• Society for Acute Medicine
• Acute Med UK
• Cork Emergency Medicine Handbook
• MPS Factsheets Urgent Care Clinicians
• Guidance for commissioning integrated urgent and emergency care
• RCGP Centre for Commissioning
• Primary Care Foundation
• Out of Hours and Unscheduled Primary Care: Making it safer MPS Sep 2011

Emergency care Red Flags

1.CARDIAC CHEST PAIN requires emergency 999 blue light ambulance admission.

If the ambulance is going to be delayed then you attend urgently

2. STROKE 999 FAST

3. SILENT ASTHMATIC
When patients’ relatives report that the patient’s asthma has suddenly improved because they have gone quiet and their breathing is much shallower they may well be describing a very serious deterioration in asthma.
Asthma severity is often under-estimated. Always check Peak Flow. Over use rather than under use steroids. Don’t be reluctant to admit children.
Stridor Do not manage stridor in children over the telephone – GO AND SEE THE CHILD

4. FAMILY CONCERN
If you are given telephone advice and the family remain clearly concerned about the patient and are unhappy with this then reconsider the decision not to see the patient and assess them face to face.
Sometimes the history given over the telephone does not marry with the condition of the patient once seen.

5. If a patient at home is considered to be ill enough to require oxygen, admit for full assessment.

6. Make proper clear legible notes after every contact.

7. Patient safety and risk takes priority over local hospital bed difficulties. Your role is to make a clinical decision not to be a bed manager.

Doctors bag

The bag should be lockable and not left unattended during home visits. If left in the car the bag should be locked and kept out of sight, preferably locked in the boot.
Most pharmaceuticals should be stored between 4-25 degrees. Ideally the doctor’s bag should be silver in colour as this keeps drugs significantly cooler than the traditional black bag. It is useful to keep a maximum and minimum thermometer in the bag to record the extremes of temperature.
Remember that bright light can inactivate some drugs so keep the bag closed when not in use.
The origin, batch numbers and expiry dates of all drugs should be recorded and the drugs checked regularly to ensure they are still in date and usable.
1. Remember to stock a good supply of water for injection, syringes and needles
2. Check periodically that the drugs are not past the expiry date
3. Keep a special book to list the controlled drugs
4. Particularly important are adrenaline for anaphylaxis, diazepam for convulsions (including Stesolid for rectal use in children), glucagon for hypoglycaemia in diabetics and Lv. hydrocortisone and aminophylline/salbutamol for use in patients with severe asthma.
Frusemide for cardiac failure is essential and for renal colic, acute gout, backache or severe sprains seen on a home visit an injection of Voltarol is highly effective (assuming no history of peptic ulceration or drug-induced asthma attacks)
5. Many GPs use a separate drugs bag for the above and a second bag for essential forms (prescriptions, sickness certificates, notepaper, continuation cards, temporary resident forms, etc.) and equipment (stethoscope, auriscope, ophthalmoscope,sphygmomanometer, thermometer, gloves, airway, etc.). How much extra equipment is carried for emergencies (nasal packing equipment, resuscitation equipment, obstetric equipment, etc.) depends on the expertise of the GP the nearness or otherwise ofthe local Casualty and the special features and situation of the GP’s practice

Accu-chek Mobile – May not in fact be suitable for multi-patient use?

Ketone Meters

Thermofocus Non-Touch Thermometer”

Optyse Lens Free Pocket Opthalmoscope

Panoptic Opthalmoscope

Macroview Otoscope

Digital Macroview Otoscope

Suppliers
http://www.firstaidwarehouse.co.uk/

http://www.pulsemedicalstore.co.uk

http://www.medisupplies.co.uk/acatalog/Diagnostics.html

http://www.wms.co.uk

OOH formulary

1 Follow local MM guidelines

2 Quantities prescribed/supplied should be sufficient to provide a full course to treat the presenting condition but no more.
Prescriptions for patients running out of their usual repeat medications should not exceed 7 days.

3. Refer to the Guidelines for the Management of Drug & Alcohol Users at Baycall for guidance on requests for addictive medicines including methadone and Subutex®.

4. Benzodiazepines can only be prescribed in the following circumstances:
Bereavement
As an adjunct to simple analgesia in severe acute spinal pain
Psychiatric emergencies

5. The out of hours clinician will consider the urgency of the situation and decide the need to:
i. Give advice only and not supply any prescription or medicine.
ii. Refer the patient to a community pharmacy for advice or self-treatment
iii. Supply the patient with a prescription
iv. Supply a medicine directly

6. When a supply of medicine is given to the patient directly, it will be in its original container, labelled accurately and legibly and a Patient Information Leaflet given. The patients will be informed of where to seek any additional advice.

7. Doctors will use FP10 prescription forms if it is necessary to supply a patient with a prescription to take to a community pharmacy.
FP10REC forms will be used for all medicines supplied or administered at the centre or in patient’s homes.

8. Patients should pay a prescription charge for medicines supplied out of hours unless the patient is exempt and completes a declaration to this effect. It is not envisaged that money will be collected directly, but by an invoice given to the patient or posted to them.
Items not subject to a prescription charge are:
Contraceptives (i.e Levonelle 2)
Items supplied for ‘immediate treatment’
Items personally administered (Immediate treatment’ means medicines that are given to the patient to take whilst in the OOH centre.)

9 The department does not keep or issue any stock drugs only those needed in medical emergencies —

10 Be aware of location of emergency drugs.

11 Pharmacy -OPENING TIMES -out this a list of local chemists OPENING TIMES and DIRECTIONS

12 Self Care is encouraged. Prescriptions for Calpol etc are positively discouraged. LINK TO ANTIPYRETICS

13 Clinical autonomy is respected but please try to stick to the formulary where possible, prescribe generically and prescribe minimal quantities of drugs to see the patient through their acute illness or enough till the next GP opening times.
We all acquiesce occasionally but patients/parents should be encouraged to purchase or otherwise not purchase clinically inappropriate medications

Kingston orange book core drugs

• Activated charcoal (50g powder)
  Adrenaline/epinephrine (1 in 1000, ie 1mg/mL ampoules)
  Amoxicillin (250mg capsules or 125mg/5mL suspension)
  Aspirin (300mg soluble tablets)
  Benzylpenicillin (600mg vials for reconstitution with water for injection)
  Cefotaxime (1g vial for reconstitution with water for injection)
  Chlorphenamine/chlorpheniramine (10mg/mL injection)
  Ciprofloxacin (500mg tablets)
  Diamorphine (5mg or 10mg powder in ampoules for reconstitution with water for injection)
  Diazepam (5mg tablets, 5mg/mL injection as Diazemuls for IV and diazepam for rectal administration 2-4mg/mL)
  Diclofenac (25mg/mL injection, 25mg tablets)
  Dihydrocodeine (30mg tablets)
  Erythromycin (250mg tablets or 125mg/5mL suspension)
  Fibrinolytic drugs (depending on local arrangements)
  Flamazine cream
  Flucloxacillin (250mg capsules or 125mg/5mL syrup)
  Furosemide/frusemide (10mg/mL injection)
  Glucagon (1mg vial with prefilled syringe containing water for injection)
  Glucose (50% solution; to dilute this carry a 50mL syringe and large bore needle)
  Glucose (Hypostop gel or glucose tablets or glucose containing drink)
  Glyceryl trinitrate (as an aerosol that delivers 400micrograms/metered dose)
  Haloperidol (1mg/mL liquid or 5mg tablets)
  Hartmann’s solution (sodium lactate intravenous infusion, compound 500mL).
  Hydrocortisone (100mg powder as sodium succinate for reconstitution)
  Ibuprofen (100mg/5mL suspension)
  Ipratropium bromide (250micrograms/mL nebuliser solution)
  Lidocaine/lignocaine (10mg/mL injection))
  Lorazepam (1mg tablets, 4mg/mL injection)
  Metoclopramide (5mg/mL injection or 10mg tablets)
  Naloxone (400 micrograms/mL injection)
  Oral rehydration salts (eg Dioralyte or Rehidrat)
  Oxygen
  Paracetamol (500mg tablets and 120mg/5mL paediatric oral solution or suspension)
  Phenoxymethylpenicillin (125mg/5mL oral solution)
  Prednisolone (5mg tablets preferably soluble)
  Procyclidine (5mg/mL injection)
  Salbutamol or terbutaline metered dose inhaler and salbutamol (1mg/mL nebules) or terbutaline (2.5mg/mL nebuliser solution)
  Sodium chloride (0.9%; 500mL or 1000mL infusion)
  Trimethoprim (200mg tablets or 50mg/mL suspension)
  Water for injection

Personally administered drugs

Personally Administered Drugs @ GP Online

In all cases the doctor must put himself/herself in a position to properly assess the medical state of a patient and thus the need for a house call.

Not having transport is not sufficient grounds on which to base the decision to undertake a home visit. Patients should be encouraged to seek help from neighbours, family or friends or use a taxi to attend a Primary Care Centre.

Why is it better to be seen in a Primary Care Centre?
There are a number of reasons why home visits are only made in circumstances where a patient’s illness makes them unable to travel.
You can be examined in better facilities and in better lighting.
The doctor can use equipment that cannot be carried in the mobile vehicle.
Should you need to be admitted to hospital, this can be quickly arranged from the PCC.
The doctor can see four patients at the PCC in the time it takes to do one home visit. This means we can see all patients promptly and see the most urgent cases more quickly.
NB – triage staff should use discretion after 10pm and consider patient safety in getting to the PCC

In most of these cases, to visit would not be appropriate use of a GP’s time:
Common Symptoms of childhood: fevers, cold, cough, earache, headache, diarrhoea/vomitting and most cases of abdominal pain. These patients are usually well enough to travel by car. It is not necessarily harmful to take a child with a fever outside. These children may not be fit to travel by bus or to walk, but car transport maybe available from friends, relatives or taxi firms. It is not a doctor’s job to arrange such transport.
Adults with common problems, such as cough, sore throat, influenza, back pain and abdominal pain, are also readily transportable by car to a doctor’s premises.
Common Problems in the elderly, such as poor mobility, joint pain and general malaise, would also be best treated by consultation at a doctor’s premises.
However, inspite of the above, some people may feel that due account needs to be taken of a patient’s circumstances and where necessary a visit should be made. This is all the more so when the safety of a child has to be taken into account.
netdoctor.co.uk/home-visits-out-of-hours-care

Cardiac arrest

Abrupt/acute  cessation of cardiac function.  Patient unconcious, not breathing and pulseless.

resus.org.uk

Cardiac output must be restored within minutes
Hypoxia is the commonest cause of cardiac arrest in children.

gponline/emergency

Cardiac arrest – managing the patient who survives NELM

BLS adults

BLS @ Sharing in health.ca

Ensure safety of rescuer and victim.
Assess responsiveness: gently shake shoulders and shout “Are you all right?”.

1/unresponsive
Open Airway: remove obvious obstruction; use head tilt and chin lift. IT neck injury is suspected use jaw thrust.
Check Breathing (max. 10 seconds): look, listen, and feel for chest movements and breath sounds at mouth.
If not Breathing
Give two rescue breaths using mouth-to-mouth ventilation.
Check Circulation (max. 10 seconds): look for any movement of victim; check carotid pulse.
If pulse present
Continue rescue breathing, recheck every minute for signs of circulation.
If no pulse (or unsure if pulse)
Start chest compressions at 100 times a minute, combined with ventilation (30 compressions to two breaths).

Mouth-to-mouth ventilation
Open Airway as above. Occlude nostrils. Ensure a tight seal around the patient’s mouth.
Gently Breathe into the patient for about 1.5-2 seconds, ensuring the chest wall rises.
If the chest wall does not move, reassess the airway, adjusting head tilt as necessary. Too vigorous a breath will force air into the stomach (so increasing risk of aspiration, vomiting, etc.).
A disposable mouth-guard provides a barrier between you and the victim but does not compromise ventilation. This is just a compact plastic sheet with a filter in the middle. If you possess a pocketmask, you can perform mouth-to-mask ventilation instead. Some masks are re-usable and oxygen can be attached if you carry it. There is a one way valve so that you do not breathe in expired air.

Chest compressions
Place the heel of one hand two finger breaths above the xiphisternum and place the other hand on top, interlocking fingers if necessary. Compress the chest to a depth of 5-6 cm, keeping the arms straight and vertically above the chest. The rate is 100n-120 compressions per minute.
Two rescuers: 15 compressions to two breaths
One rescuer: 5 compressions to one breath

Continue cardiopulmonary resuscitation (CPR) until the victim shows signs of life, someone takes over from you, or you are physically exhausted.
if rescuer unable to give ventilation then compression only cpr should be given

Oct 06 2010 Agonal respirations in an unresponsive patient indicate cardiac arrest

• youtu.be/IJaTC2rbVbM
• youtu.be/C_p-KSB6bJM
• youtu.be/Mf8EkVnOl0c
• youtu.be/XV11kplLoxw
• youtu.be/q-1T5AXDVPo

Chin lift / airway management

Airway Management ambulance technician 

BLS web.med.unsw.edu.au

AED adults and children over 8

continue chest compressions while device is charging – do not interrupt for >5 seconds

ILS and ALS

• http://youtu.be/AnTyPtVkAbg
• http://youtu.be/XV11kplLoxw
• http://youtu.be/oDvlb62Mrt4
• http://youtu.be/KCLpXtcQdo8
• http://youtu.be/V-wSWzmxWl4
• http://youtu.be/rHCD2iXNfMw
• http://youtu.be/q6_tAyZwXrk
• http://youtu.be/7n80ejhnt2g
• http://youtu.be/vaF0dgfvtbo
• http://youtu.be/-mFuts2i0bw
• http://youtu.be/MpMnpdEPAHY
• ALS ILS Courses aid-training.co.uk

Anaphylaxis

• hacking-medschool/anaphylaxis-immunology-and-allergy
• anaphylaxis.org.uk
• Anaphylaxis presentation Onmedica – registration needed
• rural health west march 2011 anaphylaxis

Follows the introduction of an antigen by injection as a insect sting, vaccine, or drug (eg penicillin or iron) foodstuffs (eg shellfish or peanuts) through the mucosa (eg latex).
Cause is not always identified
Clinical features
oedema of the face, tongue and larynx, itching, rash, bronchospasm, pulmonary oedema, hypotension and tachycardia.
Those prone to attacks often have a specific pattern of symptoms that they learn to recognise.

Management
Im emergency treat as below and transfer immediately to hospital.
Delayed reactions can occur and/or symptoms may recur.
Patients should be observed for at least the first 8 hours after the onset of symptoms. If patients present while symptoms persist but are waning, they should be transferred urgently (???) to hospital to assess the need for further treatment.

Giving adrenaline intravenously is potentially hazardous and should be reserved for patients with immediately life-threatening, profound shock, who can be monitored and in whom IV access can be gained without delay.

High concentration oxygen

Inhaled salbutamol if severe bronchospasm.

IV fluids if patient shocked and does not respond to drug treatment – rapid infusion of sodium chloride 0.9%.
Give 20mL/kg of body weight for children, 1-2 litres of fluid for adults – may need to be repeated.

Anaphylaxis adults

Anaphylaxis algorythm adults

Epipens

epipen.co.uk

youtu.be/pmGOcGYEU2k

Choking adult

Heimlich and abdominal thrusts

http://youtu.be/fjrURtyqMHY

http://youtu.be/4MQ58joyLNc

Pulse Oximetry

Pulse Oximetry Screening for CHD in neonates  Lancet Aug 2011

Knowledge of Pulse Oximetry amongst Medical & Nursing Staff Lancet 1994

Simple non-invasive method of monitoring the percentage of haemoglobin which is saturated with oxygen.
Detects hypoxia before the patient becomes clinically cyanosed
A source of light originates from the probe at two wavelengths (650nm and 805nm). The light is partly absorbed by haemoglobin, by amounts which differ depending on whether it is saturated or desaturated with oxygen. By calculating the absorption at the two wavelengths the processor can compute the proportion of haemoglobin which is oxygenated. The oximeter is dependant on a pulsatile flow and produces a graph of the quality of flow. Where flow is sluggish (eg hypovolaemia or vasoconstriction) the pulse oximeter may be unable to function. The computer within the oximeter is capable of distinguishing pulsatile flow from othermore static signals (such as tissue or venous signals) to display only the arterial flow.

Cautions
1. A reduction in peripheral pulsatile blood flow produced by peripheral vasoconstriction (hypovolaemia, severe hypotension, cold, cardiac failure, some cardiac arrhythmias) or peripheral vascular disease. These result in an inadequate signal for analysis.
2. Venous congestion, particularly when caused by tricuspid regurgitation, may produce venous pulsations which may produce low readings with ear probes. Venous congestion of the limb may affect readings as can a badly positioned probe. When readings are lower than expected it is worth repositioning the probe. In general, however, if the waveform on the flow trace is good, then the reading will be accurate.
3. Bright overhead lights in theatre may cause the oximeter to be inaccurate, and the signal may be interrupted by surgical diathermy. Shivering may cause difficulties in picking up an adequate signal.
4. Pulse oximetry cannot distinguish between different forms of haemoglobin.
Carboxyhaemoglobin (haemoglobin combined with carbon monoxide) is registered as 90% oxygenated haemoglobin and 10% desaturated haemoglobin therefore the oximeter will overestimate saturation. The presence of methaemoglobin will prevent the oximeter working accurately and the readings will tend towards 85%, regardless of the true saturation.
5. When methylene blue is used in surgery to the parathyroids or to treat methaemoglobinaemia a shortlived reduction in saturation estimations is registered.
6. Nail varnish may cause falsely low readings.

