Category: Dept. Docs.

Suspected Cauda Equina Syndrome CES

1. Red Flags: Has the patient developed any of the following?

  • Difficulty initiating micturition or impaired sensation of urinary flow
  • Altered perianal, perineal or genital sensation S2-S5 dermatomes – area may be small or as big as a horses’ saddle (subjectively reports or objectively tested)
  • Severe or progressive neurological deficit of both legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
  • Loss of sensation of rectal fullness
  • Sexual dysfunction (achievement of erection or ability to ejaculate, loss of genital sensation)

If Yes to ANY proceed to 2.

If NO to ALL consider other diagnosis and possibility of GP follow-up

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Massive Transfusion Pathway

In the case of patient with Massive Haemorrhage weather that be from Trauma, Surgical, O&G, UGIB, you can activate the MTP

Remember:

  • Do the Basics – don’t forget ABCD
  • Inform Transfusion and get someone to run a G&S sample down
  • FFP can take up to 45min and platelets come from Leeds
  • If you no longer need the MTP – inform transfusion and return products ASAP
major haemorrage

PDF:MTP

 

Concealed Illicit Drugs

Background

Those suspected of concealing illicit drugs often present near ports and borders however they can present to any ED or be brought in by the police.

Body Packers – Swallow large quantities of well packaged drugs to smuggle them into countries or institutions.  These are often well manufactured with a low risk of rupture but the potential for serious toxicity if rupture occurs.

Body Stuffers – Swallow small quantities of poorly packaged illicit substances often at the point of arrest to conceal them. These have a much high risk of package rupture but involve smaller quantities of substances.

 

Investigations

Authorisation for an intimate search or radiological investigation must come from an inspector or higher with written consent from the patient.

Intimate searches must be carried out by a police surgeon but require immediately available resuscitation facilities therefore may be conducted in the ED. ED physicians should not handle the drugs at any time.

AXR or low dose CT scanning can be used to detect concealed packages in Body Packers.

 

General Management

Try to obtain a history of what and how much has been concealed

Look for toxidromes suggestive of package leak –

  • Cocaine: Tachycardia, hypertension, agitation, diaphoresis, dilated pupils, hyperpyrexia, seizures, chest pain, arrhythmias and paranoia.
  • Heroin: pinpoint pupils, respiratory depression, decreased mental state, decreased bowel sounds
  • Amphetamines : – Nausea, Vomiting, Dilated Pupils, Tachycardia, Hypertensions, Sweating, Convulsions and the development of non-cardiogenic pulmonary oedema

ECG

Body Stuffers should be observed for signs of toxicity for a minimum 6 hours, consider activated Charcoal

Body Packers with positive imaging who are asymptomatic can be discharged back to police custody for monitoring. Bowel preparation such as Cleanprep or movicol can be used.

Toxidromes should be treated as per toxbase guidelines Toxbase

Body Packers with signs of cocaine or amphetamine toxicity or signs of obstruction/ileus require urgent surgical intervention.

Body packers with signs of Heroin toxicity should be treated with Naloxone infusion as per toxbase guidelines

 

Algorithms

 

 

Full RCEM Guide

Surgery Referral Pathway

Introduction

The Surgical and ED teams have worked closely to provide an agreed process, to aid patient flow through the ED and help to maintain our acute beds for those patient who need them.

Between 07:00-18:00 SDEC should be utilised as much as possible for those  patient who may not require admission. If you have any doubts contact the SDEC sister

SDEC exclusion criteria
  • Any patients with symptoms of or recent contacts with Covid-19 infection
  • Diarrhoea and/or vomiting
  • NEWS 4+
  • Any patient requiring oxygen treatment
  • Non-ambulant patient
  • Outlying non-surgical patients (Medicine, Orthopaedic referrals from HRI)
  • Acute vascular pathology (suspected AAA, Acute Limb Ischaemia, Diabetic Foot Sepsis)
  • Haemodynamically unstable PR bleed / Large volume witnessed PR bleed
  • Trauma patients with GCS < 15 
  • Patients with head injury or who require neurological observations
  • Suspected cauda equina-refer to CES pathway
Streaming to SDEC
Between 7AM and 6PM, the following groups of patients can be referred directly to the SDEC Nurse-In-Charge (NIC) from the ED Triage Nurse without ED doctor review (if conditions 1-3 fulfilled)
  1. ANY of the following conditions
  2. Do not meet any of the SDEC exclusion criteria
  3. Had relevant bloods and preferably a cannula (see SDEC bloods)

