to max of 10 days CAP CURB-65 ≥3 Cefuroxime 750mg – 1.5g IV TDS Plus

26 Stages of hypovolemic shock
Grade 1 Up to 15% blood volume loss (750mls) Blood pressure maintained Normal respiratory rate Pallor of the skin Grade 2 15-30% blood volume loss ( mls) Increased respiratory rate Increased diastolic pressure Narrow pulse pressure Sweating Grade 3 30-40% blood volume loss ( mls) Systolic BP falls to 100mmHg or less Marked tachycardia >120 bpm Marked tachypnoea >30 bpm Decreased systolic pressure Grade 4 Loss greater than 40% (>2000mls) Extreme tachycardia with weak pulse Pronounced tachypnoea Significantly decreased systolic blood pressure of 70 mmHg or less

27 Nexus C-spine rule Score Parameter
1 Midline c-spine tenderness Evidence of intoxication Altered consciousness Focal neurology Distracting injuries Score >1 indication for c-spine imaging

28 Alternative diagnosis less likely 1.5 HR>100
Wells criteria for PE Score Parameter 3 Clinical signs of DVT Alternative diagnosis less likely 1.5 HR>100 Immobility / surgery in last 4 weeks Previous DVT / PE 1 Haemoptysis Malignancy Low risk = 1 – 2.5 points Moderate risk = 3 – 6 points High risk = 6.5 – 12.5

29 What is your date of birth What is the year
AMTS 1 What is your age What is your date of birth What is the year Please remember “42 West Street” What is the time to the nearest hour What is the name of this hospital Can patient recognise 2 people (Dr / nurse) What year did World War II end (1945) Name the present monarch Count backwards from 20 to 1 Recount the address you were asked to remember 8 or higher is normal for an elderly patient

30 Exacerbating /relieving factors
Pain assessment Site Onset Character Radiation Associated symptoms Timing Exacerbating /relieving factors Score

31 Chest pain differentials
MI ACS Angina Aortic dissection Pericarditis PE Pneumonia Pneumothorax GORD Sickle cell crisis PUD Musculoskeletal

32 Tachyarrhythmia differentials
Sinus tachycardia Fast AF SVT Atrial flutter VT Re-entrant tachycardia (WPW)

33 Bradyarrhythmia differentials
Sinus bradycardia Complete or 3rd degree AV block / other heart blocks MI Drugs (beta-blockers, digoxin etc) Vasovagal Hypothyroidism Hypothermia Cushings reflex

34 Hypotension differentials
Hypovolemia Cardiogenic shock Septic shock Neurogenic shock Anaphylaxis Dysrhythmia Postural hypotension Vasovagal Addison’s / adrenal failure Drugs

35 Breathlessness / Hypoxia differentials
COPD / asthma Pneumonia PE Pulmonary oedema MI Pneumothorax Pleural effusion Pain Sepsis Metabolic acidosis Anaemia Chronic fibrotic lung disease

36 Upper GI bleed differentials
Peptic ulcer Oesophagitis Erosions Varices Mallory-Weiss tear Swallowed blood Malignancy

37 Rectal bleeding differentials
Polyps Diverticular disease Angiodysplasia Haemorrhoids Anal fissure IBD malignancy Upper GI bleed

38 Abdominal pain differentials
AAA Infarction / ischemia Obstruction Pancreatitis Appendicitis Perforation Strangulated hernia Torsion Ectopic Referred pain IBD PID Constipation UTI

39 Jaundice differentials
Paracetamol OD / toxins / drugs Gall stones Sepsis Viral hepatitis Alcohol Cholangitis Pancreatitis Haemolysis Gilberts

40 Dizziness differentials
Shock Arrhythmia Postural hypotension Anxiety / hyperventilation Syncope Epilepsy Hypoglycaemia Vertigo BPPV Menieres Drugs

41 Headache differentials
Haemorrhage Meningitis Encephalitis Raised ICP Temporal arteritis Glaucoma Dehydration Tension Migraine Extracranial (sinuses etc) Hypertension hypoglycaemia

42 Acute confusion differentials
Hypoxia Infection Drugs Dural haemorrhage (subdural haemorrhage) Endocrine Neoplasm Metabolic Alcohol Psychosis

43 Falls / collapse differentials
MI Arrhythmia Shock Sepsis CVA Seizure Hypoglycaemia PE Postural hypotension Mechanical Syncope

44 TIMED GET UP AND GO TEST Patient wearing regular footwear, using usual walking aid, and sitting back in a chair with armrest. Ask patient to do the following: 1. Stand up from the armchair 2. Walk 3 meters (in a line) 3. Turn 4. Walk back to chair 5. Sit down Observe patient for postural stability, steppage, stride length and sway Scoring:- Normal:- Completes task in < 10 seconds Abnormal:- Completes task in >20 seconds Low scores correlate with good functional independence High scores correlate with poor functional independence and higher risk of falls

45 ECG interpretation Complex What it looks like Changes
P wave 2-3 sq high 1.5-3sq long R wave 1st positive deflection after P PR interval 3-5 sq long QRS 5-15 sq high, up to 3 small sq long ST Should be isoelectric Max height= sq T Height= sq depending on leads Can be negative in AVR, V1,V2 QT 9-10 sq long RBBB Prolonged QRS, RSR (rabbits ears) with T wave inversion in V1, wide S and upright T in V6 LBBB Wide QRS in all leads, slurred R and T wave inversion in V6, may have ST depression / elevation

46 Suspected CO poisoning
PC:- Headache, N&V, drowsiness, dizziness, dyspnoea, chest pain Questions Do you feel better away from home or work? Does anyone else in the house have the same symptoms? Have you recently had a heating / cooking appliance installed? Have all cookers / heaters been service in the last year? Do you ever use your oven / stove for heating purposes? Has there been any change to the ventilation in your home (eg double glazing)? Have you noticed any soot / increase condensation around appliances lately? Does your work involve exposure to smoke / petrol fumes? What type of home do you live in (detached / semi / hostel etc.)? Ou notiv=ced Management Blood for COHb estimation Oxygen Do not allow patient to go home to where there are suspect appliances Contact local HPA

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