Not affected by jaundice, dark skin or anaemia.
In patients with long standing respiratory disease or those with cyanotic congenital heart disease readings may be lower and reflect the severity of the underlying disease.
Oximeters give no information about the level of CO2 and therefore have limitations in the assessment of patients developing respiratory failure due to CO2 retention.

http://youtu.be/GssaM3Bose8

http://youtu.be/GQMWZcfeKmY

http://youtu.be/eyv04smwPMs

Oxygen adults

Oxygen therapy is the treatment for hypoxemia, not breathlessness: oxygen has not been shown to have any effect on the sensation of breathlessness in non-hypoxemic patients. However, failure to administer oxygen to hypoxemic patients can be a life threatening omission.

Assessment of the degree of patient hypoxemia can be made clinically, by looking for the signs of cyanosis and dyspnoea; by simple bedside observations of respiratory rate and pulse oximetry; and ultimately by arterial blood sampling and analysis.

Critically Unwell Patients
Any patient who is critically unwell should be immediately treated with high concentration of oxygen. Oxygen saturation should be checked and recorded, along with the inspired oxygen concentration, on the observation chart, in addition to other vital signs (pulse rate, blood pressure, temperature and respiratory rate).

Initial oxygen therapy is 15 l/min via a reservoir bag and mask
Once stable, reduce the oxygen dose and aim for target saturation range of 94 – 98 %
If oximetry is unavailable, continue to use a reservoir bag and mask until definitive treatment is available

Patients with COPD and other risk factors for hypercapnia who develop critical illness should have the same initial target saturation as other critically ill patients pending the results of blood gas measurements, after which these patients may need controlled oxygen therapy or supported ventilation if there is severe hypoxemia and/or hypercapnia with respiratory acidosis

Cardiac arrest / resuscitation
Use Bag-Valve-Mask during active resuscitation
Aim for maximum possible oxygen saturations until the patient is stable
Shock, sepsis, major trauma, near drowning, anaphylaxis, major pulmonary haemorrhage
Also give specific treatment for the underlying condition

Major head injury
Early intubation and ventilation if comatose

Carbon monoxide poisoning
Give as much oxygen as possible using a bag-valve mask or reservoir mask. Check carboxyhaemoglobin levels.
A normal or high oximetry reading should be disregarded because saturation monitors cannot differentiate between carboxyhaemoglobin and oxyhaemoglobin owing to their similar absorbances.
The blood gas pO2 will also be normal in these cases.

Any Other Hypoxic Patients
Oxygen should only be administered to hypoxic patients – oxygen can have deleterious effects on cardiac, renal and pulmonary function. If the patient is not critically unwell, oxygen should only be administered if the oxygen saturations are less than 98 %.

There are some patients with chronic ventilatory problems who develop chronic type 2 respiratory failure. In this case, CO2 levels rise, resetting the normal physiological control of breathing. These patients rely on relative hypoxia to stimulate breathing, and therefore should be maintained in a state of relative hypoxia (pO2 < 10 kPa) to avoid a fall in minute volume, and therefore an increase in pCO2 and subsequent acute on chronic type 2 respiratory failure with acidaemia.

Patients with, or at risk of, any of the above diagnoses should be treated with controlled oxygen therapy, with the aim of maintaining SaO2 in the range of 88 – 92 %. Arterial blood gases should be obtained as quickly as is feasible.

If chronic CO2 retention is confirmed, oxygen therapy should continue to maintain SaO2 in the range of 88 – 92 %.
If there is no chronic CO2 retention, oxygen therapy should be altered to maintain SaO2 in the range of 94 – 98 %.
Any hypoxic patient with acute CO2 retention should be treated with oxygen to maintain SaO2 between 94 and 98 %. The cause of the acute deterioration must be sought and appropriate treatment commenced.

Oxygen Prescription
Oxygen is a drug and should be prescribed on the TPAR document – the target SaO2 should be clearly documented.

Monitoring and Continued Care
Oxygen saturations should be monitored regularly and documented on the SEWS chart. If the oxygen saturations fall outside the prescribed range the delivery device and/or flow rate should be altered to bring the saturations back into the target range, according to local guidelines.

Postoperative Patients should be given oxygen either by facemask (Hudson mask) or via the nasal route. General anaesthesia predisposes to lung atelectasis which makes patients prone to hypoxia after major surgery. The duration of oxygen therapy will be determined by the magnitude of the surgery and also the patient’s pre existing respiratory status. In general patients should receive continuous oxygen for the first postoperative night after major surgery such as laparotomy or hip or knee replacement. Patients are particularly vulnerable to hypoxic events at night, so it may be necessary to use nocturnal oxygen for a few nights after major surgery in at risk patients (eg those with COPD).

Summary
Give emergency oxygen therapy to all critically unwell patients.
If the patient is not critically unwell, only give oxygen if there is hypoxia.
If the patient is at risk of chronic CO2 retention, aim for SaO2 88 – 92 % initially and get Arterial Blood Gases (ABGs)
If chronic CO2 retention is confirmed, continue oxygen therapy aiming for SaO2 88 – 92 %
If chronic CO2 retention is refuted, continue oxygen therapy aiming for SaO2 94 – 98 %
Ensure that oxygen is prescribed on the TPAR document.
Alter the oxygen delivery device and flow to maintain the target saturation
Dr Tom Fardon Department of Respiratory Medicine, Dr Matthew Checketts, Consultant Anaesthetist December 2008
Recent update – avoid over-oxygenation in acute MI.

Emergency Oxygen in Adults BMJ 2009

Oxygen delivery

• http://youtu.be/iRniUCT0zWw
• http://youtu.be/wP1_CqcEV5Y
• http://youtu.be/MNzCfO7Z0Fk
• http://youtu.be/2GTE8S95dsA
• http://www.youtube.com/watch?v=jANeuLhiIC8
• http://youtu.be/d_5eKkwnIRs
• Aarons Tracheostomy Page

Anaesthesia / sedation

NHS Bath Sedation in the ED

Intravenous analgesia regime

Use 10 mg morphine made up to 10 ml with water give slowly intravenously in 2 mg aliquots over a few minutes until pain has eased
Don’t forget an antiemetic in adults
Don’t be afraid to use more than 10 mg morphine if the pain isn’t easing
Be aware of side-effects, eg respiratory depression – patient must be monitored

Chest pain and ACS

ACS
hacking-medschool/acs-cvs

Chest Pain NICE CG 95 

All patients with chest pain of possible cardiac origin should have an ECG performed and CVS Observations recorded.
For acute infarction/crescendo angina give oxygen and suitable pain relief. (Try Nitrate, Nifedipine then Opiates)
Note Suitable IV access and ECG monitoring should be performed whilst admission is arranged with the Cardiac SHO.
Cardiac patients should be closely observed whilst in the A&E department and during transfer to the ward.
Where myocardial infarction has been diagnosed, patients will normally be commenced on Streptokinase by syringe pump infusion in A&E prior to transfer to CCU, unless it has been contraindicated.
The Cardiac SHO will advise on this in an individual patient basis.
CPR should be performed using the Resuscitation Council Guidelines.
A copy of the most recent European guideline is attached to the wall in Resuscitation. The essential point is that defibrillation should not be delayed, and the patient must he oxygenated using the ABC principles of assessment.
The early phases of acute MI and unstable angina are often indistinguishable.
Their initial management is the same and it has become standard to treat them as a single entity known as ‘acute coronary syndrome’. Patients should be considered as having acute coronary syndrome if they present with:
recent onset of prolonged cardiac chest pain (over 20 minutes) occurring at rest
recent onset of cardiac chest pain on minimal exertion
rapidly worsening chest pain (more frequent, prolonged, severe or easily
provoked, or not responding to their normal glyceryl trinitrate), in someone with known exertional angina.

Referral advice
Patients with an episode of chest pain suggesting an acute coronary syndrome should be transferred to hospital immediately  if:
the onset of the pain is within 48 hours (even though the pain has now resolved)
there have been further episodes of pain occurring at rest or on minimum exertion
there are signs of heart failure or other complications.

Patients who have been pain free for more than 48 hours should be referred to be seen at the earliest opportunity, ideally within 2 weeks in a rapid access chest pain clinic).

Avoid injecting drugs intramuscularly as this may:
– increase the risk of bleeding if the patient subsequently receives thrombolysis
-cause muscle damage and rize in plasma enzymes
– delay the onset of effective analgesia; particularly in shocked patients in whom muscle blood flow is greatly reduced

Patients with stable angina or other evidence of ischaemic heart disease or with cardiac risk factors should be given information on what to do if symptoms of an acute coronary syndrome develop. This advice should be shared with the relatives or carers. It helps if a list of emergency numbers is kept accessible in the person’s home.
Practices should have a policy on how to respond to calls to see patients with chest pain.

Determining the cause of chest pain is a common and difficult clinical problem. The main issue is usually to determine whether it is likely to be cardiac or not via careful history of the pain (PQRST) the patients past medical history and risk factors.
Other causes of chest pain include, pulmonary, gastrointestinal, musculoskeletal or psychological problems.
Chest pain life threatening: angina, myocardial infarction, pulmonary embolism, and aortic dissection.
Chest pain less serious causes: pericarditis, pleurisy, costochondral pain, chest wall pain, esophageal pain, emotional disorders, cervical disc disease, osteoarthritis of the cervical or thoracic spine, abdominal disorders (peptic ulcer, hiatus hernia, pancreatitis, biliary colic), pneumonia and intercostal neuritis (as with herpes zoster).

Women and diabetics may present atypically and less dramatically with myocardial infarctions

Unstable angina pectoris is defined as prolonged (>20 minutes) episodes of angina, angina that occurs at rest, or angina not relieved with three nitroglycerine tablets. Unstable angina is a medical emergency.

Aortic Dissection
Aortic dissection is associated with very severe, tearing or ripping chest pain that radiates to the back and is not affected by position.Syncope associated with chest pain consider in syncope associated with chest pain.Aortic dissection is slightly more likely to occur in pregnant patients and in those with a history of hypertension (and syphilis). Immediate surgical intervention is required. Differential BP Widened Mediastinum

Pericarditis
Severe persistant pain often partially pleuritic aggravated by the supine position and relieved by sitting up.

Pulmonary Embolism
Sharp pleuritic, chest pain and shortness of breath. It may also be accompanied by cough and hemoptysis. Pulmonary emboli are more likely to occur in people who are immobilized, in a leg cast, positive for history of cancer, or people who have recently had a long car or aeroplane trip. The diagnosis of Pulmonary Embolism may be supported by Wells criteria

Pleuritis
Pleuritis is chest pain caused by inflammation of the lining of the lungs. This pain is usually described as well localized and knifelike, and it is made worse by changes in position, coughing, sneezing, or breathing. Pleuritic pain may be referred to the shoulder if the diaphragmatic (bottom) pleura is affected. This kind of pain can be initiated by pneumonia, viral syndromes or pulmonary embolism. In acute pneumothorax, there may be a history of recent chest trauma or chronic obstructive lung disease. Pleurisy can be precipitated by pneumonia or a recent viral infection.

Thrombolysis

Thrombolytic therapy reduces mortality in patients who have an acute myocardial infarction. The earlier it is given after symptoms develop the greater the benefit. Thrombolytic therapy should only be given if:you are confident of the diagnosis of acute MI, and a defibrillator and ECG monitor are at hand, and you have had specific training in thrombolytic therapy.
Ideally, a thrombolytic should be given within 60 minutes of the patient calling for help, although it may improve outcome if given up to 12 hours after the onset of symptoms. If there is likely to be a delay of at least 30 minutes before the patient can get to hospital it would be reasonable to start thrombolysis straight away.
The choice of thrombolytic, and the exact protocol for its administration, should be decided at local level in conjunction with the ambulance service and a local cardiologist.

Dissecting thoracic aneurysm

Thoracic Aneurysm Medscape

Severe and malignant hypertension

Urgent Referral if BP 180/110
Severely raised arterial blood pressure is life threatening. Management depends on the height of the pressure, the speed at which the pressure has risen and the degree of end-organ damage.
Pressure should be measured while the patient is seated and with the arm supported at the level of the heart.
The frequency of monitoring used to confirm the blood pressure depends on the initial measurement and any additional risks to the patient

Refer immediately
a blood pressure of 220/120mmHg or more
accelerated malignant hypertension (BP more than 180/110mmHg with signs of papilloedema and/or retinal haemorrhages)
acute cardiovascular complications (eg transient ischaemic attack, LVF, cerebral oedema or dissecting aneurysm)

Refer routinely
sustained BP of 140/90mmHg or more (see table above), and have any one of the following:
non-acute end-organ damage such as mild heart failure or renal impairment
a suggestion of a secondary cause of hypertension; for example, renovascular disease or Conn’s syndrome
resistance to multi-drug treatment (3 drugs or more)
aged under 20 years
aged 20-30 years needing treatment for hypertension.
Timing of the appointment will depend on local arrangements. Start treatment while the patient is waiting for a hospital appointment.

Stroke CVA

Refer urgently 999 for consideration of thrombolysis within 4 1/2 hrs.

Drugs/poisons hypnotics, sedatives, controlled drugs, poisons (carbon monoxide, solvents), alcohol
Metabolic/ endocrine hypo and hyperglycaemia, hypothermia, hypopituitarism, hypothyroidism, hepatic/renal failure
CNS pressure hydrocephalus (blocked valve), cerebral oedema
CNS injury concussion, extradural or subdural haematoma, depressed fracture
Vascular stroke, low cardiac output, cerebral or subarachnoidhaemorrhage
Epilepsy seizure, post-ictal state
Infection CNS (meningitis, encephalitis, cerebral malaria)
Generalised (septicaemia, pneumonia)
Respiratory failure carbon dioxide retention, hypoxia

Headache SAH

Distinguishing Migraine From SAH @ Medscape

SAH UCLA

Epilepsy and status epilepticus

ACUTE MANAGEMENT OF TONIC-CLONIC SEIZURES IN ADULTS
The acute management of tonic-clonic seizures depends on their frequency, duration, timing and underlying cause.

General management
During the attack, take measures to avoid the patient being injured (eg protect them from hot radiators, hot water, stairs, sharp objects etc)
After the convulsive movements have subsided, put the patient in the recovery position and check that the airway is not obstructed and that there are no injuries
When the patient has fully recovered, reassure them and any attendant family/carers

Patients in whom the seizure is associated with acute or chronic alcohol excess may need to be referred for general management (for example, to treat hypoglycaemia or infection)
If the patient is a pregnant woman, she should be transferred to hospital immediately

The single seizure
Individual episodes usually stop spontaneously within 3 minutes, although in some patients the pattern is different and they can last longer. Recovery from such individual episodes is not speeded by emergency drug treatment and their management should be as outlined above.

Referral advice
If the patient has a diagnosis of epilepsy and is otherwise well controlled, early referral is usually not necessary and they should be reviewed at their next appointment with the neurologist or epilepsy nurse. The appointment may need to be brought forward if the fit might affect the patient’s employment or driving status.
If this is a first attack, the patient should be referred to be seen by a specialist within 2 weeks (??). This is to ensure early diagnosis and initiation of therapy according to their needs.

Prolonged or serial Seizures
A patient presenting with a ‘prolonged’ seizure (ie tonic-clonic movement) lasting 5 minutes or more or, with serial seizures (3 or more in an hour), should be managed as set out in the general management advice above. In addition, give rectal diazepam 10-20mg and repeat the dose after 15 minutes if necessary; buccal midazolam is an alternative, although it is currently unlicensed for this indication.

Referral Advice
Patients should be referred to hospital immediately if the seizure develops into status epilepticus (for management see section below).

Patients should be referred to hospital urgently if:
– from their previous history, there is a high risk of recurrence
– this is the first episode
– there are difficulties in monitoring the individual’s condition

Status Epilepticus
Status epilepticus is defined as either a run of discreet seizures without full recovery in between fits, or continuous seizures lasting for 30 minutes. The mortality and morbidity of generalised tonic/clonic status is high, and it is important to control the fits as soon as possible. The following measures should be instituted as soon as status has been diagnosed.

Management
Protect the patient from injury. Do not leave the patient alone whilst fitting or recovering; do not restrain the patient or put anything, including an oral airway, in the mouth during a seizure.
Arrange for an ambulance to transfer the patient to hospital immediately

Assess cardiorespiratory function record blood pressure and pulse rate and, if possible, and not contraindicated, give oxygen.

Measure blood glucose and if the patient is hypoglycaemic give 1mg glucagon IM or IV glucose.
Try to discover evidence of previous epilepsy and/or whether the patient is on any anti-epileptic drugs. Also try to establish the time of onset of the episode. Record this information and send it with the patient to hospital.

Drug treatment
While waiting for the ambulance give diazepam 10-20mg rectally (use rectal solution; absorption from suppositories is too slow) and repeat the dose after 15 minutes if status continues to threaten. Buccal midazolam is an alternative.

If seizures continue, and you carry it, consider giving IV lorazepam 0.1mg/kg into a large vein (usually 4mg bolus, repeated once after 10-20 minutes) or IV diazepam (as Diazemuls) 10mg over 2-5 minutes.

Coma Delirium Acute Confusional State
Any patient who is comatose (GCS less than 8) should be transferred to hospital immediately.

While awaiting transfer assess the need for basic resuscitation – ABC.

1. Maintain the airway.

2. If there is no evidence of major injury, turn the patient into the recovery position and keep them warm.

3. Give oxygen at the highest concentration possible via a facemask unless the patient has COPD.

4. If hypothermia is suspected check by measuring the core temperature.

5. Establish IV access.

6. Check for hypoglycaemia (blood glucose less than 4.0mmol/L) and if present give either glucagon or glucose

7. If an opiate overdose is suspected give naloxone IV ((DOSE))

8. If possible start treating any underlying conditions (eg meningococcal septicaemia).

Try to establish a diagnosis. Look for clues such as tablet containers, suicide notes, signs of trauma etc. Whilst examining the patient question those present about:
the onset of the coma
any previous medical or drug history
any injury or relevant social circumstances.

