Emergency Department

Handbook
11/30/2012 CAH Cathy Daly

Welcome to Craigavon Emergency department. It has five main areasMajors Minors Paeds Resus CDU/Obs ward. During your time you will spend time in most of these areas. Each day there will be a handover meeting in the morning with allocation to each area. The sheet will be in the majors office. This allows you exposure in all areas and ensures you take your breaks.

GETTING HELP OUT-OF-HOURS Cardiac Arrest Adult

Contact the hospitals crash team by dialling 6666; specify ADULT CARDIAC ARREST (if there are sufficient staff in ED you may not require the team).

Major Trauma
Contact the trauma team which consists of the Anaesthetic SHO/Middle Grade, Surgical SHO and Registrar, and the ED Consultant or ED Registrar.

Cardiac arrest in a Child Contact Paediatric arrest team on 6666, stating PAEDIACTRIC CARDIAC ARREST.
Contact the Anaesthetist and the senior ED doctor.

Other Life-threatening Emergencies Up to midnight there is a senior doctor on the shop-floor so involve them. Out of hours contact the Anaesthetic, Medical,
Surgical, Obstetric SHOs on call as appropriate. Contact the senior ED doctor if you are concerned that the doctors who you have called are unsure what to do and unable to manage the situation quickly.

You can contact the ED Consultants at any time about any problem

REASONS TO CALL FIRST ON CALL OR CONSULTANT IF DELAY

POLYTRAUMA PATIENTS REQUIRING URGENT CT OUT OF HOURS PATIENT TRANSFERS WITH WHICH THERE ARE DIFFICULTIES PATIENTS WITH DETERIORATING MEWS(>5 OR MORE) PATIENTS WITH SIGNIFICANT ACTIVE BLEEDING ANY OTHER CLINICAL CONCERNS For all these conditions the relevant in house teams must also be contacted as soon as possible. In the first instance support from the appropriate specialty team is the most important step in multidisciplinary management of serious cases eg in trauma, Anaesthetics, Surgery and EM This may be done in advance of the patients arrival in some cases.

WORKING IN THE EMERGENCY DEPARTMENT

Medical students must never treat children (e.g. by suturing). You may be asked to allow sixth form students to shadow you for work experience. They require intense supervision and they are only permitted to observe. They must not be allowed to do anything whatsoever. Patients must give informed consent to their presence and they must not be exposed to inappropriate examinations or confidential information. It is essential to inform the relevant SHO about all admissions and to pass on important information. Ideally specialty teams should not be called without senior staff being aware Direct referral from ED to outpatient clinics should be discussed with the senior ED doctor. Do not perform procedures you are not trained to do or have not appropriate evidence of competency eg ATLS level training and consultant supervised experience in say chest drain insertion There should be a formal handover of patients in the department when night medical staff are going off shift and daytime staff are starting. Handovers between ED staff should document time, name of doctor patient being handed over to and proposed plan ON THE FLIMSY. Reporting deaths to the coroner. It is the responsibility of the doctor who looked after the deceased to contact the coroner and this includes completing a full clinical summary. If in doubt about reporting to the coroner d/w the consultant in charge or on call

Sickness: If you become sick and are unable to do your shift. Inform the ED consultant IN PERSON ASAP; do not leave a message with

colleagues or nursing staff.(PLEASE DONT LEAVE IT UNTIL YOU ARE ABOUT TO COMMENCE A SHIFT AS IT IS OFTEN IMPOSSIBLE TO GET COVER). If you are off sick your colleagues will be obliged to cover short term sickness. Documentation of times is essential (first seen, decision to admit/discharge). The GMC and MDU have guidance on note-keeping. See good medical practice by GMC

http://www.themdu.com/search/hidden_Article.asp?articleID=252&contentTyp e=Media+release&articleTitle=MDU+advises+on+good+record+k eeping&userType=

Please document the most specific diagnosis possible . Document any advice given, plus name and grade. Record advice for GP and copy of written letter of same for GP

SPECIALTY SHOs Do not allow an SHO to dissuade you from admitting your patient. Only a Registrar or Consultant is in a position to do this. Advice over the phone re patient management is of limited value in this context. In the event of difficulty with this, please discuss with senior ED doctor.

IT SYSTEMS IN CRAIGAVON ED To order x-rays- use Sectra. Entering the patients H&C number will get all patients details. Drop down boxes than allow you to choose the imaging required.

X-rays are viewed in NIPACS- there are numerous screens throughout the department. Labs are accessed through the labs shortcut on the desktop.

ADMISSIONS POLICY FOR THE CRAIGAVON HOSPITAL EMERGENCY DEPARTMENT

1. All discharges of major cases to be discussed with the senior doctor on the floor at all times. Please discuss admissions where there is any uncertainty rather than ask advice from specialty teams when you may get unclear advice. Eg to discharge when you may have concerns but are not yet clear who should look after the patient many mistakes occur because of this 2. All intoxicated patients must have an assessment of their personal safety carried out. If they have no urgent medical/surgical problems then they can be allowed home if they are safe to mobilize and have some form of social back up. Involvement of the social work team may be necessary if there are questions about a place of residence. 3. Checking if patients can walk and if they have responsible adults to care for them is essential

4. All intoxicated patients with a head injury must be admitted for CNS obs unless it is felt that the head injury was minor, they are not heavily intoxicated and they have somebody sober with them who can carry out Head Injury advice at home. 5. Elderly patients from Nursing Homes should have a thorough medical assessment carried out and if appropriate discharged back to their nursing home. 6. Elderly patients with social difficulties but with no emergency medical/surgical needs should have social work involvement prior to placement in the community. 7. The involvement of Specialty Nurses is encouraged at all times for a variety of patients and may help facilitate discharge. Examples include,Heart Failure Speciality nurses, Tissue Viability nurse, Respiratory nurses and the Diabetic nurse specialists. This list is not exhaustive. 8. The Obs ward admissions should be discussed with consultant or first on call at night. Check with the nursing also in case patients are too dependant for nursing team in that setting. 9. Review clinic appointments should be discussed with Consultants before appointment being given.

