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Acute Cystitis and Pyelonephritis Pathway

A joint Medical-Urology pathway has been agreed for Pyelonephritis

Study Running  – Send Urine Sample prior to Antibiotics

(if this does not interfere with treatment of Red-Flag Sepsis)

 

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

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ACS Pathway 2022

When is the ACS pathway used? 

The ACS pathway is for patients where coronary ischemia is in your differential. It is not a blanket pathway for chest pain of unknown cause. 

Patients presenting >8hrs post chest pain 

If an initial trop is taken >8 hours post chest pain, and patients have no new ECG ischaemia, and no history of unstable angina, there is no compulsion to repeat a second troponin. 

ACS Treatment (Not STEMI going for PPCI)

  • Aspirin 300mg stat
  • Ticagrelor 180mg stat
  • Fondaparinux 2.5mg sc stat. 

Anticoagulated with a NOAC, or with Warfarin (with a therapeutic INR),

  • Aspirin 300mg stat
  • Clopidogrel 300mg stat

Treatment STEMI going for PPCI

  • Aspirin 300mg stat
  • Plus Either:
    • Ticagrelor 180mg stat (Hx of CVA)
    • Prasugrel 60mg stat (NO Hx of CVA)

Direct admissions to CCU 

Patients with ST Elevation (if not accepted for primary PCI) or those with CP + new ST Depression should be discussed with a local Cardiologist and come directly to CCU. 

As it is difficult to be prescriptive for every other circumstance, a discussion with a senior / cardiologist may be worthwhile in order to best place your patient within the hospital. Factors that should make you think about a senior discussion are included on the pathway. 

Patients where MI is excluded 

If patients do exit the pathway (no new symptoms, no new ECG ischemia and troponins that meet the exit criteria to exclude an MI), two other important possibilities still require consideration: 

  1.  Is the history in keeping with unstable angina? (This is still an ACS). If so the patient will require an acute inpatient admission with telemetry and IP cardiology review. 
  2.  Is the chest pain due to a significant alternative diagnosis? If so this still needs to be actively considered/ investigated/ treated. 

NB: 2nd Trop should be done >8hr after chest pain (this may be <6hrs from the initial Trop)

Patients on Warfarin/DOAC : Use Asprin and Clopidogrel

PDF: Full Guidance

FAQ’s

  • highSTEACS pathway developed in scotland. 
  • When do we take the blood samples? – The initial troponin must be taken at least 2hrs after chest pain, a second trop may be required 6hrs after the 1st  (AAU/CDU)
  • Do we need to do a HEART score? – No, evidence shows the use of risk stratification in these pathways doesn’t increase safety but only increases admissions
  • Can we rule out ACS after the first trop? [Symptoms of Unstable Angina require admission]
    • Troponin <5ng and the ecg is normal we can rule out ACS.
    • Troponin <39ng(female)/58ng(male) and >8hrs from onset of chest pain [this is a pragmatic decision agreed locally by EM/AM?cardiology]
  • Why does it have different cut offs for male/female? – It is known women have significantly lower troponin to men, ESC recommends using the different cut offs 
  • How should we treat transgender/intersex patients – There is no good evidence I can find (I would suggest using the female cut off – as patients who have transitioned to male are probably not going to have as high a troponin, and those who have transitioned to females may have reduced their baseline troponin with hormone therapy) – Be aware the lab can only report against the one registered sex for the patient.
  • Doesn’t highSTEACS have a 3hr Trop too? – Yes it does and in time we will be aiming to utilise this too. However, this relies on using Delta’s (i.e. the change in troponin), and it is felt that it is worth delaying introduction of this until we have got used to the new pathway.
  • Why are the numbers on the official highSTEACS pathway different? – This is because it uses the Abbott test.  the highSTEACS pathway has been also validated on the Siemens assay we will be using. As to why the Abbot and Siemens cut-offs are so different, this is due to the way the assays amplify the troponin present (its not as simple as a U&E that just measures what is there).

 

Hyperemesis Gravidarum

Nausea and vomiting in pregnancy is common and at best an unpleasant experience for the patient, and at worst can be life threatening. It normal starts @ 4-7/40, peaks @ 9/40, and finishes @ 20/40.

We need to conduct a thorough history and examination looking for causes other than a high βHCG. these include:

  • Abdominal pathology
  • Urinary pathology
  • Infections
  • Drug History
  • Chronic H.Pylori

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Post ROSC CT Protocol

Within ED we often have little information about the patient we are resuscitating. Post-ROSC (return of spontaneous circulation )we commonly perform CT head, but evidence and Resus Council Guidance suggests extending this scan can pick up important pathology that can otherwise be missed (13%).

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Neuro-Obs

Neurological Observations MUST include the following:

  • A full set of NEWS2 observations
  • ACVPU assessment (alert, new confusion, voice, pain, unresponsive)
  • GCS (Glasgow coma scale)
  • Pupillary responses
  • Assessment of Limb power

Head Injury – Level 1

Head injury is witnessed, reported, suspected, or cannot be excluded.

  • There is any new onset of neurological symptoms or deterioration.
  • The patient complains of pain / tenderness to the head
  • Extra consideration should be given to patients currently prescribed anticoagulant medication at the time of the fall.

Post fall Neurological Observations must be completed for at least 12 hours and at the above intervals as a minimum:

During this time If there is any deterioration in the patient’s condition including level of consciousness, pupil reaction, limb power, cardiovascular observation you must revert to ½ hourly neurological observation and seek URGENT medical review.

Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.

Under no circumstances should Neurological observations be omitted because the patient is asleep

Head Injury – Level 2

Admitted with Head Injury

  • With a sudden deterioration in their level of consciousness
  • Who are unconscious on arrival to hospital
  • Post first seizure

During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must revert to ½ hourly neurological observations and seek URGENT medical review. Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.

Under no circumstances should Neurological observations be omitted because the patient is asleep.

Intracerebral/Subarachnoid Haemorrhage OR Stroke
  • Acute Primary Intracerebral/Subarachnoid  haemorrhage
  • Any other Ischaemic stroke 
  • Post Thrombolysis /Thrombectomy for Stroke patients only

During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must seek URGENT medical review and revert to ½ hourly neurological observations as a minimum, or ¼ hourly, if still within the first 2 hours post thrombolysis.

Under no circumstances should Neurological observations be omitted because the patient is asleep.

Major Trauma: STOP>SORT>GO

YAS crews may on occasions (rarely) bring us a Major Trauma patient that meets the criteria for bypass to the MTC because they have a problem that the crew cannot manage, or they won’t survive to LGI e.g. an unmanageable airway/ incompressible haemorrhage. In these instances we will get a pre-alert either from the crew or more likely the Major Trauma Triage Co-ordinator in EOC with some information but primarily the reason the patient is coming to us.

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