Management of refractory status epilepticus in adults NELM

Acute severe asthma Adults

Management depends on the age of the patient and whether the episode is moderate, severe or life-threatening.

Until the level has been defined, treat the attack as if it were severe.

Use objective measures of severity whenever possible, and record in patient’s notes. If the patient has signs and symptoms across all categories, treat them according to their most severe feature(s).

threshold for referral should be lowered if:

• the attack occurs in the late afternoon or at night
• the patient has had previous nocturnal symptoms or hospital admission
• the patient has had a previous severe attack
• there is concern over social circumstances, or the ability of patient or carer to cope at home
• If you are referring the patient to hospital, then stay with them until ambulance arrives; remember to send written assessment details with them.

Beta agonist nebulised or via spacer (1 puff x 10-20)

salbutamol 5mg or terbutaline 10mg

PLUS nebulised ipratropium 500micrograms

Prednisolone 40- 50mg if PEF>50-75% predicted/best and continue or step up usual treatment

Oxygen – oxygen 40-60%

Refer Immediately
features of acute severe asthma present after initial treatment or if the patient has had previous near-fatal asthma

Disposal
If good response to first nebulised treatment (symptoms improved, respiration and pulse settling and PEF >50%) continue or step up usual treatment and, if started, continue prednisolone for at least 5 days

Make clear arrangements to review the patient within 48 hours of an acute attack.

Remember: recovery from an acute attack of asthma is often gradual, and during the recovery phase patients are at risk of relapse and should be monitored carefully to check the patients inhaler technique

to provide a written self-management plan (including a ‘rescue’ plan) together with clear information about the indications for urgent recall

to address potentially preventable contributors to admission. Reference graph showing normal peak expiratory flow rates

Pneumothorax

http://youtu.be/GKEfQ9n6M0Y

http://youtu.be/rhSMCvYW8wE

http://youtu.be/C2eEPyjxczw

DVT VTE PE Wells

• SGN 122 Dec 10 QRG
• NICE CG92 Jan 10 VTE in hospital
• EEP INFOPOEMS AUG 2011 Wells?Geneva Equally effective for ruling out PE when combined with DDimer
• qthrombosis.org/
• Wells Criteria DVT MDCalc
• Wells Score for PE MDCalc
• http://emedsa.org.au/EDHandbook/medicine/Respiratory/PE/PEScores.htm
• Management of deep vein thrombosis and prevention of post-thrombotic syndrome BMJ Oct 2011
• Pulmonary embolus BMJ 2010;340:c1421

http://www.youtube.com/watch?v=I0yJTkW9y9s

http://www.youtube.com/watch?v=K7xR0hyC-TE

DVT is a common easily missed but potentially life threatening condition.  It may arise spontaneously or as a result of trauma, surgery, immobility or other risk factors. Classical clinical signs may be absent or the picture may be complicated by coexisting thrombophlebitis or cellulitis.

Wells scoring system may aid referral decisions. DDimer Blood tests may help confirm clinical impression when the index of suspicion is high but cannot itself be used for diagnosis or as a screening test. The definitive  test is ultrasound and all patients with suspected or possible DVT need referral.

Background Information
Thrombosis arises in the deep veins of the lower leg as a result of
–  vascular injury (fractures, surgery, burns, childbirth, infections, and venipuncture  – IV Drug users ),
–  immobility and stasis (pregnancy, obesity, chronic heart disease, major surgery, cerebrovascular accidents, and advanced age, air travel ) particularly in presence of risk factors promoting hypercoaguability (pregnancy, smoking systemic disease, contraceptive pill, dehydration, major surgery).  Pain may precede oedema and visible swelling.

Classically the affected leg may be swollen red warm tight shiny  high index of clinical suspicion is necessary for the diagnosis of DVT because many patients with a DVT are symptomatic, however classical signs include calf muscle or groin tenderness, pain, edema and sensation of warmth in the affected leg.

Investigations
Duplex Doppler ultrasound
DDImer

Treatments
Anticoagulants – heparin/warfarin (INR 2-3) /Thrombolytic /Analgesics /Antiembolism stockings (after acute episode)
Discharge and Follow Up Considerations
Refer All patients with suspected or possible DVT
Educate patient in identification of and measures to prevent venostasis particularly wrt air travel
Instruct on the importance of bed rest and elevation of the affected leg with proper placement of pillows so they support the entire length of the affected extremity to prevent compression of popliteal space
Instruct on signs and symptoms of bleeding if prescribed Warfarin
Instruct on proper application and use of antiembolism stockings and to report circulatory compromise

Q thrombosis prospective risk calculator BMJ Aug 2011

http://www.qthrombosis.org/

MeReC Aug 2011 – 3 month treatment for simple DVT

Acute LVF Pulmonary Oedema

Clinical features
Patients with acute left ventricular failure usually complain of sudden onset of rapidly increasing breathlessness; occasionally this is accompanied by wheezing.
The patient is usually sweating, breathless and anxious, and on examination has basal crepitations, a raised jugular venous pressure and a third heart sound.

Referral advice
Arrange for the patient to be transferred to hospital immediately.
While waiting for the ambulance, sit the patient up, establish venous access and start drug treatment. Treatment of the underlying cause can wait.

Immediate management includes:
high concentration oxygen (unless you suspect COPD)
diamorphine 5mg IV1 (2.5mg for elderly or frail patients) at a rate of 1mg/min
metoclopramide 10mg IV2. Give slowly over 1-2 minutes
sublingual glyceryl trinitrate (spray or tablet)
furosemide (frusemide) 40-80mg IV
repeat doses of furosemide and diamorphine if there is no improvement after 20 minutes.
If diamorphine causes respiratory depression give 0.4-2mg of naloxone IV every 2-3 minutes to a maximum of 10mg.
If an oculogyric crisis occurs give 5-10mg of procyclidine IM and repeat after 20 minutes if necessary.

Pneumonia (emergencies – adults)

hacking-medschool/pneumonia-respiratory

hacking-medschool/community-acquired-pneumonia-cap

Clinical features
fever, pleuritic pain and dry cough. Other characteristic features include shortness of breath, productive cough and haemoptysis as well as non-specific features such as headache, rigors, confusion and delirium.
Common signs of pneumonia are tachycardia, tachypnoea, focal crepitations and, rarely, bronchial breathing. A pleural rub may be heard or there may be evidence of a pleural effusion.
Elderly patients may present non-specifically with features such as confusion, and only careful examination of the chest reveals the likely diagnosis of pneumonia.

Pneumonia BMJ 2008

Management in the community

Patients with uncomplicated  pneumonia can often be managed in the community, but for some, pneumonia is life threatening. Those at particular risk are the very young, the very old and those with underlying diseases such as chronic cardiorespiratory disease or diabetes mellitus. Other risk factors include alcoholism and immunosuppression (as in patients with organ transplants or AIDS).  Pneumonia can also follow bronchial obstruction caused by cancer or by the inhalation of a foreign body.

Start with amoxicillin (500mg-1g tds) or erythromycin (500mg qds)/clarithromycin (500mg bd) up to 10d
Patients should be reassessed within 48 hours and if they have not responded to treatment either:
– arrange a chest X-ray to confirm the diagnosis
– add erythromycin or a tetracycline to cover Mycoplasma infection (rare in the over 65s)
– refer to hospital
Patients should be transferred urgently to hospital if they have a ‘CRB-65’ score of 3 or 4. If the patient is severely ill and not allergic to penicillin give a stat dose of benzylpenicillin (adult dose 1.2g IV) prior to transfer.

CRB65 CURB65

The threshold for referral should be lowered in patients with:
coexisting chronic disease
psychosocial reasons why they cannot manage at home
an oxygen saturation less than 92%.

Patients should be referred to see a specialist within 2 weeks if you suspect there may be an underlying malignancy.
Patients should be referred for diagnosis of HIV status if you suspect HIV/AIDS is a possible underlying cause.

Death results from CAP in around 1% of cases rising to over 10% in the elderly and those with chronic heart failure renal failure liver failure a deficient immune system or cancer. (CAP patients who require hospital admission sustain over 20% mortality.) This risk of death is reduced by prompt diagnosis and treatment.

CAP vs HAP
CAP is pneumonia that begins to develop outside hospital in patients who have not been inpatients. The invading organisms are often found among the normal flora of the human upper respiratory tract. Hospital-acquired pneumonia (HAP) occurs after admission to hospital for some other serious condition. It is caused by a variety of often antibiotic-resistant bacteria from a number of sources, most commonly intensive-care units (ICUs) in patients who are being mechanically ventilated.

Nursing-home-acquired pneumonia
Apart from the fact that patients in nursing homes are often frail and elderly, there is some evidence that when they develop pneumonia, the causative bacteria are generally similar to those that cause CAP. Consequently, similar treatment regimens should be used. Due to their age they are more likely to require hospital admission

All children suspected of having pneumonia must be admitted without delay to a specialized paediatric intensive-care unit.

Treatment of CAP General measures
A sputum sample and two pre-antibiotic blood cultures should be taken for bacteriology. Do not delay specific treatment by waiting for results
2 A full blood count and serum electrolytes and urea should be sent for urgent analysis.
3 A pulse oximeter should be used to estimate the patient’s haemoglobin oxygen saturation. Supplementary oxygen should be available from a concentrator, via nasal ‘spectacles.’
4 Near-patient screening for the causative organisms should soon be generally available, based on the presence of urinary antigens to specific organisms pneumococcus and Legionella.
5 The patient must stop smoking, stay in bed and drink copious fluids.
6 Analgesia is important if the patient develops pleurisy, e.g. strong co-codamol tablets (30/500) in the dose needed to relieve the pain. Stronger opioids (morphine-like drugs) are not recommended, since they all depress the respiratory control mechanisms.

Pneumonia is prone to cause complications in 5-20% of patients – pleural effusion or empyema pus, cardiac failure, endocarditis, meningitis, organ failure. Patients should be reviewed twice daily whether at home or in a nursing home, and admit to hospital if there is either deterioration or an inadequate response to treatment.

Abdo pain adult

http://hacking-medschool.com/abdo-pain-adults/

Acute upper GIB may present with haematemesis, melaena, or  symptoms of hypovolaemia or anaemia. These features can occur as the result of a sudden large bleed or continuous slow bleeding over many days. Mortality increases with the age of the patient, the ammount and briskness of the bleeding  and the coexistence of other medical problems.

Patients should be transferred to hospital urgently in any of the following situations:

• frank haematemesis or unformed melaena stool in the previous 24 hours (evidence from history or rectal examination)
• hypotension or tachycardia
• history of syncope  even if now recovered
• liver disease or  varices
• anticoagulants or  coagulopathy.

Patients managed at home should be referred for endoscopy which should be undertaken within 2-3 days (??).

Endoscopy will help guide management and this may be particularly useful for patients needing aspirin or NSAIDs in the future. If outpatient endoscopy within 72 hours is unlikely, it may be better to arrange for the patient to be admitted.

• The threshold for referral should be lowered if the patient:
  has anaemia
  has co-morbidity (eg ischaemic heart disease, renal impairment)
  is aged over 60 years
  has had a previous gastric ulcer
  cannot be supported or supervised at home.

If there is any evidence of further bleeding while awaiting endoscopy then the patient should be transferred urgently (???) to hospital. Ensure that patients have the information needed to allow them to deal with this eventuality if it occurs.

Gastroenteritis / food poisoning

Presents as acute diarrhoea (3 or more unformed stools per day) plus:
abdominal cramps, nausea, vomiting, fever, bloody stools and faecal urgency.
Symptoms usually resolve spontaneously over 1-2 days and antimicrobial therapy is rarely necessary.
Food poisoning, whether suspected or confirmed, is a notifiable disease even if the organism is not known.

Management
For patients with typical acute food poisoning:
examine the abdomen to exclude intra-abdominal pathology
advise the patient about fluid and electrolyte replacement; approximately 2 litres of oral rehydration solution such as Dioralyte or Rehidrat should be
taken in the first 24 hours and 200mL per loose stool thereafter
anti-emetics may help if the patient is vomiting severely
antimotility drugs such as codeine phosphate and loperamide hydrochloride may make symptoms easier to cope with.

If the patient is a food handler or a health-care worker, notify the Consultant in Communicable Disease Control (CCDC). Advise such patients not to work until they have been reviewed by occupational health or public health. If you suspect an outbreak of gastroenteritis or need advice on control contact the CCDC.

Stool microscopy/culture is necessary when:
the patient is febrile
stools contain blood
the patient has recently returned from a country where infections are likely
the patient is taking, or has recently taken, a broad spectrum antibiotic (request Clostridium difficile toxin detection)
the patient is a food handler whose occupation is such that they might spread the condition.

Referral advice
Patients should be transferred to hospital urgently (???) if they:
are severely dehydrated
have bloody diarrhoea
have severe constitutional upset.

If the patient is dehydrated start an intravenous infusion of sodium chloride 0.9% while awaiting transfer. Others may need to be referred depending on the results of stool microscopy.

The threshold for referral should be lowered if the patient is at increased risk from complications of infection; for example, older people, the immunocompromised, patients with renal failure or inflammatory bowel disease. Those taking immunosuppressants or systemic corticosteroids are also at increased risk.

Bacterial Gastroenteritis in Adults

Organisms: Campylobacter jejuni, Salmonella spp

Less common: E.coli 0157, Shigella. spp (for both usually history of bloody diarrhoea)

Management
Send sample in all cases of bloody diarrhoea, protacted symptoms or infection following travel, outbreadks in community settings, those with co-morbid factors

Oral rehydration therapy
If bloody diarrhoea, dysenteric symptoms (i.e. bloody diarrhoea with abdominal pain/tenderness and fever), high risk cases with hypo-chlorhydria, IBD, immunosuppressed or protracted diarrhoea refer or discuss with Infectious Diseases Specialist. Always consider haemolytic uraemic syndrome in patient with “bloody diarrhoea”

Avoid anti-motility drugs or opiates
Antibiotic not usually indicated
Use of antibiotics in E.coli 0157 may precipitate haemolytic uraemic syndrome

Diarrhoea in Returning Traveller
Organisms: Consider above but also giardiasis, amoebiasis or cryptosporidiosis.

Management
Stool for microscopy & culture. Discuss with microbiology laboratory
Oral rehydration therapy

Discuss with Infectious Diseases Specialist, especially if there is blood in stool, for advice on empiric ciprofloxacin 500mg twice daily or metronidazole 800mg three times daily for 5 days.

Diabetic emergencies

Hypoglycaemia

DKA
HONK

Lactic Acidosis
Rarely, metformin may cause lactic acidosis, especially in patients with renal impairment or with conditions that cause poor tissue perfusion such as cardiac failure, hypoxia, sepsis, hepatic impairment or dehydration. The most obvious clinical feature is hyperventilation. If lactic acidosis is suspected the patient should be transferred to hospital immediately.

Diabetes illness rules

hacking-medschool/diabetes-illness-rules-2

Hypogycaemia

HYPOGLYCAEMIA (blood glucose below around 4.0mmol/L)
In patients on insulin, hypoglycaemic symptoms usually develop rapidly; in those on an oral hypoglycaemic, onset is often insidious and may even be intermittent, sometimes presenting as a personality change, focal neurological signs, hunger or dizzy spells. Remember that some patients without diabetes may take insulin or other hypoglycaemic drugs as a form of self-abuse. Severe illness in children may also cause hypoglycaemia.

Clinical features
Features of hypoglycaemia may include sweating, tachycardia, tremor, visual disturbance, focal neurological signs, changes in mental state (confusion, uncooperative behaviour), headache, convulsions, and ultimately coma and death.

Initial management
Blood glucose concentrations at which symptoms develop vary. In principle, anyone with a level below around 4.0mmol/L should be considered at risk. If possible, check blood glucose by finger, or ear lobe, prick test (remember to wash and dry the prick site before taking the blood). If you are unable to measure blood glucose but you suspect severe hypoglycaemia then give glucose anyway it won’t harm the patient. If hypoglycaemia is confirmed or suspected, treatment depends on whether or not the patient is co-operative.

Oral glucose For mild to moderate hypoglycaemia where the patient is conscious and cooperative give 10-20g of a rapidly absorbed carbohydrate.

This should raise blood glucose levels within 5-15 minutes. Give more glucose after 10-15 minutes if necessary.

Approx 10g of glucose is available from: Sugar 2 teaspoons or 3 sugar lumps Hypostop gel Glucose 9.2g/23g oral ampoule

Milk 200 mL Lucozade/sparkling glucose drinks 50-55mL Coca-Cola 90mL Ribena original 15mL (dilute with water)

As symptoms improve or normoglycaemia is restored, additional long-acting carbohydrate should be given orally to maintain blood glucose levels unless a snack or meal is imminent.

Parenteral glucose For severe hypoglycaemia, where the patient is unable to take food or fluids orally and is semi-conscious or comatose, give IM glucagon, which takes around 10 minutes to work.

under 8 years old (body weight less than 25kg) 500microgra ms

over 8 years old (body weight more than 25kg) 1mg Glucagon

Adult 1mg IM, IV or SC

If the patient has not responded within 10 minutes of giving glucagon, call an ambulance (????) and, if you carry it, consider giving IV glucose.

Glucose must be given IV. Recovery usually occurs within 5 minutes of injection. Repeat the dose after 5 minutes if there is no response. High

concentration glucose is very irritant (especially if extravasation occurs) and should be given into a large vein through a large-gauge needle. If possible,

flush with sodium chloride 0.9% after administration.

