city hospitals sunderland a&e department information card pack produced by dr sarah frewin
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City hospitals Sunderland A&E Department Information Card Pack Produced by Dr Sarah Frewin Correspondence to [email protected] Review date: January 2012. Nexus C-spine rules NICE COPD guidance Glasgow pancreatitis score NICE head CT guidance (amendment) - PowerPoint PPT PresentationTRANSCRIPT
City hospitals Sunderland A&E Department
Information Card PackProduced by Dr Sarah FrewinCorrespondence to [email protected]
Review date: January 2012
Nexus C-spine rules NICE COPD guidanceGlasgow pancreatitis score NICE head CT guidance (amendment)Alvarado score NICE head CT guidanceRectal bleeding differentials Chest pain differentialsUpper GI bleed differentials Breathlessness / hypoxia differentialsAbdominal pain differentials Bradyarrhythmia differentialsJaundice differentials Tachyarrhythmia differentialsRockall score (GI bleed) Reversible causes of cardiac arrestABCD2 (TIA) ECG interpretationSevere sepsis criteria New York heart failure classificationSepsis screening tool Grading of murmursSevere sepsis 1st hour pathway Headache differentialsSoft tissue antibiotic policy Dizziness differentialsCurb 65 (pneumonia) AMTSLRTI antibiotic policy Timed get up and go testMeningitis antibiotic policy Stroke mimicsUTI antibiotic policy falls /collapse differentialsWells criteria (PE) Pain assessmentWells criteria (DVT) Confusion differentialsMRC dyspnoea scale Hypotension differentialsASA grading (anaesthetics) Stages of hypovolemic shockBTS asthma exacerbation grades CO poisoning
Reversible causes of cardiac arrest
Hypoxia Tamponade
Hypothermia Toxins
Hypovolemia Thromboembolism
Hypo / hype / hypokalaemia Tension pneumothorax
Stroke mimics
Hypoglycaemia
Seizure
Complicated migraine
Hypertensive encephalopathy
Conversion disorder
CURB-65 score for pneumoniaScore Description
1 Age 65+
1 New onset confusion
1 Urea >7mmol/l
1 Respiratory rate >30/min
1 SBP <90mmHg / DPB <60mmHg
Additional adverse
prognostic features
Hypoxaemia (SaO2 <92% or PaO2 <8 kPa) regardless of FiO2
Bilateral or multilobe involvement on CXR
Modified Glasgow Score For Pancreatitis
Parameter score
age >55 1
pO2 <8.0kpa 1
WCC >15 1
Ca2+ (uncorr) <2 1
ALT >100 1
LDH >600 1
glucose >10 1
score > 3 indicates severe pancreatitis
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
NICE criteria for immediate head CT (adults)
GCS <13 on initial assessment in ED
GCS <15 2 hours after injury / ED assessment
Suspected open or depressed skull fracture
Any sign of basal skull fracture
Post-traumatic seizure
Focal neurological deficit
More than one episode of vomiting
Amnesia for events >30 minutes before impact
NICE criteria for immediate head CT (patient experiencing LOC / amnesia since injury)
>65 years
Coagulopathy / warfarin
Dangerous mechanism of injury
ABCD2 to identify patients at high risk of stroke following a TIA
Score Description
1 A - Age >=60 years
1 B - Blood pressure at presentation >=140/90 mmHg
2 C - Clinical features of unilateral weakness
1 C - Clinical features of speech disturbance without weakness
2 D - Duration of symptoms >= 60 minutes
1 D - Duration of symptoms 10-59 minutes
1 Presence of diabetes
Scores range from 0 (low risk) to 7 (high risk)
Wells score for DVT
Score Description1 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 likelyInterpretation
2 or higher:- DVT likely (consider imaging leg veins) <2:- DVT unlikely (consider XDP to further rule out DVT)
MRC Dyspnoea ScaleScore 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
COPD Guidance (NICE)
Factors to be considered when deciding where to manage patient
Factor Favours hospital Favours homeAble to cope at home No Yes
