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Acute Medical Algorithms

Interim clinical algorithms Web Edition May November 2005

DIRECTORATE OF MEDICINE CLINICAL ALGORITHMS CONTENTS

CARDIOLOGY
Acute Coronary Syndromes without ST elevation . Use of Tirofiban in ACS.. Use of Clopidrogel in ACS Acute Left Ventricular Failure .. Use of Carvedilol Biochemical Investigation of Cardiac Chest Pain .. Management of Arrythmias.... Tachycardias. Broad Complex Tachycardia... Narrow Complex Tachcardia Atrial Flutter/Fibrillation (Rescus Council AF).... Bradycardia. ST Elevation /New Left Bundle Branch Block (LBBB) Page 3 Page 6 Page 6 Page 7 Page 9 Page 10 Page 11 Page 12 Page 53 Page 55 Page 13(54) Page 52 Page 16

DERMATOLOGY
Acute Blistering Dermatoses.... Dermatology Cellulitis Page 18 Page 20

DIABETES
Hypoglycaemia in the Adult ..... Management of Diabetic Ketoacidosis in Adults . Page 22 Page 24

GASTROENTEROLOGY
Acute Gastrointestinal Haemorrhage.. Acute Gastroenteritis/Colitis.. Jaundice.. Page 25 Page 27 Page 28

HCOOP & NEUROLOGY


Stroke .. Delirium Falls .. Syncope .. Page 29 Page 31 Page 33 Page 35

RENAL
Acutely Presenting Renal Failure Hypercalcaemia. Management of Shortness of Breath in Dialysis Patient .. Page 36 Page 40 Page 41

RESPIRATORY
Acute Exacerbation of COPD ... Asthma in Accident and Emergency Departments.. Severe Asthma in Hospitalised Patients Suspected Community Acquired Pneumonia .. Suspected Pulmonary Embolus... Page 42 Page 44 Page 46 Page 47 Page 48

RHEUMATOLOGY
Single Hot Joint.... Page 50 Page 51

RESUSCITATION COUNCIL ALGORITHMS

This web edition will be maintained as up to date as possible. There will be slight variance from the paper version which has already been distributed. Key additions: Acute Asthma British Thoracic Society Chart 2 Acute Severe Asthma in Adults Appendix Resuscitation Council UK and European Resuscitation Council Algorithms
THE ALGORITHMS ARE DESIGNED TO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THESE CONDITIONS, HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCE FROM THE ALGORITHM

CLINICAL ALGORITHM FOR ACUTE CORONARY SYNDROMES WITHOUT ST ELEVATION UNSTABLE ANGINA NON STEMI
Suspected Cardiac Pain ECG ST ECG Or new LBBB

Acute MI: exit this guideline No ECG ST Normal ECG + Troponin ECG ischaemic or raised Troponin

Suspected acute coronary syndrome IF ANY ARE ABNORMAL

Confirmed acute coronary syndrome

Normal ECG/Troponin at 4 and 12 hours: Consider discharge

Admit CCU/HDU ECG Monitor Aspirin/LMWH/ beta-Blocker

Clopidogrel6
Outpatient Stable for 48hr with no high risk features Outpatient Outpatient In-Patient Glycoprotein II B/III A inhibitor5 Recurrent symptoms or ECG changes or other indication of high risk1

Stress Test

Risk Stratification Intermediate3 4 High2 Low

Medical Rx

Coronary Angiography7

Revascularisation or medical treatment (as appropriate)

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: British Cardiac Society Guidelines. Heart 2001; 85: 133-42

2 3 4 5 6 7

Other indications of high risk include acute ischaemia associated with hypotension, arrhythmia, or heart failure; impaired LV function; and diabetes. Poor exercise capacity & myocardial ischaemia at low workload (<stage II of Bruce Protocol) Poor exercise capacity or myocardial ischaemia at low workload. Good exercise capacity and no ischaemia at low workload. Appendix on Troponin Appendix on Clopidogrel Patients who fail to settle despite optimal medical therapy or those in the high-risk group should be considered for early inpatient cardiac catheterisation after discuss with the cardiac team.

The guidelines should not be regarded as the standard for medical care for all patients. Individual care must be managed on the basis of all clinical data available for that care and are subject to change as scientific knowledge advances.

Clinical Guidelines for the Management of Coronary Syndromes (ACS) The following is an update on the management of patients with unstable angina and non Q-wave myocardial infarction. It includes risk stratification of patients and the use of low molecular weight heparin. Patients are risk stratified based on clinical, ECG and cardiac Troponin levels. Those who fall in the intermediate and high-risk groups should be admitted to CCU. Those who fall in the low risk group (normal ECG, negative Troponin levels at 4 and 12 hours) should be considered for early discharge and exercise test.
5

Consider the use of platelet IIb/IIIA antagonist in the high-risk patients (See appendix on Tirofiban).

All patients must receive Aspirin 300mg stat on admission, reduced to 150mg/day for 1 month and then 75150mg/day thereafter. If contraindicated, consider Clopidogrel (300mg stag, and then 75mg/day) as an alternative. (See Appendix on Clopidogrel).
6

All patients should be commenced on Enoxaparin 1mg/kg bd in the absence of the usual contraindications.

Beta-Blockers should be started early. If beta blockers contraindicated and in the absence of heart failure, a rate limiting calcium antagonist e.g. Diltiazem will be the alternative treatment of choice.

APPENDIX - ON THE USE OF TIROFIBAN IN ACUTE CORONARY SYNDROME PATIENTS

The IIB/IIIA inhibitor, Tirofiban, is available for use in addition to Aspirin and Heparin in high-risk acute coronary syndrome patients presenting without ST-elevation. Such patients are identified by: The combination of Troponin T rise >0.1mcg per litre and significant ST-depression, particularly where there is: Recurrent or refractory ischaemia as manifested by further chest pain or ST-segment depression Or Haemodynamic instability with pulmonary oedema or hypotension on presentation. The use of Tirofiban identifies a patient as being at high risk and therefore likely to benefit from urgent transfer to an invasive centre for angiography and possible revascularisation. In parallel therefore, urgent referral to a tertiary centre for transfer should be made. The use of Tirofiban should be restricted to Coronary Care Unit on the advice of a consultant or Specialist Registrar in Cardiology.

Dose Regimen
Intravenous infusion on the Coronary Care Unit, initially 400 nanograms/kg/minute for 30 minutes, then 100 nanograms/kg/minute for 30 minutes, then 100 nanograms/kg/minute for at least 48 hours, maximum duration of treatment 108 hours.

Contraindications
Abnormal bleeding within 30 days, stroke within 30 days, haemorrhagic stroke or other intracranial disease, severe hypertension, bleeding diathesis, increased PT or INR, thrombocytopenia.
6

APPENDIX ON THE USE OF CLOPIDOGREL IN ACUTE CORONARY SYNDROME PATIENTS

Clopidogrel is indicated to be used in addition to Aspirin and low molecular weight Heparin as anti-thrombotic therapy in patients presenting with non ST elevation MI acute coronary syndromes where: 1. 2. 3. There is evidence of a rise in Troponin T above 0.1mcg per litre There is significant ST depression on the presenting ECG without a Troponin rise There is widespread anterior T-wave inversion suggestive of an LAD syndrome.

Dose Regimen
The initial loading dose should be with 300mg of Clopidogrel followed by a maintenance dose of 75mg per day. The duration of treatment has been agreed as nine months, on line with median length of time enrolled in the CURE study.

Contra-indications to Clopidogrel
Active bleeding Breast-feeding

CLINICAL ALGORITHM FOR ACUTE LEFT VENTRICULAR FAILURE

ACUTE BREATHLESSNESS
ECG, CXR, Bloods, ABG O2 Therapy *

Pulmonary Oedema Chest X-Ray BP < 100 systolic Cardiogenic Shock

Loop diuretic, 80m IV Frusemide Stat Opiates BP > 100 systolic IV Nitrate * Regular loop diuretic

Clinical Radiological Improvement Consider: Central venous line Urinary catheter hourly output Dopamine/Dobutamine IV* ACE Inhibitor *

Echocardiogram during admission

Spironolactone *

Echocardiogram within 24 hours * Seek Urgent Specialist Advice

Carvedilol * STABLE DISCHARGE

Cardiologist/Physician OUT-PATIENT FOLLOW-UP

GP
Intermediate Specialist Nurse

Drug Dose Titration

THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM IS DESIGNED TO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THIS CONDITION, HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCE FROM THE ALGORITHM.

