City hospitals Sunderland A&E Department

Information Card PackProduced by Dr Sarah FrewinCorrespondence to s.e.frewin@doctors.org.uk

Review date: January 2012

Nexus C-spine rules NICE COPD guidanceGlasgow pancreatitis score NICE head CT guidance (amendment)Alvarado score NICE head CT guidanceRectal bleeding differentials Chest pain differentialsUpper GI bleed differentials Breathlessness / hypoxia differentialsAbdominal pain differentials Bradyarrhythmia differentialsJaundice differentials Tachyarrhythmia differentialsRockall score (GI bleed) Reversible causes of cardiac arrestABCD2 (TIA) ECG interpretationSevere sepsis criteria New York heart failure classificationSepsis screening tool Grading of murmursSevere sepsis 1st hour pathway Headache differentialsSoft tissue antibiotic policy Dizziness differentialsCurb 65 (pneumonia) AMTSLRTI antibiotic policy Timed get up and go testMeningitis antibiotic policy Stroke mimicsUTI antibiotic policy falls /collapse differentialsWells criteria (PE) Pain assessmentWells criteria (DVT) Confusion differentialsMRC dyspnoea scale Hypotension differentialsASA grading (anaesthetics) Stages of hypovolemic shockBTS asthma exacerbation grades CO poisoning

Reversible causes of cardiac arrest

Hypoxia Tamponade

Hypothermia Toxins

Hypovolemia Thromboembolism

Hypo / hype / hypokalaemia Tension pneumothorax

Stroke mimics

Hypoglycaemia

Seizure

Complicated migraine

Hypertensive encephalopathy

Conversion disorder

CURB-65 score for pneumoniaScore Description

1 Age 65+

1 New onset confusion

1 Urea >7mmol/l

1 Respiratory rate >30/min

1 SBP <90mmHg / DPB <60mmHg

Additional adverse

prognostic features

Hypoxaemia (SaO2 <92% or PaO2 <8 kPa) regardless of FiO2

Bilateral or multilobe involvement on CXR

Modified Glasgow Score For Pancreatitis

Parameter score

age >55 1

pO2 <8.0kpa 1

WCC >15 1

Ca2+ (uncorr) <2 1

ALT >100 1

LDH >600 1

glucose >10 1

score > 3 indicates severe pancreatitis

Rockall scoring system(Risk of re-bleeding / death after acute UGIB)

Variable Score 0 Score 1 Score 2 Score 3

Age in years <60 60 – 79 >80

Shock None SBP >100, pulse <100

Tachycardia pulse >100, SBP >100

Hypotension SBP <100, pulse >100

Co-morbidity Nil major Cardiac failure, IHD, other major co-morbidity

Renal or liver failure, disseminated malignancy

Diagnosis Mallory-Weiss tear, no lesion, no stigmata of recent haemorrhage

All other diagnoses

Malignancy of upper GI tract

NICE criteria for immediate head CT (adults)

GCS <13 on initial assessment in ED

GCS <15 2 hours after injury / ED assessment

Suspected open or depressed skull fracture

Any sign of basal skull fracture

Post-traumatic seizure

Focal neurological deficit

More than one episode of vomiting

Amnesia for events >30 minutes before impact

NICE criteria for immediate head CT (patient experiencing LOC / amnesia since injury)

>65 years

Coagulopathy / warfarin

Dangerous mechanism of injury

ABCD2 to identify patients at high risk of stroke following a TIA

Score Description

1 A - Age >=60 years

1 B - Blood pressure at presentation >=140/90 mmHg

2 C - Clinical features of unilateral weakness

1 C - Clinical features of speech disturbance without weakness

2 D - Duration of symptoms >= 60 minutes

1 D - Duration of symptoms 10-59 minutes

1 Presence of diabetes

Scores range from 0 (low risk) to 7 (high risk)

Wells score for DVT

Score Description1 Active cancer (treatment within last 6 months or palliative)

1 Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity)

1 Collateral superficial veins (non-varicose)

1 Pitting oedema (confined to symptomatic leg)

1 Swelling of entire leg

1 Localized pain along distribution of deep venous system

1 Paralysis, paresis, or recent cast immobilization of lower extremities

1 Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 12 weeks

1 Previously documented DVT

Minus 2 Alternative diagnosis at least as likelyInterpretation

2 or higher:- DVT likely (consider imaging leg veins) <2:- DVT unlikely (consider XDP to further rule out DVT)

