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City hospitals Sunderland A&E Department Information Card Pack Produced by Dr Sarah Frewin Correspondence to

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Presentation on theme: "City hospitals Sunderland A&E Department Information Card Pack Produced by Dr Sarah Frewin Correspondence to"— 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 1 st 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 gradesCO poisoning

3 Reversible causes of cardiac arrest HypoxiaTamponade HypothermiaToxins HypovolemiaThromboembolism Hypo / hype / hypokalaemiaTension pneumothorax

4 Stroke mimics Hypoglycaemia Seizure Complicated migraine Hypertensive encephalopathy Conversion disorder

5 CURB-65 score for pneumonia ScoreDescription 1Age 65+ 1New onset confusion 1Urea >7mmol/l 1Respiratory rate >30/min 1SBP <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 Parameterscore age >551 pO 2 <8.0kpa1 WCC >151 Ca 2+ (uncorr) <21 ALT >1001 LDH >6001 glucose >101 score > 3 indicates severe pancreatitis

7 Rockall scoring system (Risk of re-bleeding / death after acute UGIB) VariableScore 0Score 1Score 2Score 3 Age in years<6060 – 79>80 Shock None SBP >100, pulse <100 Tachycardia pulse >100, SBP >100 Hypotension SBP 100 Co-morbidityNil major Cardiac failure, IHD, other major co-morbidity Renal or liver failure, disseminated malignancy DiagnosisMallory-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 ScoreDescription 1A - Age >=60 years 1B - Blood pressure at presentation >=140/90 mmHg 2C - Clinical features of unilateral weakness 1 C - Clinical features of speech disturbance without weakness 2D - Duration of symptoms >= 60 minutes 1D - Duration of symptoms minutes 1Presence of diabetes Scores range from 0 (low risk) to 7 (high risk)

11 Wells score for DVT ScoreDescription 1 Active cancer (treatment within last 6 months or palliative) 1 Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity) 1 Collateral superficial veins (non-varicose) 1 Pitting oedema (confined to symptomatic leg) 1 Swelling of entire leg 1 Localized pain along distribution of deep venous system 1 Paralysis, paresis, or recent cast immobilization of lower extremities 1 Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 12 weeks 1 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 ScoreSymptom 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 5Too breathless to leave the house, or breathless when dressing or undressing

13 COPD Guidance (NICE) Factors to be considered when deciding where to manage patient FactorFavours hospitalFavours home Able to cope at homeNoYes BreathlessnessSevereMild General conditionPoor /deterioratingGood Level of activityPoor /confined to bedGood CyanosisYesNo Worsening peripheral oedemaYesNo Level of consciousnessImpairedNormal Already receiving LTOTYesNo Social circumstancesLiving alone / not copingGood Acute confusionYesNo Rapid rate of onsetYesNo Significant co-morbidity (IDDM / CCF) YesNo SaO2 <90%YesNo Changes on CXRPresentNo Arterial pH<7.35>7.35 Arterial PaO2<7kpa>7kpa

14 Grading of asthma exacerbations ModerateAcute severeLife threateningNear fatal Increasing symptomsPEF 33 – 50% best or predicted PEF <33% best or predicted Raised PaCO2 PEFR >50 – 75% best or predicted RR > 25 /minSpO2 < 92%Requiring mechanical ventilation with raised pressures No features of acute severe asthma HR > 110 /minPaO2 <8kpa Inability to complete sentences in one breath Normal PaCO2 Silent chest Cyanosis Feeble respiratory effort Bradycardia, arrhythmia, hypotension Exhaustion, confusion, coma Asthma Exacerbation Grades (BTS)

15 Grading of murmurs GradeDescription 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 3Moderately 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 6Very loud, with thrill. May be heard with stethoscope entirely off the chest

16 New York Association Heart Failure Classification ClassDescription 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 4Symptoms of heart failure are present at rest. If any physical activity is undertaken, discomfort is increased

17 Modified Alvarado score for appendicitis ScoreDescription 1Migratory right iliac fossa pain 1Anorexia / acetone urine 1Nausea/vomiting 2Tenderness right lower quadrant 1Rebound tenderness right iliac fossa 1Pyrexia greater than or equal to 37.5° 2 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 IIMild 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 Sepsis Screening Tool ScoreCriteria 1Temperature > 38°C or < 36°C 1Heart rate > 90 beats/minute 1Respiration > 20/min 1WCC >12 or <4 1Hyperglycaemia in absence of diabetes >6.6 1Acutely 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 OxygenTarget 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 Hartmans / Further Lactate / FBC Also ensure Hb >7 / do other bloods as appropriate CatheteriseCommence 1 hourly urine output Discuss with senior to asses if escalation in care is needed

22 Antibiotic policy for soft tissue infection Less severeMore severenotes 1 st lineFlucloxacillin 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 Treat for 5,7, 10 days according to response 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 AntibioticNotes StandardCefotaxome IV 2g QDS Or Ceftriaxone IV 2g BD Add amoxicillin IV 2gQDS if aged > 55to cover listeria AdditionalAcyclovir IV 10mg/kg TDS For suspected HSV

24 Antibiotic policy for UTI (non catheterised) Patient condition Treatment AsymptomaticNeeds no treatment SymptomaticTrimethoprim PO 200mg BD for 5-7 days Or Cefalexin PO 500mg TDS for 5 – 7 days Clinically unwellCo-amoxiclav IV 1000/200mg TDS for 5 – 7 days Or Cefuroxime IV 750mg – 1.5g TDS for 5 – 7 days Or Aztreonam IV 1g TDS for 5 – 7 days SepticSingle dose of IV gentamicin 5mg/kg (await culture)

25 Antibiotic policy for LRTI Condition1 st line2 nd line3 rd 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 Or Clarithtomycin PO 250 – 500mg BD All for 5 – 7 days In penicillin allergy Clarithromycin IV 500mg BD Or Erythromycin PO 500mg QDS 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 Clarithromycin IV 500mg BD

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 % blood volume loss ( mls) Increased respiratory rate Blood pressure maintained Increased diastolic pressure Narrow pulse pressure Sweating Grade % 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 ScoreParameter 1Midline c-spine tenderness 1Evidence of intoxication 1Altered consciousness 1Focal neurology 1Distracting injuries Score >1 indication for c-spine imaging

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

29 AMTS 1What is your age 1What is your date of birth 1What is the year 0Please remember 42 West Street 1What is the time to the nearest hour 1What is the name of this hospital 1Can patient recognise 2 people (Dr / nurse) 1What year did World War II end (1945) 1Name the present monarch 1Count backwards from 20 to 1 1Recount the address you were asked to remember 8 or higher is normal for an elderly patient

30 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 3 rd 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 Addisons / 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 ComplexWhat it looks likeChanges P wave 2-3 sq high 1.5-3sq long R wave1 st positive deflection after P PR interval 3-5 sq long QRS5-15 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 QT9-10 sq long RBBB Prolonged QRS, RSR (rabbits ears) with T wave inversion in V1, wide S and upright T in V6 LBBBWide 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.)? 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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