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Hypothermic Arrest [Adult] – European Resus Council Guidance 2021

True Hypothermic Arrest is thankfully rare in the UK. However, when it does happen it is resource intense and prolonged. The ERC 2021 guidance has introduced a new decision step HOPE score to the algorithm, once the Initial phase of resuscitation has been completed without ROSC.

If the is HOPE score is <0.1  the team may which to consider terminating CPR [Warning: Adults ONLY Children have better survival] Read more

Death in ED

Do you need to Refer to Coroner? 

Question 1: Are there clear grounds for referral to the coroner?

(The death is suspicious or unnatural, for example it is traumatic, related to drug or alcohol intoxication)

  • YESrefer to the coroner using the online form available on the intranet
  • NO – . (Go to Question 2)

Question 2: Is the cause of death known?

  • YES – the cause of death is clear.
    • MCCD can be issued, but only after  agreed with an ME
  • POSSIBLY – you are not sure but feel it may be possible to arrive at a sensible cause of death “to the best of your knowledge”
    • Discussion with an ME may be helpful in allowing you to issue an MCCD
  • NO – there is no diagnostic information that could lead to a likely cause of death
    • Likely referral to the coroner, but discussion with an ME may still help agree the appropriate course of action.

Advice can be sought directly from the ME team via email (during office hours)

Read more

#Limb Injury – Trust Treatment and Follow-Up

Select the appropriate body area for guidance table

No Spinal injuries, back pain, Cauda Equina, foot drop etc to be referred to VFC
InjuryED TreatmentDischarge Pathway
ClavicleAdult – Undisplaced Polysling/BASVFC
Adult – Displaced Polysling/BASVFC
Paediatric – UndisplacedPolysling/BASDischarge sling for 2 weeks then Mobilise as pain allows
Paediatric – DisplacedPolysling/BASDischarge

Open #/threatened skin/Floating shoulder
Polysling/BASOrtho On Call
Proximal Humerus #Paediatric – Undisplaced/minimal displacement/angulationCollar & CuffDischarge C&C for 2 weeks, mobilise as pain allows
Paediatric – Significant Displacement /angulationCollar & CuffVFC
AdultCollar & CuffVFC
Shoulder Dislocation-NO #!First time & RecurrentReduce ED + Polysling
MSK shoulder Physio Clinic
Unreducible Ortho On-Call
Fracture Dislocation Greater Tuberosity #ED Reduction- PolyslingVFC
Unreducible / Multi-fragmentaryPolysling for comfort Ortho On-Call
ACJ DislocationAll GradesPolysling /BASMSK shoulder Physio Clinic
Open Injury / Threatened skinPolysling /BASOrtho On-Call
Rotator Cuff InjuryPolysling/ BASMSK shoulder Physio Clinic
Humeral Shaft
(documentation of Radial Nerve function
pre/post application of brace)
No Nerve InjuryHumeral Brace with Check XRVFC
Radial Nerve InjuryHumeral Brace with Check XROrtho On-Call
InjuryED TreatmentDischarge Pathway
Elbow dislocationReduce ED,
Above Elbow Backslab
Supracondylar #
Distal Humerus (Paediatric)
UndisplacedAbove Elbow Backslab
(>90 Degrees Flexion)
Check XR in cast
DisplacedAbove Elbow Backslab
(Comfortable position)
Ortho On Call
Paediatric Epi/condylar #UndisplacedAbove Elbow Backslab VFC
Above Elbow Backslab Ortho On Call
Radial Head/Neck Undisplaced / Minimally displacedCollar & CuffDischarge
Comminuted/significantly displacedCollar & Cuff
(Above Elbow Backslab if pain ++)
Paediatric Radial
Head Subluxation
(with Ulna Plastic deformation)
Above Elbow Backslab VFC
OlecranonUndisplacedAbove Elbow Backslab
DisplacedAbove Elbow Backslab Ortho On-Call
Fat Pad +ve ElbowCollar & CuffDischarge – Encourage ROM,
discard C&C as comfort allows
InjuryED TreatmentDischarge Pathway
FingertipCrush # Terminal Phalanx? Mallet splint to protect

