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Medical SDEC

Note: If the referrer feels the presentation of a patient is not within the inclusion/exclusion criteria they can still contact the SDEC co-ordinator and check for acceptance into SDEC.

  • ED referrals ONLY 08-18:00
  • Check Capacity prior to sending
  • Investigations: FBC/U&E/Clotting/ECG

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1. HAZMAT – First Contact

REMOVE – REMOVE – REMOVE

Remove Them..

At reception ask them to go outside to designated area and staff will be with them shortly. Inform Nurse in Charge!

Remove Clothes..

Use the disrobing card to get the patient to safely remove and bag up clothes. Do your best to maintain privacy. CARD HERE

Remove Substance..

If we have ample warning or the number of patients will be significant, it may be worth deploying the decontamination tent but remember setting this up is time consuming.

Emergency Tracheostomy/Laryngectomy Management

Occasionally patients with Tracheostomy or Laryngectomy present with difficulty breathing due to problem. As this is rare for us in ED, this situation can be very difficult for all of us. However the protocols below can help.

 

Tracheostomy

Tracheostomy is simply a passage from the neck into the trachea. In most cases the trachea will still be connected to the nose and mouth (so can breath though their mouth too).

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Lateral Canthotomy

Like tension pneumothorax the biggest step is deciding to do it – Remember it it sight saving and they heal well

Retrobulbar Haematoma secondary to blunt eye injury is a a rare but potentially sight threatening injury.

  • Blood collects in the retrobulbar space
  • Pushing the eye forward to accommodate the extra volume.
  • The Orbital Septum (made up of the eyelids and ligaments that attach them to the orbital rim) restricts this forward movement, creating a compartment syndrome for the eye. Thus threatening the patients sight if not treated quickly.

Recognition

From Royal College Ophthalmologists

  • Severe pain
  • Red/Congested conjunctiva
  • Exophthalmos with proptosis – eye pushed forward
  • Internal ophthalmoplegia – impairment or loss of the pupillary reflex.
  • Visual flashes
  • Loss of vision – initially colour vision (esp. red), progressing to local visual loss.

However, this may only be recognised on CT if there is significant facial injury and altered conscious level.

Treatment

Call Ophthalmology immediately to attend. If there is going to be any significant delay, it may be necessary for ED to preform a Lateral Canthotomy, to allow the eye to move forward, reduce the orbital pressure & preserve the patients sight.

Kit needed

  • Lidocaine with adrenaline (needle & syringe)
  • Clamp – ideally curved to crush the tissues
  • Forceps
  • Scissors

Resources

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.

  • Complete the Ad-hoc form
  • Increase pressures from Initial 12/5 cmH2O to 20/5cmH2O – as tolerated over 1st hour

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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