Strength Dose Route

Child 10%1 2-5mL/kg IV

20% 50mL IV

Glucose

Adult 50% 25mL IV

1To make 50mL of 10% glucose Using a 50mL syringe with a large bore

needle draw up 10mL of 50% glucose and make it up to 50mL with water for

injection, then mix before injecting into a large vein.

If there is no recovery, or there are residual symptoms despite raising blood

glucose to normal, the patient should be transferred to hospital immediately

Referral advice
Patients with hypoglycaemia should be transferred to hospital immediately if:
they do not respond to glucagon/glucose
there is residual neurological deficit.
The threshold for referral should be lowered if the patient:
is unable to manage alone
raises additional clinical concerns
is a child or elderly
is taking an oral hypoglycaemic (as the effects may persist for many hours).

Subsequent management
As soon as feasible start oral glucose and complex long-acting carbohydrates and monitor blood glucose levels. If a long-acting hypoglycaemic agent has been taken, hypoglycaemia may recur. To avoid a subsequent ‘hypo’ the patient should continue having a high carbohydrate intake for 24 hours.
Blood glucose control following hypoglycaemia may be poor for a few days.
Advise the patient/carer to discuss the episode with their diabetes team. The GP, or diabetes clinic responsible for the long-term management of the patient, should try to establish why hypoglycaemia occurred in order to develop strategies to prevent it happening again. Hypoglycaemia can often be anticipated or promptly reversed by good patient/carer education.

Diabetic Ketoacidosis DKA

Blood glucose usually > 25
patients with type 1 diabetes
often precipitated by minor illnesses eg UTI ,GE or URTI.

Rate of development of ketoacidosis varies. If it is the presenting feature in a new patient with diabetes it may have taken days to become established. In an otherwise well-controlled patient with diabetes, some symptoms may begin within a few hours of glucose levels rising.

Clinical Features
polydipsia and polyuria, malaise and weakness, nausea and vomiting, abdominal pain, confusion, disturbance of consciousness and ultimately coma and death. Initially the symptoms may be masked by those of the precipitating illness. Typical findings on physical examination include:
tachycardia, postural hypotension, evidence of dehydration, fast, laboured breathing (Kussmaul breathing), and a smell of acetone on the breath

Diagnosis
clinical history
physical examination
the presence of glucose and ketones in the urine
a high blood glucose level from finger or ear lobe prick test.

Referral / Disposal
Transferred to hospital immediately . If transfer is delayed it may be appropriate to start IV fluid replacement (eg with sodium chloride 0.9%) and to give insulin, but this should only be done after discussion with the hospital medical or paediatric team.

• DKA PANICS
  Potassium
  Aspirate stomacch / ng tube
  Normal saline
  Insulin infusion
  Cultures Catheterise MSU blood cultures
  Subcut heparin

HONK

Hyperglycaemic hyperosmolar non-ketotic coma.

Characterised by profound dehydration,  hyperglycaemia  and coma with absent or low ketones. High Mortality
Elderly (or middle aged) patients with NIDDM often precipitated by have an underlying illness such as infection, myocardial
infarction. The clinical features may develop over days or weeks and may be the first presentation of diabetes. Ultimately, the patient may present with focal neurological signs, seizures or coma. The risk of coma is increased in patients taking drugs such as phenytoin, propranolol, cimetidine, thiazide or loop diuretics, corticosteroids or chlorpromazine.
Patients should be transferred to hospital immediately for rehydration, correction of a grossly disordered metabolic state and treatment of any precipitating cause. If transfer is delayed it may be appropriate to start IV fluid replacement (eg with sodium chloride 0.9%) and to give insulin, but this should only be done after discussion with the hospital medical or paediatric team. Don’t delay treatment of a life-threatening precipitating cause if it can be identified.

Ischaemic limb

Early detection and treatment of acute limb ischaemia NPSA

http://hacking-medschool.com/arterial-thrombus/

Cauda equina syndrome

http://caudaequinasyndrome.co.uk/medicalprofessionals.html

http://www.youtube.com/watch?v=Zl_EkRD6J28&feature=related

http://www.youtube.com/watch?v=M1VN5-R3PSU

Sickle cell crisis

Sickle cell disease covers a group of disorders which include sickle cell anaemia (homozygous haemoglobin SS), sickle cell haemoglobin C disease and sickle cell beta thalassaemia.
The responsible genes most commonly occur in people of African/Caribbean, African, Mediterranean, Middle Eastern or Asian origin.
All patients with sickle cell disease will have chronic haemolytic anaemia and intermittent pain crises and are at risk of organ damage. In the majority of episodes, pain is the predominant symptom (pain crisis), but there are other types of episodes which may be life threatening and are vital to recognise.

Presenting features
pyrexia
anaemia (eg sequestration)
dyspnoea and pain (eg acute chest syndrome)
abdominal pain (eg mesenteric syndrome)
confusion (eg cerebral sickling)
paralysis (eg stroke)
loss of vision (eg hyphema, retinal detachment)
fitting
prolonged painful erection (priapism).
pyrexia

Sickle cell disease should be considered in any patient from any of the susceptible groups presenting with signs and symptoms compatible with a crisis. Most patients will have had previous crises and will recognise the symptoms. The patient’s own assessment is usually a good indication of severity. If a crisis develops, most patients will be helped by the administration of fluids and oxygen.

Any infection needs to be treated promptly and effectively because of the risk of precipitating acute painful crisis or acute chest syndrome. All patients with sickle cell disease have absent or poor splenic function and so are prone to sepsis in particular caused by Pneumococcus, Haemophilus influenzae or Salmonella, which can be fatal

Patients should be transferred urgently to hospital if they: have iron overload treated with desferrioxamine and they develop fever, abdominal pain, diarrhoea or vomiting and so are at risk of having Yersinia infection.

are taking hydroxyurea and have unexplained fever or bleeding and so need to have their neutrophil and platelet count checked

have fever, rigors, headache, profuse diarrhoea or any form of febrile collapse.

Before transfer, give a stat dose of a broad-spectrum antibiotic such as cefotaxime 1g IV or ampicillin 500mg IV

If the patient is febrile then a broad-spectrum antibiotic such as amoxicillin or a cephalosporin should be started (unlesscontraindicated). Amoxicillin Child up to 10years 125mg 8 hourly Adult 250mg 8 hourly

Severe pain Diamorphine (stat dose prior to admission)
Child 12-18 years 5mg SC/IM
Adult 5-10mg If you do give diamorphine remember to tell the ambulance crew or the admitting team.

Dihydrocodeine (oral)
Child 1-4 years 500micrograms/kg every 4-6 hours
4-12 years 0.5-1mg/kg every 4-6hours
Adult 30mg every 4-6 hours

Moderate pain
Diclofenac (oral/rectal)
Child 6 months-12 years 0.3 -1mg/kg every 8 hours
Adult 75-150mg daily (maximum 150mg in 24 hours)

Mild pain
Paracetamol (oral)
Child 1-3 months 30-60mg 8 hourly maximum dose in 24 hours: <3months 60mg/kg
3-12 months 60-120mg 4-6hourly >3months-12 years 90mg/kg
1-5 years 120-250mg 46 hourly
6-12 years 250-500mg 4-6 hourly
Adult 0.5-1g 4-6 hourly adult-4

Most people with sickle cell disease will have a painful episode affecting bones or joints at least once a month. Usually symptoms are mild and can be managed in the community; more rarely the pain is agonising and relentless and requires admission to hospital. The pain may be localised to a single long bone, typically around the joint, or may develop in multiple sites. It can present symmetrically, affecting both arms and legs, or involve the central skeleton, particularly the spine once the patient has reached adolescence. In a child, the first episode of pain may be the first sign of the disease; often it presents as pain and swelling of the backs of the hands or feet (hand foot syndrome/dactylitis).

All patients with pain affecting the chest wall should be transferred to hospital immediately.
When a patient with sickle cell disease seeks analgesia for severe pain, urgent transfer to hospital is usually needed.

Fluids
It is important for patients to maintain a high fluid intake. Adults should drink > three litres of fluid daily and children 80- 100mL/kg daily.

Management
Pain relief
Fluid intake

ACUTE ANAEMIA
During infection, or other stress such as generalised illness or pregnancy, the haemoglobin can rapidly fall due to trapping (sequestration) of the red cells in the spleen or liver or because red cell production suddenly stops (‘aplastic crisis’). The symptoms include pallor, tiredness, pain (sometimes), dyspnoea and (preterminally) congestive cardiac failure. In sequestration the spleen or liver increases in size and this can cause severe pain. Many parents/carers will have been taught how to assess their child’s spleen; if they report a rapidincrease in spleen size this should be taken seriously.

Patients should be transferred to hospital immediatelyso that a blood transfusion can be given quickly and the precipitating cause identified andtreated.

ACUTE DYSPNOEA
Dyspnoea is either caused by acute anaemia, or may be part of the acute chest syndrome which is precipitated by chest infection, thromboembolic complications (including fat embolus) or sickling in the blood vessels of the lungs. Acute chest syndrome is the most common cause of death in adults and early recognition is essential; sickle pain affecting the chest wall or thoracic spine is often the first sign.

Early recognition is important. Any patient with pain in the chest wall, dyspnoea or other forms of respiratory distress should be transferred to hospital immediately. Exchange transfusion may be required, as may assisted ventilation.

ACUTE ABDOMINAL PAIN
The pain may be caused by sickling in the mesenteric circulation and this is sometimes accompanied by ‘paralytic ileus’ leading to a swollen, silent abdomen. The crisis can mimic an intra-abdominal emergency such as appendicitis with pain in a girdle around the abdomen, sometimes accompanied by diffuse tenderness. Other causes of abdominal pain include acute distention of the spleen or liver, splenic infarction (often associated with pleuritic pain), ureteric colic (renal papillary necrosis), or cholecystitis (secondary to pigmented gallstones). Remember that patients with sickle cell disease are not spared appendicitis or other intra-abdominal events.

Any patient with splenic sequestration should be transferred to hospital immediately.

Patients with other causes of acute abdominal pain should be transferred to hospital urgently

ACUTE NEUROLOGICAL DISTURBANCE
Cerebral sickling can manifest as strokes, transient ischaemic attacks, fits, coma, bizarre behaviour or psychosis. Sickling should be excluded in any person at risk of the disease presenting with such features.
Cerebral sickling is a medical emergency requiring rehydration, (exchange) transfusion and anticonvulsants. These patients should be transferred to hospital immediately

OTHER PRESENTATIONS
Patients with sudden visual loss, which may be caused by bleeding, retinal detachment or stroke, should be transferred to hospital urgently.

Men presenting with a prolonged erection, and in whom it seems likely that the priapism might last longer than 4 hours, should be transferred urgently to hospital.

GENERAL ADVICE
All patients with sickle cell disease should be immunised with pneumococcal vaccine, Haemophilus influenzae type b (Hib) vaccine, meningococcal vaccine and an annual influenza vaccine. Hib, Prevenar and meningococcal vaccinations are given in the primary course of vaccinating at 2, 3 and 4 months; pneumovax is given at 2 years.

In addition, infants and children should, unless contraindicated, take phenoxymethylpenicillin (penicillin V) daily (under 5 years 125mg every 12 hours, 6-12 years 250mg every 12 hours) or a broad-spectrum alternative such as amoxicillin as prophylaxis.
www.sicklecellsociety.org.

A septicaemic patient may present with shock, severe hypotension and tachycardia.
Other features of septicaemia include fever, rigors and mental confusion.
In the early stages, clinical features vary, particularly in the very young or old.
A petechial (non-blanching) rash indicates disseminated intravascular coagulation and/or meningococcal sepsis; acute renal failure may also develop.
Prompt recognition of septicaemia and immediate treatment is essential. Septicaemia may also present as part of the clinical picture of other infections, for example meningitis, pneumonia and urinary tract infection.
Remember that meningococcal septicaemia is a notifiable disease

Referral advice
Patients with suspected septicaemia should be transferred to hospital immediately.
Whilst waiting for the ambulance give a stat dose of benzylpenicillin or cefotaxime.

250textbooks/fever-in-returning-travellers-2

All febrile patients should be asked if they have travelled abroad otherwise diagnoses of the tropical causes of fever are likely to be missed with potential serious consequences. If a traveller has been exposed to malaria this remains the most likely diagnosis.

The febrile traveller may have a non-tropical infection such as respiratory or enteric virus infection, pneumonia or UTI.

Fever in returning travellers Medscape

A knowledge of incubation periods, global distribution and mode of transmission of disease is important to consider in the differential diagnosis. There should be consideration of referral of patients to an Infectious Diseases Unit or of taking advice from a Consultant in infectious diseases.

Discussion about interpretation of investigations and advice may be obtained from microbiologists (and haematologists for malaria).
Medical history should include
detailed travel history
dates
countries visited
type of accommodation
activities, exposure to water
insect bites
contact history
sexual history
pre-exposure immunisations
malarial prophyllaxis used

Examination should take particular note of jaundice, haemorrhage, skin rashes, insect bites, localising signs of infection, shock.
Initial investigations should include
full blood count including differential white cell count and platelet count
blood cultures
liver function tests
urinalysis
chest x-ray (if indicated)
serology serum save for subsequent testing.
If VHF is suspected then investigations may need to be done in a high security infectious disease laboratory.

Malaria
Malaria should be considered in any febrile patient without focal features, or an obvious alternative explanation, and who has returned in the last 12 months from a country where malaria is endemic. Infection can occur despite the patient taking antimalarial prophylaxis.
In most patients, malaria presents initially as a flu-like illness. However, in some it presents as vomiting, diarrhoea and jaundice. Once established, patients characteristically have periodic high fever with rigors, between which they feel relatively well. A sample of blood (EDTA) for full blood count and films (X3) for malarial parasites should be obtained urgently. The parasite yield is greatest if the sample is taken when the patient is at their peak temperature during a febrile episode. Remember that malaria is a notifiable disease.

Referral advice
Patients you suspect of having malaria, and who are known to be immunocompromised should be transferred to hospital immediately
Patients should be transferred to hospital urgently if they:? are seriously ill or vomiting have been newly diagnosed and need specialist opinion

Falciparum malaria is a life-threatening disease in a non-immune individual.
There are no dormant forms of falciparum malaria so it is highly unlikely to develop infection more than 12 weeks after the last potential exposure.
It is advisable that patients with falciparum malaria are admitted to hospital for treatment and monitoring and preferably referred to an infectious diseases unit or, if this is not practical, advice on treatment from an infectious diseases unit should be sought. This is particularly important in cases with parasitaemia >2% in whom complications are more likely.
Treatment of benign malaria (vivax, ovale) may not warrant hospital admission. The recommended treatment is described in the BNF. Primaquine should be given to prevent relapse provided the patient is not G6PD deficient.
If the type of malaria is not clear then falciparum should be presumed and treated appropriately.

Viral haemorrhagic fever

Some cases of viral haemorrhagic fever are caused by viruses (Lassa, Ebola, Marburg, Congo-Crimean Haemorrhagic Fever) which may be transmitted between humans and special consideration is needed to ensure that cross infection is avoided. These diseases are rarely imported into the UK. .
Febrile patients who have returned from potentially infected areas within 21 days should be considered for possible risk of VHF.
The risk depends on the country visited and the activities undertaken there. It may be difficult to exclude early VHF (before the haemorrhagic manifestations) on clinical grounds alone but is often possible to do so with epidemiological knowledge.

Potentially infected areas
Lassa West Africa especially Nigeria, Sierra Leone.
Ebola Republic of Congo (Zaire), West Africa, Sudan.
Marburg Sub-Saharan Africa.
Congo-Crimean HF Africa, Russia, Pakistani India, Afghanistan, Middle East, Eastern Europe.

Most patients suspected to have VHF will have some other infection and it is particularly important to look for malaria as a matter of urgency.
Patients suspected of having VHF should be discussed with a Consultant in Infectious Diseases and a Consultant in Communicable Disease Control (CCDC). In such cases of VHF, it is important to notify any laboratory handling specimens to discuss their appropriate handling.

Meningococcal meningitis (emergencies)

• Meningococcal chart
• 250textbooks/meningitis-infections
• meningitis trust Resources for Health Professionals
• SIGN qrg 102 Meningococcal disease May 08
• Bacterial meningitis and meningococcal septicaemia NICE 2010 CG102

Meningococcal Treatment Regimen
If meningococcal disease is suspected general practitioners are advised to give a single injection of benzylpenicillin by intramuscular or intravenous injection before transporting the patient urgently to hospital.
Antibiotic Doses in Meningitis & Septicaemia – see above

Meningococcal Prophylaxis
The decision to initiate contact tracing in respect of meningococcal infection will be made by the Specialist Public Health Service of Tayside NHS Board in conjunction with relevant clinicians. Responsibility for contract tracing, and organising the administration of chemoprophylaxis also lies with the Board’s Specialist Public Health Service. Chemoprophylaxis will usually be prescribed either by hospital ward or primary care medical staff. It should be given as soon as possible (ideally within 24 hours) after diagnosis of index case.
Ensure that the index case receives a course of oral rifampicin prior to discharge unless treated with ceftriaxone.
Establish a list of close contacts:
Household contacts including those sharing an overnight stay with index case in 7 days prior to illness onset.
Intimate lip kissing in 7 days prior to illness onset (social lip kissing is now not regarded as significant contact).
Health care workers giving mouth to mouth resuscitation to index case unless treatment has already eradicated carriage in index case.
Give chemoprophylaxis as outlined below including pregnant contacts. Caution in anyone with severe hepatic impairment, jaundice or on other medicines such as anticoagulants, antiepileptics, contraceptives (see below). The CPHM can advise.

Adults and those over 12 years Rifampicin 600mg orally, twice daily for 2 days
1-12 years Rifampicin 10mg/kg* orally, twice daily for 2 days
<1 year Rifampicin 5mg/kg* orally, twice daily for 2 days
*Round up to nearest convenient dose unit (capsules and mixture available)

NB. Patients taking rifampicin must be advised that body secretions (urine, saliva, sweat) may be discoloured yellow/orange. Soft contact lenses should not be worn for up to 24 hours following the 2 day course since they may be irreversibly stained.

NB. In pregnancy or when breastfeeding, mothers should be offered chemoprophylaxis with rifampicin (as above) or ceftriaxone (250mg single dose IM).

NB. Ciprofloxacin is also known to clear the organism from the throat. The adult dose is a one-off dose of 500mg orally. Avoid in pregnancy.
NB. Neither ciprofloxacin or ceftriaxone are licensed for chemoprophylaxis.

Ref: Health Protection Agency Meningococcus Forum. Guidance for Public Health Management of Meningococcal Disease in the UK 2006
The decision to initiate contact tracing in respect of Hib infection will be made by the Specialist Public Health Service of Tayside NHS Board in conjunction with relevant clinicians. Responsibility for contact tracing, and organising the administration of chemoprophylaxis also lies with the Board’s Specialist Public Health Service. Chemoprophylaxis will usually be prescribed either by hospital ward or primary care medical staff.
Hib causes meningitis, septicaemia, epiglottitis and a range of other invasive diseases, mainly in pre-school children. Rarely, older children or even adults can be affected.
The following groups are recommended to receive chemoprophylaxis:
All household contacts irrespective of age and Hib immunisation history, where there is a case of Hib disease in either a child or an adult in a household where there are one or more children under the age of 4 years who are unvaccinated or incompletely vaccinated. Chemoprophylaxis for household contact is not indicated if all contacts under the age of 4 years have been fully vaccinated against Hib disease.
All pre-school or school class or group contacts (including teachers) if there has been a case of invasive Hib infection in a child over the previous 120 days which can be related to the present index case.
All index cases before discharge from hospital.

Contacts should be advised of the side-effects and contraindications of rifampicin therapy. These are set out in the meningococcal guidelines above.

‘Red flag’ symptoms for meningitis
Confusion, leg pain, photophobia, rash and neck pain or stiffness
British Journal of General Practice – 345 children with meningitis vs 407 with minor febrile infections.
Of the ‘classic’ meningitis symptoms, photophobia and neck pain/stiffness were highly specific indicators of the disease, but headache was not helpful for distinguishing the condition from other ailments.
Leg pain, which has previously been proposed as a red flag for meningitis was highly predictive of the disease, but other possible red flags – pale colour and cold hands or feet – were not.

Meningococcal chart

Bacterial meningitis and meningococcal septicaemia NICE 2010 CG102

HIV emergencies

Those at greatest risk of infection are:
men who have sex with men
individuals from areas of high prevalence, particularly sub-Saharan Africa
injecting drug users
people with haemophilia
sexual partners and children of the above.

Referral advice
Individuals who might have been exposed to the virus through needlestick injury, unprotected vaginal or anal sex, or sexual assault should be referred urgently to hospital (???) for advice and, if appropriate, postexposure prophylaxis ideally started within one hour of exposurePatients not known to be HIV positive may present with symptoms of an acute opportunistic infection. Patients at risk of HIV infection (see list above) should be referred urgently (???) for diagnosis if they present withsymptoms of any of the following:
Pneumocystis carinii pneumonia: pneumonia-like symptoms, which are insidious in onset, eg breathlessness, dry cough, fever, weight loss and/or night sweats
Cerebral toxoplasmosis: may present with focal neurological signs or non-specific symptoms of headache, nausea and/or vomiting and and acute confusional stateCryptococcal meningitis: typically presents with non-specific features of fever and headache but rarely signs of meningism.If you suspect the patient has seroconversion illness (typically presenting with sore throat, oral or genital mucosal ulceration, rash, fever, lymphadenopathy) they should be referred to hospital to be seen within 24 hours.Testing HIV status
For diagnosis of HIV status and/or advice on HIV, patients may be referred to the local HIV/GUM or infectious diseases clinic. Sometimes HIV status can be tested in the community.
If the patient is not known to be HIV positive, it may be worthwhile suggesting they have an HIV test if they are at risk of infection (see above) and have any of the following:
an unexplained low platelet count
a diagnosis of TB
any symptoms or signs suggestive of immune deficiency, eg unexplained
oral candidiasis, oral hairy leukoplakia, shingles, lymphadenopathy,
diarrhoea, weight loss.Management in the community of patients with known HIV
Patients known to have HIV infection may present with symptoms such as malaise, skin rashes, candidiasis (oral or genital), respiratory tract infection or diarrhoea, all of which can often be treated symptomatically in the same way as patients without HIV. Remind the patient to report these conditions at their next HIV clinic appointment.Rarely, these patients may present with a potentially life-threatening reaction to a drug used to treat HIV. If the patient is taking Abacavir, for instance, they may present with a flu-like illness, with or without a rash (usually within 6 weeks of commencing the drug). It is vital that patients are reminded not to
stop taking Abacavir until they have been reviewed (urgently) by an HIV specialist. Contact an HIV treatment centre for advice.

Urology emergencies

ABC of Urology: Urological Emergencies in General Practice Dawson and Whitfield BMJ 1996

UCLA Urology

Acute retention

Most commonly a complication of benign prostatic hypertrophy in men – other causes include prostate carcinoma and prostatitis. Causes in both men and women include urinary tract infection, neurological disorders, urethral stricture and postoperative pain or immobility.

Clinical features
Typically the patient complains of severe suprapubic pain and an inability to pass urine and/or to satisfactorily empty the bladder, although pain from a chronically distended bladder may be minimal. The bladder will be palpable and usually tender when compressed.

Management
The patient should be catheterised to reduce pain and avoid the risk of causing, or exacerbating, renal failure. Prompt catheterisation is essential.
This can be done in the community although it may prove difficult in a patient with a large prostate or urethral stricture. Syncope can follow rapid bladder decompression and a patient with a chronically distended bladder may bleed.

Referral advice
A patient with acute urinary retention should be transferred to hospital urgently (???), either to introduce a catheter de novo, or to introduce one when an attempt to catheterise in the community has failed.
If catheterisation in the community is successful, the patient should be referred for an outpatient appointment to be seen within two weeks with a view to reviewing management and the possibility of either a Trial Without Catheter (TWOC) or in men, possible prostatectomy

Renal Colic

Diclofenac intramuscular injection 75mg/3ml stat then repeat 30mins if necessary or by rectal suppositories 100mg

Papaverine iv may provide additional relief ^[1]

Clinical features
Typically, the patient has severe pain in the loin radiating down to the groin.
Common accompanying symptoms include nausea, chills, fever, haematuria and frequency of urination.
Abdominal examination should be performed to exclude other conditions, particularly acute appendicitis or, in older patients or those at particular risk, a leaking aortic aneurysm.

Management
Initial management primarily aims at controlling pain and maintaining a good urine flow. In most patients these can be attempted at home but this may depend on the patient’s social circumstances. In those managed at home:
Ensure the patient has a high fluid intake.
Arrange to review the patient to assess the need for referral.

Referral advice
Patients with renal (ureteric) colic should be transferred to hospital urgently if they have any of the following:
persistent pain despite analgesia
high grade fever and/or rigors
other clinical evidence of systemic infection
low urinary output
a non-functioning kidney
altered renal function
no reliable social support.

Patients managed in the community should be referred for investigation (eg for a CT scan, intravenous urogram, or ultrasound) ideally within 24 hours, to exclude or treat complete obstruction, to manage infection or other complications.

Renal colic. This should be referred to hospital for investigations and management. An infected obstructed kidney presents with fever, rigors and loin pain. This is a life-threatening condition and should be referred immediately, as the kidney will require drainage with stenting or a nephrostomy.

In the acute phase
Microscopic haematuria is a positive predictor of stone disease, but may be absent.
Exclusion of infection is important (nitrites or leucocytes on dipstick).
Unenhanced helical CT is the best radiological test.

Most ureteric calculi <5 mm will pass through within 4 weeks; if they do not pass within 4 weeks intervention is indicated to prevent complications such as ureteral strictures and impaired renal function.

Urgent intervention is Indicated if:
infection with obstruction
intractable pain, vomiting or both
impending acute renal failure
obstruction in a solitary or transplanted kidney
bilateral obstruction

For follow-up
Plain abdo X-rays or CT can be used to monitor disease activity.
Patients with risk factors should have a metabolic work-up.

Management
o increase fluid intake to produce a urine output of at least 2litres a day
o decrease animal protein intake
o restrict salt and oxalate intake
o dietary restriction of calcium intake is not recommended

Shock wave lithotripsy can treat 80-85% of simple stones.
Complex and staghorn calculi are best treated by percutaneous nephrolithotomy.
Ureteroscopy is useful when other treatments fail or when other factors such as pregnancy, coagulopathy or morbid obesity prevent lithotripsy.

• International Kidney Stone Institute 
• American Urological Association
• Edinburgh Royal Infirmary Renal Unit Information about Kidney Stones
• http://www.kidney.niddk.nih.gov

Haematuria (emergencies)

http://hacking-medschool.com/nvh

Referral advice
Patients with macroscopic (frank) haematuria should be transferred to hospital urgently if they have:
clot retention
bleeding following trauma
unexpectedly heavy bleeding following urinary tract surgery.
Patients with unexplained painless haematuria need investigation within 2 weeks to exclude underlying malignancy.

If the patient, or their relative(s) are excessively anxious, or the bleeding gives rise to clinical symptoms or laboratory confirmed anaemia, the patient should be seen by the next working day if possible.

http://youtu.be/B-q7G2dxa1M

Paraphimosis

Paraphimosis Medscape

Access emergency medicine.com Magraw Hill

Retracted foreskin forms constricting band around the corona causing increasing oedema and swelling so that foreskin cannot be easily reduced
More common in catheterised patients.
Always ensure foreskin is replaced following catheterisation.
Patient presents with a painful swollen glans and foreskin.
Presentation may be delayed due to embarrassment.
Apply ice and topical anaesthesia then attempt to reduce.
If the attempt at reduction fails, the patient should be transferred urgently to hospital.

Priapism

Persistent, painful, erection > 2 or 3 hours. If it is prolonged (over four hours) the patient is at risk of developing permanent impotence. Priapism can be idiopathic, although more commonly it occurs as
the result of an unwanted effect of drugs used to treat erectile dysfunction or, sometimes drugs (eg phenothiazines) taken in overdose. Other causes of priapism include sickle cell disease or sickle cell trait malignant infiltration or spinal cord injury.Referral advice

A patient presenting with an erection which has already lasted for more than 4 hours should be transferred to hospital immediately. Patients presenting at 2-3 hours in whom it seems likely that the erection might last longer than 4 hours should be transferred urgently to hospital.Men undergoing treatment for erectile dysfunction will usually be warned of the risk of developing priapism and probably advised to try simple measures first such as walking or cold bathing.

Torsion and Acute Scrotal Pain

Acute scrotal pain should, until proved otherwise, be regarded as being caused by torsion of the testicle. Viability of the testis is directly related to the time between the onset of symptoms and surgical intervention. If torsion lasts for longer than 6 hours then ischaemia or infarction of the testicle is common.
The differential diagnosis includes: strangulated hernia, trauma, torsion of a testicular appendage and acute epididymitis or orchitis (here the pain is associated with fever and urethral discharge).

Clinical features
Torsion can occur at any age, although it is uncommon in those aged over 30 years. Characteristically the pain is of sudden onset, severe and usually felt primarily in the scrotum, but may radiate to the groin or lower abdomen. It is often accompanied by nausea and/or vomiting. Patients may have a history of previous episodes of pain that were transient and resolved spontaneously.

Referral advice
Any patient with scrotal pain due to, or suspected to be due to, torsion of the testes, should be transferred to hospital immediately

Opthalmic Emergencies Sudden Loss Of Vision

Loss of vision may be unilateral or, less commonly, bilateral. Remember that patients who develop homonymous hemianopia may describe it as loss of

vision only in the ipsilateral eye. Patients with bilateral loss of vision may not have noticed any loss of vision in one eye, and present only when vision in

the second eye fails. This is particularly common in age-related macular degeneration.

In general practice, the common causes of unilateral loss of vision include (approximate proportion of these presenting as emergencies shown in brackets):

1. age-related macular degeneration (ARMD; 47%)
2. blindness secondary to vascular occlusion (24%, of which around three quarters are venous)
3. giant cell arteritis (GCA, ‘temporal arteritis’; 18%)
4. retinal detachment (6%)
5. acute angle-closure glaucoma (3%)
6. acute anterior ischaemic optic neuropathy (AION; 3%).

Other causes include demyelinating disease, vitreous haemorrhage (from diabetic retinopathy, venous occlusion or a retinal tear), migraine and stroke.

It can be difficult to recognise the underlying cause and, if in doubt, refer the patient immediately (????).

Assessment
A quick assessment of the vision is useful, checking the patients visual acuity and field affected (include findings in any referral letter). Remember to test each eye separately.

1. If possible, assess acuity using a Snellen chart at 3 metres instead of 6.
Someone who just sees the top letter (6/60) would be recorded as 3/60.

2. If acuity is less than 3/60, check if the patient can count fingers (CF) at a metre, or see hand movements (HM).

3. If they cannot count fingers or see hand movements, check whether they perceive a bright light (perception of light; PL) or not (NPL).

4. Checking the confrontation fields, with hand movements in the 4 quadrants, give an idea of field loss.

1. Age-related MACULAR DEGENERATION (ARMD)
ARMD is very common and in most affected patients causes a gradual fading of reading vision (‘dry’ ARMD). In some, however, it presents acutely because of exudative or haemorrhagic detachment at the macula (‘wet’ ARMD). Patients in whom you suspect the loss of vision to be due to ARMD should be referred, ideally to be seen within 48 hours (??).

2. Vascular occlusion (arterial or venous occlusion, anterior ischaemicoptic neuropathy – AION)
Vascular occlusion is more likely in patients with hypertension, hypercholesterolaemia, arrhythmias and vascular disease generally. Patients with glaucoma or ocular hypertension are prone to vascular occlusion, especially venous ones. Carotid artery disease is also seen in those with arterial occlusion. Venous occlusion often presents with sudden development of blurred vision in one eye, commonly on waking. Often the blurring will affect one quadrant of the visual field. In patients with arterial occlusion caused by small emboli, visual loss can present as blindness in the top (or bottom) half of the field as though a blind were being lowered. In many patients, the loss is mild and transient, as in amaurosis fugax, and useful vision returns.

Referral advice
If there is a sudden loss of vision and vascular occlusion is suspected, the patient should be referred to hospital urgently to be seen within a few hours. In those in whom arterial occlusion is diagnosed, anterior chamber paracentesis may allow some recovery.
If visual loss is transient the patient should be assessed in an outpatient clinic within 2 weeks (??). While awaiting the appointment start the patient on aspirin 75mg daily, unless contraindicated.

3. Giant cell arteritis (GCA, ‘temporal arteritis’)
Prompt treatment of giant cell arteritis can save sight. Most of these patients are aged over 60 years and will also have vague polymyalgic rheumatica-like aches and may complain of temporal tenderness when brushing the hair or jaw pain on chewing. They may be generally unwell, have unexplained neck/shoulder aches, weight loss and anorexia. Remember that blindness associated with GCA can still occur in patients already taking corticosteroid in a low dose.

Referral advice
Prompt treatment with a corticosteroid (given intravenously in a high dose) can prevent blindness in the affected eye and reduce the likelihood of problems in the other eye. Any patient who you suspect has loss of vision due to giant cell arteritis should be referred to an emergency eye unit immediately

4. Retinal detachment
Patients with retinal detachment may present with recent onset of peripheral flashes and floaters due to a posterior vitreous detachment. As the retina detaches a peripheral ‘shadow’ moves inwards towards the central vision. This change may take place over hours or more usually days. Patients with myopia are at particular risk; the greater the myopia, the higher the risk. There is an association between retinal detachment and previous cataract operations. There does not need to be a history of trauma.

Referral advice
Patients with suspected retinal detachment in whom the central vision is still preserved should be referred to hospital immediately. In these patients operative intervention can prevent the macular detaching. Patients with suspected retinal detachment in whom the central vision is not preserved should be referred to hospital urgently.

Patients with recent onset (1-2 weeks) posterior vitreous detachment symptoms should be referred, ideally to be seen within 7 to 10 days.
Referral is less urgent if the patient only has floaters, which have already been present for a few weeks. Here the object is to obtain a definitive diagnosis, which requires a dilated examination of the peripheral retina to exclude a traction retinal hole or detachment. Patients can be assured that the vast majority of those with posterior vitreous detachment do not go on to develop retinal problems.

5. Acute angle-closure glaucoma
This often presents after prodromal symptoms of haloes around lights at night, and may be accompanied by localised browache or headache which can be very painful. Very occasionally, glaucoma can present as a more general upset such as nausea and stomach pains. The eye is usually plum-red and tender, with circumcorneal injection. The cornea itself may be hazy (oedematous) and the pupil fixed and semi-dilated. Loss of vision can be irreversible and occur within hours.

Referral advice
Patients who you suspect have loss of vision due to acute angle-closure glaucoma should be referred immediately to hospital.

Orange Book Advice on the Management of Common Medical Emergencies in Primary Care Kingston PCT Oriana Dwight and Joe Collier Crown Copyright © 2004

Cancer emergencies

• Cancer Emergencies Oncoprof.net
• Oncological Emergencies PUK
• Treatment of Oncologic Emergencies AAFP 2006
• Pediatric Oncologic Emergencies Medscape

Psychiatric Emergencies

http://hacking-medschool.com/psychiatric-emergencies-2/

Patients experiencing a psychiatric emergency can feel overwhelmed and vulnerable and it is important to understand how distressing this can be for the patient and those around them. Most patients with mental health problems pose no physical risk either to themselves or others. However, if the patient does become aggressive or violent the police should be called.