PROTOCOL FOR UNSCHEDULED RE-ATTENDERS TO CRAIGAVON HOSPITAL ED

1. If a person re-attends within 1 week of initial attendance they should be seen by the middle grade or more senior on duty. 2. If a person subsequently attends a third time, within a short time period, then strong consideration should be given to admission.

3. There will be a group of patients who regularly attend the ED to whom these guidelines may not apply. 4. Special care and heightened levels of suspicion should be present in the following cases Elderly patients with abdominal pain Elderly patients with acute SOB Diabetic patients Immuno-compromised patients

PSYCHIATRY PROTOCOL
The Psychiatric Liaison service works between 09.00-17.00 hrs for over 18s. The contact number is ext 4791. At weekends bleep 1208/1203 on Saturday and bleep 1203 on Sunday. Between 1700- 2100 contact the Psych SHO on call bleep 1208/1203. After 2100 hours contact the bleep holder for Pschyiatry on 1377 Low risk patients (not at risk of further self harm) can be discharged under the Card before You Leave Scheme. The details must be phoned through to whoever is holding the bleep for psychiatry and the risk assessment form must be filled out and left with the patients notes. They will be told to return for an appointment the following day at 2pm. For <18 years involve CAMHS. Portadown tel 38392112 Dungannon- tel 87713494 Newry- tel 30835400

. DEALING WITH POISONING IN THE EMERGENCY DEPARTMENT

1. 2. 3. 4. Ensure your safety and the safety of other members of staff. Take appropriate protective measures. Assess the patient using the ABC resuscitation approach. After initial assessment and history obtain further information on management of the poison from Toxbase. 5. Treat as per Toxbase 6. If the case involves self-poisoning then make an initial assessment of mental state. Use the SADPERSONS score. 7. A lot of overdose patients can be admitted to CDU unless the medication is particularly toxic or the have abnormal vitals.

ACTIVITIES IN THE EMERGENCY DEPARTMENT

A Senior Review Clinic on Monday, Tuesday, Thursday and Friday. Undergraduate medical teaching Postgraduate medical training occurs Wednesday morning 8.30am Paramedic training Medical audit Research (Support will be given to any SHO who would like to carry out a research project or write a case report)

FINAL PLACEMENT OF PATIENTS

Discharged patients must be told that if their condition deteriorates or they have any concerns, they should return immediately for reassessment and this advice must be recorded on the notes. Patients should be told to return to their GP for repeat BP checks, for review of soft tissue infections, rashes, sore ears, paediatric and medical conditions etc. Patients should be advised to re-attend their GP if symptoms persist, and this advice must be recorded on the notes. Patients are referred to their Treatment Room Nurse for dressings and removal of sutures.

REVIEW CLINICS Conditions suitable for review clinic: clinical scaphoid : ?toddlers fracture : limping child : crush injuries to fingers with complicated wounds or distal phalanx fractures :dislocated fingers :mallet fingers STI to ankles/ knees do not require review; if they are severe sprains referral to ED physio is appropriate. Toe fractures do not need reviewed. Fractures requiring manipulation that present out of hours can sometimes be brought back the next day, usually 2pm. Discuss with sister in charge. GP treatment rooms are suitable areas for review of simple wounds, ROS, simple burns and cellulitis.

CARDIOLOGY
1. Chest pain HISTORY IS VERY IMPORTANT. A patient with a history suggestive of cardiac chest pain should be admitted for observation, repeat ECGs and troponins. 2. Every patient with chest pain to be admitted must be discussed with the Cardiac SHO. 3. A negative troponin alone should not be used to send patients alone. 4. The cardiac arrest team may not be required when senior ED doctors are on site.

STEMI ALL PATIENTS WITH ST ELEVATION MI or NEW LBBB MUST CONTACT CARDIOLOGY SHO FOR PRIMARY PCI
PRIMARY PCI If the patient presents when the Craigavon cath lab is open, then primary PCI is usually the treatment of choice. IMMEDIATE transfer to the cath lab should occur as a priority. Antiplatelet 1. Aspirin 300mg od stat 2. P2Y12 blocker If <75yrs, >60kg and no prior TIA/CVA give Prasugrel 60mg od stat Otherwise, give Clopidogrel 600mg od stat Anticoagulant Bivalirudin bolus and infusion is usually preferred (given in cath lab) thus avoid giving unfractionated heparin or enoxaparin unless advised otherwise. THROMBOLYTIC THERAPY If Primary PCI is not available onsite then consider thrombolytic therapy.

http://vsrintranet.southerntrust.local/SHSCT/HTML/documents/ST EMIguidelinesJuly2012.pdf

RESUS GUIDELINES AS PER ALSG, found on intranet http://www.resus.org.uk/pages/alsalgo.pdf http://www.resus.org.uk/pages/bradalgo.pdf http://www.resus.org.uk/pages/tachalgo.pdf CARDIOLOGY GUIDLEINES Available on trust intranet http://vsrintranet.southerntrust.local/SHSCT/HTML/documents/CardiologyG uidelinesJuly2012.pdf For Acute LVF, there is Drager CPAP available in the department. Normal measures oxygen, morphine and nitrates should be used in conjunction as normal.