LEFT VENTRICULAR FAILURE GUIDELINES


Specialist Advice IV Nitrates ACE Inhibitor Local or Tertiary Centre, contact for Cardiology Advice on Cardiogenic Shock Initiate dose to keep blood pressure greater than or equal to100 systolic Contraindicated by clinically or echocardiographically significant AS Existing significant renal impairment requires careful monitoring and consider Renal Artery Stenosis Requires monitoring if used with ACE Inhibitor. Contraindicated in renal failure See Therapeutic Guidelines regarding Carvedilol Consider low dose Dopamine 1 microgram/kg/min via central line Dobutamine 2.5 20 micrograms/kg/min to get systolic BP greater than or equal to 100 mmHg Unless already known left ventricular failure ABGs determine safety of oxygen dosage.

Spironolactone Beta Blocker Dopamine/Dobutamine

Echocardiography O2

THERAPEUTIC GUIDELINE FOR THE USE OF CARVEDILOL IN SEVERE SYMPTOMATIC CHRONIC HEART FAILURE

This guideline has been formulated following the adoption of Carvedilol onto the Trust formulary for the treatment of certain patients with heart failure in the light of the COPERNICUS trial.1 This trial showed that in appropriately selected patients Carvedilol can reduce the risk of death by 35%. The benefits of Carvedilol (7 lives saved for 100 patients treated for 1 year) in these patients may be comparable to ACE Inhibitors. Carvedilol is suitable for patients with very severe heart failure in whom other -Blockers are contraindicated. This guidance updates and supplements the guidelines regarding the use of Beta-Blockers in Heart failure issued by PRICCE. It complements the guidelines for the use of Bisoprolol (previously issued by Guys & St Thomas Trust and adopted by East Kent Hospitals Trusts) which remain unchanged.

SUITABLE PATIENTS FOR CARVEDILOL


Carvedilol is indicated for the treatment of severe (NYHA IV)2 stable chronic heart failure with poor systolic left ventricular function (ejection fraction <25% on echocardiography) as an adjunct to standard therapy.2 It may also be tried in patients considered suitable for treatment with Bisoprolol (NYHA III4 stable chronic heart failure and ejection fraction of 35% or less) who have been unable to tolerate Bisoprolol. Carvedilol is indicated in these patients regardless of age and regardless of the aetiology of the heart failure unless it is due to uncorrected major valve disease. Patients must be: Stable Euvolaemic i.e. no signs of pulmonary oedema, and no/minimal peripheral oedema or cardiac origin Systolic blood pressure >85mmHg, heart rate >68/min Creatinine <247 micromol/l The COPERNICUS trial also excluded patients who had had calcium antagonists, Beta-Blockers or class I antiarrhythmics in the last 4 weeks and patients who had had a recent (<2 months) MI,CVA or revascularisation. Conventional contraindications to Beta-Blockers such as asthma, first, second and third degree heart block apply.

-Blockers should not be used in heart failure patients who are already on a combination of both ACE inhibitors and angiotensin II antagonists, but are indicated in patients who fulfil the above criteria and are only on either an ACE inhibitor or angiotensin II antagonist.

1 2

Effect of Carvedilol on Survival in Severe Chronic Heart Failure. New England Journal of Medicine 1651-8, 344, 22 May 2001 Dyspnoea at rest 3 ACE inhibitor or AII antagonist, Spironolactone, other diuretics +/- Digoxin 4 Dyspnoea on minimal exertion

DOSING REGIMEN
Warning: Carvedilol treatment in heart failure should be initiated at a low dose and gradually titrated up in a similar fashion to Bisoprolol. If patients are unable to tolerate it in higher doses they should revert to their previous lower dose. Carvedilol must not be stopped abruptly. Starting Dose: Increasing to: Then: Final target dose: 3.125mg bd for 2 weeks 6.25mg bd for 2 weeks 12.5mg bd for 2 weeks 25mg bd

Patients should be assessed before each increase in dose. If there is a delay in this assessment the patient should be maintained on the current dose until a full assessment is possible. Assessment should include direct questioning about any change in exercise tolerance (may improve), side effects and cardiovascular examination including blood pressure. The dose of diuretics may need to be adjusted (either increased or decreased).

SIDE EFFECTS
Patients should be warned about potential side effects. These are essentially the same as occur with Bisoprolol but there is some suggestion that Carvedilol may be better tolerated. It is common for patients to feel generally exhausted initially during treatment but if this occurs they should be encouraged to persist with the tablets since this often improves over a few weeks. It often helps to delay increasing the dose for 2-4 weeks while they get used to the tablets. Dizziness if it occurs after a dose increase may be self-limiting. Check they are not bradycardic. It may be due to an improvement in the heart failure so that a reduction in diuretics may be needed to avoid dehydration and postural hypotension. It may also help to take the Carvedilol 12 hourly and take ACE inhibitors and diuretics at a different time of day (eg 2 hours later). Increased fluid retention may occur and patients should be advised to monitor their weight daily and watch for ankle swelling and worsening breathlessness. If this occurs they must be assessed to see whether their diuretics need to be increased or Carvedilol reduced. Diabetic patients may find that their normal warning symptoms of sweating and shaking during hypoglycaemia are masked. Hypoglycaemic symptoms of decreased mental alertness and agility are unaffected and should be heeded. Diabetic control may worsen during initiation of treatment with Beta-Blockers so regular monitoring of blood glucose is advised during the early stages of treatment.

ALGORITHM FOR BIOCHEMICAL INVESTIGATION OF CARDIAC CHEST PAIN

Suspicious cardiac chest pain Suggestive history Manage patient according to Trust Guidelines for acute MI Single CK measurement indicated

ECG

New onset ST segment elevation or new LBBB

Non-diagnostic ECG changes Manage patient according to Trust Guidelines for acute coronary syndromes

Measure Troponin on admission

Troponin increased

Troponin normal

Repeat Troponin and CK 12 Hours after onset of chest pain

Troponin increased

Manage patient according to Trust Guidelines for acute coronary syndromes

Troponin normal

Consider early discharge and arrange exercise test

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm.

Ref:

British Cardiac Society Guidelines. Heart 2001; 85: 133-42

10

Management of Tachycardia
Tachycardia HR > 100

If haemodynamically unstable (systolic BP less than 90 mmHg), or have chest pain, or breathlessness Seek immediate senior advice Always check the serum potassium urgently aim for K > 4.0 mmol/l 3. If pulseless manage with standard ALS algorithms.

Sinus Tachycardia

Narrow Complex Tachycardia Consider IV adenosine to aid diagnosis

Broad Complex Tachycardia


See notes on differentiation 2

Irregularly irregular Atrial fibrillation

Rate 150 bpm Atrial flutter with 2:1 block

Regular Re-entrant SVT AVNRT/AVRT

Ventricular tachycardia

SVT with abberancy Regular

SVT with abberancy irregular

See algorithm on AF/A Flutter

See algorithm on AF/A Flutter

Vagal manoeuvres/ Adenosine 1

Vagal manoeuvres/ Adenosine

Treat as AF

Treat underlyinig cause eg sepsis/bleeding

Seek senior advice Registrar or above Haemodynamically stable Consider Magnesium infusion 3 IV lidocaine or IV Amiodarone 4 Haemodynamically unstable Synchronised DC Cardioversion

Seek senior advice Registrar or above

Synchronised DC Cardioversion if chemical cardioversion unsuccessful

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: European Resuscitation Council Guidelines 2000 for Adult Advanced Life Support Resuscitation 48 (2001) 211221. See ERC algorithms in appendix.

Notes AF = Atrial flutter SVT = Supraventricular tachycardia AVNRT = Atrio-ventricular nodal re-entry tachycardia AVRT = Atrio-ventricular re-entry tachycardia 1. Adenosine. By rapid intravenous injection into central or large peripheral vein, 3 mg over 2 seconds with cardiac monitoring; if necessary followed by 6 mg after 1-2 minutes, and then 12 mg after a further 1-2 minutes. Ideally each injection should be flushed by a rapid injection of 5-10 mls of saline. Adenosine will terminate those SVTs which are dependent on the AV node to sustain the re-entry pathway. In other SVTs, adenosine can be helpful in the diagnosis of the underlying rhythm. Increments in dosage should not be given if high level AV block develops at any given dose. Heart transplant patients are extremely sensitive to adenosine, patients on dipyridamole (Persantin) and carbamazepine are also very sensitive to adenosine and adenosine should not be used in these patients unless under the supervision of a Consultant Cardiologist. Differentiation of regular Broad Complex Tachycardia. Remember that patients with VT may have a normal blood pressure and not appear that unwell. BUT THEY CAN ARREST AT ANY TIME. These patients must be assessed very quickly by Senior members of the team ie Registrar or above. There are rules on differentiation of VT from SVT with aberrancy. These include: History abnormal myocardium (eg IHD, cardiomyopathy): Clinical signs variable first heart sound, canon waves: ECG Criteria direct evidence of independent atrial activity, fusion beats, coupled beats, QRS duration > 140 msec, QRS mean axis < - 90 or > + 180 degrees, concordance etc. All these features are suggestive of VT. If in doubt manage as VT. Remember, adenosine can be utilised to help in differentiation BUT it can cause significant deterioration in haemodynamic status and should only be used in Coronary care or in an area where full resuscitation facilities are immediately available. Electrolyte infusions. Aim for a serum potassium in the normal range and ideally > 4 mmol/l. Give potassium chloride up to 60 mmol, maximum rate 30 mmol/hr. If the serum potassium is known to be low also give magnesium sulphate IV 5 ml of 50% over 30 minutes. Amiodarone or lidocaine (lignocaine) NOT BOTH. Amiodarone 150 mg IV over 10 mins OR Lidocaine (Lignocaine) 50 mg IV over 2 minutes, repeated to a maximum dose of 200mg. If after these doses cardioversion has not occurred SEEK EXPERT HELP. Then proceed to synchronised DC conversion. Amiodarone can be repeated at a dose of 150 mg IV over 10 minutes then 300 mg over 1 hr and then repeat shock.

