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:
Severity – Severe or Life threatening – think RESUSLink to ALL Trust protocols – HERE
Read moreHigh Consequence Infectious Diseases (HCIDs) include a group of rare but severe infections that require
Severe pain is the most common reason that patients with sickle cell, will attend the ED. The pain can be agonising (and often underestimated by us), we need to act fast to help ease the symptoms
Read more
Aortic Dissection (AD), is uncommon (1 AD:200 ACS) but is…Rapidly FATAL! Unfortunately recognising aortic dissection is difficult with a clinician pickup rate of 15-43%. Read more
Recent 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, OR complete Form
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)
Rabies and Immunoglobulin Service (RIgS), National Infection Service, Public Health England, Colindale (PHE Colindale Duty Doctor out of hours): 0208 327 6204 or 0208 200 4400
Registered Medical Practitioners in England and Wales have a statutory duty to notify Public Health about the following diseases. To facilitate rapid treatment and control of outbreaks. (Links to Wikipedia for illustrative purposes) Read more