Psychosis
Patients may present with a first episode, or with a history of psychotic illness. Illicit drugs may induce a psychotic episode or worsen an existing illness.

Clinical features
Individual episodes develop over days or weeks. Clinical features will vary:
Presentation Characteristic features
Schizophrenia delusions, hallucinations; patients may complain that their thoughts are being interfered with; their speech may be difficult to follow or understand

Hypomania/mania
elated mood, irritability, impulsive behaviour, over-activity, over-talkativeness, flight of ideas, reduced need for sleep, grandiose delusions, pressured speech

Depressive psychosis
pervasively lowered mood, feelings of depression, sleep and appetite loss, suicidal thoughts and acts, delusions of guilt, agitation or retardation, 2nd person auditory hallucinations

Referral advice
Most patients experiencing a psychotic episode, who have good support at home, can be managed in the community and can be referred to the appropriate community team. Where the patient is sent will depend on local protocols.

However, a patient should be referred urgently if:
they have active plans to harm themselves or others, or their behaviour is disturbed to such an extent that community management is inappropriate (eg the family or carer can no longer cope).

Management
If medication is needed, and the patient has not previously taken a neuroleptic, give a benzodiazepine orally (eg diazepam 5mg or lorazepam 12mg). Otherwise give oral haloperidol 5-10mg plus lorazepam. Do not use parenteral ‘rapid tranquillisation’ drugs in the community.

Orange Book Advice on the Management of Common Medical Emergencies in Primary Care Kingston PCT Oriana Dwight and Joe Collier Crown Copyright © 2004

Drug and alcohol intoxication/withdrawal

Intoxication Drugs and alcohol frequently complicate the presentation of mental health problems. Intoxication with drugs or alcohol is not in itself an indication for a mental health assessment or for admission to hospital. If possible, carry out a mental health assessment once the patient is no longer intoxicated.

Patients with acute mental health problems who you think are a risk to themselves or others (even if under the influence of drugs or alcohol) should be referred to psychiatric services immediately (????). If the problem is solely one of intoxication and behaviour is disturbed then call the police.

Heroin withdrawal A patient presenting with symptoms of heroin (diamorphine) withdrawal should be managed symptomatically with NSAIDs, anti-emetics and/or loperamide. Generally, these patients do not need to be referred urgently but should be offered a routine referral to the community drug team.

Alcohol withdrawal Patients presenting with alcohol abuse problems should be referred to a community alcohol team for detoxification.

Remember that abrupt cessation of alcohol can lead to withdrawal symptoms.

Delirium tremens This should be suspected in any patient with a history of alcohol abuse who presents with confusion, hallucinations and autonomic

instability. If untreated, mortality rate is high. These patients should be referred to the medical team urgently (???) for treatment. The patient should not be managed in a psychiatric ward/unit

Orange Book Advice on the Management of Common Medical Emergencies in Primary Care Kingston PCT Oriana Dwight and Joe Collier Crown Copyright © 2004

Suicidal ideas and plans or acts of self-harm

Suicidal ideas and self-harm commonly occur in patients with mental health problems, and are particularly likely in patients with depression. A detailed history needs to be taken to establish the degree of intent, whether there are active plans and whether there are protective factors.
A patient should be referred immediately to hospital for a medical assessment, if they have attempted suicide and are developing, or, likely to develop, life-threatening features for a psychiatric assessment, if you assess the intent to commit suicide to be serious.

A patient should be referred to hospital urgently for a medical assessment if they have attempted suicide but you do not consider their clinical features to be immediately life threatening. Those who do not need a medical assessment will still need to be referred for an urgent psychiatric assessment.

Orange Book Advice on the Management of Common Medical Emergencies in Primary Care Kingston PCT Oriana Dwight and Joe Collier Crown Copyright © 2004

Acute confusion / delirium

• NICE CG103 Jun 10 Delirium
• Confusional States and Acute Memory Disorders Medscape
• Acute Confusional State PUK
• Hospitalisation Phenomena PUK
• Acute Confusion (Delirium) in the Elderly Luton and Dunstable NHS
• iTunes U Delirium Dementia Rock Valley College

Sudden onset of global psychological impairment, together with impaired consciousness (both often fluctuating)

Causes
infection,
haemorrhage,
head injury,
hypoglycaemia,
epilepsy,
constipation,
ischaemic heart disease,
transient ischaemic attacks or stroke,
metabolic disturbance (hypoglycaemia, electrolyte imbalance)
drug toxicity intoxication and withdrawal

Lithium toxicity

http://hacking-medschool.com/lithium

http://hacking-medschool.com/lithium-2

Symptoms usually occur at a serum-lithium level over 1.5mmol/litre. The patient may present with confusion and ataxia associated with diarrhoea, vomiting, drowsiness, and a coarse tremor.
If symptoms are mild do urgent U&E’s and lithium levels. If levels are high (over 1.2mmol/litre) then the lithium should be stopped and further management discussed with the responsible psychiatrist.
If the patient is unwell and lithium toxicity is suspected, an immediate referral should be made to the medical team for IV hydration.

Iatrogenic psychiatric states

Acute dystonias 
This may present with sudden onset of muscle rigidity, torticollis and, in severe cases, oculogyric crisis. The patient should be given procyclidine 5-10mg IM or IV and then regular oral procyclidine. Further neuroleptic management should be discussed with patient’s psychiatrist(??).

Neuroleptic malignant syndrome (NMS) 
Potentially fatal condition caused by psychotropic drugs (usually antipsychotics).
Patients usually present with sweating/pyrexia, rigidity, confusion and their level of consciousness may fluctuate. Sometimes they have tachycardia and a fluctuating blood pressure. The symptoms may develop rapidly, over 24-72 hours.
In people with learning disability, the syndrome may present as an increase in challenging behaviour.
If NMS is suspected stop the antipsychotic drug and refer the patient immediately (????) to the medical team.

Risk factors/ warnings
males
agitation
dehydration
recent start of neuroleptic drug
IM or high dose, neuroleptic drugs
in whom there has been a recent increase in neuroleptic drug dose with a history of organic brain disease (including learning disability and dementia)

Serotonin Syndrome

Serotonin Syndrome

Serotonin Syndrome Wessex DMIC via NeLM Dec 2011

http://youtu.be/Ii0U7aMGt1g

Diarrhoea, shivering, myoclonus, hyper-reflexia and/or agitation in patient taking (multiple) serotonergics. Treatment usually involves withdrawing the medication and supportive measures. Symptoms usually resolve within 24 hours. In rare, more severe cases, autonomic instability can occur and if this is the case the patient should be referred urgently to the medical team.

<em>Orange Book Advice on the Management of Common Medical Emergencies in Primary Care Kingston PCT Oriana Dwight and Joe Collier Crown Copyright © 2004 </em>

NEJM Mar 2005

Antidepressant withdrawal
All antidepressants can cause withdrawal symptoms on stopping. These symptoms are usually mild and self-limiting but can occasionally be severe, particularly if the drug is stopped abruptly. Of the SSRIs, paroxetine and venlafaxine seem to be associated with a greater frequency of withdrawal reactions. The most commonly experienced reactions include dizziness, numbness and tingling, gastrointestinal disturbances (particularly nausea and vomiting), headache, sweating, anxiety, agitation and sleep disturbances. These usually occur in the first days of discontinuing but may occur after a ‘missed’ dose.

Management If the withdrawal symptoms are mild, reassurance that the symptoms will resolve is usually all that is needed. If the symptoms are severe, restart the antidepressant at the dose that was effective (or consider changing to a drug with a longer half-life,eg fluoxetine) and reduce the dosegradually while monitoring the symptoms.

Benzodiazepine withdrawal

Symptoms
agitation
restlessness
poor concentration
hypersensitivity to light and sound
depression
flu-like symptoms
Rarely, abrupt withdrawal can precipitate fits or psychosis.

Management
If the patient has had a fit, refer them to the emergency department immediately.
If managing in primary care, restart benzodiazepines, changing to diazepam, which has a longer half-life, and withdraw it gradually.
If the case is complicated refer the patient to a community drug team.

Neuroleptic Problems

(1) Dystonic reactions: may occur early and after small dose of neuroleptic (and stemetil) (occ fatal).
Treatment im or iv anticholinergics (procyclidine) gives rapid relief.

(2) Akathisia: motor restlessness; inability to sit s ill, very distressing. Treatment some response to anticholinergic, consider reduction in dose of neuroleptics.

(3)Malignant neuroleptic syndrome: muscle rigidity; hyperpyrexia . Treatment admit to medical ward.

G-Lynch

ALCOHOL PROBLEMS
(1) Simple drunkeness is not a psychiatric problem.
(2) DTs is a medical problem with a definite mortality.
(3) Assessment of mental state is unreliable in drunkeness if apparently suicidal or depressed, give him some time, a sympathetic interview and arrange for a psychiatric interview when sober.
(4) Become aware of the range of services available to alcoholics in your local area.
(5) Beware suicide in the socially isolated, older chronic alcoholic.

ACUTE ANXIETY
Patient is usually terrified that they are going to die.
Treatment

(1) Simple, calm explanation of the nature of anxiety reassure that patient is not going to die, go mad, have an MI or CYA.
(2) Breathing exercises.
(3) Arrange for psychiatric evaluation.
(4) ? Drugs perhaps a short course of benzodiazepines or neuroleptics.

ACTUAL OR POTENTIAL VIOLENCE
(1) Arrange for adequate but unobtrusive help to be readily available.
(2) Interview in a quiet place; if in a room, onsider leaving the door open.
(3) Keep arms length away; do not attempt physical examination unless consent explicitly given.
(4) Speak quietly and in a finn distinct rna er.
(5) Observe for behavioural cues posture, speech, motor activity, startle response.
Think is there any evidence of psychiatric illness? Otherwise violence is a police matter.

Conditions associated with violence
1) Alcohol and drug intoxication
2) DTs
3) Delerium
4) Acute psychoses
5) Post ictal state.

Treat the cause
If restraint really necessary, at least four peopIe and use the patient’s own clothing and restrain limbs.

Psychogeriatric Emergencies

(1) Confusion: requires careful medical evaluation, should not be admitted to a psychiatric unit as an emergency. This applies even to a patient who is known to have dementia and presents with increasing confusion.
(2) True dementia presenting as an emergency should be very rare and an admission to a scarce dementia bed may not be the best policy. Involve the on-call social worker to arrange placement, eg emergency R.A.
(3) All elderly people presenting with psychiatric/hysterical symptoms should be carefully evaluated to exclude organic cause.
(4) Beware suicide/DSH in the elderly evaluate carefully for psychiatric illness.

Acutely Psychotic Patients

Causes
organic mental illness
drug intoxication
alcohol withdrawal
Although patients may appear to lack contact with reality, they may be aware of what is happening -lack of respect or empathy may worsen the situation.
In functional illnesses, differentiation between schizophrenic and affective psychoses has important implications for treatment and prognosis.
Interview may be very important in establishing diagnosis. Record verbatim examples of speech. Alleviate tensions and distress by a constant attendance and a calm unhurried manner.
Interview and attempt to establish a diagnosis before using drugs.
http://hacking-medschool.com/emergency-sedation/

Mental Health Act 2005 Grounds for compulsory admission

(1) The patient suffers from a mental disorder of a nature or degree which warrants his detention in hospital for assessment. and
(2) Failure to detain would create a substantial likelihood of serious physical harm to self or others.

Mental illness a state of mind which affects a person’s thinking, perceiving, emotion or judgement to the extent that he requires care or medical treatment in his own interests, or those of other people.

No person can be detained by reason only of personality disorder, immoral conduct, promiscuity, sexual deviancy or dependency on alcohol or other drugs.

Medical recommendation is generally by the GP (Form 3). Application for admission for assessment is based on the medical recommendation :lnu made either by an approved SW (Form 2) or the nearest relative (Form 1).

Temporary holding power is available to a MO for a patient already admitted to hospital (Form 5).

Section 2 Used to permit a period of assessment in hospital for up to 28 days Requires an Approved Social Worker (ASW) and two doctors, one being a section 12-approved psychiatrist

Section 3 Used to permit a period of treatment in hospital for up to six months Requires an ASW and two doctors, one being a section 12-approved psychiatrist

Section 4 Used in emergency situations to transfer a patient to hospital for further assessment. Powers last for up to 72 hours Requires one doctor (of any speciality) and an ASW

Section 135 Used if a mental health problem is suspected which requires intervention and the person is refusing access to their own home An ASW can apply for a warrant to gain access

Section 136 Used to allow the police to transport a person acting in a disturbed way in a public place to a place of safety (usually hospital), if they suspect the disturbance is caused by an underlying mental health problem

In cases where there is immediate risk of harm to self or others, common law can be used. Using common law the police can gain access to a property and a patient can be taken to hospital.

The mental health act cannot be used to treat physical/organic problems.

Where there is threat to life and the patient is refusing investigations or management and does not have the capacity to consent, action needs to

be taken under common law. Accordingly, patients cannot be sectioned for the medical management of an overdose.

If in doubt about mental health act issues, then seek advice from the on duty ASW

Suicide Parasuicide and Deliberate Self Harm

Suicide Risk Assessment PUK

NICE CG16 Self-harm Jul 2004

NICE CG133 Nov 2011 – longer term management of Self Harm

Poisoning / Overdose

Poisoning Rural Health West

Drug Identification:
• Up to 50% of initial OD histories may be incorrect.
• Seek information from patient, friends, family, GP.
• Support materials e.g. Tablet bottles etc. should be sought.
• Recognise specific toxic syndromes.
• Vital signs, CNS status, pupillary reaction, CVS responses, abdominal examination, ABGs , UandEs etc. may suggest a particular toxicity.
• Screen all suspected ODs for PARACETAMOL, ASPIRIN and ALCOHOL.

• Proceed with supportive therapy while awaiting results. Seek specific advice from Poisons computer or National Poisons Information Service (Toxbase)Information Centre

Supportive Care
AIRWAY patent?
VENTILATION adequate?
HYPOTENSION IV Fluids +/dopamine
ARRYTHMIA Rx depends on agent
COMA Dextrose 50mls 50% IV; Narcan 2mg IV; Anexate 5mg
IV Parentrovite 1Omls IV as appropriate.
Prevention of further drug absorption
Gastric Lavage or Emesis (Ipecac) within 3-4 hours except Aspirin, tricyclics, ( Avoid Ipecac also in ingested corrosives and oils.) Activated charcoal 50-100g.

Removal of absorbed drug
Consider forced alkaline diuresis (e.g. aspirin, barbiturate); peritoneal / haemo dialysis (alcohol, lithium); and haemoperfusion (in aspirin, theophylline)

Specific Antidotes

ALL overdoses must have PARACETAMOL levels checked. If 4 hr level > 150 use IV Acetyl cystiene.

Paracetamol poisoning calculator BNF extra

Disposal
Apparently trivial ODs may have taken lethal agents or be actively suicidal. All overdose patients should be admitted for Psychiatric and SW assessment after medical support

Poisons Information Services

• MIMS Poisons Information
• TOXBASE
• 0844 892 0111 more complex cases
• National Poisons Information Service 
• Guys and St Thomas’ Poisons Unit 0870243 2241 24 hrs
• ROI 00 3531 837 9966
• Health Protection Agency

Antidotes

Carbon Monoxide Poisoning

• toxbase.org
• Carbon Monoxide Poisoning hpa.org.uk
• Carbon Monoxide hpa.org.uk
• Carbon Monoxide Poisoning dh.gov.uk
• http://youtu.be/Wh8tqEV9E2A

Shock

• C cardiac
  A anaphylactic
  S septic
  H hypovolaemic
  E endocrine (addisons)
  D drugs (anaesthetics)

http://youtu.be/9a7N9AU1GiQ

Haemorrhage

• Haemorrhage Shock Medscape
• http://youtu.be/HQXgldR_LEA
• http://youtu.be/9NeN4T7Ll6w

Burns

Immediate management
Apply cool (8 to 15C) running water to the affected area for 5-10 minutes.
Remember that hypothermia can occur in children and in those with extensive burns. Do not use ice.
Cover the burn loosely with a single layer of clingfilm, avoiding constriction of limbs.
Do not apply ointments or creams prior to assessment of burn depth.

Burns are categorized based on the source of the burn and the degree of damage done to the body’s tissue

Assessment of burn depth
It is usually possible to assess the depth of the burn by inspection. Most burns are of mixed depth. Characteristic features are as follows:

Superficial Red,blistered Blanchess Very painful heals 14 -21d with no scar (may be pigment changes)

Deep White or red base. No blisters Non blanching Painful Healing takes more than 21d. Always leaves a scar

Full thicknessLeathery white or charred Less painful Heals Slowly with contracture and scarring. Skin graft unless v small.

Predicting depth
Scalds caused by hot drinks and kettles can cause deep burns in children and older people.
Burns caused by prolonged contact with heat (eg hot fat, flame, electrical, burns in an unconscious patient) are likely to be deep.

Assessment of surface area
In children, the extent of the burn can be assessed using the palmar surface of the child’s hand. This represents 1.25% (1% in adults) of their total body surface area.

In adults, the ‘Rule-of-Nines’ is commonly used to assess the extent of a burn. In this scheme, the head represents 9% of the total body surface area

(TBSA), each arm 9%, each leg 18%, either the back or front of trunk 18% and perineal area 1% (areas of slight erythema are ignored).

Referral
Patients should be referred immediately to hospital if they have any of the following:
a suspected smoke inhalation injury
a facial burn
a deep dermal or full-thickness burn involving 5% or more of the TBSA
a burn involving 10% or more of the TBSA in a child or 15% or more in an adult.

Whilst waiting for the ambulance start IV Hartmanns solution if available

[0.25mL X body weight in kg X % TBSA burned] per hour

parkland formula –Fluid replacement (mls in first 24hrs)= 4 x wt of patient x %age burn

Half in first 8 hrs, second half over next 16hrs + normal daily fluid requirements.

If intravenous fluids are not available, give clear oral fluids. Avoid milk and juice because of the possible need for urgent surgery. Give intravenous diamorphine for pain relief.

Patients should be referred urgently to hospital (???) if they have any of the following:
burns of their hands, feet, perineum or areas overlying major joints, unless very minor
a co-existing medical condition or other injury or are pregnant
severe pain
an electrical burn
chemical burn
a deep dermal or full-thickness burn covering 5% or less of the TBSA
a circumferential burn of limb or chest.

In children and vulnerable adults, the burn might be the result of abuse or neglect. If suspicious, refer the patient to the Emergency Department preferably within 24 hours.

Toxic shock syndrome
Remember that any patient, even one with a minor burn, who experiences fever, rash or general malaise may develop toxic shock syndrome. These patients should be referred to hospital immediately. Whilst the patient awaits transfer give a stat dose of an anti-staphylococcal agent, eg flucloxacillin IV.

Management of minor burns in the community
Ensure that the burn is clean. If a blister is intact leave it unless it is large, painful or restricting joint movement. Apply an antibacterial agent such as Flamazine. The wound should be covered with a non-adherent dressing (eg Mepitel or Atrauman), an absorbent layer such as gauze or Gamgee (if there is a lot of exudate), and secured with a bandage or adhesive tape. Remember that the application of Flamazine alters the appearance of the wound, which complicates assessment.

Check that the tetanus vaccination is up-to-date and give a booster or start therapy as necessary.

Check the burn at 48 hours. Necrosis may have progressed and the burn may appear deeper. Remove the dressings and re-assess the depth. If the burn appears deep, refer the patient to the local plastic surgery or burns unit, preferably within 24 hours. If not, re-dress the wound.

Leave the new dressing on for 2 days unless the exudate strikes through to the outside of the dressing or the patient is in pain. Wash away any surface exudate. Re-apply the dressing after thorough cleaning.

Hydrocolloid dressings can be used for small areas and changed between 2 and 3 days after application.

Burn wound infection
If an infection develops (features of which include: cellulitis, increased pain or an unpleasant odour) then a staphylococcal or streptococcal infection should be suspected and the patient started on flucloxacillin or erythromycin. A wound swab should be taken to confirm the diagnosis and to obtain bacterial sensitivities. The infected wound should be washed with dilute chlorhexidine, covered with Flamazine and the dressings changed at least daily. If infection becomes established it may prevent healing and skin grafting may be required.

Referral advice
If a burn is not healed after 14 days the patient should be referred to a specialist unit.
Care after wound healing
After superficial burns have healed, the skin may become flaky and require a moisturiser (eg aqueous cream applied twice daily). Patients should avoid sun exposure to the affected area to prevent the development of hyperpigmentation. Advise the patient to cover the area with suncream (SPF25+), clothing and to avoid the early afternoon sun.
Patients with deep burns will usually be cared for by a specialist unit (plastic surgery department or burns unit).

Determining the Degree of a Burn
The severity of a burn may be determined by the depth of tissue damage.
Superficial burns cause damage to the epidermis only,
Partial -thickness burns damage the epidermis and part of the dermis.
Full-thickness burns affect the epidermis, dermis, subcutaneous tissue and the underlying muscle and bone.

Full-thickness burns
Full thickness burns over 5% of BSA cover with dry sterile dressing and transfer to specialized burn center (prepare by keeping patient warm and wrapping in dry sterile sheet and elevate the area of the burn to minimize edema)

An adult patient’s burn severity can be estimated using the Rule of Nines which divides the body surface area into percentages and will assist with determining fluid resuscitation
The Lund-Browder chart is used for infants and children due to differences in body percentages.

PARTIAL THICKNESS BURNS
Partial thickness burns can be epithelial, dermal or deep dermal the first two are referred to as first degree, the last as second degree. In first-degree burns, erythema occurs. Superficial second-degree burns, with only little loss of dermis, are characterized by blisters and a wmorm pinkish-red colour of the skin.

Deep second degree burns, in which only the deeper dermal structures remain intact, show an alternately red and waxy white discoloration. In full thickness burns, also known as third-degree burns, the entire dermis is destroyed; the appearance is whitish-yellow to brownish-black.

The pin-prick test helps to distinguish between superficial burns, which bleed quickly after being pricked and which are very painful, and deeper burns, which are less sensitive or painless due to the loss of sensitive nerve endings, and which bleed less quickly. The capillary refill is intact for superficial burns, and is less or not present at all for deeper burns. This distinction is important, because spontaneous recovery of deep secondand third-degree burns can occur only in the sweat glands or hair follicles or at the edges of the burn, while regeneration of superficial burns can occur in the remaining epithelial tissue. This has implications for prognosis and treatment. In particular, deep second-degree burns that are not recognized as such can later lead to scarring. This can cause functional as well as cosmetic problems.

The critical percentage for hospital admittance is 15% of the body surface area for adults and 10% for children, regardless of the depth of the burn.

First-degree burns generally recover spontaneously within 1 week. A soothing skin cream may be applied to prevent the burn from drying out. Moist compresses may also be used. Analgesics are appropriate if pain is a problem.

Conservative therapy for superficial second-degree burns can be classified as follows: open-wound treatment, half-closed-wound treatment and closed-wound treatment.

The open-wound treatment involves letting air heal the burn: serous wound fluid dries up and forms a crust that seals the injury,protecting it against dehydration and infection. However, this is only possible if the injury is localized, so that it can be constantly exposedto air.

The half-closed-wound treatment consists of covering the wound with ointments and creams, followed by gauze and/or a bandage. Infected or easily infected wounds should be treated this way, in addition to burns that, due to their position, cannot be treated in any other way.

The preferred course of treatment involves using 1%s ilver sulfadiazine cream (very effective against Pseudomonas aeruginosa), applied on hydrophilic gauze that must be changed daily. The temporary white-yellow discoloration of the burn makes it difficult to assess its depth; it is important to be sure that the burn is superficial.

If in doubt, begin with a neutral ointment (possibly after cleaning the wound) or with semipermeable membranes (see below). Povidone iodine ointment 10% is indicated for possible contamination with Gram-positive bacteria (usually Staphylococcus aureus). The creams have a limited shelf-life once opened.

The closed-wound treatment can only be used for burns that are sterile. If there is a blister, it is easiest to leave this intact. Paraffin gauze can be used to support the blister top. Puncturing the blister is often not necessary; however, the blister top must be removed after 3-5 days and the treatment continued according to the half-closed-woundmethod.

Another closed-wound treatment with excellent results involves hydroactive or biosynthetic bandages, which consist of semipermeable (i.e. allows gases and water to evaporate through, but not bacteria) polyurethane film on the outside and a layer of hydrocolloid on the inside. The inner layer seals the wound off and enables the formation of a gel, so that no damage is done when the bandage is removed; in other words, it forms an ‘artificial skin’ under which re-epithelialization can take place. The dressing must be changed once every 1 or 2 days.

It has been observed that healing takes place faster using this method than, for example, using silver sulfadiazine cream. Unfortunately, this method is relatively expensive and cannot be used for every wound site, given the limited diversity and shape of the bandages. The gel that is formed (which looks and smells like pus) can make the patient think something is wrong; therefore, inform the patient and the caregivers about this. Very clear agreements should always be made with regard to further treatment.

A superficial second-degree burn must be fully healed in a maximum of 3 weeks. If the GP considers the parents or caregivers to be sensible and reliable, he can ask them to contact the surgery if the wound has not completely healed after this time. Alternatively, a specific follow-up appointment could be arranged. In the case of more extensive lesions, the healing process should be monitored by the GP in the first 2 weeks. The patient must also be told how to deal with complications, such as infection of the wound.

The depth of a burn is the most important parameter for prognosis and therapy.

A Burn is an injuries to tissue caused by heat or flames, chemicals, radiation, electricity, gases, or severe cold exposure.  Burns can be devastating to a person both physically and emotionally due to disfigurement, scaring, and the painful treatment required.  Severe burns often require surgeries and or rehabilitation to completely recover, and may cause death either directly related to the burn(s) or complications associated with the burn.

Different criteria in the choice of hospital centre if required – Children require hospitalization more often than adults. Experienced rescue workers have to decide whether young patients have to be transported to the nearest emergency department or directly to a local burns centre, after confirmation that the patient has been accepted.

Consider abuse if physical evidence supports it such as cigarette burns to arms, legs or torso or scald burns to feet, legs or bottom due to being held in scalding hot water

Specific circumstances

Chemical burns these need irrigation with tap water for at least 30 minutes. If contamination is extensive the patient might require a shower.
Always irrigate with water do not attempt to neutralise the effect with another chemical.

Scald In a patient with a scald, immediately soak any wet clothing with cool water. Remove the clothing covering the scald as soon as possible and continue to irrigate with cool water.

Smoke inhalation
secure the airway, give oxygen and transfer the patient to hospital immediately. Beware singed or sooty nasal hairs.
Thermal Burns
Thermal burns are the most common type of burn and are typically caused by direct contact with a heat source such as clothing that  has caught on fire, boiling water, grabbing a hot iron, playing with matches, or household fires due to contact with flame, flash, scalds or hot objects.

Sunburns
Sunburns are the most common type of thermal burn caused by excessive exposure to sunlight or sunlamps.  Most sunburns are superficial causing redness, however, more severe sunburn causes blistering.  Sun poisoning is a severe reaction to over exposure to the sun causing not only the damage to the skin but also nausea, fever, headache and dizziness.

Frostbite
Frostbite is injury to the tissues of the body resulting from freezing of the tissues.  It is caused by prolonged exposure to cold temperatures.  Tissue damage from frost bite may be superficial or deep.  Most common sites for frost bite include the hands and feet and those areas of skin around the face and ears or other areas that are often exposed to cold wether.  Deep frostbite damage goes beyond the subcutaneous tissue and is usually seen in the hands and feet.  If frostbite is left untreated or not treated correctly it may cause gangrene and require amputation.

Chemical Burns
Chemical burns result from contact, inhalation, ingestion, or injection of a harsh or toxic substance.  Burning and tissue damage will occur as long as the agent remains in contact with the skin, immediate removal of the agent with large amounts of water or normal saline is crucial to preventing further damage.  Tissue damage can occur for up to 72 hours after the substance has been removed.

Chemical burns to the eyes can be serious and cause visual damage.  Immediate flushing of the eyes with large amounts of water or normal saline is imperititve to decrease pain and damage to the eye from the chemical(s).

Electrical Burns
Injury from electrical burns results from intense heat generated by an electrical current.  The severity depends on the amount of voltage, tissue resistance, current pathway, surface area in contact with current, and length of time the electrical current was sustained.  Electrical burns often have an entry and exit site and underlying tissue damage which may not be visible. Electrical burns usually result from contact with faulty electrical wiring or high voltage power lines which typically occur when the person is elevated above the ground, therefore consider cervical spine injury as well.  Electrical burns place the patient at risk for cardiac arrest or arrhythmias, for up to 24 hours after the injury was sustained.

Smoke and Inhalation Injury
Breathing in smoke, hot air, or noxious chemicals can cause tissue damage to the respiratory tract.  Types of inhalation injury are; carbon monoxide poisoning or inhalation of hot air, steam or smoke.  Signs of inhalation injuries include facial burns, singed nasal hair, hoarseness or painful swallowing.  The inhalation of chemicals caused by household cleaning agents or chlorine can cause inhalation burns as well.  Respiratory distress or failure can occur and lead to the need for mechanical ventilation.

Chemical burns
Irrigate wound with generous amounts of normal saline
Eye injury- flush the eyes with large amounts of water or normal saline for at least 30 minutes, cover eyes with dry sterile dressing and refer to ophthalmology
Find out the type of chemical that caused the burn and consider inhalation or airway damage if noxious fumes involved

Frostbite injury
Re-warm the injured area
Do not rub injured area
Elevated injured area and leave uncovered at room temperature
Referral to burn care specialty unit or center or A&E
Prescribe or advise re oTC analgesia
Watch for worsening in swelling, pain, fever, redness, purulent discharge, chill, malaise, and loss of appetite report to GP

Burn Foundation au

Burns rule of nines (adult)

• back torso 9% x 2
  front torso 9% x 2
  each arm 9%
  each leg 18%
  head and neck 9%
  perineum 1%
  hand 1%
  do not include simple erythema

Hypothermia

Hypothermia Medscape

hypothermia.org

Hypothermia sja.org.uk

Animal Bites

Organisms Streptococci, Staphylococcus aureus, Anaerobes, Pasteurella multocida, Capnocytophaga canimorsus.
Assess rabies risk if bitten abroad

Assess tetanus immunisation status. Cleanse wound thoroughly, debride, consider elevation and immobilisation. Co-amoxiclav 625mg three times daily for seven days. Penicillin allergic individuals, metronidazole 400mg 8-hourly plus doxycycline 100mg twice daily for seven days (NB doxycycline contraindicated in pregnancy).
Give IM triplopen followed by oral augmentin (vs pateurella septica/multocida, staph aureus and Capnocytohaga canimorsus) if wound soiled.

Dress wound with tinct iodine.
Dog bites (15% risk infection) to face of children need early and careful repair often under GA. Otherwise try to avoid suturing.
Cat wounds more deep penetrating. Rx as above.(25-50% risk infection)
Cat bite fever regional lymphadenopathy with microabcesses proximal to the cat (or dog) scratch or bite.
PIGS Very strong jaws can inflict severe tissue damage including fractures through undamaged skin and clothing.
Horse Usually superficial nip. Actinobacillus lignieresii. Beware broken horses tooth.

Human Bites

Human bites/clenched fist
Occur over the extensor aspect of the MP joint usually of the dominant hand occur when the patient strikes another in the mouth. This results in laceration transversely over the joint by a front tooth, and because of the force involved and the negative pressure within the joint when tightly clenched, often results in salivary contamination around the extensor hood or within the joint. Mixed anaerobic infection is common (>60%). The wound should be thoroughly cleaned and inspected and where significant injury to the extensor mechanism, or joint penetration occurs may require admission for formal exploration.
Use Augmentin prophylactically and arrange early A&E review.

Assess HIV/Hep B/Hep C risk for human bites.

250textbooks/hiv-post-exposure-prophylaxis

Stings

Stings

Trauma

Rapid Mental Status Assessment AVPU

Rapid Injury Asssessmment
Deformations
Contusions
Abrasions
Penetrations / Paradoxical Movement
Burns
Tenderness
Lacerations
Swelling

Patent History Assessment
Assessment of a patient who has experienced minor trauma can be focused on one area if the injury is localized (sprained ankle, dislocated finger).

However, a patient who is involved in a motor vehicle accident, significant fall or reports a mechanism of injury that may cause injury to multiple parts of the body should undergo a standardized trauma assessment – the ATLS – which can be applied to any patient regardless of injury.

ABC’s
IV access; monitor vital signs
Emergency transfer for suspected injury to head/neck/chest/abdomen/pelvis
Signs of shock – hypotension, altered mental status, hypoxia
Severe bleeding
Open fracture or gross deformity
Primary survey of the trauma patient involves the ABCDE’s.

Airway patency – can the patient speak normally, is there any facial/neck trauma?

Breathing – assess by auscultation of both lungs and noting any respiratory distress.

Circulation – check skin color, blood pressure, pulse rate and by palpate major pulses.

Disability – make quick scan of any obvious neurological deficits or life-threatening injury.

Exposure – remove all clothing to fully evaluate the patient.

The secondary survey involves a careful head-to-toe examination.

In addition, a concise history should be obtained from the patient including

• Signs/symptoms
  Allergies,
  Medications,
  Past medical history,
  Last meal
  Events/environment of the trauma

Examination
General – Level of consciousness, Glasgow Coma Scale (GCS) score

Head – Pupils, extra-ocular movements, lacerations, signs of skull fracture

Face – Dental malocclusion, midface instability/crepitus, lacerations, contusions

Neck – lacerations, subcutaneous air, tracheal deviation, midline cervical tenderness, hematoma, jugular venous distention

Chest – Heart tones, breath sounds, respiratory effort, point tenderness, lacerations,subcutaneous air

Abdomen – lacerations, bruising/hematoma, focal tenderness, peritoneal signs

Pelvis – stability of pelvis/symphysis, lacerations, check for blood at urethra/vagina/rectum

Neurological – midline bony tenderness, paresthesias, sensation, motor function, rectal tone

Extremities – lacerations, hematoma/bruising, deformity, capillary refill, pulses

Any patient with potential life-threatening injuries should have two large bore IV catheters (14 or 16g), continuous vital sign monitoring, fluid resuscitation for hypovolemia/hypotension, cervical spine immobilization, oxygen therapy and emergency transfer.

Trauma Rural Health West au

Trauma ATLS

http://hacking-medschool.com/trauma-2

http://youtu.be/RMeOUeDgfNY

ATLS principles

1. Cerebral oxygenation comes first. Efforts should be directed to the restoration / protection of this before you consider the treatment of specific injuries.

2. When the patient’s basic survival physiology has been stabilised, proceed to a thorough examination of the patient to document all injuries.

Establish
Airway
Remember the possibility of unstable neck injury

Breathing
All patients should be given oxygen
Know about airway intervention and how to intubate and ventilate a patient manually and using the automatic ventilators.