PULMONARY EMBOLISM Have a high index of suspicion. Even people without risk factors can have pulmonary embolism. Use risk stratification tool (Wells) and D-dimer then if necessary. CG144 - Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing - 1 Guidance - National Institute for Health and Clinical Excellence In some instances low risk, stable patients requiring further investigations can be managed on an outpatient basis, however discuss with senior if available. In unstable patients, involve senior staff early. Cardiology will be involved for bedside ECHO and lysis may be considered. (Alteplase 50mg bolus)

ANAPHYLAXIS Anaphylaxis is likely when all of the following 3 criteria are met: Sudden onset and rapid progression of symptoms Life-threatening Airway and/or Breathing and/or Circulation problems Skin and/or mucosal changes (flushing, urticarial, angioedema) The following supports the diagnosis: Exposure to a known allergen for the patient Remember: Skin or mucosal changes alone are not a sign of an anaphylactic reaction Skin and mucosal changes can be subtle or absent in up to 20% of reactions (some patients can have only a decrease in blood pressure, ie a Circulation problem) There can also be gastrointestinal symptoms (eg vomiting, abdominal pain, incontinence)

http://www.resus.org.uk/pages/reaction.pdf STROKE
Stroke lysis occurs 24/7 in CAH. Assess using the ROSIER scale and if within 3 hours then contact team re lysis. http://vsrintranet/SHSCT/HTML/documents/RosiersScaleproformafinalversi on.pdf In hours, 9-5pm contact the stroke lysis team on 6000. Out of hours, contact med reg. http://vsrintranet/SHSCT/HTML/documents/SuspectedStrokeMondayFriday9am-5pmCAHfinalversion.pdf http://vsrintranet/SHSCT/HTML/documents/SuspectedStrokeOOHCAHphysi cianoncallfinalversion.pdf

TIA Use ABCD2 score to assess risk of stroke. Transient Ischaemic Attack NB this scoring system does not apply to recurrent TIAs and those on warfarin. ABCD2>4 discuss with stroke team for admission if 9-5pm Mon-Fri. OOH discuss with med reg on call. Lower risk patients can be given Aspirin 300mg and continued on Aspirin 75mg, unless contraindicated, and discharged to the TIA clinic filling in the referral form(in drawers in Majors). GP review re secondary measures should be advised also.

HEADACHES
The history is so important. CAUTION: Subarachnoid haemorrhage (sudden onset) Meningitis (fever and/or rash) Encephalitis (fever, ataxia, drowsiness/confusion) Raised ICP (CNS signs or papilloedema) Temporal arteritis (older patients check ESR) Venous sinus thrombosis (hypercoaguable)

Thunder clap headaches should be admitted to rule out SAH. This can be to CDU provided the patient does not have an altered GCS. If decreased level of consciousness or neurological signs - need urgent CT scan. Dr Forbes, Consultant Neurologist, has developed migraine and headache advice on trust intranet. http://vsrintranet/SHSCT/HTML/documents/Migraineflowchartversion4april1 0.pdf http://vsrintranet/SHSCT/HTML/documents/HeadacheLifestyleAdviceapril10. pdf

http://vsrintranet/SHSCT/HTML/documents/ProphylaxisofMigrainefinaldraft APRIL10_2_.pdf

ASTHMA Use the ABC approach and BTS guidelines. If not improving or tiring involve seniors and ICU ASAP. http://www.britthoracic.org.uk/Portals/0/Guidelines/AsthmaGuidelines/sign101%20Jan%20 2012.pdf pg 116

COPD Treat as per BTS guidelines. Often useful to contact respiratory nurses as patients often known and with their help can avoid admission. http://www.britthoracic.org.uk/Portals/0/Guidelines/AsthmaGuidelines/sign101%20Jan%20 2012.pdf NIV is available in the department. It should be started for acidotic, hypercapnic patients in whom medical treatment is failing and the patients premorbid status and wishes are taken into consideration. Patients should be able to maintain their airway and not be obtunded unless its the ceiling of treatment(may require a discussion with ICU). Initial settings are usually IPAP 10 and EPAP 4. Involve senior staff if unsure.

PSYCHIATRY Risk stratification helps with disposal of patients.

SAD PERSONS SCORE

S = Sex: Male A = Age: <19 or >45 D = Depression: admits to depression/decreased concentration/ appetite/sleep/libido P = Previous attempts/psychiatric care E = Excess alcohol/drug use R = Rational thinking loss S = Separated/divorced/widowed O = Organised or serious attempt N = No social support (family/friends/job/active religious affiliation) S = Stated future intent (determined to repeat/ambivalent) Less than 3 3-6 >6 = = = Low risk Medium risk High risk

If a patient has diminished capacity through alcohol or drugs and has or is at risk of DSH they should be admitted to CDU for observation and reassessment.

