Faltering growth and poor weight gain in neonates are handled very differently.
Fortunately for us our paediatric colleagues have developed a very robust (read long) guideline to help us understand what we may need to do for these children.
They also appreciated we aren’t so good in PED at reading long guidelines so please refer to the bottom of the linked document for the appendices – one for babies and one for children.
Working out what your patient might have been vaccinated for can be tricky, and more so if they were raised outside of the UK. Luckily there are a couple of tools online you can use to make this easier.
Time Critical Medication (TCM) is scheduled medication that the patient is already on when they present to the Emergency Department (ED).
The medications are “time critical” because a delayed or missed dose can result in harm with exacerbation of symptoms and the development of complications leading to an increased mortality.
Movement disorders – Parkinson’s / Myasthenia medication Immunomodulators including HIV medication Sugar (Insulin) Steroids – Addison’s and adrenal insufficiency Epilepsy – anticonvulsants DOACs and warfarin
Its really important for our patients that these medications are prescribed and given while in ED/uSDEC/fSDEC.
If you are withholding these medication (which may be necessary) -please the reason for this clearly in the notes.
As we all know frailty and care of older patients is becoming a more and more important in the ED. The elderly population is growing rapidly and as you age your health costs shoot up.
The study day not only highlighted several import areas of care within ED, but also how relatively small interventions/conversations can make significant differences.
Think Home First:
What is stopping them going home?
What tests will guide your decision making? (don’t just investigate because you can)
Get them up (you don’t need to wait for physios)
Do the easy stuff: Feed, Water, Toilet, Communicate
DON’T create barriers: e.g. catheters, exessive testing
Ask for help: Local service are your friend
Topics
Population & Costs
Increasing aging population:
Costs as we age:
Life Expectancy
Life Expectancy:
Average life expectancies are often longer than you imagine and after 100yrs life expectancy increases!
80yr woman – 10yr
85yr woman – 7yr
90yr woman – 5yr
99yr woman – 2yr
However, Clinical frailty score is often more predictive.
Frailty Trajectory and Life Expectancy
Study shows that the rate of change in frailty has a significant impact on life expectancy. People with “Stable” growth in frailty score remaining at their base line but the faster the CFS changes more impact that has.
So its worth asking how things have changed over the last year.
Trauma
Frailty has a significant influence on recovery and mortality in relation to both “MINOR” and “MAJOR” trauma.
Rib injury is probably more important than most of us realise – suggesting 15% increase in mortality for every rib a frail person fractures. JRCALC have since updated guidance to recommend “rib spring” rather than “gentle palpation” in examination.
Silver Trauma Review Clinic:
Mater hospital Dublin have introduced a review clinic for patients following significant traumas.
Mater hospital – Adult only ED
90’000 attendances/yr
10.5WTE ED consultants
Major Trauma Centre
Silver Trauma Review Clinic
Weekly clinic sees 10 patients/week
Follows up: trauma patients discharged with non-operative management or post admission
Team: EM, Geris, Frailty ACP, Physio
Main work: Thoracic, Spinal, humeral, pelvic injuries
Requires access to DEXA and MRI (they MRI all spinal injury through clinic not only to age but also find other diagnosis)
“Decisions about not resuscitating a patient, or about putting a DNACPR notice on a patient’s record, are made by doctors and do not need patient consent. This can be an immediate clinical decision made when a patient is seriously unwell, or a decision that goes on a patient’s records in advance and affects treatment at a later stage. But it is a legal requirement for doctors to consult with a patient about a DNACPR decision if they have capacity, and with their next of kin otherwise.”
But our communication needs to be clear to patients and families, not just saying “they are sick” but how sick. And not just what we are not going to do but what we are going to do for the patient.
Preparation:
Ensure Anticipatory Medication prescribed
End of Life trolly (Dandilion trolly – QLD)
Syringe driver kit
Paperwork
Black towels – to hide blood loss (reduces distress)
Taste for pleasure – mouth care with things people actually like (families can bring)
The prevalence of Tuberculosis in our region is increasing and has significant issues for both the patient and public health if we miss it.
Symptoms
Cough
Fever
Night Sweats
Lymphadenopathy
Weight loss
High-Risk factors to consider
Characteristics
Previous/Latent TB
TB Contact
Immunocompromised
Substance Misuse
Homeless/Prision
Pubs – esp. Vulcan Hudds
Travel/Ethnicity
Eastern Europe
India/Pakistan
East Asia
Africa
CXR Changes
Upper Lobe Consolidation
Hilar Lymphadenopathy
Cavities
Actions
Provide 3 AFB samples – Ideally performed in ED/Ward (but if patient fit for discharge and unable provide samples in ED give patient pots and request which they return to their GP.
Don’t Commence TB treatment – unless instructed by respiratory team
If admitted isolation requested
If discharged Patient told to isolate and if must go into public wear face mask
Contact TB team:
Huddersfield/Halifax – Based on GP postcode
In-Hours: either through Switch board or as EPR referral
Out of Hours: Though EPR referral
They will ensure appropriate notification of Public Health
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
Onset is usually after 20 weeks of gestation, but it can also occur up to a few weeks postpartum.
Eclampsia- This is pre-eclampsia that has progressed to seizures
Risk Factors:
Clinical features of pre-eclampsia:
Asymptomatic hypertension (picked up on screening or incidentally when presenting with another issue)
Headache (usually frontal)
RUQ or epigastric pain (also a symptom of HELLP syndrome)
Nausea and vomiting
Oedema (common but not specific). Especially if rapidly increasing and involving face and hands.
Visual disturbance (flashing lights in the visual fields or scotomata)
Shortness of breath (uncommon but can occur due to pulmonary oedema)
Hyper-reflexia and/or clonus
HELLP syndrome is a variant of severe pre-eclampsia characterised by haemolysis, elevated liver enzymes and low platelets.4
Symptoms and signs are similar to those of pre-eclampsia but also include jaundice and bleeding.
Management of Pre-eclampsia:
Contact obstetrics early
Manage the patient in an area with close monitoring if pre-eclampsia with severe features
BP management:
Labetalol first line unless unsuitable or contraindicated3 (e.g. asthma)
Nifedipine MR second line
Methyldopa third line (not used postpartum due to risk of depression)
Careful fluid balance monitoring
Fluid restriction to reduce the risk of pulmonary oedema
Monitor urine output if severe
Consider IV magnesium sulphate for eclampsia prophylaxis if severe features of pre-eclampsia
Definitive management:
Definitive management of pre-eclampsia is ultimately delivery of the fetus. Timing of delivery will be decided by senior members of the obstetric team according to the severity of pre-eclampsia, the current gestation and in consultation with the patient. Following diagnosis of pre-eclampsia, the majority of women are managed as inpatients until delivery.
ED Management of Eclampsia:
Ask for help early from ITU and obstetric teams
ABC approach, manage in left lateral position
Airway and breathing assessment with high flow oxygen
If inadequate ventilation, consider early intubation (laryngeal oedema in pre-eclampsia and increased risk of aspiration in pregnancy)
Magnesium sulphate IV is treatment of choice for seizures – 4g loading dose over 5-10 mins then 1g/hr infusion for 24 hours
Further 2g boluses of magnesium sulphate can be given if further seizures occur after initial loading.3
Patients will need to be managed in HDU/ITU to stabilise blood pressure prior to delivery