Category: Surgical

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

Early Pregnancy Bleed <16/40

Bleeding in early pregnancy is a relatively common problem and in the many cases (esp. with spotting) the pregnancy remains viable. However, bleeding in early pregnancy should never be thought of as normal, and it is vital that we investigate this appropriately.

 

Communication is also vital at a very stressful time

  • Who you are discussing this pregnancy in front of? – Does the patient want them to know
  • Manage expectations – There is nothing we or mum can do to change the out come of the pregnancy apart from ensuring mum is well
  • Ensure the patient has all the details they need – Return advice, clinic time, where to go, what is happening
  • Be sensitive to the patients feelings – Patients respond very differently, be careful not to impose your emotions/assumptions on the situation

Think Anti-D!

Anti-D immunoglobulin guide

 

Search: ectopic pregnancy, Ectopic Pregancy, pv bleed, MISCARRIAGE, vaginal bleed, EPAU

Sore Throat

Background

Acute sore throats are often caused by a virus, last about a week and get better without antibiotics. withholding antibiotics rarely causes complications. Antibiotic stewardship is everyone’s responsibility to prevent resistance developing.

Assessment

Are there any concerns regarding airway compromise?  – If yes – transfer to resus, give high flow Oxygen, IV steroids, IV antibiotics, Nebulised adrenaline 1:1000, IV fluids, take bloods and refer to both anaesthetics and ENT registrar.

Otherwise:

Assess all under 5s  with a temperature as per the NICE fever guidelines

Assess the patient for signs of severe sepsis – if present use the severe sepsis guidelines

If no signs of sepsis assess patient, exclude Quinsey (unilateral swelling, paina nd trismus) and calculate the FeverPAIN score and Centor score

FeverPAIN = 1 point for each of –

  • Fever
  • Purulent tonsillar exudate
  • Attendance within 3 days of onset
  • severely Inflamed tonsils
  • No cough/coryza

Centor = 1 point for each of –

  • Tonsillar exudate
  • Tender anterior cervical lymphadenopathy or lymphadenititis
  • History of fever >38
  • No cough

Treatment

Can the aptient swallow fluids and medication – if not give a stat dose of IV Dexametasone, IV antibiotics, IV fluids and analgesia – review in 2 hours. If they can swallow at this time then you can consider discharge with a patient information leaflet.

  • FeverPAIN = 0 or 1/ Centor = 0,1 or 2 – no antibiotics, self care advice
  • FeverPAIN = 2 or3 – no antibiotics or a script for 3-5 days time if no better, self care advice
  • FeverPAIN = 4 or 5 / Centor 3 or 4 = give Antibiotics immediately, self care advice

Patients to seek medical advice if become more unwell or not improving after 1 week

Self care advice – Paracetamol, Ibuporfen, Adequate fluids, Medicated lozenges

 

Antibiotics –

Phenoxymethylpenicillin 5-10 days

If Penicillin allergy – Clarithromycin or Erythromycin 5 days

Tonsillitis Patient Information Leaflet

Full NICE Guidance

 

Search: tonsillitis

Epistaxis – Management

Nose bleeds are a bloody common problem (bad pun intended) – most originating at the front to the nose where there is a cluster of blood vessels – Little’s Area.

In the young the bleeding often starts after trauma (e.g. picking or punching noses). In the elderly however, it is commonly a manifestation of underlying vascular disease. Read more

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

Upper GI Bleed (UGIB)

Not normally difficult to spot, but look for it in unexplained anaemia, or collapse.

Questions

  • Is it VARICEAL? Mortality 35%, so is an emergency whatever the GBS is.
  • Non-Variceal what’s the GBS? will help guide treatment

Anyone being admitted should be brought to HRI

Emergency Endoscopy is arranged by Med Reg

Read more

Bell’s Palsy

Bell’s Plays is a lower motor neurone (LMN) lesion of the facial nerve (CN VII), which causes one side of the face to “droop” [1% of cases are bilateral], and patients are often concerned that it is a stroke.

However, unlike in stroke the whole face is affected, in stroke and other upper motor neurone (UMN) lesions the upper portion of the face is unaffected due to input from both sides of the brain. Read more