2.

3.

4.

Also see Resuscitation Council AF Guideline

Atrial Flutter/Fibrillation

Acute < 24 hrs

> 24 hrs

Synchronised DC cardioversion. Consider TOE

Chemical cardioversion

Ventricular rate control & anticoagulation

TOE + Synchronised DC cardioversion

Propafenone 600 mg PO Stat or Sotalol 80 mg PO Stat or Amiodarone 150 mg IV over 10 mins. Can be repeated once or IV Flecainide 100-150 mg over 30 mins if no known structural heart disease.

IV or oral Digoxin Or IV or oral Verapamil Or Oral or IV Diltiazem Or Oral or IV Beta blocker

Anticoagulation +/antiarrhythmic drugs

Consider synchronised DC cardioversion in 4-6 weeks

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: European Resuscitation Council Guidelines 2000 for Adult Advanced Life Support Resuscitation 48 (2001) 211221. See ERC algorithms in appendix.

Notes: 1. This algorithm applies in the absence of heart failure or haemodynamic instability. If these are present refer to the ERC algorithm in the appendix. Always have the serum potassium result available ideally this should be > 4.0 mmol/l Patients who are haemodynamically unstable ie systolic BP < 90 mmHg, chest pain, or are in heart failure/breathless have a pre-arrest tachycardia and should be managed on the Coronary Care Unit and should be considered for urgent synchronised DC conversion seek Senior advice. TOE = transoesophageal echocardiography. IV Amiodarone should be administered via a long peripheral line or a central line. Verapamil and Diltiazem are not to be used in patients already on Beta blockers.

2. 3.

4. 5. 6.

CLINICAL ALGORITHM FOR ST ELEVATION / NEW LEFT BUNDLE BRANCH BLOCK (LBBB)

CHEST PAIN

5 Min ECG ST ELEVATION1 NEW LBBB2

Aspirin 300mg stat, 02, Analgesia

Thrombolysis WITHIN 20 minutes / of arrival2 3 ADMIT CCU

Early Beta-Blocker4

CK Measurement 6-12 Hours

Day 1 Continue 150mg Aspirin/Day

CARDIAC REHABILITATION

Statin5

ACE Inhibitor Day 26

DISCHARGE
DAY 5-6

ETT/ANGIOGRAPHY FOR RISK STRATIFICATION

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: National Service Framework: Coronary Heart Disease

GUIDELINES
1

Thrombolysis: 1mm elevation in two or more limb leads 2mm elevation in two or more consecutive chest leads

If thrombolysis is considered appropriate for a patient presenting with LBBB then it should be administered within the time stated in the hospital protocol. It is not acceptable to delay thrombolysis in order to track old ECGs or await Troponin results if the history supports a diagnosis of acute myocardial infarction. Patients under the age of 70 with an anterior MI presenting within 4 hours of onset of chest pain should receive accelerated tPA or Retaplase. tPA should also be used in any patient who has previously received Streptokinase. Early use of Beta-Blockers is advised in the absence of the usual contraindications. They should be prescribed after the administration of thrombolytic agent has been completed usually in the CCU setting. Beta-Blockers should be continued long-term and the agents of choice are Atenolol, Metoprolol and Bisoprolol. Patients should be commenced on a statin (Pravastatin or Simvastatin at starting doses of 40mg and 20mg respectively). All patients with MI should be commenced on an ACE inhibitor (if no contraindications) on day 2 and continued long-term. This is in view of the recent findings of the HOPE study. Routine echocardiography of all MI patients is not recommended, as it will not alter their management. Use of echo should be restricted to those patients with suspected complications e.g. valvular dysfunction, VSD, left ventricular thrombus (esp. large anterior MIs). The recommended ACE inhibitors are Lisinopril and Ramipril at maximum tolerated dose.

The main indications for urgent transfer to a tertiary centre for cardiac catheterisation are continuing myocardial ischaemia or a catastrophic complication such as VSD or acute mitral regurgitation. All proposed emergency transfers should be discussed with a consultant cardiologist. At discharge, a copy of the final page of the MI integrated care pathway must accompany the routine discharge summary to the GP. The information included on this page must include diagnosis, thrombolysis (and door to needle times), any complications, list of discharge medication in particular the reasons for absence of any of the key medication. This data should also be entered on a database at the time of patient discharge to facilitate future audit. The patients should receive a booklet with a list of their medication and a timetable of further appointments and investigations. All MI patients are reviewed in the MI clinic run by the cardiac rehabilitation nurses at 2 to 4 weeks. Their symptoms and medication (in particular dosages) will be reviewed. Their assessment will include a treadmill exercise test that will be reviewed by a consultant cardiologist who will decide whether cardiac catheterisation is indicated. This will lead to fast-tracking of high-risk patients.

CLINICAL ALGORITHM FOR ACUTE BLISTERING DERMATOSES

ACUTE BLISTERING DERMATOSES

Localised

Generalised

History & Examination

Consider Differential Diagnosis: Consider Differential Diagnosis: Swab for bacteriology/virology as appropriate Treat with simple dressing and topical treatment appropriate for suspected diagnosis

Assess Need for Admission NO YES

Consider referral to primary care for ongoing care if required

Investigations: FBC, U&E, LFT & ESR If suspicion of infection, take skin swabs and consider blood cultures If suspicion of allergy consider likely cause and stop unnecessary or suspected medication as appropriate If suspicion of pemphigus or pemphigoid contact Dermatologist to arrange skin biopsy before starting steroids and discuss management strategy

Management: Consider need for special bed Regular observations Fluid Balance Pain Chart Blister Chart

or for more severe disease


Consider urgent dermatology outpatient referral for diagnosis and further management

NOTE: DO NOT START ANTIBIOTICS, ANTIHISTAMINES OR STEROIDS UNLESS THERE IS A CLEAR CLINICAL NEED Discuss with Dermatologist

Call a Dermatologist for advice if there is any doubt about the initial management or, in severe cases, at the earliest opportunity

THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM IS DESIGNED TO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THIS CONDITION, HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCE FROM THE ALGORITHM.

Presentation: Blistering can have a large number of causes. The blistering process can be localised or generalised. The patient may have generalised symptoms and signs either associated with or independent of the blistering disease process itself. One needs to consider all aspects of the patient history and their disease presentation, in order to formulate a differential diagnosis and active management plan. Cause: During the clerking process, it should become apparent from a combination of the accurately taken history and examination what the likely diagnostic possibilities are. Think about the age of the patient, their medication history, recent events and possible infections as potential contributing or causative factors. Other causes of blistering include some eczemas, bullous impetigo, herpes simplex virus, T.E.N., autoimmune bullous diseases and phytophotodermatitis. Management: It is likely that the Dermatologist will be required to be involved in the investigation and management of all but the mildest cases, including the possibility of skin biopsies. Please advise the Dermatologist early in the day should you need their input.

CLINICAL PATHWAY FOR DERMATOLOGY: CELLULITIS CELLULITIS

History & Examination

Nursing Observations: Temperature Pulse Blood Pressure Mark edge of advancing erythema with pen Pain Chart/Assessment

Initial Investigations: FBC, U&Es, LFTs, ESR, blood cultures Skin swabs Consider skin scrapings for mycology

ASSESS THE NEED FOR ADMISSION

NO
(For mild cases) Treatment: Refer back to community care (GP, District Nurse) as appropriate Treat with oral antibiotics (See below) for 10 days minimum Gentle compression/elevation Treat underlying cause/trigger

YES
(For More Severe Cases) Immediate Treatment: Admit and elevate limb Analgesia as appropriate IV antibiotics (see chart below) for at least 5 days Encourage oral fluids

Improvement: Discharge when stable

No Improvement/Deterioration: Seek Specialist advice

Medication Guide: Both the IV antibiotics shown below must be started in combination to cover the likely organisms, unless there is an allergy to penicillin. If positive cultures are obtained, then one can alter the regime as appropriate. When oral therapy is subsequently commenced, any of those suggested can be used, as appropriate.