Conditions

  • Upper abdominal pain in Patients with known gallstones
  • Lower abdominal pain in patients aged between 16 and 50
    • With a negative pregnancy test and no PV bleeding (in female patients)
    • No prior history of inflammatory bowel disease or liver disease (in all patients)
  • Small volume red rectal bleeding in a haemodynamically stable patient

    • ‘Small volume’ rectal bleed includes bleeding predominantly on the toilet paper, <200mls, maximum of two bleeds prior to ED attendance, haemodynamically stable, no evidence of collapse/dizziness. If in doubt, speak to the NIC

    • Absence of melaena – a PR examination by ED clinical is required

  • Post-operative wound problem who have had general surgery, breast, urology or plastic surgery operations over the past 4 weeks
    • (triage nurse to have details of name of operation at time of referral to SDEC nurse)
  • Abscesses; Peri-anal, Pilonidal, Back or Chest
    • Limb abscesses should be referred to Orthopaedics
    • Groin abscesses in IVDU patients should be assessed by an ED doctor to ensure correct referral to general or vascular surgery.
    • Patients who are not septic with ‘general surgery’ abscesses who present outside SDEC opening hours can be discussed by the triage nurse with the SAU NIC. If the patient is stable, they can be sent home and asked to return to SDEC at 7AM once all the details have been given to the SAU NIC. The patients should be asked to fast from 2AM but can drink clear water up to 6AM.
  • Patients with known umbilical or groin hernia – presenting with worsening symptoms from their hernia
SDEC Streaming Bloods

Blood test requirements:

  • Abdominal pain: FBC, U+E, LFT, CRP, Amylase, Clotting Screen
  • Rectal bleeding: FBC, U+E, CRP, Clotting Screen
  • Wound problem: FBC, U+E, CRP
  • Abscess: FBC, U+E, CRP
  • Hernia: FBC, U+E, CRP, Clotting Screen
Surgical Referrals – (Non-Streaming Patients)

All other surgical referrals should be referred as normal to the surgical team. For patients who require an in-patient bed:

  • If the surgical team need a CT / Ultrasound to aid decision-making, this may be facilitated or requested in ED. If the surgical registrar feels that the patient may not be suitable for surgical admission, they should contact the on-call surgical consultant before the CT result is obtained to obtain a rapid in-reach surgical consultant review and aid appropriate transfer out of ED
  • If the surgical team feel the referral is inappropriate or unclear (or more likely to need a different specialty), senior surgical review will be delivered within 30 minutes of referral in ED with three possible outcomes (accept onto Surgery, discharge home, Surgical team to make onwards referral as necessary)
  • Criteria for contacting the on-call surgeon include:
    • Delays or difficulties in contacting the surgical team (often due to theatre or other acute pressures)
    • Delay in treatment or surgical review or indecision/disagreement on destination of the patient
    • Consultant surgical opinion should be sought early if needed by the senior ED doctor or sister in charge to avoid delays
    • The first port of call should be the first on consultant (day or night, depending on the time) and if unavailable, the second on-call consultant should be called
    • At CRH the surgical consultant can arrange for review by the “Sub-Acute surgeon”

If patients require urgent surgical assessment and/or treatment at CRH and no bed is available at HRI, the patient must be transferred immediately to HRI ED for surgical assessment

CRH ED to HRI Surgical pathway
  • Patient at CRH referred to surgeons (registrar or on-call consultant) and requires CT
  • Send for CT
  • Ambulance booked and patient transferred to HRI P2 (without result) – communication with CSM to determine patient destination.
  • Arrive at HRI, CSM to have allocated placement for the patient prior to arrival, considering placement in the following order:
  1. Admit to SAU
  2. Move SAU patient to Ward 10, birth centre or elsewhere
  3. Open full capacity bed on SAU
  4. Transfer to Theatre Recovery (Surgical nurse to support from SAU or Ward 10)
  5. HRI ED