Breathlessness Severe MildGeneral condition Poor /deteriorating GoodLevel of activity Poor /confined to bed Good
Cyanosis Yes NoWorsening peripheral oedema Yes No
Level of consciousness Impaired NormalAlready receiving LTOT Yes No
Social circumstances Living alone / not coping GoodAcute confusion Yes No
Rapid rate of onset Yes NoSignificant co-morbidity (IDDM /
CCF)Yes No
SaO2 <90% Yes NoChanges on CXR Present No
Arterial pH <7.35 >7.35Arterial PaO2 <7kpa >7kpa
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 chestCyanosis
Feeble respiratory effort
Bradycardia, arrhythmia, hypotension
Exhaustion, confusion, coma
Asthma Exacerbation Grades (BTS)
Grading of murmursGrade 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
New York Association Heart Failure ClassificationClass 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
Modified Alvarado score for appendicitisScore Description
1 Migratory right iliac fossa pain
1 Anorexia / acetone urine
1 Nausea/vomiting
2 Tenderness right lower quadrant
1 Rebound tenderness right iliac fossa
1 Pyrexia greater than or equal to 37.5°
2 LeucocytosisScore <5 is not likely appendicitis
5 or 6 is equivocal7 or 8 is probably appendicitis
9 means patient is highly likely to have appendicitis
ASA Grading (assessment of fitness for anaesthesia and surgery)
Grade Definition
INormal healthy individual
II Mild systemic disease that does not limit activity
IIISevere systemic disease that limits activity but is
not incapacitating
IVIncapacitating systemic disease which is constantly
life-threatening
VMoribund, not expected to survive 24 hours with or
without surgery
Sepsis Screening Tool
Score Criteria
1 Temperature > 38°C or < 36°C
1 Heart rate > 90 beats/minute
1 Respiration > 20/min
1 WCC >12 or <4
1 Hyperglycaemia in absence of diabetes >6.6
1 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
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
Severe Sepsis First Hour PathwayOxygen 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 / N/saline @20ml/kg. Further boluses @10ml/kg
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
Antibiotic policy for soft tissue infection
Less severe More severe notes
1st line Flucloxacillin PO500mg – 1g QDS
Flucloxacillin IV 1-2g QDS
Treat for 5,7, 10 days according to
responsePenicillin
allergyClindamycin PO
300 – 600mg QDSClindamycin IV
600mg QDSTreat for 5,7, 10
days according to response
Caution in elderly due to risk of C-diff
MRSA suspected
Doxycline PO 100mg BD
Plus eitherSodium fusidate PO
500mg TDSOr
Rifampicin PO 300mg BD
Contact microbiology
Antibiotic policy for acute meningitis infection
Antibiotic Notes
Standard Cefotaxome IV 2g QDSOr
Ceftriaxone IV 2g BD
Add amoxicillin IV 2gQDS if aged > 55to cover listeria
Additional Acyclovir IV 10mg/kg TDS
For suspected HSV
Antibiotic policy for UTI (non catheterised)Patient
conditionTreatment
Asymptomatic Needs no treatment
Symptomatic Trimethoprim PO 200mg BD for 5-7 daysOr
Cefalexin PO 500mg TDS for 5 – 7 days
Clinically unwell Co-amoxiclav IV 1000/200mg TDS for 5 – 7 daysOr
Cefuroxime IV 750mg – 1.5g TDS for 5 – 7 daysOr
Aztreonam IV 1g TDS for 5 – 7 days
Septic Single dose of IV gentamicin 5mg/kg (await culture)
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
daysSystemic 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 BDOr
Erythromycin PO 500mg QDSOr
Clarithtomycin PO 250 – 500mg BD
All for 5 – 7 days
In penicillin allergyClarithromycin IV
500mg BDOr
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 TDSPlus
Clarithromycin IV 500mg BD
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 (750 - 1500mls) Increased respiratory rate Blood pressure maintained Increased diastolic pressure Narrow pulse pressure Sweating
Grade 3