Route: Intravenous Plus Oral or or Plus 1. 2. 1. 2. 3.

Medication: Flucloxacillin Benzylpenicillin Amoxycillin Erythromycin Clarithromycin Flucloxacillin

Dose: 500mg 6 hourly 1.2g 6 hourly 500mg 8 hourly 500mg 6 hourly 500mg bd 500mg 6 hourly

Duration: At least 5 days or until pyrexia settles At least 5 days or until pyrexia settles For a further 10 days For a further 10 days Can be started orally For a further 10 days in a penicillin allergic
Patient from day 1

For a further 10 days

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref:.
Presentation:

Cellulitis is an inflammation of subcutaneous tissues in which an infective cause is assumed or proved. The patient is normally unwell and pyrexial often with flu-like symptoms. The affected area is red, hot and swollen. It is frequently tender to touch and localised pain can restrict movement. Cellulitic areas may present with blistering and skin necrosis in association. Cause: The usual cause of cellulitis in immunocompetent individuals is a group A Streptococcus, but other Lancefield groups have also been implicated. Occasionally Staphylococcus aureus is implicated either alone or in association with the Streptococcus. In children under the age of 2 with facial cellulites, consider Haemophilus influenzae type b. In immuno-compromised patients, other organisms may need to be considered, such as Pseudomonas aeruginosa and Campylobacter jejuni. Medication: Beta haemolytic Streptococci are sensitive to penicillin with IV Benzylpenicillin being the treatment of choice. Patients allergic to penicillin can be given erythromycin (or Clarithromycin). This can be given via the oral route from the outset, as its bioavailability is high, and with IV erythromycin being very irritant to the veins leading to rapid tissueing of the venflon. Treatment must be continued for at least 2 weeks otherwise relapse is very likely. As suggested in the table above, the oral antibiotics should be continued after at least 5 days of IV therapy. If a positive culture is obtained, antibiotic therapy can be altered if sensitivities indicate that this is appropriate. Local Treatment: Gentle cleansing with an antibacterial soap substitute can be beneficial. Particular attention to foot hygiene is important. If there is significant blistering or erosions, a daily soak or wash with diluted potassium permanganate can help, as this is a good antiseptic and drying agent. Topical therapy is limited to bland emollients that can help to soothe. Blistered or eroded areas may be dressed with simple non-adherent dressings with or without an absorbent dressing over, such as Allevyn or Lyofoam, if there is significant ooze. Topical antifungals can be used when there is associated fungal infection. Leg ulcers should be managed conventionally, except that the compression bandaging should be discontinued until the acute, painful phase of the cellulitis has settled. Mild compression bandaging can be introduced during the healing phase, especially when mobilising the patient. In uncomplicated cases of lower leg cellulitis, consider class 2 compression below knee support hosiery for 4 to 6 months, following resolution of acute phase.
References: Rook, Wilkinson, Ebling. Textbook of Dermatology. 6 Edition. (1998). Blackwell Science Ltd Hughes and van Onselen. Dermatology Nursing: a particle guide. (2001). Churchill Livingstone Leppard and Ashton. Treatment in Dermatology. (1995). Radcliffe Medical Press
th

Clinical Algorithm Hypoglycaemia in the Adult:


Admission with Hypoglycaemia

(Check finger prick blood glucose & also take blood for laboratory glucose for later analysis. If not known diabetic take blood for Insulin & C-Peptide) Altered Consciousness, altered behaviour or neurological signs Mild Hypoglycaemia without altered consciousness

Give 25-50 ml 50% Glucose IV Give Glucagon 1mg IM or SC if no venous access


(NB glucagon relatively ineffective in chronic hypoglycaemia, Type 2 diabetes, alcohol induced hypoglycaemia )

Give oral glucose solution

Symptomatic recovery
Maintain normoglycaemia Organise meal If type 2 diabetic on Sulphonylurea will need continuous IV glucose 10% for 24 hours

Identify Cause

Identify Cause: Excess insulin/oral hypoglycaemic. Malnutrition, starvation, alcohol, liver disease, other drugs (aspirin OD, ACE), hypoadrenalism, hypopituitarism, insulinoma, reactive (e.g. post gastrectomy)

Discharge Arrangements: Patient should not drive. Notify Diabetic Nurse to contact patient and review (K&C & QEQM only) Organise review by normal medical Supervisor

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref:

CLINICAL ALGORITHM FOR THE MANAGEMENT OF DIABETIC KETOACIDOSIS IN ADULTS

Clinical History: Polyuria Polydipsia Abdominal Pain Weakness Vomiting Confusion

Clinical Signs: Assess dehydration Deep sighing respiration (Kussmaul) Smell of Ketones Lethargy

Biochemical Signs: Ketones in Urine Elevated Blood Glucose Acidaemia Take blood also for electrolytes & urea Perform other investigations as indicated

Confirmed Diagnosis Diabetic Ketoacidosis

Shock Reduced Conscious level Coma Vomiting

Dehydration Clinically Acidotic

No Dehydration Clinically Well Tolerating fluid orally

Resuscitation: Airway/ NG Tube Breathing (100% 02) Circulation IV Colloid/ Crystalloid) until circulation restored

Intravenous Therapy: Correct fluid balance over 24-48 hours tailored to individual needs 0.9% saline - with KCL may need between 10 to 30mmol K per hour MONITOR see below 6 unit IV insulin / hour (IV bicarbonate very rarely indicated and only after discussion with registrar/Consultant)

Therapy: Start with sc insulin Give oral fluids Contact diabetic nurses to enable same day discharge and community management

Check insulin infusion connected via dedicated line Deteriorating Neurological Status? Meningitis? Cerebral Oedema

No Improvement?

Observations: Hourly blood glucose Neurological status at least hourly Hourly fluid input/output (ensure input exceeds output until fluid deficit corrected, avoid over-rapid correction of fluid deficit). Electrolytes 2 hours after start of IV therapy, then 4-hourly hypo-kalaemia kills Monitor ECG for T-wave changes NG Tube if impaired consciousness Bladder catheter if doubt about urine

Identifying Underlying Cause: Sepsis MI Should not Stroke be Gastroenteritis dismissed Abdominal Pain

Amylase may be elevated

Good Progress (Blood Glucose reduction ~ 1-2 mmol/hour, Good urine output and vital signs normal) Continue standard insulin infusion (see drug chart overleaf) Ensure serum potassium always remains within normal range Change to dextrose containing fluids when Blood glucose <10 mmol/l Commence S/C insulin (Actrapid QDS) when tolerating oral fluid (may still have urinary ketones) Continue insulin infusion for 1 hour after s/c insulin

CLINICAL ALGORITHM FOR THE MANAGEMENT OF DIABETIC KETOACIDOSIS


GUIDELINE NOTES For newly diagnosed Type 1 or 2 Diabetic, admission is rarely necessary, confirm diagnosis of diabetes and type and refer to Diabetic nurse to initiate protocol for management of Newly Diagnosed type 1 Diabetes and to commence outpatient insulin. The Diabetic physicians will be happy to give advice on further management and follow up. HYPEROSMOLAR COMA More common in elderly and mortality greater
Fluid depletion greater. Fluid resuscitation should be slow over 48-72 Hours Insulin sensitivity greater and may only need 1-2 units/hour of IV insulin. Discharge on oral hypoglycaemic or diet may be possible. High risk of thrombotic events. Fully anticoagulate with LMWH if not contraindicated.

IV SLIDING SCALE INSULIN REGIME FOR GENERAL USE:


Add 50 units of human Actrapid Insulin to 50mls of 0.9% Saline in a Syringe Driver. Give Insulin as below. Capillary Blood Glucose (mmol/l) <4 4.1-7 7.1-11 11.1-15 15.1-20 >20 IV Human Actrapid (U/Hr) 0.5 1 2 3 5 6

If BM remains persistently above 20 mmo/l inform Doctor. Hypoglycaemia is corrected by giving carbohydrate and not being discontinuing insulin. If hypoglycaemia develops it must be corrected quickly. Fluids: If BM>12 give 0.9% saline 1L with 20mmol/l KCL over 6hours If BM<12 give 5% Dextrose 1L with 20mmol/l KCL over 6hours Return to subcutaneous Insulin: Once patient eating normally and not vomiting, switch back to normal daily insulin regime. Ensure this overlaps with the insulin infusion. ie. Give S/C injection at mealtime, 60 min before insulin infusion is discontinued. If not previously on insulin use 24-hour insulin requirement when stable on sliding scale regime to estimate dose.