OVERDOSES Toxbase should be consulted and acted upon in all cases. (Document this in notes) In paracetamol OD determine if patient is higher risk or not and use appropriate line on the nomogram. Standardised Nacetylcysteine administration charts have been produced to avoid drug errors. See charts in majors. http://vsrintranet/SHSCT/HTML/documents/ParacetamolPoisoning.pdf

ALCOHOL WITHDRAWAL Intoxicated patients cannot be detoxed. Mild to moderate withdrawal can be admit to CDU. Ensure kardex is written up with chlordiazepoxide and pabrinex. Ensure no evidence DSH, injury or other medical problems(High risk group). Severe/DTs is a life threatening emergency and should be treated fully with benzodiazepines and admitted to Medicine. Severity is monitored using GMAWS scale http://vsrintranet.southerntrust.local/SHSCT/HTML/documents/AlcoholWith drawalGuidelinesNov11_003.pdf

DIABETES Hyperglycaemia alone in the absence of ketosis or dehydration doses not necessarily require immediate intervention. Explore possible reasons for the raised blood sugar and involve the diabetic nurse specialists.

New presentation diabetes without ketoacidosis should be discussed with Dr Bradley/ Ritchie and diabetic nurse specialists who will often follow up these patients without requiring admission. DKA DKA is a life threatening emergency. Follow trust protocol. http://vsrintranet/SHSCT/HTML/documents/DiabeticKetoacidosisTreatment. pdf

ABDOMINAL PAIN
In all abdominal pain, both adults and children, the groin should be examined and in males the testicles should be examined.

ABDOMINAL AORTIC ANEURYSM

Rupture of an abdominal aortic aneurysm can be a sudden event, leading to severe pain, hypotension and collapse or can be a slow process with symptoms lasting up to two weeks. Symptoms of AAA rupture include Back pain Loin to groin pain Scrotal pain Lower abdominal pain

SUSPECT the diagnosis in all abdominal and back pain over the age of 50, particularly the renal colic. CAUTION: Haematoma is NOT pulsatile the tender non-pulsatile mass in the lateral abdomen is a manifestation of ruptured AAA. If there is a doubt over the diagnosis, contact Senior ED doctor. Vascular is only available occasionally out of hours. RENAL COLIC

Suspect if loin pain to groin, restless and haematuria (although not always present). Ensure no evidence of AAA especially in>55years. Use Diclofenac(PR rapid onset) and opoids if not settling. Initial investigations: FBP, U+E, CRP, Ca2+, plus PFKUB. If not settling or deranged renal function needs more urgent investigations. If possible obstructed kidney and infected symptoms discuss with urology urgently. IVP are more routinely used than CTKUB. Discuss with senior ED doctor and radiographer re timing of same. If already known to Urology a discussion with them may be best. If stone present and pain controlled without complications the patient can be followed up in the stone clinic.

ACUTE URINARY RETENTION. If pain, palpable bladder with no PU catheterise ASAP. Check U+E and urinalysis. Treat any infection. If U+E normal and <1000ml then discharge on tamsulosin. A referral letter should be sent to the Urology Consultant on call who will arrange to bring the patient back for TROC.

HAEMATEMESIS
Some patients alleging haematemesis do not always have it. In other words, some patients presenting with this symptom do not require admission. Rockall score/Blatchford score is used to stratify those requiring admission/discharge. A score >0 requires inpatient investigation.

http://vsrintranet/SHSCT/HTML/documents/UpperGIEndoscopyReferralForm .pdf http://www.nice.org.uk/nicemedia/live/13762/59549/59549.pdf

MANAGEMENT OF PATIENTS WITH BLEEDING OESOPHAGEAL VARICIES

Insert a wide bore (grey) IV cannula Take blood for: FBP Coagulation Screen LFTs Group + x-match 3 units Resuscitate with colloid (eg Haemaccel) and blood (if necessary) If prothrombin time prolonged, give fresh frozen plasma + IV Vit K Give terlipressin 2mg IV. Can be repeated 4-6hrly. Make arrangements for emergency upper GI endoscopy + injection sclerotherapy Do NOT use Sengstaken tube routinely - only for: Urea & Electrolytes

Control of profuse haemorrhage in a patient with known varices (with persistent haemodynamic instability, despite IV Sandostatin) while awaiting upper GI endoscopy Control of persistent bleeding, not controlled by injection sclerotherapy When using Sengstaken tube 1. Check balloons 2. Water-soluble jelly to lubricate 3. OG insertion until gastric balloon in stomach (confirm with XR) 4. INFLATE BALLOON WITH 100mls OF AIR UP TO MAX 400-500ml AIR 5. Small amount traction 6. If bleeding not stopped inflate Oesophageal balloon 7. USE A PRESSURE OF BETWEEN 35-45mmHG RECORDED BY INLINE MANOMETER

8. Use lowest level to stop bleeding

ELDERLY PATIENTS These are automatically a higher risk group of patients. Be wary of elderly patients with abdominal pain. If the problem is sub acute and involves new mobility problems, fall, acute balance impairment, mild chest or urinary infections or new onset confusion then a referral to one of the rapid access clinics may be appropriate. (Notice of contact numbers/fax in Minors). WARFARIN REVERSAL Check indications for warfarin and bleeding and embolic risk. The trust has guidelines for reversal of warfarin. http://vsrintranet.southerntrust.local/SHSCT/HTML/documents/Warfarinreve rsalguidelinesJuly2012.pdf In some instances of head injury reversal prior to a CT scan may be required. Discuss with senior staff and haematologists.

MAJOR TRAUMA
The patients are identified using the protocol given below.

