Category: Resus

0-12yrs WETFLAG

Tips: 

  • If particularly BIG – go up 1-2 yrs
  • If particularly SMALL – go down 1-2 yr
  • Prepare ET Tubes 0.5mm bigger and smaller
  • Chid’s weight known – specific calculations can be found after tables.

Boys 0-14yrs

AgeBirth1mth3mth6mth12mth18mth2yr3yr4yr5yr6yr7yr8yr9yr10yr11yr12yr14yrAge
Weight3.5kg4.5kg6.5kg8kg9.5kg11kg12kg14kg16kg18kg21kg23kg25kg28kg31kg35kg43kg50kgWeight
Energy20J20J30J30J40J40J50J60J60J80J80J100J100J120J130J140J150J150JEnergy
Tube 3.0/3.5mm3.5mm3.5mm4mm4.5mm4.5mm4.5mm5mm5mm5.5mm5.5mm6mm6mm6.5mm6.5mm6.5mm7.5mm8mmTube
Fluid-Medical70ml90ml130ml160ml200ml220ml240ml280ml320ml360ml420ml460ml500ml500ml500ml500ml500ml500mlFluid-Medical
Fluid - Trauma 35ml45ml65ml80ml100ml110ml120ml140ml160ml180ml210ml230ml250ml250ml250ml250ml250ml250mlFluid-Trauma
Lorazepam 0.4mg0.5mg0.7mg0.8mg1.0mg1.1mg1.2mg1.4mg1.6mg1.8mg2.1mg2.3mg2.5mg2.8mg3.1mg3.5mg4.0mg4.0mgLorazepam
Adrenaline 1:10'0000.4ml0.5ml0.7ml0.8ml1.0ml1.1ml1.2ml1.4ml1.6ml1.8ml2.1ml2.3ml2.5ml2.8ml3.1ml3.5ml4.3ml5.0mlAdrenaline 1:10'000
Glucose 10% (ml)10ml13ml19ml24ml28ml33ml36ml42ml48ml54ml63ml69ml75ml84ml93ml105ml129ml150mlGlucose 10%

Girls 0-14yrs

AgeBirth1mth3mth6mth12mth18mth2yr3yr4yr5yr6yr7yr8yr9yr10yr11yr12yr14yrAge
Weight3.5kg4.5kg6kg7kg9kg10kg12kg14kg16kg18kg20kg22kg25kg28kg32kg35kg43kg50kgWeight
Energy20J20J30J30J40J40J50J60J60J80J80J90J100J120J130J140J150J150JEnergy
Tube 3.0/3.5mm3.5mm3.5mm4mm4.5mm4.5mm4.5mm5mm5mm5.5mm5.5mm6mm6mm6.5mm6.5mm6.5mm7.5mm8mmTube
Fluid-Medical70ml90ml120ml140ml180ml200ml240ml280ml320ml360ml400ml440ml500ml500ml500ml500ml500ml500mlFluid-Medical
Fluid - Trauma 35ml45ml60ml70ml90ml100ml120ml140ml160ml180ml200ml220ml250ml250ml250ml250ml250ml250mlFluid-Trauma
Lorazepam 0.4mg0.5mg0.6mg0.7mg0.9mg1.0mg1.2mg1.4mg1.6mg1.8mg2.0mg2.2mg2.5mg2.8mg3.2mg3.5mg4.0mg4.0mgLorazepam
Adrenaline 1:10'0000.4ml0.5ml0.6ml0.7ml0.9ml1.0ml1.2ml1.4ml1.6ml1.8ml2.0ml2.2ml2.5ml2.8ml3.2ml3.5ml4.3ml5.0mlAdrenaline 1:10'000
Glucose 10% (ml)10ml13ml18ml21ml27ml30ml36ml42ml48ml54ml60ml66ml75ml84ml96ml105ml129ml150mlGlucose 10%

Calculations

  • Energy (J) [max 150J] =4 x Weight(kg)
  • Fluid Medical (ml) = 20 x Weight(kg)
  • Fluid Trauma (ml) = 10 x Weight(kg)
  • Lorazepam (mg) [max 4mg] = 0.1 x Weight(kg)
  • Adrenaline 1:10’000 (ml) [max 10ml] = 0.1 x Weight(kg)
  • Glucose 10% (ml) = 2 x Weight(kg)

Information from APLS Aide-Memoire

 

1. HAZMAT – First Contact

REMOVE – REMOVE – REMOVE

Remove Them..

At reception ask them to go outside to designated area and staff will be with them shortly. Inform Nurse in Charge!

Remove Clothes..

Use the disrobing card to get the patient to safely remove and bag up clothes. Do your best to maintain privacy. CARD HERE

Remove Substance..

If we have ample warning or the number of patients will be significant, it may be worth deploying the decontamination tent but remember setting this up is time consuming.

2. HAZMAT – Suspected Contamination Incident

So a patient comes to ED after white powder thrown is at them what do you do? Your initial response can help them and everyone in the department!