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: Evidence-based On-call. NHS National Electronic Library for Health and is adapted from the Diabetes UK Guideline on DKA in Children and Adolescents (09-02-2002).

CLINICAL PATHWAY FOR ACUTE GASTROINTESTINAL HAEMORRHAGE


History: Haematemesis/Melaena. NSAIDs/Aspirin/Warfarin. Previous peptic ulcer disease. Alcohol intake.

Examination: Features of chronic liver disease. Heart rate/Blood pressure. Lymphadenopathy/Abdominal masses.

Management: Full blood count/Urea and electrolytes. Stop NSAIDs/Aspirin. Group and save/cross-match IV fluids Large bore intravenous cannula.

If liver disease suspected: Clotting studies/LFTs Avoid normal saline If varices suspected: Consider Terlipressin

If patient unstable & Hb < 10g

Pt stable & Hb >10g

Contact surgeons Urgent OGD

Endoscopy following morning Calculate Rockall score*

High risk of re-bleeding, stabilise + surgical review

If low risk of re-bleeding,

Early discharge Surgery/Discharge

THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM IS DESIGNED TO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THIS CONDITION, HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCE FROM THE ALGORITHM.

22

Notes: Initial Management of Upper GI Bleeding 1. Coagulation screening is not required for all patients with suspected upper GI bleeding. However, the test should be requested in the following situations: Patient on warfarin (INR only) or heparin (APTR only) Known coagulation abnormality Known/ suspected chronic liver disease or jaundice Massive bleeding requiring large volume transfusion 2. The following are strong indicators of the need for immediate fluid resuscitation: Systolic Hypotension (<100mHg) Tachycardia (>100) Postural drop in blood pressure of >20mmHg However remember: Normal range of BP for individual patients may vary (BP 90 systolic is normal for some patients Drugs (eg betas blockers), anxiety, and arrhythmias (eg paroxysmal AF) may influence heart rate irrespective of degree of blood loss. Postural hypotension may have other causes. Therefore always interpret haemodymamic indices in the context of the amount of blood loss. 3. Suspect variceal bleeding if: History of, or clinical evidence of chronic liver disease Evidence of portal hypertension Previous varices or variceal bleeding 4. CVP lines provide a means of monitoring fluid requirements and early identification of rebleeding, particularly where other haemodynamic indicators may be unreliable (eg elderly patients or patients on beta blockers). CVP insertion should be considered in the following situations: Patients with known renal or cardiac failure Patients who have brisk / ongoing bleeding Patients with suspected / proven variceal bleeding Patients at high risk of rebleed (Rockall score 6 or more) Rockall Score is a means of assessing risk of rebleed and mortality following non-variceal upper GI bleeding. Reference: Rockall TA, Logan RF, Devlin HB, et al: Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 38: 316321
0 <60 Systolic >100 Pulse <100 None 1 60-79 Systolic >100 Pulse >100 2 >=80 Systolic <100 Heart Failure IHD Major Comorbidity. All other diagnoses Upper GI Malignancy 3

Age Shock Co-Morbidity

Renal Failure Liver failure Disseminated Malignancy

Diagnosis

Mallory-weiss tear Normal (and no blood seen) None (or dark spot only)

Stigmata of Haemorrhage

Fresh Blood seen; Adherent clot;Visible Vessel;Spurting vessel

Total score
8+ 7 6 5 4 3 0 to 2

Death % (95% CI) 40% (30% to 51%) 23% (15% to 31%) 12% (6.3% to 17%) 11% (6.3% to 15%) 8.0% (4.0% to 12%) 1.9% (0.0% to 3.9%) 0.0% (0.0% to 0.93%)

Rebleeding (95% CI) 37% (27% to 47%) 37% (28% to 46%) 27% (20% to 34%) 25% (19% to 31%) 15% (10% to 21%) 12% (6.8% to 17%) 5.9% (3.3% to 8.5%)

CLINICAL PATHWAY FOR ACUTE GASTROENTERITIS/COLITIS


History: Travel/Symptoms History of inflammatory bowel disease. Other people affected, bleeding ?. Antibiotic therapy.

Examination: Features of inflammatory bowel disease. Joints/Eyes/Skin. Evidence of circulatory compromise.

Presumed Gastroenteritis Full blood count Urea and Electrolytes Stool cultures if had antibiotics c.diff toxin if vomiting -> I.V. fluids

Presumed relapse IBD or new diagnosis IBD Full blood count U&Es/CRP Stool cultures +/c.diff toxin I.V fluids Sigmoidoscopy +/rectal biopsy

Discharge

Infection unlikely start Hydrocortisone 100mg IV tds +/- oral steroids (eg Prednisolone 40 mg) Consider 5-amino salicylates if IBD likely after discussion with Gastroenterologist.

?Colonoscopy ?Surgical procedure Discharge when stable.

THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM IS DESIGNED TO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THIS CONDITION, HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCE FROM THE ALGORITHM.

CLINICAL PATHWAY FOR JAUNDICE


History: Drugs/Alcohol. Sexual partners/Contacts. Family history. Pruritis/Fever. Dark urine/Pale stools.

Examination: ?Alcohol. Stigmata of chronic liver disease. Masses/Stigmata of malignant disease. Lymphadenopathy/Hepatomegaly.

Investigations: FBC, U&Es, LFTs, clotting studies & blood cultures

?Haemolysis

?Ascending cholangitis/sepsis antibiotics as per antibiotic policy

Ultrasound

Dilated ducts ERCP +/- PTC

Non-dilated ducts Consider: Hepatitis A&C serology. Auto-immune profile. Drugs/Alcohol. Metastases. Liver biopsy.

THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM IS DESIGNED TO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THIS CONDITION, HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCE FROM THE ALGORITHM.

Has there been an acute onset of a focal neurological deficit? Have the symptoms resolved within 24 hours YES FBC, U+ES, Glucose, Cholesterol, ECG NO

NO

STROKE Does the patient require urgent CT @ YES NO

Exit Algorithm Consider alternative diagnosis

TIA Start Aspirin 75mg od Neurovascular clinic appointment DISCHARGE

CT SCAN

Is survival likely? YES ADMIT STROKE UNIT

NO

Palliative care, decision re: CPR. Exit Algorithm

CT WITHIN 48 HRS IF NOT ALREADY DONE

Is Bp < 140/90 NO Check 4o YES

Is Temp <37.5 C NO YES

Can patient swallow? NO

Are O2 SATS <93% YES NBM IV fluids O 2 24%

Is haemorrhage unlikely/excluded NO Await CT Is BM >11 YES

Is pt mobile? YES

Is there evidence of PVD or DM NO

Check 4 o YES

Evidence of infection NO

Normal diet

Aspirin 75mg od Physio/OT assessment

Compression stockings

Only lower acutely if evidence of accelerated hypertension

SALT Treat appropriately Paracetamol 1g 6 o Normal diet NG Feed Modified diet

YES IV insulin sliding scale

Is pt safe to discharge YES NO REHABILITATION

DIETICIAN

Discharge CART/FDH/stroke OPD

ACUTE MANAGEMENT OF STROKE

a check list for the first 3 days Prompt appropriate care saves lives and improves outcome Once presumptive diagnosis is made initiate following care: Monitor neurological state: vital signs Pulse 4 hrly cardiac monitor if irregular or rate >100 Respiration 4 hrly BP 4 hrly ) O2 Saturation 4 hrly ) manage as below Temperature 4 hrly ) conscious level Glasgow coma scale 4 hrly Assess History: obtain as detailed a history as possible from patient/relatives/carers. Examine: including full neurological assessment Investigate: FBC, U&E, LFTs, Glucose, ESR, Clotting if on Warfarin, ECG, CXR. CT with in 48 hours. @ urgent (same day) if potential bleed (on warfarin, recent trauma, possible subarachnoid) or worsening neurological state. Other specialised tests see guidelines. Maintain homeostatic control Temperature if above 370 - Paracetamol. If above 37.5 look for infection and add antibiotics. Oxygenation if O2 saturation < 95% - provide 2 4 l O2 by nasal cannulae. Blood pressure systolic 180 220 and/or diastolic 105 120 mm Hg - Do not treat systolic > 220 on three or more readings, or diastolic 120 140 mm Hg or both Treat diastolic > 140 Urgent treatment Glucose if blood glucose > 10mmol/l maintain normoglycaemia with insulin Hydration maintain normal hydration with iv/subcut fluids. Fluid balance chart Metabolic status check and monitor electrolytes daily. Correct as required Antithrombotic therapy Aspirin 300mg immediately, ideally after haemorrhage has been excluded on CT Management of stroke impairment Swallowing Assess, including bedside water test if appropriate. If swallow unsafe or possibly unsafe, make nil by mouth and review at 6 hours, repeat after 24 hours, if continues to be unsafe refer to SALT Paralysis Ensure good positioning and pressure relieving bed/mattress Continence Avoid catheterisation unless in retention or skin at risk Prevention/treatment of complications DVT/PE Ensure full length TED stockings are provided. Pneumonia ensure swallow assessment and swallow guidelines are followed. Good positioning and changes in position to facilitate chest movement. Monitor for signs of infection Pressure sores ensure good positioning and regular changes in position Epilepsy iv diazepam or clonazepam followed by oral valproate, carbamazepine or phenytoin This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: National Clinical Guidelines for Stroke RCP 2000 ; European Stroke Initiative Recommendations for stroke management Cerebrovasc Dis 2000;10 : 335 - 351

