Three large scale multi-centre trials into Severe Sepsis and Septic Shock:ProCESS (USA), ARISE(Aus), ProMISe(UK), all showed the same thing. What works is good early resuscitation (Not the fancy stuff from ICU – however, that does have its place later on).
As we all know frailty and care of older patients is becoming a more and more important in the ED. The elderly population is growing rapidly and as you age your health costs shoot up.
The study day not only highlighted several import areas of care within ED, but also how relatively small interventions/conversations can make significant differences.
Think Home First:
What is stopping them going home?
What tests will guide your decision making? (don’t just investigate because you can)
Get them up (you don’t need to wait for physios)
Do the easy stuff: Feed, Water, Toilet, Communicate
DON’T create barriers: e.g. catheters, exessive testing
Ask for help: Local service are your friend
Topics
Population & Costs
Increasing aging population:
Costs as we age:
Life Expectancy
Life Expectancy:
Average life expectancies are often longer than you imagine and after 100yrs life expectancy increases!
80yr woman – 10yr
85yr woman – 7yr
90yr woman – 5yr
99yr woman – 2yr
However, Clinical frailty score is often more predictive.
Frailty Trajectory and Life Expectancy
Study shows that the rate of change in frailty has a significant impact on life expectancy. People with “Stable” growth in frailty score remaining at their base line but the faster the CFS changes more impact that has.
So its worth asking how things have changed over the last year.
Trauma
Frailty has a significant influence on recovery and mortality in relation to both “MINOR” and “MAJOR” trauma.
Rib injury is probably more important than most of us realise – suggesting 15% increase in mortality for every rib a frail person fractures. JRCALC have since updated guidance to recommend “rib spring” rather than “gentle palpation” in examination.
Silver Trauma Review Clinic:
Mater hospital Dublin have introduced a review clinic for patients following significant traumas.
Mater hospital – Adult only ED
90’000 attendances/yr
10.5WTE ED consultants
Major Trauma Centre
Silver Trauma Review Clinic
Weekly clinic sees 10 patients/week
Follows up: trauma patients discharged with non-operative management or post admission
Team: EM, Geris, Frailty ACP, Physio
Main work: Thoracic, Spinal, humeral, pelvic injuries
Requires access to DEXA and MRI (they MRI all spinal injury through clinic not only to age but also find other diagnosis)
“Decisions about not resuscitating a patient, or about putting a DNACPR notice on a patient’s record, are made by doctors and do not need patient consent. This can be an immediate clinical decision made when a patient is seriously unwell, or a decision that goes on a patient’s records in advance and affects treatment at a later stage. But it is a legal requirement for doctors to consult with a patient about a DNACPR decision if they have capacity, and with their next of kin otherwise.”
But our communication needs to be clear to patients and families, not just saying “they are sick” but how sick. And not just what we are not going to do but what we are going to do for the patient.
Preparation:
Ensure Anticipatory Medication prescribed
End of Life trolly (Dandilion trolly – QLD)
Syringe driver kit
Paperwork
Black towels – to hide blood loss (reduces distress)
Taste for pleasure – mouth care with things people actually like (families can bring)
We all recognise the importance of ensuring patients with Parkinson’s disease (PD) get their medication, but..
What do you do if the patient can’t swallow?
We will need to work out what alternative routes we could use, for example dispensable via NG or patches, and what dose. For an ED clinical it is most likely beyond us and we need help! However, that may be extremely difficult to get especially Out of Hours
Excellent website that can give you options – select the patients normal regime (initially just one line but you can add as many as needed) and press calculate. It gives you a dispensable and patch dose, which can help the discussion with pharmacy about where we can get it. (however, no calculator is perfect)
Middle East respiratory syndrome coronavirus (MERS-CoV)
MERS is classified as a High Consequence Infectious Disease (HCID), and although unlikely is serious and could be imported into the UK at ANY time. Risks are higher when there is increased travel to endemic areas such as Hajj.
Symptoms include fever and cough that progress to a severe pneumonia causing shortness of breath and breathing difficulties. In some cases, a diarrheal illness has been the first symptom to appear.
It is vital that patients returning to police custody as discharged as safely as possible. Part of that is ensuring the custody team has adequate information about the patient. So so complete the Return to custody form, documenting…. Read more
The prevalence of Tuberculosis in our region is increasing and has significant issues for both the patient and public health if we miss it.
Symptoms
Cough
Fever
Night Sweats
Lymphadenopathy
Weight loss
High-Risk factors to consider
Characteristics
Previous/Latent TB
TB Contact
Immunocompromised
Substance Misuse
Homeless/Prision
Pubs – esp. Vulcan Hudds
Travel/Ethnicity
Eastern Europe
India/Pakistan
East Asia
Africa
CXR Changes
Upper Lobe Consolidation
Hilar Lymphadenopathy
Cavities
Actions
Provide 3 AFB samples – Ideally performed in ED/Ward (but if patient fit for discharge and unable provide samples in ED give patient pots and request which they return to their GP.
Don’t Commence TB treatment – unless instructed by respiratory team
If admitted isolation requested
If discharged Patient told to isolate and if must go into public wear face mask
Contact TB team:
Huddersfield/Halifax – Based on GP postcode
In-Hours: either through Switch board or as EPR referral
Out of Hours: Though EPR referral
They will ensure appropriate notification of Public Health
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]
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:
Blood pressure: Systolic ≥180mmHg OR Diastolic ≥110mmHg (often >220/120mmHg)
