Category: Resus

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).

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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

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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)

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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 [6-8weeks] – referral form attached tho the PDF

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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

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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

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.

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

 

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.”

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