CLINICAL ALGORITHM FOR THE MANAGEMENT OF DELIRIUM

AMT

<8/10

8+

possible delirium

delirium unlikely consider other diagnoses eg dementia, depression

is there a change from the normal mental state?

yes

no

DELIRIUM

Investigate and identify underlying causes

Infection

Drugs

Other

Cultures, Urinalysis FBC, ESR CXR

Review all drug treatment eg drugs with anticholinergic activity, benzodiazepines, other CNS depressants digoxin, antihypertensives

U&E, LFT, Glucose ECG Other tests

Specific/empirical antibiotic treatment

Discontinue likely drugs Caution with benzodiazepine withdrawal

Treat cause found

Progress

Improving

Worsening

Continue

Review diagnosis

Monitor with AMT Avoid sedatives/restraint Multidisciplinary discharge planning

Seek expert help Consultant Old Age Psychiatry/ Geriatrician

Follow up

Features of Delirium 1. Disturbance of consciousness with reduced ability to focus, sustain or shift attention 2. A change in cognition or development of perceptual disturbance not better accounted for by pre-existing or evolving dementia 3. Disturbance develops over short period of time (hours or days) and fluctuates during course of day
Reference: The Guidelines are based on those developed by Dr Lesley Young and Dr Jim George, Cumberland Hospital, Carlisle and the American Psychatric Association Practice Guidelines, 1998.

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: The Guidelines are based on those developed by Dr Lesley Young and Dr Jim George, Cumberland Hospital, Carlisle and the American Psychiatric Association Practice Guidelines, 1998.

Summary of Carlisle guidelines for management of delirium


In all stages during the hospital admission, ensure good communication with the patient and carer and between professionals caring for the patient. 1. 2. Identification of delirium using established diagnostic criteria (see over). Recognition of delirium can be increased by the routine assessment of cognitive state, e.g. using the AMT (see over). Repeated use of the AMT may help to determine recovery or onset of delirium in those not delirious on admission. Assessment of patients pre-admission cognitive, functional and social status. This information may need to be clarified with the carer. Identification of risk factors such as dementia, severe illness, sensory impairments, alcohol use. Identification of underlying cause (commonly infection or drugs). Treatment of underlying cause or removal of offending drugs. Avoidance of physical restraints. Avoidance of major tranquillizers, where possible, but if necessary use only one drug and in the lowest dose possible (e.g. haloperidol 0.5-3mg orally up to QDS). Review drug treatment regularly. Multi-disciplinary team involvement in treatment and discharge planning.

3. 4. 5. 6. 7. 8.

9.

10. Create optimum environment for care (e.g. single room, good lighting). 11. Use reality orientation techniques and rehabilitative care models. 12. Ensure adequate discharge and follow up to avoid unnecessary readmissions and to provide support to patient and carers.

FALLS ALGORITHM
Patient present to A&E/CDU having falls

Stabilise medically

HISTORY
Can you remember falling? Did you slip/trip on something? Any preceding symptoms? Do you know why you fell?

EXAMINATION
Full medical examination Remember L+S BP Rule out fractures/other fall related injury

DRUG HISTORY
>4 drugs leads to increased risk of falling Look for drugs causing postural hypotension Look for sedatives, eg Benzodiazepine

INVESTIGATIONS
FBC CXR U&E ECG RBG MSU Ca2+ Trop T (if necessary)

DECIDE ON CAUSE OF FALL The common causes are 1. Acute illness 2. Blackout/dizzy spell/cause unknown 3. 4. Simple slip/trip Frail older person often with cognitive impairment

Treat as appropriate and falls screening tool 2 ECG Normal ) refer to falls clinic or Abnormal 24 hour ECG ) investigate as in-patient Falls screening tool 2 Falls screening tool 2

DECIDE ON NEXT STEP


1. Admit (a) Acute medical ward (b) Rehab ward (c) Orthopaedic ward 2. Discharge (a) No further input needed (b) CART (c) Rapid response

FOLLOW UP
If dizzy spell/blackout or cause of fall unknown ask nurses to do screening tool 2 and refer to falls clinic Otherwise follow up as usual Refer to falls service as advised in screening tool 2. Osteoporosis prevention Separate Guidelines exist locally and from NICE (2005)

Acute Assessment Syncope (One of causes Transient Loss of Consciousness = T-LOC)

Is loss of consciousness attributable to syncope or not? Is heart disease present or absent? Are there important clinical features in the history that suggest the diagnosis? o Any nausea/ vomiting/ abdominal pain (unless suspect partial complex seizure) o patient pallor after o no prolonged confusion after Avoid common diagnostic errors o TIAs do not have loss of consciousness o Tonic clonic convulsion <15 seconds after loss of consciousness is consistent with syncope, longer than this => epilepsy o Drop attack diagnosis Do not waste investigations in T-LOC. A proper history is worth any number of tests (History from witness, by telephone etc). CT/MRI head scan without neurology EEG is not for syncope Dizziness is not syncope Think of Driving (below for basic license)
Simple Vasovagal faint: No restriction Probable Syncope(low risk): At least 4 weeks off Probable Syncope(high risk): 4 weeks off after Rx, or 6 months free Other T-LOC no seizure pointers: At least 6 months off T-LOC with seizure pointers: 1 year off

When to admit for observation/Consultant level review (most of rest have low morbidity and/or no needed immediate treatment so can be discharged from A&E or CDU)
Suspected or known significant heart disease ECG shows o Bifascicular block (defined as either left bundle branch block or right bundle branch block combined with left anterior or left posterior fascicular block) o Other intraventricular conduction abnormalities (QRS duration _012 s) o Mobitz I second degree atrioventricular block o Asymptomatic sinus bradycardia (<50 beats/min) or sinoatrial block o Pre-excited QRS complexes o Prolonged QT interval o Right bundle branch block pattern with ST-elevation in leads V1-V3 (Brugada syndrome) o Negative T waves in right precordial leads, epsilon waves and ventricular late potentials o suggestive of arrhythmogenic right ventricular dysplasia o Q waves suggesting myocardial infarction Syncope occurring during exercise Syncope causing severe injury Family history of sudden death Discuss patients without heart disease but with sudden onset of palpitations shortly before syncope, syncope in supine position and patients with frequent recurrent episodes, patients with minimal or mild heart disease when there is high suspicion for cardiac syncope Cardiac arrhythmias as cause of syncope Syncope due to cardiac ischaemia Syncope secondary to the structural cardiopulmonary disease Stroke or focal neurologic disorders Cardioinhibitory neurally-mediated syncope when urgent pacemaker implantation is planned
Ref: Guidelines on management (diagnosis and treatment) of syncope European Heart Journal (2001);22:12561306

Relevant East Kent Services


Tilt Table evaluation is usually through Cardiologist or Care of Elderly Physician interested in Falls/Syncope. Any ECG abnormality like AF, LVH or ectopics is an abnormal ECG and needs 24hr tape first !

CLINICAL ALGORITHM ACUTELY PRESENTING RENAL FAILURE


Urea/SCr Increase Normal or big kidneys (excluding amyloidosis polycystic kidney disease

Small Kidneys

and

Rate of rise SCr < 50umol/l/day

Rate of rise SCr > 50 umol/l/day

Previous SCr increased

Previous SCr normal

CRF

ARF

+ Rate of rise SCr > 50 umol/l/day Renal Ultrasound Urinary tract dilatation

Normal Flare of previous disease Acute-on-chronic renal failure Normal

No

Prerenal factors?

Yes

Obstructive ARF

Parenchymatous glomerular or systemic ARF

Yes

Data indicating glomerular or systemic disease?

No

Improvement with specific treatment

Vascular ARF

Yes

Great or small vessel disease Data indicating interstitial disease?

No

Yes

Acute tubulointerstitial nephritis

Yes

No

Prerenal ARF

Tumour Iysis Sulfonamides Amyloidosis Other

Yes

Crystals or tubular deposits?