30-40% blood volume loss (1500 - 2000mls) 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
Nexus C-spine rule
Score Parameter
1 Midline c-spine tenderness
1 Evidence of intoxication
1 Altered consciousness
1 Focal neurology
1 Distracting injuries
Score >1 indication for c-spine imaging
Wells criteria for PEScore Parameter
3 Clinical signs of DVT
3 Alternative diagnosis less likely
1.5 HR>100
1.5 Immobility / surgery in last 4 weeks
1.5 Previous DVT / PE
1 Haemoptysis
1 Malignancy
Low risk = 1 – 2.5 pointsModerate risk = 3 – 6 points
High risk = 6.5 – 12.5
AMTS1 What is your age
1 What is your date of birth
1 What is the year
0 Please remember “42 West Street”
1 What is the time to the nearest hour
1 What is the name of this hospital
1 Can patient recognise 2 people (Dr / nurse)
1 What year did World War II end (1945)
1 Name the present monarch
1 Count backwards from 20 to 1
1 Recount the address you were asked to remember
8 or higher is normal for an elderly patient
Pain assessment
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating /relieving factors
Score
Chest pain differentials MI
ACS
Angina
Aortic dissection
Pericarditis
PE
Pneumonia
Pneumothorax
GORD
Sickle cell crisis
PUD
Musculoskeletal
Tachyarrhythmia differentials
Sinus tachycardia
Fast AF
SVT
Atrial flutter
VT
Re-entrant tachycardia (WPW)
Bradyarrhythmia differentialsSinus bradycardia
Complete or 3rd degree AV block / other heart blocks
MI
Drugs (beta-blockers, digoxin etc)
Vasovagal
Hypothyroidism
Hypothermia
Cushings reflex
Hypotension differentialsHypovolemia
Cardiogenic shock
Septic shock
Neurogenic shock
Anaphylaxis
Dysrhythmia
Postural hypotension
Vasovagal
Addison’s / adrenal failure
Drugs
Breathlessness / Hypoxia differentialsCOPD / asthma
Pneumonia
PE
Pulmonary oedema
MI
Pneumothorax
Pleural effusion
Pain
Sepsis
Metabolic acidosis
Anaemia
Chronic fibrotic lung disease
Upper GI bleed differentialsPeptic ulcer
Oesophagitis
Erosions
Varices
Mallory-Weiss tear
Swallowed blood
Malignancy
Rectal bleeding differentialsPolyps
Diverticular disease
Angiodysplasia
Haemorrhoids
Anal fissure
IBD
malignancy
Upper GI bleed
Abdominal pain differentialsAAA
Infarction / ischemiaObstructionPancreatitisAppendicitisPerforation
Strangulated herniaTorsionEctopic
Referred painIBDPID
ConstipationUTI
Jaundice differentialsParacetamol OD / toxins / drugs
Gall stones
Sepsis
Viral hepatitis
Alcohol
Cholangitis
Pancreatitis
Haemolysis
Gilberts
Dizziness differentialsShock
Arrhythmia
Postural hypotension
Anxiety / hyperventilation
Syncope
Epilepsy
Hypoglycaemia
Vertigo
BPPV
Menieres
Drugs
Headache differentials Haemorrhage
Meningitis
Encephalitis
Raised ICP
Temporal arteritis
Glaucoma
Dehydration
Tension
Migraine
Extracranial (sinuses etc)
Hypertension
hypoglycaemia
Acute confusion differentialsHypoxia
Infection
Drugs
Dural haemorrhage (subdural haemorrhage)
Endocrine
Neoplasm
Metabolic
Alcohol
Psychosis
Falls / collapse differentialsMI
Arrhythmia
Shock
Sepsis
CVA
Seizure
Hypoglycaemia
PE
Postural hypotension
Mechanical
Syncope
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 armchair2. Walk 3 meters (in a line)3. Turn4. Walk back to chair5. 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 independenceHigh scores correlate with poor functional independence and higher risk of falls
ECG interpretationComplex What it looks like Changes
P wave 2-3 sq high1.5-3sq 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= -0.5 - +1 sq
T Height= 0.5-10 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
Suspected CO poisoning
PC:- Headache, N&V, drowsiness, dizziness, dyspnoea, chest pain
QuestionsDo 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.)?
ManagementBlood for COHb estimationOxygen Do not allow patient to go home to where there are suspect appliancesContact local HPA