  1. Ask them to leave the department
    • Going to garage was useful
    • Inform Nurse in Charge and Consultant
  2. Dynamic risk assessment
    • Performed by nursing/medical staff while outside
  3. Decontaminate
  4. Return to ED

If you haven’t seen the Initial Operational Response (IOR) training video please watch it.

The patient can then be thoroughly assesses, to identify the substance involved (this may involve witnesses, police info and symptomatology), and treated appropriately.

Police should be informed of the incident for several reasons: 1. Public safety, 2. To collect the evidence and possible find out what it was for you. (if this is not a criminal act Public health England can advise on return/disposal of personal effects)

Inform Manager On-Call of incident as it may disrupt the functioning of ED and can provide support.

 

Patient symptom-free and substance unknown

In our recent case Public Health England advised

  • 4-6hr observation
  • Discharge with advice:
    • “if developing symptoms to return to the ED via ambulance but the patient must be aware that they must inform 999 of the original exposure.”

Resourses

3. HAZMAT – CBRNe (Chemical, Biological, Radiological and Nuclear) incidents

NHS England, Public Health England and the Health Protection Agency have produced several very useful resources for us to use – BUT First.

Remove – Remove – Remove

Basics

Contacts

  • Health Protection Agency Teams – HERE
    • West Yorkshire
      • In hours: 0113 386 0300
      • Out of hours: 114 304 9843

  • ECOSA (Emergency Coordinated Scientific Advice System) – 0300 3033 493

  • UK NPIS – 0344 892 0111

Guides

Read more

A-a gradient

A-a gradient = Alveolar Oxygen – arterial Oxygen

This is “relatively” simple way of working out if the paO2 on a ABG is normal, and demonstrates V/Q mismatch well. V/Q mismatch is simple terms is either an area of the lung either under ventilated(pneumonia) or under perfused (PE). Read more

Acidosis & VBG’s

We are frequently asked to check the lactate on Venous Blood Gases (VBG’s), by the nursing staff. However, remember to look at the first result (pH) it is the most important.

Acidosis: Unless you have a good reason (e.g. you know its due to DKA) you should be investigating and performing an Arterial Blood Gas (ABG)

Read more

Acute Behavioural Disturbance / Excited Delirium

Most of us will have seen patients like this – agitated, aggressive and often with police or security pinning them down.

  1. High risk of Cardiovascular Collapse/Death – likely due to adrenaline surge, heat exhaustion and injury. It can happen very suddenly.
  2. Keep physical restraint to a minimum – Don’t allow patient to forced face down, it’s the most likely way of killing them.
  3. Sedation – if you’re restraining you will almost certainly need to sedate. IV is best but if access is too risky IM will have to do.
  4. Aggressive management of underlying issues – esp. hyperthermia and acidosis and look out for rhabdomyolysis and DIC

Refusing treatment = Mental Capacity Assessment [LINK]


DrugRouteTypical Dose (mg)Onset (min)Duration (min)Warning
MidazolamIV2-51-530-60Respiratory depression, IM unpredictable onset
IM510-15120-360
LorazepamIV2-42-560-120
IM415-3060-120
HaloperidolIV5-1010180-360Arrhythmia Risk: Only if previously used OR ECG
IM10-2015-30180-360
KetamineIV1-2mg/kg120-30Theoretical risk of worsening cardiovascular instability
IM2-4mg/kg3-560-90

PDF:abd

Anion Gap & Metabolic Acidosis

The anion gap (AG) represents the amount of unmeasured anions in the plasma.

AG =([Na]+[K]) – ([HCO3]+[Cl])

The main contributor to the AG is albumin (decreasing albumin by 1g/l reduces the AG by 0.25) so hypoalbuminaemia can falsely reduce the AG.

Corrected AG = AG + (0.25*(40-[albumin]))

(However, this relies on getting LFT’s back about 1 hour) Read more

Are You CO Aware?

With the onset of colder weather, many households in the UK are turning on their heating for the first time in months. Heating appliances need chimneys and flues to work safely – and these can block up over the summer months. So autumn is traditionally the period when people get poisoned by carbon monoxide (although it can happen any time of the year!)

Carbon monoxide (CO) is produced when anything containing carbon burns or smoulders. For practical purposes, this means the burning of any kind of fuel, commonly:

  • Gas
  • Coal
  • Wood/Paper/Card
  • Oil/Petrol/Diesel – (All UK cars have a ‘catalytic converter’ in the exhaust system, which converts carbon monoxide (CO) to carbon Dioxide (CO2), which is less poisonous. However, these converters need to warmed up – a cold car produces fatal amounts of CO in the exhaust)

CO is very poisonous. Exposure to as little as 300 parts per million (that’s just 0.03%) can prove fatal.

Read more

Atrial Fibrillation/Flutter (AF)

Before you start 

  • Whats the cause? – treating the precipitant often sorts the AF (adding B-Blockers to Sepsis can make things worse)
  • Stable or Unstable?  – Electricity vs. Drugs
  • CHADS-VASC vs. ORBIT– Anticoagulation (previously HAS-BLED)
  • Rhythm vs. Rate control??
  • NEW Symptomatic Arrhythmia Clinic – referral form attached tho the PDF

Read more

Burns Referral Pathway

A new burns referral pathway has been developed with Mid Yorks to securely send images of the patients burn. Allowing the burns team to arrange the most appropriate follow-up for your patient.