No No

Acute tubular necrosis

30

THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM IS DESIGNED TO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THIS CONDITION, HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCE FROM THE ALGORITHM.

Diagnostic Approach to Acutely Presenting Renal Failure Step 1 History (including drug history and recent changes in drug therapy), notes review for evidence of pre-existing disease and previous renal function, physical examination, urinary bladder catheterisation (if oligoanuric) 3 crucial assessments: volume status, urinalysis, renal ultrasound Step 2 Consider whether the presentation is acute renal failure, acute on chronic renal failure, or acutely presenting end stage renal failure. Refer acutely presenting end stage renal failure to the renal service Step 3 Consider whether acute/acute on chronic renal failure is prerenal, renal or postrenal. Refer suspected renal causes of acute/acute on chronic renal failure to the renal service Step 4 Consider simple therapeutic measures for prerenal and postrenal failure (volume expansion, relief of obstructive uropathy). If no response to simple measures for prerenal failure refer to the renal service. If no response to simple measures for postrenal failure refer to urology unless either biochemistry or volume status is life-threatening in which case refer to the renal service. Favours Acute No past history History of systemic illness Stigmata of systemic disease Normal sized kidneys Favours Chronic Past history of renal disease No history of systemic illness No stigmata of systemic disease Small kidneys (<8 cm on renal USS)

Management of Acute Renal Failure


Acute fall in GFR leading to rising urea and creatinine sometimes associated with oligo/ anuria Initial investigations: Renal unit profile (1) (urgent) Arterial Blood gases (2) ECG Urine dipstick / microscopy / Sodium content

Insert urinary catheter Measure urine output hourly Maintain BP >120/80 Consider CVP line (3) Maintain CVP 8-10 cm

Once fully resuscitated: Fluid restrict previous hours output plus 30 ml/hr

Arrange urgent renal ultrasound (4) Immunological screen (5) if urinalysis positive CK +/- myoglobin the lab will not process myoglobin requests next am Hepatitis screen if dialysis likely Refer to renal team (6) if creatinine either >250 or rising by > 50 mol/L/day or persistent oligo/ anuria despite fluid resuscitation. or for further advice if diagnosis uncertain

Notes : Acute Renal Failure 1. Treat Hyperkalaemia If ECG is abnormal give 10 mls 10% calcium gluconate or calcium chloride by slow intravenous injection over 5 minutes . Follow with 10 units intravenous Actrapid, plus 50 ml 50% glucose (watch BM stix and give further glucose as required), and then with calcium resonium (30g od rectally or 15g tds orally with lactulose ). Insulin and Glucose can be repeated if necessary depending on response and insulin infusion may be necessary. Watch potassium intake (especially IV fluids). Treat acidosis first. (see below)

2. Metabolic Acidosis should be treated if base deficit >5. If there is space to give fluid, 1.4% bicarbonate solution can replace normal saline as crystalloid infusate until fluid resuscitation is complete. If no fluid space, give more cautiously and obtain advice from renal team. NB higher bicarbonate concentrations risk sodium overload and can precipitate heart failure. 3. CVP lines should be considered to guide fluid requirements, particularly if JVP is not visible, or in frail / elderly patients. 4. Ultrasound of renal tract should be undertaken urgently if the patient is anuric or deteriorating if obstruction is confirmed bleep on-call urology SpR for further advice. 5. Immunological Screen should include: AIP / ANCA / anti-GBM ; Immunoglobulins; C3/ C4; ESR/CRP 6. To contact renal team: Bleep 504 for the on call renal SHO, switchboard for renal registrar or renal consultant

CLINICAL ALGORITHM FOR HYPERCALCAEMIA

Hypercalcaemia (Corrected Ca2+ of > 2.60mmol/l


Full history and Examination Investigations: ECR, LFT, bicarbonate, PTH level, TFT, protein electrophoresis, urine BJP, CXR, (ACE level, Vit D may be indicated D/W Consultant Biochemist)

Mild chronic asymptomatic hypercalcaemia (Calcium 2.6-2.8mmol/l)

Moderate-severe, symptomatic hypercalcaemia (Calcium 2.9-3.5mmol/l)

Severe hypercalcaemia (Calcium above 3.5mmol/l)

Outpatient Management

IV Rehydration (up to 4-6litres/24hrs) N/Saline Monitor electrolytes and volume status Catheterise Consider CVP in elderly or impaired renal function Consider loop diuretic once hypervolaemia induced diuresis occurs Consider steroids in steroid sensitive cases* Check corrected Ca2+ in 24hrs

If Calcium >4.5 mmol/l and neurologic symptoms

Consider haemodialysis Hypercalcaemia persists: IV Pamidronate See BNF for dosage and administration Continue rehydration Check Ca2+ after 48hrs Treat underlying cause Treat underlying cause

* Steroid sensitive cases myeloma, sarcoid, Patients whose primary disease cannot be cured e.g. disseminated malignancy, oral bisphosphonates, phosphates, steroids and aggressive oral hydration may be tried after acute therapy. Repeated infusions of IV Pamidronate at 2-3week intervals may be required. Patients in renal failure who present with severe hypercalcaemia may require urgent dialysis

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: Evidence Based on call. NHS National Electronic Library for Health.

CLINICAL ALGORITHM MANAGEMENT OF SHORTNESS OF BREATH IN A DIALYSIS PATIENT


On presentation document baseline observations: Pulse / Blood Pressure / Temperature / Respiratory Rate / Oxygen Saturations

Inform duty doctor

Obtain history from patient or witness: Is the patient on dialysis? Is the patient on Haemodialysis or Peritoneal Dialysis (CAPD)? When and where did the patient last receive dialysis treatment? When did episode of SOB begin? Any associated symptoms such as chest pain, cough, frothy sputum etc With a CAPD Patient: Ask whether any recent problems with drainage of dialysate, use of high concentration bags.

Differential Diagnosis:

Common problems include pulmonary oedema and fluid overload.


BUT CONSIDER: Myocardial ischaemia Pneumonia Pulmonary embolus Asthma/COPD Pneumothorax

Examine Patient: Immediate assessment of patient with breathlessness to include baseline observations as above. Assess level of distress/dyspnoea/sweating/cyanosis Examine for signs of fluid overload such as raised JVP, leg/sacral oedema/ raised BP Examine chest for signs of pulmonary oedema, pleural effusion, consolidation, bronchospasm or pneumothorax.

Investigations: ECG and CXR Routine Bloods/CRP/Cardiac Enzymes if cardiac aetiology suspected Consider Arterial Blood Gases

Treatment: Discuss patient with a senior member of renal team. This may be on-call SpR at KCH or on-call Renal Consultant (contact via KCH switchboard Haemodialysis Patient: Inform the on-call renal SpR or Consultant. Inform the dialysis unit early since patient may require urgent fluid removal by ultrafiltration (UF) Give Oxygen if patient clearly fluid overloaded, then treatment can be commenced prior to receiving treatment on the dialysis unit. NB The dialysis patient will NOT respond to Frusemide Commence patient on GTN infusion. Stop GTN if systolic blood pressure <100mm/Hg. Commence infusion at 0.8mls/min Discontinue GTN before patient begins treatment on dialysis machine since blood pressure will drop following UF. If patient is in extremis then consider venesection of between 300-400mls of blood. If not able to be transferred safely to Dialysis Unit contact ITU for ventilatory support and haemofiltration. CAPD Patient In general, the approach is the same however, fluid overload again will require specialist input. Inform on-call Renal SpR or Consultant

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref:

CLINICAL ALGORITHM FOR ACUTE EXACERBATION OF COPD ACUTE EXACERBATION OF COPD

HISTORY AND EXAMINATION

NURSING OBSERVATIONS: PEF / FEV O2 SATS Temp, Pulse, BP,RR

IMMEDIATE INVESTIGATIONS: ABG (Note inspired O2 conc.) CXR FBC, U+E.