MRC Dyspnoea ScaleScore Symptom

1 Not troubled by breathlessness except on strenuous exercise

2 Short of breath when hurrying on walking up a slight hill

3 Walks slower than contemporaries on the level because of breathlessness, or has to stop for

breath when walking at own pace

4 Stops for breath after walking about 100m, or after a few minutes on the level

5 Too breathless to leave the house, or breathless when dressing or undressing

COPD Guidance (NICE)

Factors to be considered when deciding where to manage patient

Factor Favours hospital Favours homeAble to cope at home No Yes

Breathlessness Severe MildGeneral condition Poor /deteriorating GoodLevel of activity Poor /confined to bed Good

Cyanosis Yes NoWorsening peripheral oedema Yes No

Level of consciousness Impaired NormalAlready receiving LTOT Yes No

Social circumstances Living alone / not coping GoodAcute confusion Yes No

Rapid rate of onset Yes NoSignificant co-morbidity (IDDM /

CCF)Yes No

SaO2 <90% Yes NoChanges on CXR Present No

Arterial pH <7.35 >7.35Arterial PaO2 <7kpa >7kpa

Grading of asthma exacerbations Moderate Acute severe Life threatening Near fatal

Increasing symptoms PEF 33 – 50% best or predicted

PEF <33% best or predicted

Raised PaCO2

PEFR >50 – 75% best or predicted

RR > 25 /min SpO2 < 92% Requiring mechanical

ventilation with raised pressures

No features of acute severe asthma

HR > 110 /min PaO2 <8kpa

Inability to complete sentences in one

breath

Normal PaCO2

Silent chestCyanosis

Feeble respiratory effort

Bradycardia, arrhythmia, hypotension

Exhaustion, confusion, coma

Asthma Exacerbation Grades (BTS)

Grading of murmursGrade Description

1 Very faint, heard only after listener has "tuned in" may not be heard in all positions

2 Quiet, but heard immediately after placing the stethoscope on the chest

3 Moderately loud

4 Loud, with palpable thrill (ie, a tremor or vibration felt on palpation)

5 Very loud, with thrill. May be heard when stethoscope is partly off the chest

6 Very loud, with thrill. May be heard with stethoscope entirely off the chest

New York Association Heart Failure ClassificationClass Description

1 No Limitation. Ordinary activity does not cause undue fatigue, dyspnoea, or palpitations

2 Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in heart

symptoms

3 Marked limitation of physical activities. Comfortable at rest, but less than ordinary activity causes heart

failure symptoms

4 Symptoms of heart failure are present at rest. If any physical activity is undertaken, discomfort is

increased

Modified Alvarado score for appendicitisScore Description

1 Migratory right iliac fossa pain

1 Anorexia / acetone urine

1 Nausea/vomiting

2 Tenderness right lower quadrant

1 Rebound tenderness right iliac fossa

1 Pyrexia greater than or equal to 37.5°

2 LeucocytosisScore <5 is not likely appendicitis

5 or 6 is equivocal7 or 8 is probably appendicitis

9 means patient is highly likely to have appendicitis

ASA Grading (assessment of fitness for anaesthesia and surgery)

Grade   Definition  

INormal healthy individual

 

II Mild systemic disease that does not limit activity  

IIISevere systemic disease that limits activity but is

not incapacitating  

IVIncapacitating systemic disease which is constantly

life-threatening  

VMoribund, not expected to survive 24 hours with or

without surgery  

Sepsis Screening Tool

Score Criteria

1 Temperature > 38°C or < 36°C

1 Heart rate > 90 beats/minute

1 Respiration > 20/min

1 WCC >12 or <4

1 Hyperglycaemia in absence of diabetes >6.6

1 Acutely altered mental state

Ask patient about history suggestive of new infection

Sepsis present in patients presenting with 2 or more criteria PTO for severe sepsis criteria

Severe Sepsis Criteria SBP <90 or MAP <65

Urine output <30mls/hr for 2 consecutive hours

Unexplained metabolic acidosis pH<7.35

Acute change in mental state

New need for O2 to keep SPO2 >90

Plasma lactate >2

Platelets <100

Creatinine >177

Severe Sepsis First Hour PathwayOxygen Target SPO2 >94% / COPD target 88-92%

Blood cultures

Also consider other microbiology samples (urine / sputum /swabs)

IV antibiotics

As per trust guidelines (contact microbiology for advice)