This requires BOTH online referral & phone call

The Process

  1. GoTo –  Burns Homepage (NHS computers ONLY)
  2. Select – New Referral (NO login required)
  3. Complete – the following sections (* means required field)
    • Referrers Details – you will need an NHS email address
    • Patient Details
    • Injury Details – Answering “Yes” to airway burns or fluid resuscitation will open further boxes
    • Additional Details – Patient’s phone number and address (only appears if NO airway or resuscitation issues)
  4. Checklist – Ensure ALL completed and submit
  5. Sending an Image – After submission a QR code will appear to send an image you will need to us the SID App
    • Launch the SID App on mobile device – Yours or ED Co-Ordanator (apple/android)
    • Scan the QR code
    • Consent the patient – Patient Information Leaflet
    • Take Photo of Injury  – this will not be saved on the device
  6. Phone Burns team – They can review the details and images and better advise you on management.

Resources

C-Spine Injury

C-spine injury ranges from the obvious fracture-dislocation to the less obvious ligamentous injury, affecting about 2.5% of blunt trauma patients. However, ALL of them are serious and can lead to life changing injuries, that we obviously don’t want to miss.  Unfortunately reported miss rates range from 4-30%. [IJO 2007]

Read more

COVID-19 (Awake Self-Proning)

There is increasing evidence that Awake Self-Proning of our Covid-19 patients can improve oxygenation. Proning the patient can has several effects which can dramatically improve their SaO2

  • Improves Ventilation to back of the lung (the back of the lung contains more alveoli than the anterior lung)
  • Improves Perfusion – as blood supply to the back of the lung is always better than the front
  • Improves Clearance of secretions
  • Be patient can take 15-20min

Contraindications (all seem obvious)

Absolute contraindications:

  • Respiratory distress (RR ≥ 35, PaCO2 ≥ 6.5, accessory muscle use) 
  • Immediate need for intubation 
  • Haemodynamic instability (SBP < 90mmHg) or arrhythmia 
  • Agitation or altered mental status 
  • Unstable spine/thoracic injury/recent abdominal surgery 

Relative Contraindications: 

  • Facial injury 
  • Neurological issues (e.g. frequent seizures) 
  • Morbid obesity 
  • Pregnancy (2/3rd trimesters) 
  • Pressure sores / ulcers 

 

COVID-19 (Paediatric multisystem inflammatory syndrome)

AKA: Paediatric Inflammatory Multi-system Syndrome – Temporally associated with SARS-CoV 2 

Although COVID-19 seems a benign disease in almost all children there are increasing evidence (however rare) of a “Paediatric multisystem inflammatory syndrome”. This is a RARE and newly emerging condition and there are many questions still e.g. It is currently unclear if it is directly related to the COVID-19 pandemic.

Read more

COVID-19 (X-Ray learning resource)

British Society of Thoracic Imaging (BSTI) have released a free learning resource containing CXR and CT of confirmed Covid-19 cases, will short history including time image was taken from onset of symptoms.

From the China experience CXR/CT doesn’t seem to be a rule out strategy in ED at the moment – However, its a useful resource to help recognition of Covid-19 CXR’s

BSTI Covid-19 image bank

 

CPAP Set-Up

NIPPV 3 machines are used throughout the trust to deliver NIV and CPAP – and should be commenced in ED if transfer to ward/ICU is adding significant delay

  • NIV/CPAP  is NOT an Aerosol Generating Proceedure (AGP) [as of Sept 2022]
  • CPAP/EPAP levels of 8-15cmH2O

This video demonstrates how to set up CPAP on the NIPPV 3

 

Domestic Abuse

Domestic abuse can affect anyone and often its not readily disclosed on an ED admission. We must be alert to the fact some of our patients may be attending with domestic abuse. Please explore concerns and escalate if you’re unsure. Our colleagues in the Pennine Domestic Violence Group have kindly drawn this a guidance up for us.

Read more

ECG placement & mis-LEADing ECG’s

  • V1: 4th intercostal space (ICS), RIGHT margin of the sternum
  • V2: 4th ICS along the LEFT margin of the sternum
  • V4: 5th ICS, mid-clavicular line
  • V3: midway between V2 and V4
  • V5: 5th ICS, anterior axillary line (same level as V4)
  • V7: Left posterior axillary line, in the same horizontal plane as V6.
  • V8: Tip of the left scapula, in the same horizontal plane as V6.
  • V9: Left paraspinal region, in the same horizontal plane as V6.

Read more

EMBRACE & Paediatric Critical Care

In our trust we don’t have paediatric critical care beds. However, in our region we use EMBRACE (a paediatric critical care transport team), who can transfer critically  ill children to specialist centers (in or out of region).