Circulation
Use large cannulae to administer IV fluids.
Start with crystalloid infused quickly. For replacement of &gt; 2 litres get colloids and blood.

GET HELP IF YOU ARE IN DIFFICULTY Do Not Wait until the situation deteriorates.

Management of Specific Injuries

Head
Alcohol should not alter your management. If GCS &lt;8 or p02 &lt;80 mmHg Protective Intubation is required (Get Anaesthetist.)

Neck
Assume a neck injury in the unconscious until you have proven otherwise with a Lateral Cl Spine X-Ray. You need to see all 7 vertebrae. If a stiffneck collar is not already insitu put one on immediately and control all movements.

Chest
With penetrating trauma (e.g. GSW or stabbing) insert a chest drain immediately (before X-Rays etc.). Check Blood gas analysis and monitor Sa02. Chest X-Ray (erect if possible) to asses mediastinal widening and haemothorax. Tension pneumothorax should be drained immediately with a large needle, as should pericardial tamponade. Both are life threatening and are diagnosed clinically.

Abdomen
Pelvic fractures are easy to miss clinically, so get pelvic X-Rays. If patient is hypovolaemic and there is no overt source of bleeding, he will require a laparotomy. There are some circumstances in which Peritoneal lavage may be appropriate for the diagnosis of covert bleeding. Consult a surgeon. Do not catheterise patients with urethral

Extremities.
Splint all fractures. Check for peripheral pulses and sensation in distal limb. Compound fractures require cleaning in theatre: Get an Orthopaedic Surgeon.

Analgesia
Head, chest or abdominal injury is not a contra-indication to opiate analgesia, which should be diluted, titrated &amp; intravenous.

Revised trauma score

Glasgow Coma Scale GCS adults and children over 4
Eye Opening
Spontaneously 4
To verbal stimuli 3
To pain 2
No response to pain 1

Best motor response
Obeys verbal command 6
Localises to pain 5
Withdraws from pain 4
Abnormal flexion to pain (decorticate) 3
Abnormal extension to pain (decerebrate) 2
No response to pain 1

Best verbal response
Orientated and converses 5
Disorientated and converses 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1

Minimum score 3 max 15

Impaired Conciousness Descriptors (ER/Nursing Facts Incredibly Fast Lippincott 2007)
Alert
Oriented in time place and person
Follows commands and responds completely and appropriately to stimuli

Confused
Loss of ability to think rapidly and clearly
Impaired judgement and decision making

Disorientated
Beginning loss of conciousness
Disoriented in time progressing to disorientation in place
Impaired Memory
Lack of recognition of self
Lethargic
Limited spontaneous movement or speech
Easy to arouse by normal speech or touch
Possible disorientation to time place or person

Obtunded
Mild to moderate reduction in arousal
Limited response to environment
Able to fall asleep easily
Answers questions with minimal response

Stuporous
Deep sleep or unresponsive
Arousable (motor or verbal response) only to vigorous and repeated stimuli
Withdrawal or grabbing response to stimulation

Comatose
No motor or verbal response to any stimuli
No response to noxious stimuli eg deep pain
Unrousable

Pontine versus cerebral lesions in coma
Pontine lesions eyes point to paralysed limbs
Cerebral lesions eyes stare at satisfactory limbs

AVPU

• A Alert
• V responds to Voice commands
• P responds to Pain
• U Unresponsive

Head injury

• http://hacking-medschool.com/head-injuries
• NICE CG56 Head injury Sep 2007 QRG
• iTunes U Head Injury Rock Valley College
• SIGN qrg 110 Head Injury May 09

Assessment of patients who have sustained a head injury is directed towards identifying those at increased risk of complication, particularly intracranial haemorrhage amenable to surgery, and so in need of urgent referral to the emergency department with a view to imaging and/or admission. The onset of features of intracranial haemorrhage (or other complication) may be delayed, and treatment may then be an emergency. Identifying and referring ‘at risk’ patients before deterioration will therefore help prevent avoidable morbidity and mortality.

History Mechanism and nature of injury, e.g. was patient wearing a helmet?
Headache, other injuries, bleeding
Past medical history
Coagulopathy
Drug history
Aspirin, warfarin

Social history Alcohol, drugs
Redflags LOC, amnesia before event, vomiting, drowsiness, focal neurology,
High impact, >65 years, alcoholism
Consider non-accidental injury especially in child <1 year
Examination Glasgow coma scale, pupils, neurological examination, local injuries Bruising around eyes/ears CSF/blood from ears and nose

Management
Investigations CT head if any red flags
Management Analgesia: paracetamol, ibuprofen (avoid opiates as you may need to assess pupil size)

Safety net Refer to AandE if any red flags
Warn regarding concussion, give written information: dizziness, headaches, poor concentration, visual disturbance
Consider delayed presentation of subdural haemorrhage if: elderly, signs of alcoholism, confusion, falls, memory and balance problems.

Subdural /epidural haematoma

http://www.youtube.com/watch?v=ELIRrGAmMbs

http://www.youtube.com/watch?v=oi6TdJnNOP

http://www.youtube.com/watch?v=lBgQqvYK8xA

Extradural haematoma

http://www.youtube.com/watch?v=0I_5JHlnWyc

http://www.youtube.com/watch?v=ELIRrGAmMbs

Patients presenting after head injury

History – enquire about the following:
Mechanism of injury associated with increased risk of complication:
possible high kinetic energy (high momentum) injury: eg pedestrian hit by a car; occupant ejected from a vehicle; fall from a height of greater than 1 metre or more than 5 stairs (less for a child under 5 years old); diving accident; high speed motor vehicle accident; rollover motor vehicle accident; accident involving a motorised recreational vehicle; bicycle collision; or any other potentially high energy mechanism event likely to have caused a depressed skull fracture: eg blow from a golf club
suspected non-accidental injury
suspected penetrating injury.
History of loss of consciousness or depressed level of consciousness at any time since the injury. Check for amnesia, particularly if there is no witness.
Seizure or focal neurological deficit at any time since injury.

Persistent headache following injury.
Irritability or abnormal behaviour (this may be the only clue in a child aged under 5 years).
Vomiting: note the number of times (use clinical judgement regarding the cause of vomiting in children of 12 years or less).
Other relevant problem: eg alcohol or drug intoxication;
coagulopathy/treatment with an anticoagulant; previous cranial neurosurgery (eg hydrocephalus).
Age 65 years or more; adverse social circumstance, eg no responsible adult at home.

Examination
Assess the patient’s level of consciousness using the Glasgow (or Child) Coma Scale Record ‘eye’, ‘verbal’ and ‘motor’ components individually. Any score of less than 15, or other evidence of altered mental state, is significant.
Assess for post-traumatic (retrograde) amnesia; check short-term recall.
Note if there is any pre-injury (antegrade) amnesia, particularly significant if for more than 30 minutes before injury.
Check whether pupillary reflexes are abnormal, and look for any focalneurological abnormality.
Look for injury to the scalp consistent with skull vault fracture (eg haematoma, tenderness), and/or ‘open’ head injury (overlying wound).
Check for any signs of base of skull fracture: CSF rhinorrhoea; loss of sense of taste/smell; periorbital haematoma without local injury to orbit (‘panda eyes’); bleeding from the ear (without external wound to account for it)/haemotympanum; new deafness; bruising behind the ear over the mastoid bone (Battle’s sign).

Referral advice
If a patient has a positive finding for one or more of the features in the history or examination as outlined above, or you, the patient or carer is concerned about diagnosis or management, the patient should be transferred immediately (????) to the emergency department. Transfer should be by 999 ambulance. If however, alternative transport is considered appropriate, the patient must be escorted by a competent adult who will be responsible for taking them directly to the emergency department. Inform a senior clinician at the emergency department (consultant/registrar/nurse in charge) and, if time allows, send an accompanying letter recording symptoms and signs.

For patients for whom referral to hospital is not thought necessary; advise patient and carer of the small risk of delayed complications or persistent symptoms, how to access further advice, and give head injury instructions (for child/adult as appropriate).

Management of patients awaiting transfer to hospital
Immobilise the cervical spine prior to transfer if the patient has, or has had, any of the following:
a GCS of less than 15 at any time since the injury
neck pain or tenderness
focal neurological deficit
paraesthesia in the extremities
any other clinical suspicion of spinal injury.

If the patient deteriorates before transfer, treat using the prioritised approach of life support courses (Advanced Trauma Life Support, Advanced Paediatric Life Support)

Patients who present late after head injury or return
When patients present late after a head injury, or return after an initial consultation, the principles of assessment and indications for referral to the emergency department are essentially the same as those for acute presentation.

The following symptoms are reported as common after a head injury: mild headache, dizziness, forgetfulness, poor concentration, irritability, tiredness, poor sleep. However, if following neurological assessment, there is doubt as to whether persistent symptoms could be due to raised intracranial pressure or intracranial infection in particular, the patient should be referred to the emergency department for further assessment and possible imaging.

Neck injury (emergencies)

http://hacking-medschool.com/neck-injuries

Neck trauma Medscape

Canadian neck and CT head rules

• Canadian CT Head Rule
• Canadian C spine rule
• http://youtu.be/B1x0DBxFOLU

Spinal injury (emergencies)

http://hacking-medschool.com/spinal-injuries

http://www.youtube.com/watch?v=PseUxltIw_U

Lumbar spine fractures

For minor compression fractures (<10% Vertebral height) bed rest and analgesia at home if circumstances permit, depending on pain severity.
Advise to avoid stooping and lifting for 4-6 weeks should be given.
Orthopaedic Fracture Review should be arranged. More significant compression fractures should be admitted for bed rest etc.
http://hacking-medschool.com/vertebral-fracture
Burst fractures are Unstable and will require Orthopaedic Intervention.
Patients should be handled carefully where spinal injury is suspected, to avoid further injury.

Chest Trauma

http://hacking-medschool.com/chest-injuries

Blunt chest trauma Medscape

RTA and assault records and reports

Reporting gunshot and knife wounds

MPS Factsheet Reporting gunshot and knife wounds

Prehospital Care 

RTA assessment

Foreign bodies

May be accidental or intentional and involvesoft tissues or orifices – skin, eyes, ears, nose and gastrointestinal and genital tracts. Less common sites involve the airway, oesophagus, anus/rectum, vagina, and urethra.
Foreign bodies might include glass, fragments of wood or metal, dirt or soil, or objects such as tampons, coins, safety, pins, small toys or batteries.  Detailed assessment with early treatment and referral are essential to prevent inadvertent retention of undetected foreign bodies, infection or other adverse outcomes: retained foreign bodies (particularly GLASS) are one of the most common reasons for medical lawsuits.
All glass lacerations always need Xrays.
All wounds need thorough examination exploration and visualization before closure.
Consider penetrating eye injuries in high velocity environments where the patient not wearing protective goggles. Consider ophthalmic asssessment and or /Xray
Fishbone in the throat needs ENT assessment. There have been deaths from missed punctured oesophgus.
Careful consideration of inhaled or swallowed FB
Consider the possibility of multiple foreign bodies- if there is one there may be more eg glass or metal fragments
Emergency transfer/referral for endoscopy or bronchoscopy for foreign bodies in the respiratory or gastrointestinal tract
Seek toxicology advice for ingested foreign bodies eg batteries
Document visual acuity for foreign bodies of the eye before and after removal
Consider other associated injuries e.g.  tendon or nerve injuries or fractures
Occasionally removal of a foreign body may be deferred or not attempted if an inert object and unlikely to cause any long term problems.
Follow your own departmental guidance on seeking consent for any procedures and using chaperones for intimate examinations.
Risk factors for accidental introduction of foreign bodies include injuries in patients of all ages, ingestion and aspiration in infants and toddlers, patient’s with mental illness and the neurologically impaired. Pediatric patients constitute a significant proportion of the population for all foreign bodies and will frequently present with foreign bodies in the nose, ear or gastrointestinal tract.
The mechanism and time of introduction of the foreign body and the nature of the foreign body should be established if this information is available.

Skin and Soft Tissue
Splinters, glass shards, fish hooks, nails and missiles such as BB’s are among the more common foreign bodies of the skin and soft tissues.  A careful history will usually alert the clinician to the possibility of a foreign body.  Organic foreign bodies such as splinters have higher rates of infection compared to inert materials such as glass or metal. X-rays may be useful in detecting some foreign bodies e.g. metal, although glass and wood are often missed due to their lower density and radiolucency. X-rays in 2 different planes will help pin point the location. Remove any objects such as clothing, splints or dressings which may cause misinterpretation of the X-ray films.  But tape a radioopaque marker eg a paper clip to the site of entry.

Ears Nose and Throat
Nasal (and auricular)  foreign bodies often present with unilateral, foul-smelling nasal discharge. This usually means they have been present for some time. Epistaxis may occur.
Refer to a specialist for removal if the foreign object cannot easily be seen or grasped – you may push the object further into the nose or ear without the appropriate skills or tools, making it more difficult to remove or causing additional damage.
Foreign bodies within the throat require emergency specialist consultation.

Eye
Foreign bodies of the eye are common in occupations that involve nailing, operation of machinery, cutting or grinding.  Most foreign bodies remain within or on the cornea, but if the mechanism of injury involves significant force, intra-ocular injury must be considered. Request Orbital Xray  for metal FB (usual from steel grinding) and or referral. Missed Intra ocular Iron can cause a delayed opthalmitis and blindness
Check visual acuity before attempting removal of the foreign body. Use of fluorescence stain may help identify the foreign body or the damage it has caused. Check beneath the upper and lower eyelids. Carry out fundoscopy.
Those who have not been trained to carry out ocular assessment or foreign body removal, should be referred the patient to a specialist to ensure optimal outcome is achieved.

Gastrointestinal Tract
Most objects which have been ingested and are within the stomach or intestines at the time of presentation will pass without complication.
Foreign bodies may become stuck at the junction between the oesophagus and the stomach or within the pylorus and may require urgent surgical removal (endoscopically or sometimes via laparotomy).
Toxic effects as well as physical effects of ingested foreign bodies should be considered e.g. contents from ingested button batteries can cause perforation of the GI tract due to corrosive effects and early removal is recommended.
If the patient presents with difficulty swallowing, vomiting, gastrointestinal bleeding, constipation or abdominal pain which is considered to be related to a foreign body further investigation by a specialist will be needed.  Plain X-rays may be taken to determine the location of the foreign body and occasionally serial X-rays may be required to identify whether the object is moving distally through the intestines.
Rectal foreign bodies may be very difficult to remove secondary to the vacuum effect that occurs within the rectum and surgical removal may be required.
Drug trafficking may lead to “body packing” with drugs and individuals may present with signs of obstruction or rupture of packet of drugs.

Respiratory tract
Aspiration of foreign bodies can lead to choking if the foreign body lodges in the upper airway or trachea or may lead to atelectasis of a lung or part of a lung if lodging in a bronchus or bronchiole. Infants, patients with neurological conditions affecting their ability to swallow and patients with mental health disorders are all vulnerable. In addition, aspiration of a tooth/teeth may follow dental treatment or facial injury in other individuals. Although a foreign body in the respiratory tract may not clearly be seen on X-ray (e.g. a tooth) it may be possible to identify the location due to atelectasis of a segment of the lung which can be detected radiologically.
Early referral for consideration of endoscopic removal of the FB should be considered.

Investigations
X-rays may be useful in detecting some foreign bodies e.g. metal, although glass and wood are often missed due to their lower density and radiolucency. X-rays in 2 different planes may help pin point the location of a foreign body.
Remove any objects such as clothing, splints or dressings which may cause misinterpretation of the X-ray films e.g. a pin in the clothing could be confused with an ingested foreign body.
CT is preferred for foreign bodies of the sinus and orbit. May also detect objects not visualized on plain films
Ultrasound is increasingly being used to detect skin/soft tissue foreign bodies

Treatment
Foreign bodies should be removed at the earliest opportunity but only by those who have the skills and equipment to do so safely.
Thorough exploration and cleaning of a wound by a practitioner with the necessary skills and experience is mandatory.
The whole tract through which the foreign body has travelled should be thoroughly cleaned
Consider antibiotics for secondary infection or contaminated wounds although this does not replace wound toilet
Consider local anesthesia prior to exploration and removal of foreign body
Consider the need for tetanus prophylaxis
Not all foreign bodies can be successfully removed without specialist intervention.  Arrange appropriate follow up care/referral
Educate patient on signs of infection from retained foreign body.

Tetanus protocols

Tetanus @ HPA

Tetanus prone wounds
more than 6 hours old
deep punctures
contaminated by soil and dirt
sustained in the garden or farm
infected
devitalised tissue.

Sudden unexpected death

http://hacking-medschool.com/registration-of-a-death/

Incident management

Major Incident PUK

Gynae emergencies

http://youtu.be/i37l-KqA9Hg

Bleeding in early pregnancy

Early Pregnancy Loss Medscape

Ectopic pregnancy

Diagnosis and Management of Ectopic Pregnancy AAFP 2005

Rhesus prophylaxis

Rh Incompatibility Medscape

rcog.org.uk use of anti-d-immunoglobulin

Obstetric emergencies

Obstetric emergencies Chamberlain and Steer BMJ 1999

http://youtu.be/4pOSNcEOaTI

Neonatal Resusitatation

Airway
Gentle Suction
o2 stream directed over nose & mouth
Pulse and Resps
Consider Intubation – Hr<100 and falling, no spont resps at 1 min
O2 @ 5l/min 30cm H2O pressure
Give Narcan 0.01mg/kg iv or im to reverse respiratory affect of pethidine

Assess at 1 and 5 minutes. If 5 min score <7 reassess every 5 mins for total 20 min.
Do not delay resuscitation whilst assessing scores.
Preterm babies may have lower scores which are not due to asphyxia.