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COVID-19 (Respiratory Flow Chart)

As we know COVID-19 is putting an incredible burden on resources, especially for higher level respiratory support. It is important to target those resourses in the most effect way, hence the development of the “Respiratory Flow Chart”

 

Escalation Decisions

This is going be very difficult for us all, but is something we need to do early. As unfortunately there are no magic bullets, mortality for patients requiring ventilatory support through any modality is high. CPAP has increasing evidence for its use however,  it may have little effect on clinical course for many patients. Read more

Ophthalmology Referral (COVID-19 escalation)

Any patient presenting to ED with ONLY Ophthalmic symptoms should be referred directly by the ED triage team to Ophthalmology:

Referral

  • 08:30 – 17:30 Mon-Fri, and 09:00 – 12:00 Sat all referrals are to be made directly to dedicated phone
  • Out is these times refers to Ophthalmology on-call

Minimum dataset:

    1. Referrer name + grade + location.
    2. Patient details – 3 points of ID (name + D.O.B. + NHS / hospital number).
    3. Best contact number for patient.
    4. COVID-19 status of patient.
      • Asymptomatic, COVID-19 NOT suspected.
      • Symptomatic, COVID-19 SUSPECTED.
      • Symptomatic, COVID-19 CONFIRMED.
    5. Ophthalmic symptoms / signs on presentation.

Any patient presenting to ED with Ophthalmic symptoms/signs IN ADDITION TO other systemic issues should continue to be assessed and managed by ED as normal:

  • Refer as above once deemed stable 
  • If admitted under another team (e.g medics) – ensure admitting team area aware that the referral is still to be made (Document clearly in notes and verbally hand over)

Full Guide – HERE

COVID-19 (CPR)

Deteriorating Patients

  • Early senior decision making around DNACPR, is vital for both staff, patients, and families.
  • Document decsion making and communications clearly
  • There will be regular updates in “handover” about ICU admission criteria – as these may change over time

CPR (Aerosol Generation Procedure)

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COVID-19 (X-Ray learning resource)

British Society of Thoracic Imaging (BSTI) have released a free learning resource containing CXR and CT of confirmed Covid-19 cases, will short history including time image was taken from onset of symptoms.

From the China experience CXR/CT doesn’t seem to be a rule out strategy in ED at the moment – However, its a useful resource to help recognition of Covid-19 CXR’s

BSTI Covid-19 image bank

 

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.

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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Retrobulbar haemorrhage

What is retrobulbar haemorrhage?

  • Rapidly progressing haemorrhage into the retrobulbar space which is rare but potentially sight threatening.
  • Retrobulbar haemorrhage causes a rapid rise in intraorbital volume and pressure.
  • If not treated it can quickly lead to retinal ischaemia and infarction resulting in permanent visual impairment or complete visual loss.

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