EMBRACE

Y&H Paed Critical Care

Drugs:

  • Trust guide
  • Remember: Midazolam 10mg/2ml is used(not the 5mg/5ml we have  in ED)

 

Emergency Tracheostomy/Laryngectomy Management

Occasionally patients with Tracheostomy or Laryngectomy present with difficulty breathing due to problem. As this is rare for us in ED, this situation can be very difficult for all of us. However the protocols below can help.

 

Tracheostomy

Tracheostomy is simply a passage from the neck into the trachea. In most cases the trachea will still be connected to the nose and mouth (so can breath though their mouth too).

Read more

Head Injury

Background

  • Defined as any traumatic injury to the head other than superficial facial injuries.
  • The commonest cause of death and disability in people age 1-40 in the UK.
  • Account for 1.4 million ED attendances each year, 95% of these are minor head injuries that can be managed in the ED.

Read more

Hyperkalaemia

Remember: is it a haemolysed blood sample? (you can do an iSTAT)

Severity

  • Mild: 5.5-5.9mmol/l – No urgent action required (Dietary & Medication modification & GP F/U)
  • Moderate: 6.0-6.4mmol/l – Follow treatment guide (maybe suitable for discharge)
  • Severe: ≥6.5mmol/l OR ECG changes – Follow treatment guide, must admit

Read more

Hyponatraemia

Hyponatraema is a common finding, especially within our elderly population. However, its significance is is not a simple numbers game, and needs senior input. Prior to treatment the following need to be considered and balanced.

  1. Symptoms Severity – these are not exclusive to hyponatraemia and may be due to other disease processes (esp. if the low sodium is long-term)
  2. Sodium Level – the sodium concentration doesn’t always correlate to the clinical picture, and is dependant on speed of change, and co-morbidities
  3. Rate of Drop – the faster sodium levels drop the more symptomatic the patient often is (i.e. with long term hyponatraema the patient may be profoundly hyponatraemic but asymptomatic)
  4. Co-morbidities – Increasing sodium too quickly risks osmotic demyelination. How well will the patient cope with treatment?

Emergency treatment (hypertonic saline) is generally indicated in those with Severe Symptoms ONLY

Read more

Hypothermia

Remove COLD, Add WARM, Don’t SHAKE

  • 32-35ºC [Mild] – Shivering, Tachycardia, Tachypnoeic, Vasoconstriction
  • 30-32ºC [Moderate] – Shivering stops, Pale/Cyanosed, Hypotensive, Confused, Lethargic
  • <30ºC [Severe] – Low GCS, Bradycardia/pnoeic, Hypotensive, Arrhythmias, Cardiac Arrest

Read more

Hypothermic Arrest [Adult] – European Resus Council Guidance 2021

True Hypothermic Arrest is thankfully rare in the UK. However, when it does happen it is resource intense and prolonged. The ERC 2021 guidance has introduced a new decision step HOPE score to the algorithm, once the Initial phase of resuscitation has been completed without ROSC.

If the is HOPE score is <0.1  the team may which to consider terminating CPR [Warning: Adults ONLY Children have better survival] Read more

Ingested Magnets

Ingestion of Strong Magnets is a TIME CRITICAL EMERGENCY

(Multiple Magnets OR a single Magnet and Metallic Objects)

Strong magnets  (such as Neodymium)

  • Now common place around the house
  • From; fridge magnets to toys and peicings

Ingested:

  • Intestinal injury can occur within 8-24 hours
  • However, symptoms may take weeks to develop
  • Symptomatic patients are a SURGICAL emergency

Detection:

  • Use X-Ray (NOT metal detectors)
  • May require AP and lateral images to see how many

RCEM recommendation (best practice)

Read more

Intranasal Fentanyl

There is currently a national shortage of Intranasal Diamorphine therefore we are using Intranasal Fentanyl as a replacement.

Dose is 1.5micrograms/Kg for the initial dose and 0.75micrograms/kg 10 minutes later if required.

Drug Delivery

Draw up the appropriate dose plus 0.1ml to allow for the dead space in the Mucosal Atomizer Device

Attach the MAD to the syringe

Sit the child at 45 degrees insert MAD loosely into the nostril and press the plunger

Doses greater than 0.5ml should be split between 2 nostrils

 

Contraindications

  • Blocked nose due to upper respiratory illness or epistaxis
  • Respiratory depression
  •  Hypovolaemia
  • Altered consciousness
  • Hypersensitivity to fentanyl
  •  Children below 1 year old

Full Intranasal Fentanyl SOP

LA – Toxicity

We are regularly doing femoral blocks next to major vessels. So warn the patient of the symptoms, & keep them monitored(at least 15 min).