Fluid Bolus of Hartman’s / N/saline @20ml/kg. Further boluses @10ml/kg

Lactate / FBC

Also ensure Hb >7 / do other bloods as appropriate

Catheterise Commence 1 hourly urine output

Discuss with senior to asses if escalation in care is needed

Antibiotic policy for soft tissue infection

Less severe More severe notes

1st line Flucloxacillin PO500mg – 1g QDS

Flucloxacillin IV 1-2g QDS

Treat for 5,7, 10 days according to

responsePenicillin

allergyClindamycin PO

300 – 600mg QDSClindamycin IV

600mg QDSTreat for 5,7, 10

days according to response

Caution in elderly due to risk of C-diff

MRSA suspected

Doxycline PO 100mg BD

Plus eitherSodium fusidate PO

500mg TDSOr

Rifampicin PO 300mg BD

Contact microbiology

Antibiotic policy for acute meningitis infection

Antibiotic Notes

Standard Cefotaxome IV 2g QDSOr

Ceftriaxone IV 2g BD

Add amoxicillin IV 2gQDS if aged > 55to cover listeria

Additional Acyclovir IV 10mg/kg TDS

For suspected HSV

Antibiotic policy for UTI (non catheterised)Patient

conditionTreatment

Asymptomatic Needs no treatment

Symptomatic Trimethoprim PO 200mg BD for 5-7 daysOr

Cefalexin PO 500mg TDS for 5 – 7 days

Clinically unwell Co-amoxiclav IV 1000/200mg TDS for 5 – 7 daysOr

Cefuroxime IV 750mg – 1.5g TDS for 5 – 7 daysOr

Aztreonam IV 1g TDS for 5 – 7 days

Septic Single dose of IV gentamicin 5mg/kg (await culture)

Antibiotic policy for LRTI

Condition 1st line 2nd line 3rd line

Bronchitis / COPD

Doxycycline PO 200mg loading dose then 100mg OD for 5 days

Amoxicillin 500mg – 1g TDS for 5 days (IV or PO)

Moxifloxacin PO 400mg OD for 5

daysSystemic Sepsis

Cefuroxime 750mg – 1.5g IV TDS (switch to co-amoxiclav PO 625mg TDs to complete 5 days

ASAP)

Contact microbiology

CAP CURB-65

≤ 2

Amoxicillin 1g TDS (initially IV)Plus either

Clarithromycin IV 500mg BDOr

Erythromycin PO 500mg QDSOr

Clarithtomycin PO 250 – 500mg BD

All for 5 – 7 days

In penicillin allergyClarithromycin IV

500mg BDOr

Erythromycin PO 500mg QDS

For 5 – 7 days

Moxifloxacin PO 400mg OD for 5 days (up to max

of 10 days

CAP CURB-65

≥3

Cefuroxime 750mg – 1.5g IV TDSPlus

Clarithromycin IV 500mg BD

Stages of hypovolemic shock

Grade 1

Up to 15% blood volume loss (750mls) Blood pressure maintained Normal respiratory rate Pallor of the skin

Grade 2

15-30% blood volume loss (750 - 1500mls) Increased respiratory rate Blood pressure maintained Increased diastolic pressure Narrow pulse pressure Sweating

Grade 3

30-40% blood volume loss (1500 - 2000mls) Systolic BP falls to 100mmHg or less Marked tachycardia >120 bpm Marked tachypnoea >30 bpm Decreased systolic pressure

Grade 4

Loss greater than 40% (>2000mls) Extreme tachycardia with weak pulse Pronounced tachypnoea Significantly decreased systolic blood pressure of 70 mmHg or less

Nexus C-spine rule

Score Parameter

1 Midline c-spine tenderness

1 Evidence of intoxication

1 Altered consciousness

1 Focal neurology

1 Distracting injuries

Score >1 indication for c-spine imaging

Wells criteria for PEScore Parameter

3 Clinical signs of DVT

3 Alternative diagnosis less likely

1.5 HR>100

1.5 Immobility / surgery in last 4 weeks

1.5 Previous DVT / PE

1 Haemoptysis

1 Malignancy

Low risk = 1 – 2.5 pointsModerate risk = 3 – 6 points

High risk = 6.5 – 12.5

AMTS1 What is your age

1 What is your date of birth

1 What is the year

0 Please remember “42 West Street”

1 What is the time to the nearest hour

1 What is the name of this hospital

1 Can patient recognise 2 people (Dr / nurse)

1 What year did World War II end (1945)

1 Name the present monarch

1 Count backwards from 20 to 1

1 Recount the address you were asked to remember

8 or higher is normal for an elderly patient

Pain assessment

Site

Onset

Character

Radiation

Associated symptoms

Timing

Exacerbating /relieving factors

Score

Chest pain differentials MI

ACS

Angina

Aortic dissection

Pericarditis

PE

Pneumonia

Pneumothorax

GORD

Sickle cell crisis

PUD

Musculoskeletal

Tachyarrhythmia differentials

Sinus tachycardia

Fast AF

SVT

Atrial flutter

VT

Re-entrant tachycardia (WPW)