MAJOR TRAUMA TRIAGE PROTOCOL Abnormal physiology

1. GCS less than or equal to 12 2. Systolic BP < 90 3. Respiratory rate > 30 or < 10

Obvious serious injury

4. 5. 6. 7. Two or more proximal long bone fractures Burns > 15% or to face and airway Severe chest injury Penetrating injury to head, neck or trunk

Evidence of high energy impact

8. Fall of 20 feet or more 9. High speed RTA (& childrens bike crashes) 10. Ejection from vehicle during crash 11. Death of same car occupant 12. Pedestrian hit at speed

If any one of these 12 criteria are fulfilled you MUST * bring the patient to Resus Room and inform senior ED doctor and consider informing trauma team. The trauma team consists of the Anaesthetic SHO/Middle Grade, Surgical SHO and Registrar and senior ED doctor. If the ambulance service gives good stand-by information you can activate the trauma team before the patient arrives.
* Sometimes a patient who fulfils just one of the criteria 8-12 has absolutely no evidence of serious injury. In this situation you may wish to discuss the case with the ED Consultant or Registrar rather than activating the trauma team.

BURNS
Importance of history - Nature of burn - Likelihood of inhalational injury - Probability of other injuries Indications for intubation 1. Erythema or swelling of oropharynx on direct visualisation 2. Change in voice 3. Stridor, tachypnoea or dyspnoea Fluid Resuscitation : Parkland Formula - Total fluid requirement in 24 hours = - 4ml x ( total Burn surface area [%]) x ( weight [kg]) - 50% in first 8 Hours from burn Criteria for transfer/plastics opinion 1. Partial + Full thickness burns >10% BSA in pts <10 or >50y.o. 2. Partial + Full thickness burns > 20% in other age groups 3. Partial + Full thickness burns involving face, hands, feet, perineum, genitalia or over major joints 4. Full thickness > 5% in any age 5. Significant electrical burns incl. lightning injury 6. Significant chemical burns 7. Inhalation injury 8. Co-morbidity which may complicate management/delay recovery

HEAD INJURY These patients should have vitals and GCS documented. Document if on anticoagulants/antiplatelets. Management guidance is per NICE guidelines. http://www.nice.org.uk/nicemedia/live/11836/36257/36257.pdf Elderly, alcoholics and patients on anticoagulants/antiplatelets are at increased risk and may require observation in CDU if suitable. In patients on warfarin there is increased risk of delayed bleeding and therefore they should be monitored for at least twelve hours even if there is a normal scan. Anticoagulant patients with a significant head injury will require reversal even before CT scan. CDU has a POC INR machine and contact haematologist re use of PCC. In head injury patients ensure assessment of C-spine is considered, as with other injuries. If the patient is sent home, a responsible adult should if possible be given written instructions about possible complications and appropriate action.

TETANUS Consider need for tetanus immunisation if wounds, burns. As per HPA green book. https://www.wp.dh.gov.uk/immunisation/files/2012/07/chap-30dh_103982.pdf pg 381, 379

ALL GLASS INJURIES SHOULD BE X-RAYED TO EXCLUDE A FOREIGN BODY.

HAND INJURIES All hands should be examined for tendon function, sensation (pinprick) and joint swelling. Record patients occupation and hand dominance. Uniquely, hand injuries should be x-rayed even if fracture unlikely if only one finger involved request for finger x-ray rather than hand x-ray. FINGER SPRAINS AND VOLAR PLATE INJURIES These generally affect PIP joints any swelling here, treat as sprain. If hyperextension (staving) injury, treat as Volar Plate Injury. All should have neighbour strapping. Swelling of PIP joint can persist for months but can be mobilise after a few weeks once pain has settled. EXTENSOR TENDON INJURIES Refer to the Plastic Surgeons even if you know how to repair them, you dont have time. FLEXOR TENDON INJURIES Test both FDS and FDP check flexion at DIP joint for profundus, and flexion with uninjured fingers hyper extended for superficialis HAND INFECTIONS Acute paronychia - incise around the cuticle until pus expressed Look out for suppurative tenosynovitis, a very serious condition which usually follows a trivial or forgotten finger prick. The finger is swollen, stiff and very painful especially when extended passively. URGENT REFERRAL TO PLASTIC SURGEONS is required for washout.

FINGERTIP INJURIES Providing no bone is exposed they can be dressed, immobilised and reviewed in clinic. Antibiotics are often indicated. If bone is exposed refer to Plastic Surgeons for terminalisation. Flexor tendon injuries, significant amputation or degloving injuries, nerve damage, high-pressure injection injuries, suppurative tenosynovitis or multiple hand fractures should be referred to the Plastics Surgeons If a patient presents with a GSW or knife wound that is not self inflicted discuss with ED consultant re disclosure of information to the police. FRACTURE MANAGEMENT It is important to check and document neurovascular status and whether it is a close or open injury with all fractures. In hours if a fracture requires manipulation discuss with nurse in charge and senior doctor on the floor. Only patients category ASA 1 and 2 are suitable for sedation in the ED. Ensure good pain relief has been given. ASA Physical Status Classification System If a displaced fracture requiring manipulation presents out of hours in children then they should be discussed with the T+O registrar for discussion with the paeds ortho team in Belfast. If this arises in adults then discuss with sister in charge who will review staffing for next day arrange for return, if however its a weekend or Monday coming up manipulations are not carried out in this semi-elective manner and so the case should be discussed with the T+O on call. FRACTURE CLINIC REVIEWS Manipulated fractures require follow up within 1 WEEK. Dislocated shoulders and clavicle fractures can be seen in 2 weeks. Undisplaced stable extraarticular fractues can be seen in 2 weeks. If unsure ask Senior Doctor. Any cast applied but especially a lower limb POP can be associated with an increased risk of DVT. Please ensure a cast is required. An undisplaced