Symptoms of local anaesthetic toxicity

  • Circumoral and/or tongue numbness
  • Metallic taste
  • Lightheadedness/Dizziness
  • Visual/Auditory disturbances (blurred vision/tinnitus)
  • Confused/Drowsiness/Fitting
  • Arrhythmia
  • Cardio-Resp Arrest

Remember – Do basics WELL

Intralipid – in antidote cupboard (Green Majors treatment room)

    1. Bolus – 1.5ml/kg 20% lipid solution over 1min
    2. Then start Infusion – 15ml/kg/hr 20% lipid solution
    3. 5 mins reassess if Cardiac instability/deterioration
      • Rpt Bolus 1.5ml/kg over 1min (max 3 boluses inc. initial)
      • Increase infusion rate – up to 30ml/kg/hr
      • Total Max dose 12ml/kg

Propofol is not a suitable substitute for lipid emulsion

Without Cardio-Resp Arrest

Use conventional therapies to treat:

  • Seizures
  • Hypotension
  • Bradycardia
  • Tachyarrhythmia (Lidocaine should not be used as an anti-arrhythmic therapy)

In Cardio-Resp Arrest

  • CPR – using standard protocols (Continue CPR throughout treatment with lipid emulsion)
  • Manage arrhythmias – using standard protocols
  • Consider the use of cardiopulmonary bypass if available
  • Recovery from LA-induced cardiac arrest may take >1 h
  • Lidocaine should not be used as an anti-arrhythmic therapy

PDF:la_tox

 

Lateral Canthotomy

Like tension pneumothorax the biggest step is deciding to do it – Remember it it sight saving and they heal well

Retrobulbar Haematoma secondary to blunt eye injury is a a rare but potentially sight threatening injury.

  • Blood collects in the retrobulbar space
  • Pushing the eye forward to accommodate the extra volume.
  • The Orbital Septum (made up of the eyelids and ligaments that attach them to the orbital rim) restricts this forward movement, creating a compartment syndrome for the eye. Thus threatening the patients sight if not treated quickly.

Recognition

From Royal College Ophthalmologists

  • Severe pain
  • Red/Congested conjunctiva
  • Exophthalmos with proptosis – eye pushed forward
  • Internal ophthalmoplegia – impairment or loss of the pupillary reflex.
  • Visual flashes
  • Loss of vision – initially colour vision (esp. red), progressing to local visual loss.

However, this may only be recognised on CT if there is significant facial injury and altered conscious level.

Treatment

Call Ophthalmology immediately to attend. If there is going to be any significant delay, it may be necessary for ED to preform a Lateral Canthotomy, to allow the eye to move forward, reduce the orbital pressure & preserve the patients sight.

Kit needed

  • Lidocaine with adrenaline (needle & syringe)
  • Clamp – ideally curved to crush the tissues
  • Forceps
  • Scissors

Resources

LVAD – Resus & Troubleshooting

ctsurgerypatients.org

LVADs (Left Ventricular Assist Device) are becoming more common and there are patients in our region with them as a bridge to transplant or recovery and in some cases a destination therapy.

The patient and their family will likely know more about this device than you and should have brought spare parts. Our local LVAD centre is Wythenshaw however, there are other units around the country the patient may direct you to.

The patient may not have a palpable pulse, the blood pressure will be low and the heart pump sounds like a buzz when you listen.

If patient is unresponsive or has a history of collapse its important to troubleshoot the device and resusitation may be required

Read more

Major Trauma Network

We are part of the West Yorkshire Major Trauma Network with our MTC at LGI

WYMTN: Guides

We know that from time-time patient are brought to us and we find injuries that are more appropriate to manage at the MTC. This is inevitable as the on scene triage tool is never going to identify every major trauma patient – this is a failing of the tool not the crew. The decision tree below can help you  arrange transfers in the most timely and appropriate manner. Read more

Major Trauma: STOP>SORT>GO

YAS crews may on occasions (rarely) bring us a Major Trauma patient that meets the criteria for bypass to the MTC because they have a problem that the crew cannot manage, or they won’t survive to LGI e.g. an unmanageable airway/ incompressible haemorrhage. In these instances we will get a pre-alert either from the crew or more likely the Major Trauma Triage Co-ordinator in EOC with some information but primarily the reason the patient is coming to us.

Read more

Malignant/Accelerated Hypertension

There are several terms commonly used “Accelerated Hypertension”, “Hypertensive Emergency”, “Malignant Hypertension”. They all have a very similar definition (ESC/ESH, NICE, ACEP)

Patient has both:

  1. Blood pressure: Systolic ≥180mmHg OR Diastolic ≥110mmHg (often >220/120mmHg)
  2. End-Organ Damage: Retinal Changes, Encephalopathy, Heart Failure, Acute Kidney Injury, etc.

Mortality has improved in recent years with 5yr survival of 80% if treated. However, untreated average life expectancy is 24 months.

Read more

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

 

Methaemoglobinaemia

Q: Why are Smurf’s Blue? 

A: Methaemoglobin (MetHb) of course!

