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
Those suspected of concealing illicit drugs often present near ports and borders however they can present to any ED or be brought in by the police.
Body Packers – Swallow large quantities of well packaged drugs to smuggle them into countries or institutions. These are often well manufactured with a low risk of rupture but the potential for serious toxicity if rupture occurs.
Body Stuffers – Swallow small quantities of poorly packaged illicit substances often at the point of arrest to conceal them. These have a much high risk of package rupture but involve smaller quantities of substances.
Authorisation for an intimate search or radiological investigation must come from an inspector or higher with written consent from the patient.
Intimate searches must be carried out by a police surgeon but require immediately available resuscitation facilities therefore may be conducted in the ED. ED physicians should not handle the drugs at any time.
AXR or low dose CT scanning can be used to detect concealed packages in Body Packers.
Try to obtain a history of what and how much has been concealed
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.
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.
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 –
Purulent tonsillar exudate
Attendance within 3 days of onset
severely Inflamed tonsils
Centor = 1 point for each of –
Tender anterior cervical lymphadenopathy or lymphadenititis
History of fever >38
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
Phenoxymethylpenicillin 5-10 days
If Penicillin allergy – Clarithromycin or Erythromycin 5 days
The provision of out of hours mental health services for Children and young people (under the age of 18) is changing: –
Between 8pm and 9am the onsite Mental Health Liason team (RAID) will see these patients initally and help with the mental health aspects of their care. Between 9am and 8pm contact CAMHS via switchboard as normal.
Some patients who present with COVID-19 infection will be not suitable for escalation and actively dying when they attend the ED, for these patients the best management may be palliative care. The primary symptom that causes distress is breathlessness.
Palliative Care of COVID-19 patients will ideally be provided with a syringe driver and their symptoms well controlled using the standard guidance available via the Kirkwood Hospice Palliative Care Toolkit available HERE – Latest
However if there is no syringe driver available an alternative pathway has been produced