ASSESS THE NEED FOR ADMISSION: (See Table 1 Overleaf)

NO
REFER TO COMMUNITY SPECIALIST RESPIRATORY TEAM (K+CH, QEQMH only)

YES
IMMEDIATE TREATMENT: Controlled Oxygen to achieve Pa O2 of 8.0 kPa (Sats = 92%) If Pa CO2 > or = 6.5 and pH <7.35 consider referral for NIV (See Table 2) / ITU Nebulised Bronchodilators: Salbutamol 2.5-5mg qds and/or Ipratropium 0.25-0.5mg qds (If PaCO2 elevated drive nebuliser on air) Prednisolone 30-40mg PO / day Antibiotics if evidence of infection (2 out of : increasing sputum volume, purulent sputum, or increasing dyspnoea) If severe treat as severe CAP. 1. 2. 3. Co-amoxiclav 625mg TDS PO Cefixime 200mg BD PO Doxycycline 100mg BD PO

01227-594640

Consider prophylactic s/c heparin Avoid sedatives

IMPROVEMENT Discharge when stable See Table 1

PATIENT DETERIORATES Seek specialist advice Consider HDU / ITU admission

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: BTS Guidelines for the Management of Chronic Obstructive Pulmonary Disease. Thorax 1997;52 (Suppl 5): S1-S28

TABLE 1

Accept onto Community Admit to Hospital Specialist Respiratory Team


Respiratory Rate * Blood Pressure Pulse Temperature * Chest X-Ray PO2 * PCO2 * PH * Confusion * Social * Urea and Electrolytes Cardiac Status * ECG * I/V Therapy <25 per minute Normal for patient <110 beats per minute <37.9C No changes from previous >8kPa <6.5kPa >7.35 No Coping Normal Stable Normal for patient I/V Antibiotics only >25 per minute Abnormal for patient >110 beats per minute >37.9C Abnormal/new changes <8kPa >6.5kPa <7.35 Disorientated Live alone/no phone Abnormal Unstable Abnormal / new changes I/V Fluids & Bronchodilator

Essential to meet criteria for acceptance onto CRT

TABLE 2 INDICATIONS FOR NIV CONTRAINDICATIONS FOR NIV (Consider referral to ITU) pH < 7.25 uncooperative/decreased conscious level Inability to clear secretions/co-existent pneumonia Facial abnormality (eg trauma /burns) Vomiting / bowel obstruction Haemodynamically unstable / Respiratory arrest

PaCO2 > 6.5 pH < 7.35

N.B: CPAP is not recommended for patients with respiratory failure due to acute exacerbations of COPD (Use only after specialist advice).

CLINICAL ALGORITHM FOR SUSPECTED COMMUNITY ACQUIRED PNEUMONIA (CAP)


SUSPECTED COMMUNITY ACQUIRED PNEUMONIA (CAP) History & Examination
INITIAL OBSERVATIONS:
Temp / PR / BP/RR O2 Saturations Mental Status

INITIAL INVESTIGATIONS CXR FBC, U+Es Sputum (C+S) [+/- Gm stain] Blood Culture Clotted serum for store

DIAGNOSIS OF CAP CONFIRMED ? :


Symptoms and signs of LRTI New radiographic shadow

YES ASSESS SEVERITY:


New mental confusion Urea > 7mmol/l RR > 30/min BP < 90/60 mmHg AGE > 65

NO EXIT PATHWAY

None Present

1-2 Features Present

3-4 Features Present

Pre-Existing Adverse Features Present


Age > 65 Years Co-Existent Chronic Disease

Non-Severe Pneumonia YES ADMIT

Severe Pneumonia

ADMIT
Consider HDU/ITU

NO INITIAL PREFERRED ANTIBIOTIC: INITIAL PREFERRED ANTIBIOTIC:


Co-amoxiclav 1.2g TDS IV (if allergic to Pen (rash) Cefuroxime 1.5g TDS IV) plus Clarithromycin 500mg bd IV If allergic to Penicillin (anaphylaxis) Levofloxacin 500mg BD IV for Penicillin allergy (change to Moxifloxacin after 3 days) Amoxycillin 1g tds PO (no clarithromycin) OR Moxifloxicin 400mg OD PO for Penicillin allergy

DISCHARGE
Outpatient management Amoxicillin 500mg-1g tds PO

INITIAL MANAGEMENT:
Check ABG if O2 Saturations < 92% Continuous O2 to maintain pa O2 >8kPa (Sats > 92%) IV Fluids if volume depleted Pleural Aspiration (M,C&S) if fluid present

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: BTS Guidelines for the

If Severe or selected non-severe: Pneumococcal Antigen (urine, blood or sputum) Legionella Antigen (urine) Atypical and viral serology

management of Community Acquired Pneumonia in Adults www.bit.Thorasic.org.uk

IMPROVEMENT:
Review Antibiotic duration and route Change to PO when apyrexial for 24hr

SPECIFIC PATHOGEN IDENTIFIED


Review Antibiotic Choice

FAILURE TO IMPROVE/ COMPLICATIONS: DISCHARGE


6 Week F/U CXR if persistent symptoms/signs and/or higher risk of underlying malignancy Seek Specialist Advice

CLINICAL ALGORITHM FOR SUSPECTED PULMONARY EMBOLUS SUSPECTED PULMONARY EMBOLUS


Start Enoxaparin & Warfarin (see prescription) stickers
Initial investigations FBC/ECG/CXR/D-Dimer ABG

Nursing Observations
Temp/PR/BP/O2 sats

Clinical Probability of PE See Table 1

Collapse or hypotension present YES NO

Urgent spiral CT

VQ Scan See guidelines for interpretation

Normal

Indeterminate (low/intermediate Probability)

High Probability

PE CONFIRMED

PE EXCLUDED Consider alternative diagnoses

D-Dimer Result

Anticoagulate (+/- thrombolysis)

-ve & low clinical probability

-ve & interim or high clinical probability

+ve

Spiral CT
No DVT

Ultrasound of Legs

DVT

Anticoagulate

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: Suspected Acute Pulmonary Embolism: A Practical Approach. Thorax;52 (Suppl 4): S1-S24

Note: Once PE is suspected the patient should be started on Enoxaparin and warfarin pending investigations unless anticoagulation presents higher than acceptable risks. All patients should have a VQ scan unless a large PE is suspected in which case a spiral CT should be arranged. When the VQ test is indeterminate (low/intermediate Probability) further investigations are required as shown in the algorithm. Further details are available via the hospital intranet.

Clinical Probability: There is no well validated clinical scoring systems for PE but an estimate of clinical probability (low/intermediate/high) should be made from presenting clinical features and basic tests before the VQ scan result is known. Table 1 covers the important positive features:

Previous history of DVT/PE Current DVT Active cancer Recent immobility/surgery Known inherited or acquired thrombophilic condition Family history of venous thromboembolism Heart rate of over 100

The following features are more consistent with infection: Productive cough A white cell count above 15,000/microlitre High fever Extensive radiological shadows on CXR

CLINICAL PATHWAY FOR SINGLE HOT JOINT


HISTORY Enquire for: EXPOSURE TO INFECTION (? Recent antibiotic) INTERCURRENT ILLNESS PAST HISTORY RASH / PSORIASIS ? IS THE PATIENT ON STEROIDS (THIS COULD MASK INFECTION) ? PROSTHETIC JOINT

EXAMINATION OTHER JOINT INVOLVEMENT SKIN TOPHI MUCOSAL ULCERATION FEVER

INVESTIGATION ASPIRATION OF JOINT --- GRAM STAIN ENSURE SAFE & RAPID TRANSIT TO LABORATORY (POLARISED MICROSCOPY IF GOUT/PSEUDO GOUT SUSPECTED) BLOOD CULTURE

SEPSIS DISCOUNTED
GOUT NSAID OR COLCHICINE OR INTRAARTICULAR STEROID REVIEW NEED FOR ALLOPURINOL AT FOLLOW UP. DO NOT START ALLOPURINOL DURING ACUTE ATTACK REVIEW MEDICATION FOR SECONDARY CAUSES REACTIVE ARTHRITIS ? GUM OPINION CULTURE THROAT/ URINE/STOOL NSAIDs INTRA-ARTICULAR STEROID PHYSIOTHERAPY

SEPSIS SUSPECTED/CONFIRMED
ADMIT IV ANTIBIOTICS FLUCLOXACILLIN 1g QDS ALONE IF PENICILLIN SENSITIVE USE CLINDAMYCIN (D/W MICROBIOLOGY) IF PATIENT IS KNOWN MRSA CARRIER USE VANCOMYCIN DISCUSS WITH RHEUMATOLOGIST/ORTHOPAEDIC CONSULTANT WITHIN 24 HOURS BED REST/PHYSIO REVIEW DIAGNOSIS AT 48 HOURS (AS SOON AS MICROBIOLOGY AVAILABLE)

PSORIATIC ARTHRITIS NSAID/INTRA-ARTICULAR STEROID

CULTURE NEGATIVE REVIEW DIAGNOSIS (Consider AFB)

SEPSIS CONFIRMED CONTINUE IV FOR 7 DAYS ORAL ANTIBIOTICS X 6 WEEKS IN CONSULTATION WITH MICROBIOLOGIST

POSSIBLE PRESENTATION OF POLYARTHRITIS CONSIDER IF OTHER JOINTS BECOMING INVOLVED

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients

presenting with this condition, however, clinical need may require that there is variance from the algorithm. Ref: Journal of the Royal College of Physicians of London Vol 26 1 January 1992

APPENDIX RESUSCITATION COUNCIL UK AND EUROPEAN RESUSCITATION COUNCIL ALGORITHMS