– MetHb is produced by oxidisation of the Iron in Haemoglobin (Hb) from Fe2+ to Fe3+

– Fe3+ prevents Hb carrying oxygen (thus produces symptoms of hypoxia)

– Often due to chemical ingestion, but may also be genetic

– Treated with Methyl Blue & supportive measures

Read more

Myocardial Infarction (MI) – PPCI/Thrombolysis

PPCI (Leeds PPCI Pathway)

  • Target: Door to balloon 90min
  • Criteria:
    • Time: Chest pain within 12hrs (or worsened within 12hrs)
    • ECG:  ST elevation MI (1mm Limb or 2mm Chest leads) OR New LBBB. (Posterior MI do posterior leads and discuss with LGI)
  • Actions:
    • Resuscitate
    • Contact PPCI team @ LGI (Mobile No. up in Resus)
    • Arrange blue light (P1) ambulance to LGI
    • Prasagrel 60mg if no previous CVA or Ticagrelor 180mg if previous CVA and Aspirin 300mg (if anti-coagulated Discuss with PCI team)
  • Problems: 
    • Intubated patient: Often LGI would accept but need to arrange Cardiac ICU. If no bed patient could go for PCI to return locally immediately after PCI to our ICU’S?
    • LGI Full: Occasionally the cath lab is full and can’t accept your patient
      • Calling Manchester and Sheffield: It’s worth a go but they don’t have agreements with us  so having your patient accepted can be difficult
      • Don’t Forget Thrombolyisis: We need to open up the patients artery, if there is no quick decision to go for PPCI – Consider Thrombolysis

Read more

Necrotising Fasciitis

Necrotising fasciitis (NF) is a rare but serious bacterial infection that affects the soft tissue and fascia (Fournier gangrene, is NF affecting the perineum). In many cases NF progresses rapidly and early recognition and treatment is vital to halt progress. The mainstay of treatment is IV antibiotics and aggressive surgical debridement. Any delay increased the amount of tissue loss as well as the mortality. Read more

Neonatal Seizures

Seizures are a common neurological emergency in the neonatal period, occurring in 1–5 per 1000 live births.1 The majority of neonatal seizures are provoked by an acute illness or brain insult with an underlying aetiology either documented or suspected, that is, these are acute provoked seizures (as opposed to epilepsy). They are also invariably focal in nature.

Clinical diagnosis of neonatal seizures is difficult. This is in part because there may be no, or very subtle, clinical features, and also because neonates frequently exhibit non-epileptic movements that can be mistaken for epileptic seizures.

Read more

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.

NIV (Non Invasive Ventilation)

NIV should be considered for use in patients with a  persisting Acute Hypercapnic Respiratory Failures after a maximum of one hour of standard medical therapy.

  • Complete the Ad-hoc form
  • Increase pressures from Initial 12/5 cmH2O to 20/5cmH2O – as tolerated over 1st hour

However, ICU should be contacted early if the patient has one of the following:

  • Asthma – Intubation the option of choice in Life threatening
  • Pneumonia – NIV should only be considered as a bridge to intubation
  • No pre-exisiting respiratory issue – NIV not likely helpful
  • pH <7.25 (low threshold for ICU input)
  • pCO2 >6.5kPa (low threshold for ICU input)
  • Type 1 Respiratory Failure (low threshold for ICU input)

Read more

Obstetric Emergencies at HRI

Pregnant patients with Severe Life threatening conditions e.g serious trauma, cardiac arrest, serious medical condition

  • Manage as per ALS/ATLS/MOET guidance (Don’t forget uterine displacement manually).
  • Complete triage of patient and assess fetal gestation and viability. This is not primarily to assess fetal well-being but to influence maternal management
  • Obstetric/Gynae Registrar to be fast bleeped and to attend resus as soon as possible. If they are not contactable or unable to immediately attend, contact the on-call obstetric consultant.
  • Phone the midwifery LDRP coordinator on Tel 01422 223524
  • Senior midwife to accompany SpR.
  • Prepare resus area for emergency caesarean section (equipment in ED).
  • Call the obstetric consultant on call if not already done.
  • Contact the neonatal unit if delivery is imminent. (But do not delay delivery awaiting neonatal team’s arrival)

 

Pregnant patients with a major medical illness potentially requiring admission, e.g. severe asthma/suspected PE

  • Manage as per normal protocols for that condition.
  • Obstetric/Midwifery input may be required, therefore contact the LDRP Coordinator telephone 01422 223524.
  • Dependent on the clinical situation, appropriate specialty team to review and/or inform the consultant of admission.
  • Daily review/status check of the patient in relevant clinical areas.

 

Minor injury or medical illness not necessarily requiring admission, e.g. minor fracture or mild asthma attack

  • Manage as per normal protocols and treat as appropriate.
  • If there are no fetal or obstetric concerns, discharge as appropriate.
  • Pregnant women attending less than 16 weeks to be discussed with the Early Pregnancy Assessment Unit( EPAU)
  • All pregnant women attending ED with reduced fetal movements should be referred to either the Maternity Assessment Centre (MAC) as soon as possible.
  • If there is a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of a knock to the abdomen or abdominal pain or concerns or anxiety; then an antenatal review would be indicated by an obstetric/gynae doctor or midwife.
  • It may be appropriate for the women to be reviewed in ED or Maternity Assessment Centre (MAC) after discussion with a midwife, the obstetric registrar or SHO on call. If the woman is to be reviewed in MAC or other maternity areas she should be escorted to the area.
  • NB: have a low threshold for suspected thromboembolic disease and possibly escalate