NailbedWound Management
GP Practice Nurse Wound review
Significant Soft Tissue
Injury/? terminalisation
Mallet FingerExt Tendon (No Bony Injury)Well-fitting Mallet splint
(Ensure allows PIPJ Flexion)
8/52 then 4/52 at night
Avulsion # <50%
Joint Surface
6/52 then 4-6/52 night
(XR in splint to ensure joint congruence)
Avulsion # >50%
Joint Surface
6/52 then 4-6/52 night
(XR in splint to ensure joint congruence)
Undisplaced Phalangeal # /
Metacarpal #
StableNeighbour strapping 2/52
+/- Splint
Concern over stabilityNeighbour strapping 2/52
+/- Splint
Displaced phalangeal # ED Reduction
N/S +/- Volar Slab
(check Rotation)

IP DislocationExtensor Mechanism - Intact
(post reduction)
ED Reduction & NS
Extensor Mechanism - Disrupted
(post reduction)
ED Reduction & Capner SplintVFC
Metacarpal Neck #Neighbour strap Discharge
Bennett’s/ 1st MC Basal #Bennett’s Slab (Ensure IPJ Mobile)VFC
ScaphoidFracture IdentifiedScaphoid SlabVFC
Query FractureScaphoid Slab/SplintFace-Face # Clinic
2/52 post injury
Thumb MCPJ Injury StableSplintVFC
? UnstableBackslabFace-Face # Clinic
Volar Plate Injury
(+/- Avulsion #)
Neighbour Strap 2/52Discharge
Minor Trauma
Evidence of OA No #
Symptomatic Treatment
? Splint 2/52
Paediatric Torus #
Distal Radius
Futura splint 3-4/52Discharge
Paediatric Radius /Ulna UndisplacdAE backslabVFC
Displaced/AngulatedAE backslabOrtho On-Call
InjuryED TreatmentDischarge Pathway
No TraumaSymptomatic Treatment

OASymptomatic Treatment Discharge
Atraumatic Acute
swollen Knee
Ortho On Call
Tibial Plateau/ Femoral Condlye #ImmobiliseOrtho On Call
Patella DislocationFirst Time – no OC#
Knee Splint WBATMSK Lower Limb Physio Clinic
First Time – OC# Knee Splint VFC
Recurrent Knee Splint WBATMSK Lower Limb Physio Clinic
Patella Tendon/ Quads Tendon Rupture
Knee Splint Ortho On Call
?Meniscal, ?Ligament Injury Knee Splint
MSK Lower Limb Physio Clinic
InjuryED TreatmentDischarge Pathway
Isolated avulsion # tip
of lateral/medial malleolus
Treat as sprain WBAT, RICE
Ankle Brace/Walker boot if necessary

Isolated Weber A distal fibula #sTreat as sprain WBAT, RICE
Ankle Brace/Walker boot

Advice to contact VFC if symptoms > 3/12
Isolated Weber B Lateral Malleolar #
(Documentation must include:
Is there medial swelling? Yes/No
Is there medial tenderness? Yes/No
Is there medial bruising? Yes/No)
Talar shift/displacement - PresentBackslabOrtho On-Call
Talar shift/displacement - NONEWalker Boot WBAT
Isolated Weber C fibula #
(Also Need Assessment for medial injury& syndesmotic injury)
Ortho On-Call
UndisplacedWalker Boot WBAT
Bimalleolar/ TrimalleolarBackslab
Ortho On-Call
Tarsal fractures - Small avulsions without
disruption of tarsal alignment
Treat as sprain -Walker boot, analgesia, WBATDischarge
If UnsureTreat as sprain -Walker boot, analgesia, WBAT

Tarsal or cuneiform #Walker boot, analgesia, WBAT
Metatarsal #Intra-articular/basal # ? Lis FrancWalker boot, analgesia, WBATVFC
Definite Lis Franc/ Significant displacementBackslabOrtho On-Call
Neck & Shaft #s
Minor Trauma/Minimally displaced/stress #Walker boot /flat post op shoe WBATDischarge
High Energy/ Multiple / Significant displacement
BackslabOrtho On-Call
Isolated 5th Metatarsal Base
(diagram below)
Zone 1Walker boot /flat post op shoe WBATDischarge
Zone 2/3 Walker bootVFC
Lesser Toe Injuries #’s/dislocationsED reduction (if needed)
Neighbour Strap
WBAT flat shoe/ Normal footwear
Achilles Tendon RuptureEquinous Slab, NWB,
VTE prophylaxis
Face-Face # Clinic
Talus Neck/Body #BackslabOrtho On-Call
Calcaneal #Walker boot NWBOrtho On-Call
Tongue Type #Equinous Slab NWB (Keep NBM) Ortho On-Call

5th MT zones


Infant Feed Volumes – what is expected?

