Category: Surgical

Early Pregnancy Bleed <16/40

Bleeding in early pregnancy is a relatively common problem and in the many cases (esp. with spotting) the pregnancy remains viable. However, bleeding in early pregnancy should never be thought of as normal, and it is vital that we investigate this appropriately.

 

Communication is also vital at a very stressful time

  • Who you are discussing this pregnancy in front of? – Does the patient want them to know
  • Manage expectations – There is nothing we or mum can do to change the out come of the pregnancy apart from ensuring mum is well
  • Ensure the patient has all the details they need – Return advice, clinic time, where to go, what is happening
  • Be sensitive to the patients feelings – Patients respond very differently, be careful not to impose your emotions/assumptions on the situation

Think Anti-D!

Anti-D immunoglobulin guide

 

Search: ectopic pregnancy, Ectopic Pregancy, pv bleed, MISCARRIAGE, vaginal bleed, EPAU

Epistaxis – Management

Nose bleeds are a bloody common problem (bad pun intended) – most originating at the front to the nose where there is a cluster of blood vessels – Little’s Area.

In the young the bleeding often starts after trauma (e.g. picking or punching noses). In the elderly however, it is commonly a manifestation of underlying vascular disease. Read more

Upper GI Bleed (UGIB)

Not normally difficult to spot, but look for it in unexplained anaemia, or collapse.

Questions

  • Is it VARICEAL? Mortality 35%, so is an emergency whatever the GBS is.
  • Non-Variceal what’s the GBS? will help guide treatment

Anyone being admitted should be brought to HRI

Emergency Endoscopy is arranged by Med Reg

Read more

Bell’s Palsy

Bell’s Plays is a lower motor neurone (LMN) lesion of the facial nerve (CN VII), which causes one side of the face to “droop” [1% of cases are bilateral], and patients are often concerned that it is a stroke.

However, unlike in stroke the whole face is affected, in stroke and other upper motor neurone (UMN) lesions the upper portion of the face is unaffected due to input from both sides of the brain. Read more

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

Urology Referral Pathways

Referral

The first point of contact for urology advice and referral is the general surgical SHO. This is the on-call surgical SHO carrying the on-call bleep. Some of the on call general surgical SHO have a urology background.

If a time critical emergency such as torsion is presenting, then the first point of contact should be the urology registrar.

In the case of Urological/Surgical emergency

  1. Refer directly to Middle Grade on-call
  2. If Middle Grade unavailable/uncontactable – Contact speciality consultant on-call
  3. If NO senior available – inform ED senior
    • Admit directly (admission rights) to SAU/Ward 4 HRI
    • Attempt to contact surgical SHO (to inform)

(agreed with both surgical and urological leads)

 

Under 3’s go to Leeds

Urologist are happy to operate on patients over the age of 3 years old. Under the age of 3 if this on a urological emergency such as a torsion then this patient should be referred to Leeds paediatric urology services.

Streaming

Any patent with a post op complication for up to 7 days form urological procedure – should be streamed directly to the urology team via the surgical SHO. If the patient is unwell and needs resuscitation and immediate management for example sepsis, then ED team needs to be involved in resuscitation measures and the urological registrar needs to be involved as well

Pyelonephritis

Currently ALL Pyelonephritis should be admitted under the urology team. There is a conversation between urology and medical teams happening currently to see if that requires further rationalisation. However currently the position is all pyelonephritis patients who need admitting are done so under the urology team.

  • Uncomplicated pyelonephritis – does not require CT scanning or ultrasound scanning from the emergency department.
  • Suspicion of an obstructive uropathy –  CT KUB needs to be arranged from the ED

Investigations including:

  • FBC
  • U&E, CRP
  • Blood Cultures
  • Urine cultures

Appropriate Antibiotics should be prescribed using the current antibiotic guidelines.

Renal Colic

CTKUB are now available 24/7.

Patient presenting >50 years old  with a renal colic story, should have a ultrasound scan done at the bedside to ensure that there is no aortic aneurysm before being sent for a CT KUB.

Uncomplicated renal colic needs a non contrast CT scan. This should be organised by the ED

Uncomplicated renal colic patients can wait CT KUB for  results on SDEC. (The case must be to be discussed with the surgical SHO on-call and accepted by them before transfer of the patient. SDEC closes at 6 pm)

Haematuria

All frank hematuria needs investigation

  • Admit + 3-way catheter – those at risk of clot retention and shock 
    • Hb <100
    • Post void bladder scan>250 ml 
  • All those discharged: will need a OPD cystoscopy arranged as well as a USS (the request for flexible cystoscopy on EPR is Urol Cystoscopy  post Wd Dis)
Catheters

New catheters and catheter complications – follow current guidelines. Community nurses follow up for TWOC or other catheter care (HOUDINI team in Kirklees)