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Pseudo-Hyperkalaemia Pathway

When patients sent in by GP “” – how much do you do?

Pseudo-Hyperkalaemia Pathway

* Examples of High Risk Patients: Dialysis, Renal Transplant, CKD under renal team. Previous Hyperkalaemia.

  ** All patients being discharged need to be discussed/seen by a Tier 3+ level Dr who will assign themselves to the patient. Put the Diagnoses as ‘No abnormality Detected’ AND ‘Potassium Level.’

 

Streaming Pathway:

Patients POC results, ECG and PMH reviewed.

Make sure the patients contact number is correct. Inform them if their lab result comes back high then we will contact them. If they do not hear from us then their result is normal.

 Move the patient to the ‘Streaming’ Tab and record the time they left in the bubble. Once the lab result is back, if it is raised then recall the patient for treatment. If it is normal then discharge from the system ensuring to put the discharge time as when they left the department.

If the lab sample haemolyses – The decision to recall is at the discretion of the Tier 3+ doctor.

Notes:

This pathway has been created as a guide to help reduce the investigation burden and length of stay of patients with pseudo-hyperkalaemia. The purpose of having an Tier 3+ level doctor responsible for these patients is they can make a quick global assessment of the patient and decide whether the patient is high risk and if the streaming pathway is appropriate, rather than relying on a regimented list of conditions or parameters.

In hours this should be done by the front door doctor. Out of hours Tier 1/2 doctors can still see these patients but they should then be discussed with a Tier 3+ Doctor.

 

Thanks to Dr Stuart Mitchell

2WW – Suspected Cancer

Some patients present to ED with symptoms or investigations suspicious an undiagnosed cancer, but don’t require emergency admission. To reduce the barriers to care the trust has implemented a referral route for ED.

Emergency Department MDT referral request – HERE

Once completed the PPC team will review the request and feed them into either “Fast-Track Clinics” if further workup required or MDT’s if fits those pathways.

This should allow our patients quick access to appropriate clinics, without the inherent delays and wasted clinical time of asking the patient to attend their GP. BMA/NHSe

Paediatric ECG

Use the following chart as a quick checklist to review what’s normal and what’s not in a paediatric ECG. 

Remember:

  • Lead V4R in under5’s
  • Manually calculate QTc
  • WPW needs referral for ablation – increase risk of sudden death

If in any doubt discuss with paediatric registrar/senior. If in need of urgent interven:on then contact the paediatric cardiology team in LGI.

1. Placement of Leads: Precordial Leads

In young children, the right ventricle normally extends to the right side of the sternum. To appropriately display right ventricular potentials, ECGs for children in the under five-year age group must include an alternate lead (‘V4R’) on the right side of the chest at a point analogous to the left sided V4.

2. P Waves:

3. Axis:

In utero- high pulmonary pressures and a relatively thick Right Ventricle (RV) -> Initial Right Axis on ECG is normal and resolves after the first 6 months of life

QRS Axis Deviation

  • Chest leads in wrong position

     

RAD:

  • Newborns
  • RVH secondary to Right ventricular outflow tract obstruction eg: Pulmonary
    Stenosis ,Tetralogy Of Fallot, Noonans (characterized by mildly unusual facial features, short stature, heart defects, bleeding problems, skeletal malformations, and many others)
  • RBBB

 

LAD:

  • LBBB
  • LVH secondary to LVOTO (Left Ventricular Outflow Tract Obstruction) e.g. Aortic Stenosis, HOCM

 

Superior Axis

  • AVSD (Atrio ventricular septal defect – Trisomy 21)
4. QTc:

Manually calculate QTc – HERE

Normal QTc:

  • Infants less than 6 months = < 0.49 seconds.
  • Older than 6 months = < 0.44 seconds.

QTc is prolonged in:

  • Hypocalcaemia
  • Myocarditis
  • Long QT syndromes such as Romano-Ward Drugs

QTc is short in:

  • Hypercalcaemia
  • Congenital short QT syndrome
5. Ventricular Hypertrophy

6. T waves:
  • The precordial T-wave configuration changes over time
  • For the first week of life, T waves are upright throughout the precordial leads.
  • After the first week, the T waves become inverted in V1-3 (= the “juvenile T-wave pattern”)
  • This T-wave inversion usually remains until ~ age 8; thereafter the T waves become upright in V1-3.
  • However, the juvenile T-wave pattern can persist into adolescence and early adulthood (= “persistent juvenile T waves”).

Tall, peaked T waves are seen in:

Hyperkalaemia, Dilated LV (volume overload), Benign early repolarisation

 

Flat T waves are seen in:

Normal newborns, Hypothyroidism, Hypokalaemia, Pericarditis, Myocarditis

7. ST Segment:

Some ST changes may be normal:

  • Limb lead ST depression or elevation of up to 1mm (up to 2mm in the left precordial leads).

  • J-point depression: the J point is depressed without sustained ST depression, i.e. upsloping ST depression

  • Benign early repolarisation in adolescents: the ST segment is elevated and concave in leads with an upright T wave.