As you know part of assesses sing an infant is asking about how well it is feeding, especially in Bronchiolitis. However, our paediatric colleagues have noticed that many infants are over fed, and although their intake may have reduced it would still be considered adequate for normal growth.

The tables below give an indication of what a healthy intake is and should be used when assessing how well an infant is feeding. Read more

Sexual Health Referrals

Appropriate Conditions for GUM
  • Genital ulcers
  • Urethral discharge
  • Pelvic Inflammatory Disease (PID)
  • Testicular pain
  • Genital warts
  • Vaginal discharge
  • Emergency/ongoing Contraception
  • HIV risk concerns
  • Possible syphilis
  • PEP follow up
  • Pre-menopausal irregular vaginal bleeding
  • Known HIV patient please contact 01484 347077
PID Referral Criteria

History/Exam. – NICE CKS (Here) 

  • History:
    • Pelvic or lower abdominal pain (usually bilateral but can be unilateral).
    • Deep dyspareunia particularly of recent onset.
    • Abnormal vaginal bleeding (intermenstrual, postcoital, or ‘breakthrough’) which may be secondary to associated cervicitis and endometritis.
    • Abnormal vaginal or cervical discharge as a result of associated cervicitis, endometritis, or bacterial vaginosis. This is often very slight and may be transient, especially with chlamydial infection.
    • Right upper quadrant pain due to peri-hepatitis (Fitz–Hugh–Curtis syndrome).
    • Secondary dysmenorrhoea.
    • Ask about the possibility of pregnancy.
  • Exam: 
    • Lower abdominal tenderness (usually bilateral).
    • Adnexal tenderness (with or without a palpable mass), cervical motion tenderness, or uterine tenderness (on bimanual vaginal examination).
    • Abnormal cervical or vaginal mucopurulent discharge (on speculum examination).
    • A fever of greater than 38°C, although the temperature is often normal.

GUM Exclusions – Ref to Gynae

  • Pregnancy
  • Sepsis
  • Abscess

No GUM Exclusions – Complete following

  • Patient to preform 2 High Vaginal Swabs- Send For:
    • Chlamydia +Gonorrhoea 
    • TV
  • If Clinical Signs of PID – Treat with following (if allergies D/W Micro)
    • Ceftriaxone 1g i.m. – ONCE ONLY
    • Doxycycline 100mg twice a day & Metronidazole 400mg twice a day for 14 days
  • Refer to GUM (with/Without Signs)
Testicular Pain Criteria

GUM Exclusions – Ref to Urology

  • Torsion
  • Sepsis
  • Abscess

No GUM Exclusions – Complete following

  • 2 Urine Samples:
    • First Pass (white top) – Chlamydia +Gonorrhoea 
    • MSU (red top)
  • Treat with following (if allergies D/W Micro)
    • Doxycycline 100mg twice a day for 14 days
  • Refer to GUM 



  • E-Mail referral (patient details and brief description):
  • Patient Self Referral: 01422 261370
  • Address: Broad St, Halifax, HX1 1UB

Acute Cystitis and Pyelonephritis Pathway

A joint Medical-Urology pathway has been agreed for Pyelonephritis

Remember- Imaging in ED is only required if ED suspects:

  • Ureteric Obstruction – Renal colic symptoms/Hx of stone
  • Acute Surgical Abdomen
  • Emphysematous pyelonephritis – Rare necrotising infection of the renal tract, presenting with flank pain and fever, 90% in uncontrolled diabetes mellitus (but immunocompromise and stones also increase chances)
  • Renal Abscess – Presents with flank pain and fever, risk factors include; diabetes mellitus, Renal stones, obstruction

Read more