 

Stable women with an obstetric problem with no other issues, e.g. labour, PV bleeding, abdominal pain, reduced foetal movements, raised blood pressure, or headache

  • All pregnant women attending with reduced ED with reduced fetal movements should be referred to either the Maternity Assessment Centre (MAC) or Antenatal Day Unit (ANDU) as soon as possible.
  • Contact the maternity unit via the midwifery co-ordinator on LDRP Tel 01422 223524
  • Transfer to ANDU/MAC/LDRP as advised by above.
  • If the woman is to be reviewed in ANDU/ MAC/ LDRP she should be escorted to the area.
  • Pregnant women attending less than 16 weeks to be discussed with the Early Pregnancy Assessment Unit (EPAU)
  • Ensure the woman has booked for maternity care. If she has not booked for care she should be asked to arrange the booking appointment

 

If these women have presented during working hours the on call registrar (bleep 509) can assess if the patient can be managed in ANDU at HRI depending on gestation and severity of symptoms. Out of hours contact MAC or LDRP at CRH.

 

Pregnant patients who have attempted suicide or presented with a psychiatric problem

  • Contact the mental health liaison team to come and review the patient
  • Psychiatric services to be contacted following the Guideline for. The Care of Pregnant Women Suffering Maternal Mental Health Problems available on the Intranet.
  • Associated injuries/illness to be treated appropriately as per previous categories.
  • If there is a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of abdominal trauma or abdominal pain, call the obstetric Registrar on call for advice and possible review.
  • The on call team should inform the patient’s consultant or assign a consultant as per unit policy.
  • Contact the LDRP co-ordinator Tel 01422 223524 to inform community midwifery team and Perinatal Mental Health Lead.
  • Antenatal follow-up (with community midwife or consultant as appropriate) appointment to be arranged within 10 days of discharge from hospital or psychiatric care.

 

Pregnant patients who present as victims of domestic abuse (suspected or confirmed)

  • Treat any injuries sustained as discussed depending on the category.
  • If there are any obstetric concerns, a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of a trauma to the abdomen or abdominal pain; or concerns raised by the woman then please contact the maternity unit via LDRP for advice and possible review.
  • Safeguarding protocols should be enacted, even if this is her first pregnancy.
  • Contact the LDRP co-ordinator Tel 01422 223524 to ensure community midwifery follow-up
  • Provide support and information, explaining that violent assault by a partner represents a real potential threat to her life in the future, the willingness of police to protect her and the availability of domestic abuse support organisations
  • Please refer to the Trust Midwifery Domestic Abuse Guideline available on the Intranet.

Paediatric – Time Critical Transfers (non-trauma)

Definition of a time critical transfer 

Transfer of a patient for life, limb or organ saving treatment when the time taken to provide this treatment is a critical factor in outcome. 

Principles 

  1. Acceptance by the regional centre is NOT dependent on bed availability. 
  2. Time critical transfer should normally be provided by the referring hospital team NOT Embrace. 

Read more

Paediatric Blast Injury

Save the Children, have published a used full guide on management on blast injuries in children. Taking you through pre-hospital, ED and inpatient care.

Although blast injury is rare in the UK it’s worth a read as an adjunct to APLS/ATLS training.

  • Recognising “Blast Lung” – which may be subtle initially and develop over hours (p51)
  • Prophylactic antibiotics
  • Compartment syndrome and fasciotomy (p105)
  • Burns Fluids and escharotomies (p112)

Ful Guide[PDF] – HERE

paed blast injy manual

Post ROSC CT Protocol

Within ED we often have little information about the patient we are resuscitating. Post-ROSC (return of spontaneous circulation )we commonly perform CT head, but evidence and Resus Council Guidance suggests extending this scan can pick up important pathology that can otherwise be missed (13%).

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Primary Intracerebral Haemorrhage

In anybody who there is suspicion of a non-traumatic haemorrhage arrange an urgent CT Head.

All patients need IV access and  U&E, FBC, Coag

If CT confirms PICH (not traumatic, not SAH): –

Anticoagulation

If anticoagulated with warfarin or NOAC discuss with stroke consultant and Haematologist regarding reversal

If not anticoagulated give Tranexamic acid – 1g in 100mls Saline/Glucose over 10 mins followed by 1g in 250mls Saline over 6 hours.

Blood Pressure

BP needs to be <150/80 – use labetalol (max 400mg – until BP <160 or HR <50) and GTN infusion

Neurosurgical Referral

Not all patients with intracerebral bleeds need referral to neurosurgery – you could save yourself and your patient a lot of time and effort!