 

 

Others are pathological:

  • A downward slope of the ST followed by a inverted T.

  • A sustained horizontal ST segment depression

     

 

Pathological ST segment changes are commonly associated with T wave changes and occur in:

  • Pericarditis.

  • Myocardial ischaemia or infarction.

  • Severe ventricular hypertrophy (ventricular strain pattern)

Thanks to the paediatric dept for supplying the guidance –  trust PDF here

Swallowed Foriegn Body

The ingestion of a foreign body or multiple foreign bodies (FB) is a common presenting complaint in paediatric surgery, with a peak incidence from 12-24 months however, can occur at any age. Ingested foreign bodies rarely cause problems; almost 80% of patients pass the foreign body without intervention – in seven days2 (only 1% require surgical removal). However, occasionally foreign bodies can cause significant morbidity (for example, oesophageal rupture) and 1% require surgical removal.

The presenting symptoms and outcomes of an ingested foreign body is highly dependent on the swallowed object, and for this reason, the guidance for hazardous and non-hazardous foreign body ingestion has been divided accordingly.

Using the Metal Detector

Non-Hazardous Objects

Button Battery

Magnets

 

Sharp Objects

PDF copy – HERE

Parkinson’s Disease & can’t swallow

We all recognise the importance of ensuring patients with Parkinson’s disease (PD) get their medication, but..

What do you do if the patient can’t swallow?

We will need to work out what alternative routes we could use, for example dispensable via NG or patches, and what dose. For an ED clinical it is most likely beyond us and we need help! However, that may be extremely difficult to get especially Out of Hours

https://www.parkinsonscalculator.com/calculator2-withoutNG.htmlpdmedcalc

Excellent website that can give you options – select the patients normal regime (initially just one line but you can add as many as needed) and press calculate.  It gives you a dispensable and patch dose, which can help the discussion with pharmacy about where we can get it

Mpox (Formerly: Monkeypox)

Wear Gloves & Wash Your Hands!!!

There have been >100 patients identified as having Mpox in the UK during the current outbreak. Most of these cases have been amongst men who have sex with men.

Reports have suggested that although lesions occur any where including palms and soles. Genital lessons and lymphadenopathy are very common

March 2024 – UKHSA warn there is increasing cases in DRC (Democratic Republic of Congo), so stay vigilant in travellers from central Africa.

 

Trust SOP -HERE

Read more

DKA – Adult

Things to remember

  • Give 0.9%NaCl
  • Actrapid “Fixed Rate” 0.1unit/kg/hr
  • Basal Insulin e.g. Levemir, Lantus, Semglee, Abasaglar, Toujeo, Tresiba,
    please continue this at usual dose and times
  • Potassium – if below 5.5 will need KCl infusion (see guide)
  • BM <14 – Start 10% Dextrose 125ml/hr
  • BEWARE SGLT-2 inhibitors chance of Euglycaemic DKA

Read more

Unsuspected NoF

We have seen multiple incidence where clinicians of ALL grades have assessed patients with falls and examined hips and even mobilised patients

Evidence shows (and reflected in the incidents) this predominantly effects patients with:

  • Communication difficulties: inc. Delirium, dementia, learning difficulties
  • Live in Supported accommodation
  • Normally require help mobilising

If a patient presents with ANY of these and a fall – X-ray Pelvis

 

Neuro-Obs

Neurological Observations MUST include the following:

  • A full set of NEWS2 observations
  • ACVPU assessment (alert, new confusion, voice, pain, unresponsive)
  • GCS (Glasgow coma scale)
  • Pupillary responses
  • Assessment of Limb power

Head Injury – Level 1

Head injury is witnessed, reported, suspected, or cannot be excluded.

  • There is any new onset of neurological symptoms or deterioration.
  • The patient complains of pain / tenderness to the head
  • Extra consideration should be given to patients currently prescribed anticoagulant medication at the time of the fall.

Post fall Neurological Observations must be completed for at least 12 hours and at the above intervals as a minimum:

During this time If there is any deterioration in the patient’s condition including level of consciousness, pupil reaction, limb power, cardiovascular observation you must revert to ½ hourly neurological observation and seek URGENT medical review.

Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.

Under no circumstances should Neurological observations be omitted because the patient is asleep

Head Injury – Level 2

Admitted with Head Injury

  • With a sudden deterioration in their level of consciousness
  • Who are unconscious on arrival to hospital
  • Post first seizure

During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must revert to ½ hourly neurological observations and seek URGENT medical review. Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.

Under no circumstances should Neurological observations be omitted because the patient is asleep.

Intracerebral/Subarachnoid Haemorrhage OR Stroke
  • Acute Primary Intracerebral/Subarachnoid  haemorrhage
  • Any other Ischaemic stroke 
  • Post Thrombolysis /Thrombectomy for Stroke patients only

During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must seek URGENT medical review and revert to ½ hourly neurological observations as a minimum, or ¼ hourly, if still within the first 2 hours post thrombolysis.

Under no circumstances should Neurological observations be omitted because the patient is asleep.