metatarsal fracture (unless its a Jones fracture) can be managed with metatarsal strapping and crutches. Phalangeal fractures It is important to check for any rotational deformity. Intra articular and spiral fractures can slip and should be seen in fracture clinic in 1 week. They can be immobilised with a zimmer splint or neighbour strapping. Thumb fractures In any thumb injury it is important to document assessment of collateral ligaments(ulnar and radial). If laxity but end point and no fracture can be reviewed in ED review clinic. Treat with spiral strapping. If laxity or opening then review with fractures. Place in a Bennetts POP. Fractures of the base of the proximal thumb require treatment in a Bennetts cast and 1 week review in fracture clinic, unless badly displaced may need sooner. Metacarpal fractures Check for rotational deformity. Some angulation in metcarpal fractures can be acceptable, up to 20o in metaphysis is acceptable and up to 45 o at the neck of the fifth can be acceptable. If greater than this a metacarpal block can allow manipulation and moulding in POP. POP should have MP joints at 90o Carpal bone fractures Scaphoid- check ASB, scaphoid tubercle on palmar aspect and distraction of thumb if tender in all three with correct mechanism of injury, then x-ray scaphoid. If no fracture place in future splint or cast, depending on pain level and review ED clinic 10-14 days. In wrist injuries pay particular attention to the alignment of the carpal bones with each other and distal radius to ensure lunate and perilunate dislocations are not missed. Reduction although often achieved closed needs an image intensifier therefore discuss with T+O. Widening of scaphoid lunate gap(Terry Thomas sign) suggests dissociation and needs treated in a POP and seen fracture clinic in a week. Other carpal fractures are rare and generally treated in cast for 6 weeks(3 weeks for avulsions of hamate) unless displaced. WRIST FRACTURES Undisplaced fractures can be treated in cast and follow up at fracture clinic.

Colles is the most common. They are usually grossly deformed however if unsure if requires manipulation then look at lateral view and if if the tilt of the joint line is >10o posteriorly then manipulation is usually required. The key step in Colles manipulation is disimpaction of the fractures. When disimpacyed the radial styloid should lie 1cm beyond the end of the ulnar styloid. Then correct ulnar deviation with radial displacement. Smiths and Bartons fracture can also be manipulated but often slip or cause problems so involvement of T+O early may be useful. ANKLE INJURIES Follow Ottawa ankle and foot rules. Please check and document tenderness around fibula head, tenderness round malleoli and fifth metatarsal. KNEE INJURIES Follow Ottawa knee rules. Check and document extensor mechanism. Check fibula head. Assess stability of collaterals and cruciates ligaments. Not all ankle and knee soft tissue injuries require review. If gross swelling and difficulty weight bearing consider ED physio follow up.

PAIN RELIEF People in severe pain require IV opiate analgesia Children MORPHINE 0.1mg/kg Take 10mg of Morphine and dilute with sterile water to a total volume of 10mls. This gives a 1mg/ml solution. Estimate the childs weight: Weight in kg = (Age + 4) X 2 e.g.: Child aged 3 years -

Weight in kg = (3 + 4) X 2 = 14kg Therefore estimated dose of Morphine would be 14 x 0.1 = 1.4 mg To make life easier, round the estimated dose up to 1.5mg and give 1.5mls of the diluted solution. Give the injection slowly, monitoring its effect. or ORAMORPH (10mg/5ml vial) 0.4mg/kg orally via a syringe (can be used even if patient should be fasting) e.g.: Child aged 5 years Weight in kg = (5 + 4) X 2 = 18kg Therefore dose of Oramorph would be 18 x 0.4 = 7.2mg To make life easier, round the estimated dose down to 7mg (3.5ml) Adults Morphine 10mg Elderly Dilute the adult dose in a total volume of 10 ml water. Give in 2.5mg aliquots slowly until satisfactory pain relief is obtained. CAUTION: The full effect of an IV injection takes longer to act in the elderly. If analgesia hasnt worked, give half as much again slowly and keep incrementing until pain relief obtained. EYE EMERGENCIES The triage nurse will check visual acuity and will apply Amethocaine drops for corneal discomfort. If visual acuity is abnormal you must re-check it and frequently may need to use a pinhole. Patients requiring immediate ophthalmic assessment Significant visual loss Severe eye pain Penetrating ocular trauma and lid lacerations Post-operative red or painful eye

All penetrating ocular trauma to be referred to RVH.

In cases of suspected orbital cellulitis secondary to paranasal sinus disease referral should be made to ENT. Patients requiring early (within 24 hrs) referral to the Eye Clinic: Iritis (pain, photophobia, circumcorneal red eye, cloudy cornea) Retinal detachment (flashes, curtains, post-traumatic visual disturbance) Hyphaema Dendritic ulcers (pain, photophobia, staining lesion on cornea)

Conditions suitable for ED management: Corneal foreign body (remove with cotton bud or orange needle, dont forget to evert upper lid) Conjunctivitis (Fucithalmic ointment bd daily for five days or Chloromycetin ointment qid for five days) Corneal abrasion including abrasions caused by foreign body removal (Cyclopentolate, Fucithalmic ointment and Voltarol drops/oral medication) Chemical burn (irrigate immediately with several litres of normal saline until pH neutral, remember to evert upper lid). If large corneal burn or decreased VA, discuss with Ophthalmologist RVH Welders flash (Amethocaine, Cyclopentolate and Voltarol drops) ENT EMERGENCIES

In all nasal traumas, inspect for septal haematoma. If present, this must be referred immediately to ENT for incision and drainage. Nasal fractures should be reviewed in the ENT Clinic in 5-7 days. Foreign body in nostrils attempt removal only if easily seen. In children it can be worth getting parent to blow into the childs mouth while occluding the nasal passage without the FB in. Otherwise refer to ENT on-call. They must not be left overnight.

Foreign body in ears attempt removal only if easily seen. Except for batteries, these can be left to the next day. Every child in whom there is the suggestion of choking upon a foreign body should have a chest x-ray and lateral neck x-ray and referred to ENT doctor on-call for assessment as a bronchoscopy may be required even if x-rays are normal. For Bells Palsy ( LMN Facial nerve palsy ) i.e. pt has weakness of forehead muscles Treatment Prednisolone 4060 mg OD for 10/7 in reducing dose Aciclovir or Famciclovir Arrange ENT review(letter to consultant on call that day). RHEUMATOLOGY Acute swollen painful hot non traumatic joints need septic arthritis excluded with bloods, x-ray and joint aspiration. Advice can be sought from rheumatology reg (bleep 1205)/associate specialist(bleep 1053) or consultant. An allocation sheet of who to contact and when can be found in CDU.

OBSTETRICS AND GYNAECOLOGY Women presenting with bleeding in early pregnancy (<13 weeks) need their vitals checked, urinalysis/HCG and assessment of abdomen performed. Any patient with abdominal tenderness or abnormal vitals should be assessed by the O+G team then. If stable and in hours Early Pregnancy Assessment Clinic can be contacted directly to assess the patient. Out of hours a diary is kept on ward 1West who will give you a date and time for the patient to attend EPAC. Any pregnant lady with bleeding >13 weeks should be seen by the O+G team. There is guidance and safe prescribing of antibiotics in pregnancy and breast feeding. http://vsrintranet.southerntrust.local/SHSCT/HTML/documents/Antimicrobia ltherapyinpregnacybreasfeedingFeb2012.pdf

There is guidance on the trust intranet on management of hyperemesis. http://vsrintranet/SHSCT/HTML/documents/MANAGEMENTOFHYPEREMESI SGRAVIDARUM.pdf Post -partum haemorrhage can be a life threatening emergency. Manage ABC but contact O+G early and consider ergotamine or syntocinon. http://vsrintranet/SHSCT/HTML/documents/QuickReference-PPH.pdf Imminent eclampsia is managed as per regional gudelines with early involvement of anaesthetics and O+G. http://vsrintranet/SHSCT/HTML/documents/ManagementofImminentEclamps iaorEclampsia.pdf Pregnant women presenting post exposure to varicella or parvovirus should have nature of exposure and duration of exposure explored. If a woman is unsure of previous exposure or immunity to varicella, titres should be performed. http://www.dhsspsni.gov.uk/hss-md-11-2009.pdf In the case of parvovirus trust protocol should be followed. http://vsrintranet/SHSCT/HTML/documents/GuidelinesformanagementofPar vovirusB19andrashillnessinpregnancy.pdf

RECOGNITION OF THE SERIOUSLY ILL CHILD

A B C D E Airway Breathing Circulation Disabilities Exposure

Recognition of potential respiratory failure

AIRWAY & BREATHING 1. Respiratory rate 2. 3. 4. 5. 6. Recession - intercostal, subcostal, sternal recession Stridor Grunting Accessory muscle use Flare of the alae nasi

HEART RATE 1. Tachycardia 2. Bradycardia - PRE-TERMINAL SIGN

SKIN COLOUR 1. Pallor 2. 1. 2. 3. Cyanosis - LATE AND PRE-TERMINAL SIGN Agitation Drowsiness Loss of consciousness MENTAL STATUS

RESUCITATION OF CHILDREN Involve senior help early. Use ABC approach, as per guidelines. http://www.resus.org.uk/pages/pblsalgo.pdf http://www.resus.org.uk/pages/palsalgo.pdf http://www.resus.org.uk/pages/pchkalgo.pdf

NON-ACCIDENTAL INJURY
ED SHOs are not expected to diagnose NAI or to confront parents BUT ARE EXPECTED TO BE ALERT TO THE POSSIBILITY and to report any suspicions to a doctor experienced in dealing with such cases.

If NAI is suspected, contact the senior ED doctor. Make a meticulous record of the history and physical findings and tell the parents that you need a second opinion. Reasons for suspecting NAI include Abnormal patterns of injury, e.g. slap marks, cigarette burns, bite marks History inconsistent with type of injury e.g. # long bones in an infant who has not started walking Delay in presentation Child brought to ED by someone other than parent Abnormal behaviour in child e.g. withdrawn, poor rapport with parent Signs of physical neglect Frequent attendances Note that there is often an innocent explanation for suspicious situations and diseases (e.g. bleeding disorders) can mimic NAI.