Bradyarrhythmia differentialsSinus bradycardia

Complete or 3rd degree AV block / other heart blocks

MI

Drugs (beta-blockers, digoxin etc)

Vasovagal

Hypothyroidism

Hypothermia

Cushings reflex

Hypotension differentialsHypovolemia

Cardiogenic shock

Septic shock

Neurogenic shock

Anaphylaxis

Dysrhythmia

Postural hypotension

Vasovagal

Addison’s / adrenal failure

Drugs

Breathlessness / Hypoxia differentialsCOPD / asthma

Pneumonia

PE

Pulmonary oedema

MI

Pneumothorax

Pleural effusion

Pain

Sepsis

Metabolic acidosis

Anaemia

Chronic fibrotic lung disease

Upper GI bleed differentialsPeptic ulcer

Oesophagitis

Erosions

Varices

Mallory-Weiss tear

Swallowed blood

Malignancy

Rectal bleeding differentialsPolyps

Diverticular disease

Angiodysplasia

Haemorrhoids

Anal fissure

IBD

malignancy

Upper GI bleed

Abdominal pain differentialsAAA

Infarction / ischemiaObstructionPancreatitisAppendicitisPerforation

Strangulated herniaTorsionEctopic

Referred painIBDPID

ConstipationUTI

Jaundice differentialsParacetamol OD / toxins / drugs

Gall stones

Sepsis

Viral hepatitis

Alcohol

Cholangitis

Pancreatitis

Haemolysis

Gilberts

Dizziness differentialsShock

Arrhythmia

Postural hypotension

Anxiety / hyperventilation

Syncope

Epilepsy

Hypoglycaemia

Vertigo

BPPV

Menieres

Drugs

Headache differentials Haemorrhage

Meningitis

Encephalitis

Raised ICP

Temporal arteritis

Glaucoma

Dehydration

Tension

Migraine

Extracranial (sinuses etc)

Hypertension

hypoglycaemia

Acute confusion differentialsHypoxia

Infection

Drugs

Dural haemorrhage (subdural haemorrhage)

Endocrine

Neoplasm

Metabolic

Alcohol

Psychosis

Falls / collapse differentialsMI

Arrhythmia

Shock

Sepsis

CVA

Seizure

Hypoglycaemia

PE

Postural hypotension

Mechanical

Syncope

TIMED GET UP AND GO TEST

Patient wearing regular footwear, using usual walking aid, and sitting back in a chair with armrest.

Ask patient to do the following:

1. Stand up from the armchair2. Walk 3 meters (in a line)3. Turn4. Walk back to chair5. Sit down

Observe patient for postural stability, steppage, stride length and sway

Scoring:- Normal:- Completes task in < 10 seconds

Abnormal:- Completes task in >20 seconds

Low scores correlate with good functional independenceHigh scores correlate with poor functional independence and higher risk of falls

ECG interpretationComplex What it looks like Changes

P wave 2-3 sq high1.5-3sq long

R wave 1st positive deflection after P

PR interval

3-5 sq long

QRS 5-15 sq high, up to 3 small sq long

ST Should be isoelectric Max height= -0.5 - +1 sq

T Height= 0.5-10 sq depending on leads

Can be negative in AVR, V1,V2

QT 9-10 sq long

RBBB Prolonged QRS, RSR (rabbits ears) with T wave inversion in V1, wide S and upright T in V6

LBBB Wide QRS in all leads, slurred R and T wave inversion in V6, may have ST depression / elevation

Suspected CO poisoning

PC:- Headache, N&V, drowsiness, dizziness, dyspnoea, chest pain

QuestionsDo you feel better away from home or work?Does anyone else in the house have the same symptoms?Have you recently had a heating / cooking appliance installed?Have all cookers / heaters been service in the last year?Do you ever use your oven / stove for heating purposes?Has there been any change to the ventilation in your home (eg double glazing)?Have you noticed any soot / increase condensation around appliances lately?Does your work involve exposure to smoke / petrol fumes?What type of home do you live in (detached / semi / hostel etc.)?

ManagementBlood for COHb estimationOxygen Do not allow patient to go home to where there are suspect appliancesContact local HPA