Those to refer:

  • GCS 9-12/15 with lobar haemorrhage
  • Isolated intraventricual haemorrhage
  • Hydrocephalus on presentation
  • Rapid deterioration following arrival (gcs drop by 2 points or more in the motor component)
  • Cerebellar bleed

Admit those not going to Neurosurgery to HASU at CRH after discussion with Stroke team

Pulmonary Embolism – PE

PE is somehow both the most over and under diagnosed condition. with severity ranging from the questionable sub-segmental PE to the Massive PE (an indication for thrombolysis). So think:

  • Does this presentation sound like a PE? – If not STOP here
  • Pregnant?  – Click Here
  • Do you think this is likely a PE? (if so you can’t use PERC)
  • Does D-Dimer answer  your question? (whats the Wells)
  • Massive PE  – think Thrombolysis
  • Sub-Massive PE – there is lots of debate (involve seniors), locally needs 2 consultant sign off and not considered time critical.

Read more

Purple Glove Syndrome – Case

Is a rare complication of I.V. Phenytoin, which presents with a triad of: Pain, Oedema & Discolouration, typically in the hand.

In our case a child presented in status epilepticus, having received rectal diazepam from the ambulance crew, then 0.1mg/kg lorazepam in the ED, followed by 20mg/kg I.V. Phenytoin over 30 min, via a 24g cannula in back of the hand.

After intubation the patients thumb, index and middle fingers were all noted to be purple. Radial pulse was weak however, we saw good flow on ultrasound doppler in the ED. The patient had no cardiovascular Hx or FHx.

 

What the literature says

Mechanism (poorly understood)

  • Phenytoin is highly Alkaline and may induce vasoconstriction and thrombus, resulting in  leakage into the extravascular tissue.
  • Phenytoin may precipitated when it mixes with acidic blood (More common in status patients rather than prophylaxis)
  • I.V. Canulation may cause small tears promoting extravasation (In our case the cannula required repositioning on insertion)

Prevention

  • Phenytoin infusion rate should be the lesser of 1-3mg/kg/min OR under 50mg/min (In our case the infusion rate was 22mg/min, less than 1mg/kg/min)
  • Smaller hand veins should be avoided (As in our case, most reports in literature involve the use of hand veins)
  • Use 20G cannula or larger (This is ideal for adults and older children)
  • Ensure filter used with phenytoin infusions

Stages

  1. Dark purple – Pale blue discolouration occurs around or distal to injection site 2-12hrs after administration. (In our case approx 30 min)
  2. Discolouration and Oedema progresses around site and into fingers, hand and forearm over the next 12-16 hours
  3. Healing, starts at the periphery  moving towards the injection site – most patients have a full recovery over 72hrs (few cases of necrosis requiring amputation have been reported

Treating

  • Stop giving phenytoin
  • Dry Warm Heat (moist heat my contribute to skin breakdown)
  • Elevate
  • Analgesia
  • Regular neuromuscular assessments
  • Avoid Cold (this will worsen the vasoconstriction)
  • GTN patches have also been used in several of the cases but efficacy is unknown

Learning Points

  • Avoid Hand veins for I.V. Phenytoin (this seems to be a contributing factor form the evidence, be it due to small size or more frequent injury of the vein though need to reposition?)
  • Avoid Cannulas that required repositioning (increase chance of leaking)
  • Use a big cannula (easier said than done in a fitting child)

 

References

Rape & Sexual Assault

Don’t

Preform intimate examinations on Sexual assault/Rape patients

  • Unless life-threatening injuries are suspected e.g Haemorrhage.
  • As our examination will inevitably destroy evidence that may aid this patient’s case

Do’s

  • Consider contamination injury (HIV, HepB, HepC) – Guide
  • Consider emergency contraception
  • Children must have police referral for safeguarding
  • Refer to The Sexual Assault Referral Centre, either via Police or Self referral

Read more

Silver Trauma

The population is ageing and thus our ‘typical’ trauma patient is also changing. In 2017 the TARN report “Major injury in older people” highlighted the following issues:

  • The typical major trauma patient: has changed from a young and male to being an older patient.
  • Older Major Trauma Patients (ISS>15): A fall of <2m is the commonest mechanism of injury
  • Triage/Recognition of ‘Silver Trauma’ is POOR
    • Pre-hospital: Not identified hence taken to TU’s (Here) not MTC’s (Leeds).
    • The ED: Often seen by Junior Staff and endure significant treatment delays.
    • Hospital: Much less likely to be transferred to specialist care.
    • Outcomes: More likely to die, but those who survive have similar levels of disability to younger people.

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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

Transfusion Care Pathway

PDF: Transfusion Care Pathway

When giving blood products you need to use the transfusion care pathway.

It can be found on intranet > Policies & Documents Library >Other Systems [green button] > Clinical records repository > Search [title And transfusion] – its only 9 clicks away (and some writing)

TXA – Tranexamic Acid

TXA a bleeding wonder drug!

Crash 2 Study (2010)

  • Multi-Centre RCT of the use of TXA in trauma
  • Inclusion – Adult trauma patients with ≥1 of
    • Suspicion of significant haemorrhage
    • HR ≥110bpm
    • sBP ≤90mmHg
  • Treatment – 1g TXA IV over 10min then a second 1g TXA IV over 8hrs
  • Outcome – Significant reduction in Death, bleeding with NO increase in clots(thrombotic disease)
    • Most benefit seen if given early (<3hr – NNT 53)

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