Reasons for suspecting sexual abuse include Disclosure by child or other member of family Underage pregnancy Genital injury

 Sexually transmitted disease Precocious sexual behaviour Deliberate self harm/behaviour problems All these situations require urgent consultation with senior ED doctor. NAI is not solely a problem suffered by children. Vulnerable adults and the elderly can also be subject to this. Be alert if you believe the injury pattern and history are not compatible.

http://publications.nice.org.uk/when-to-suspect-childmaltreatment-cg89/guidance

MENINGOCOCCAL DISEASE
Meningococcal septicaemia is difficult to diagnose. In the early stages it may present with symptoms and signs of a simple viral illness, a maculopapular rash or may even present as gastroenteritis. In the older child it may present with pyrexia and back pain. Symptoms and signs to look for Headache Drowsiness/lethargy Neck stiffness Photophobia Vomiting Rash initially maculopapular then petechial Irritability

Infants may also Refuse feeds Have a high pitched cry Have pallor Be irritable

In addition to the above symptoms, patients with developing septicaemia may have

Cold peripheries Tachypnoea Pains in joints, muscles, abdomen, back Petechial rash No child must be discharged who remains pyrexic, irritable or drowsy

MANAGEMENT OF SUSPECTED MENINGOCOCCAL DISEASE

USE MENINGOCOCCAL PACK LOCATED IN RESUS ROOM 1. Resuscitation - contact Anaesthetist and senior ED doctor 2. Venous or intra-osseous access Meningococcal pack in Resus Room Blood cultures BM FBP U&E/Glucose Clotting screen Blood group Arterial blood gases Sample for PCR (FBP bottle) Serum sample for serology

3. Ceftriaxone 80mg/kg 4. Children allergic to penicillin, with a history of anaphylaxis Consider Chlorampenicol 25mg/kg after discussion with senior ED doctor 5. Fluid resuscitation - consider crystalloid 20ml/kg Repeat if necessary 6. Inform Public Health

CHILDHOOD SEIZURE
Brain injury is caused by hypoxia and also from repeated electrical discharge.

Causes:
febrile convulsion meningitis encephalopathy acute cerebral trauma poisoning hypo/hyperglycaemia, hyponatraemia, hypocalcaemia, hypomagnesium idiopathic

Treatment: 1. 2. 3. 4. 5. ABC Check BM - if low give 10% Dextrose 2ml/kg Diazepam pr 0.5mg/kg if unable to get IV access IV access - blood sugar/U&E/WCC/calcium/magnesium If still having seizure after pr dose - IV Lorazepam 0.1mg/kg iv/io If not settling - Paraldehyde 0.4ml/kg pr (0.2ml under six months old) 50:50 made up in olive oil or physiological saline. Do not leave Paraldehyde standing in a plastic syringe for longer than a few minutes. Phenytoin - MUST NOT BE ON PHENYTOIN 18mg/kg IV over 20 mins (with ECG monitoring) Rate 1mg/kg/min in an infusion of normal saline 1mg/ml Infants or if already on Phenytoin Phenobarbitone 15mg/kg over 5 mins is preferred Contact Anaesthetist, senior ED doctor on-call and RBHSC Paediatric Registrar http://vsrintranet/SHSCT/HTML/documents/EpilepticStatusinChildren.pdf

6.

7. 8.

ASTHMA Should be managed as per BTS guidleines. Children should be assessed and categorised into mild, moderate and severe. Early senior involvement if moderate to severe. http://vsrintranet/SHSCT/HTML/documents/AcuteAsthmaManagem entPaediatrics.pdf BRONCHIOLTIS Bronchiolitis is often mild. Management is mainly reassure to parents and ensuring adequate feeding. Admission is considered under SIGN guidelines. http://vsrintranet/SHSCT/HTML/documents/BronchiolitisSIGNGuid eline.pdf Hypertonic saline can be nebulised with suctioning to clear secretions to allow feeding.

CROUP Croup presents usually with prodrome of coryzal symptoms then a barking cough. Croup should be classified and treated accordingly. ANY CHILD WITH STRIDOR AND RESPIRATORY DISTRESS SHOULD NOT BE AGITATED. INVOLVE SENIORS AND PAEDIATRICS EARLY. http://vsrintranet/SHSCT/HTML/documents/CroupAlgorithm.pdf

DKA Close attention to fluid management is essential. Involve seniors and paediatrics early. Follow trust/ national protocols. http://vsrintranet/SHSCT/HTML/documents/DiabeticKetoacidosisM anagementGuidelineBSPED.pdf http://vsrintranet/SHSCT/HTML/documents/DKAEmergencyIVFluid sCalculatorBSPED.pdf

THE LIMPING CHILD All children require careful examination including comparison of the various joints, systemic temperature, white cell count, ESR, CRP and x-ray (usually hips). Any discharges should be asked to return within 24 hours if no improvement. CAUTION: septic arthritis (any age group but may not be obvious in babies) unsuspected fracture (dont forget NAI) Perthes disease (primary school age - x-ray abnormality)

slipped upper femoral epiphysis (secondary school age restricted internal rotation and x-ray abnormality on the Lowenstein view) The commonest cause is a sprain or an irritable hip related to a viral illness, but all pyrexic children with a limp must be referred to RBHSC orthopaedics.

For subacute problems unable to wait OPD follow up, ie feeding problems but not unwell, constipation, headaches without red flags it may be possible to refer to the Paeds ambulatory clinic in South Tyrone. The patient firstly must come from that area and then discuss with staff in the clinic re suitability.