Not normally difficult to spot, but look for it in unexplained anaemia, or collapse.
Questions
Anyone being admitted should be brought to HRI
Emergency Endoscopy is arranged by Med Reg
Read moreRecent Incident: Bat contact was not recognised (effectively touching a bat without gloves means treatment is recommended)
Important: Rabies Vaccine is in short supply and we must do a UKHSA risk assessment. Call RIgS 09:30-17:00 7 days, Info required HERE
Rabies is an acute viral encephalomyelitis caused by members of the lyssavirus genus. The UK has been declared “Rabies-Free”. However, it is known that even in “Rabies-Free” counties the bat population posse a risk.
In the UK the only bat to carry rabies is the Daubenton’s Bat [Picture on the Left] and this is not a common bat in the UK. The UK and Ireland are Classified as “low-risk” for bat exposure. Despite our “low-risk” status in 2002 a man died from rabies caught in the UK from bat exposure.
Although rabies is rare it is fatal so we must treat appropriately, Public Health England – Green book details this.
To establish patients risk and thus treatment you need to establish the Exposure Category and Country Risk [Link to Country Risk]
Obviously patients with wounds will need appropriate wound care and cleaning, specifics for rabies are below.
If in ANY doubt, or you feel you need advice about treatment contact: On-Call Microbiologist (who will contact PHE or Virology advice)
You will likely need to liaise with the duty pharmacist to obtain vaccine or HRIG – which may need to be sent from a different hospital. [it is probably worth trying to obtain the 1st weeks treatment if possible, to avoid treatment delays]
IN HOURS 08:30AM-5PM PLEASE CALL PHARMACY TO INFORM THEM TO EXPECT A DELIVERY OF IMMUNOGLOBULIN SO THIS CAN BE SEGREGATED FOR THE CORRECT PATIENT. PLEASE ASK TO SPEAK TO THE RESPONSIBLE PHARMACIST CRH (4218/4279) HRI (2422/7123)
Routine operating hours: 09:30–17:00, seven days per week, including weekends.
All patients presenting with a possible rabies exposure should undergo an initial clinical assessment, including wound management, assessment of the exposure and previous vaccination history.
During routine hours: Contact RIgS for specialist risk assessment, advice on post-exposure vaccination and any requirement for human rabies immunoglobulin (HRIG).
Outside routine hours:
All advice and administered treatment must be documented in the patient’s clinical record. Pharmacy must be informed of vaccine and HRIG administration, and arrangements made for subsequent doses.
HRIG: Indications, dosage and administration must follow the current UKHSA interim recommendations for HRIG use (June 2025), alongside the national rabies post-exposure treatment guidance.
Information required for next morning referral – HERE
Mitochondrial diseases are a diverse group of inherited disorders characterised by dysfunction of the mitochondrial respiratory chain, resulting in impaired cellular energy production.
These conditions frequently affect multiple organ systems and can present significant challenges in the Emergency Department. Evidence to guide management remains limited, particularly for specific complications, and specialist advice is often required.
Key principles for emergency care:
Access specialist NHS information about mitochondrial diseases, including clinical features, diagnosis and management.
View NHS Mitochondrial Disease InfoAccess specialist NHS guidance for healthcare professionals on the assessment, management and ongoing care of patients with mitochondrial disease.
View NHS Clinical Care GuidelinesRemember: is it a haemolysed blood sample? (you can do an iSTAT)
Severity
Target:
Door to balloon 90min
Criteria Time:
Chest pain within 12hrs (or worsened within 12hrs)
ECG:
ST elevation MI (2 contiguous: 1mm Limb or 2mm Chest leads)
New LBBB.
(Posterior MI do posterior leads and discuss with LGI)
Actions:
Resuscitate as required
Contact PPCI team @ LGI (Mobile No. up in Resus)
Arrange blue light (P1) ambulance to LGI
Medication:
Prasagrel 60mg if – no previous CVA
Ticagrelor 180mg if previous CVA and Aspirin 300mg
Anti-coagulated Discuss with PPCI team
Aortic Dissection (AD), is uncommon (1:980 non-traumatic chest pain) but is…Rapidly FATAL! However, is testable for 80% if recognised early, unfortunately recognising aortic dissection is difficult with a clinician pickup rate of 15-43%.
Read moreRecognising that someone may be approaching the end of their life can be difficult, particularly in the busy and sometimes unpredictable environment of the Emergency Department. We may meet people and families at a moment of profound distress, with little time to build a relationship or understand what matters most to them. It is understandable that these conversations feel daunting.
Yet recognising the possibility of dying creates an opportunity to offer the right care: to treat distress, consider reversible problems, explain uncertainty honestly and help patients and those close to them make informed choices. End of life care is not an alternative to good emergency medicine; it is part of it. Compassionate care remains active care.
Read more
It’s essential any Modifiable causes are treated, these include:
“Early cardioversion is not recommended without appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h, or there is scope to wait for spontaneous cardioversion.”
In reality risks increase beyond 12hrs from onset, and those reverted in ED will often return to AF by the time they get to AF clinic follow up.
Arrhythmia clinic is for patients with newly diagnosed and symptomatic AF/SVT (if the patient is not symptomatic they should be followed up through their GP).
It should be remembered that patients will be seen after at least 6 weeks so anticoagulation decisions should not be delayed for clinic.
Based primarily on:
EMbeds clinical quick guide
Last evidence review: October 2026
Suggested next review: October 2026
This is a clinical support guide and does not replace clinical judgement, current CHFT medicines guidance or specialist advice.
First take a good history, not ALL chest pain needs to be investigated as ACS. However, its worth noting older patients and women are more likely to have atypical presentations. Be wary that some patients with negative troponin give a history of Unstable Angina and therefore require admission.
Read more: Acute Coronary Syndrome (ACS) – 2025
Anticoagulated with a DOAC, or with Warfarin (with a therapeutic INR),
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 manage and place your patient within the hospital.
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:
