City hospitals Sunderland A&E Department

Information Card Pack

Produced by Dr Sarah Frewin
Correspondence to s.e.frewin@doctors.org.uk

Review date: January 2012

Nexus C-spine rules
Glasgow pancreatitis score
Alvarado score
Rectal bleeding differentials
Upper GI bleed differentials
Abdominal pain differentials
Jaundice differentials
Rockall score (GI bleed)
ABCD2 (TIA)
Severe sepsis criteria
Sepsis screening tool
Severe sepsis 1st hour pathway
Soft tissue antibiotic policy
Curb 65 (pneumonia)
LRTI antibiotic policy
Meningitis antibiotic policy
UTI antibiotic policy
Wells criteria (PE)
Wells criteria (DVT)
MRC dyspnoea scale
ASA grading (anaesthetics)
BTS asthma exacerbation grades
NICE COPD guidance
NICE head CT guidance (amendment)
NICE head CT guidance
Chest pain differentials
Breathlessness / hypoxia differentials
Bradyarrhythmia differentials
Tachyarrhythmia differentials
Reversible causes of cardiac arrest
ECG interpretation
New York heart failure classification
Grading of murmurs
Headache differentials
Dizziness differentials
AMTS
Timed get up and go test
Stroke mimics
falls /collapse differentials
Pain assessment
Confusion differentials
Hypotension differentials
Stages of hypovolemic shock
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 pneumonia
Score Description
1 Age 65+
1 New onset confusion
1 Urea >7mmol/l
1 Respiratory rate >30/min
1 SBP <90mmHg / DPB <60mmHg
Additional Hypoxaemia (SaO2 <92% or PaO2 <8 kPa)
adverse regardless of FiO2
prognostic Bilateral or multilobe involvement on CXR
features
 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 Tachycardia Hypotension
>100, pulse pulse >100, SBP <100,
<100 SBP >100 pulse >100
Co-morbidity Nil major Cardiac Renal or liver
failure, IHD, failure,
other major disseminated
co-morbidity malignancy
Diagnosis Mallory-Weiss All other Malignancy of
tear, no lesion, diagnoses upper GI tract
no stigmata of
recent
haemorrhage
 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 Description
1 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 likely
Interpretation
2 or higher:- DVT likely (consider imaging leg veins)
<2:- DVT unlikely (consider XDP to further rule out DVT)
 MRC Dyspnoea Scale
Score 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 home

Able to cope at home No Yes
Breathlessness Severe Mild
General condition Poor /deteriorating Good
Level of activity Poor /confined to bed Good
Cyanosis Yes No
Worsening peripheral oedema Yes No
Level of consciousness Impaired Normal
Already receiving LTOT Yes No
Social circumstances Living alone / not coping Good
Acute confusion Yes No
Rapid rate of onset Yes No
Significant co-morbidity (IDDM / Yes No
CCF)
SaO2 <90% Yes No
Changes on CXR Present No
Arterial pH <7.35 >7.35
Arterial PaO2 <7kpa >7kpa
 Asthma Exacerbation Grades (BTS)

Grading of asthma exacerbations

Moderate Acute severe Life threatening Near fatal
Increasing symptoms PEF 33 – 50% best PEF <33% best or Raised PaCO2
or predicted predicted
PEFR >50 – 75% RR > 25 /min SpO2 < 92% Requiring
best or predicted mechanical
ventilation with
raised pressures
No features of acute HR > 110 /min PaO2 <8kpa
severe asthma
Inability to complete Normal PaCO2
sentences in one
breath

Silent chest
Cyanosis
Feeble respiratory effort

Bradycardia, arrhythmia,
hypotension

Exhaustion, confusion,
coma
 Grading of murmurs
Grade 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 Classification
Class 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 appendicitis
Score 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 Leucocytosis
Score <5 is not likely appendicitis
5 or 6 is equivocal
7 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

Normal healthy individual

I

II Mild systemic disease that does not limit activity

Severe systemic disease that limits activity but is

III
not incapacitating
Incapacitating systemic disease which is constantly
IV
life-threatening
Moribund, not expected to survive 24 hours with or
V 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 Pathway
Oxygen Target SPO2 >94% / COPD target 88-92%
Blood Also consider other microbiology samples (urine /
cultures sputum /swabs)
IV As per trust guidelines (contact microbiology for
antibiotics advice)
Fluid Bolus of Hartman’s / N/saline @20ml/kg. Further
boluses @10ml/kg
Lactate / Also ensure Hb >7 / do other bloods as
FBC 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 PO Flucloxacillin Treat for 5,7, 10
500mg – 1g QDS IV 1-2g QDS days according to
response
Penicillin Clindamycin PO Clindamycin IV Treat for 5,7, 10
allergy 300 – 600mg QDS 600mg QDS days according to
response
Caution in elderly
due to risk of C-diff

MRSA Doxycline PO 100mg Contact

suspected BD microbiology
Plus either
Sodium fusidate PO
500mg TDS
Or
Rifampicin PO 300mg
BD
 Antibiotic policy for acute meningitis infection

Antibiotic Notes

Standard Cefotaxome IV 2g Add amoxicillin IV 2gQDS if

QDS aged > 55to cover listeria
Or
Ceftriaxone IV 2g
BD
Additional Acyclovir IV For suspected HSV
10mg/kg TDS
 Antibiotic policy for UTI (non catheterised)
Patient Treatment
condition
Asymptomatic Needs no treatment
Symptomatic Trimethoprim PO 200mg BD for 5-7 days
Or
Cefalexin PO 500mg TDS for 5 – 7 days

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

Or
Cefuroxime IV 750mg – 1.5g TDS for 5 – 7 days
Or
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 Doxycycline PO 200mg loading Amoxicillin 500mg Moxifloxacin PO

/ COPD dose then 100mg OD for 5 days – 1g TDS for 5 400mg OD for 5
days (IV or PO) days
Systemic Cefuroxime 750mg – 1.5g IV Contact
Sepsis TDS (switch to co-amoxiclav PO microbiology
625mg TDs to complete 5 days
ASAP)
CAP Amoxicillin 1g TDS (initially IV) In penicillin allergy Moxifloxacin PO
CURB-65 Plus either Clarithromycin IV 400mg OD for 5
≤2 Clarithromycin IV 500mg BD 500mg BD days (up to max
Or Or of 10 days
Erythromycin PO 500mg QDS Erythromycin PO
Or 500mg QDS
Clarithtomycin PO 250 – 500mg For 5 – 7 days
BD
All for 5 – 7 days
CAP Cefuroxime 750mg – 1.5g IV
CURB-65 TDS
≥3 Plus
Clarithromycin IV 500mg BD
 Stages of hypovolemic shock
Up to 15% blood volume loss (750mls)
Blood pressure maintained
Grade 1 Normal respiratory rate
Pallor of the skin
15-30% blood volume loss (750 - 1500mls)
Increased respiratory rate
Blood pressure maintained
Grade 2 Increased diastolic pressure
Narrow pulse pressure
Sweating
30-40% blood volume loss (1500 - 2000mls)
Systolic BP falls to 100mmHg or less
Grade 3 Marked tachycardia >120 bpm
Marked tachypnoea >30 bpm
Decreased systolic pressure
Loss greater than 40% (>2000mls)
Extreme tachycardia with weak pulse
Grade 4 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 PE
Score 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 points
Moderate risk = 3 – 6 points
High risk = 6.5 – 12.5
 AMTS
1 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 differentials
Sinus bradycardia

Complete or 3rd degree AV block / other heart blocks

MI

Drugs (beta-blockers, digoxin etc)

Vasovagal

Hypothyroidism

Hypothermia

Cushings reflex
Hypotension differentials
Hypovolemia
Cardiogenic shock
Septic shock
Neurogenic shock
Anaphylaxis
Dysrhythmia
Postural hypotension
Vasovagal
Addison’s / adrenal failure
Drugs
Breathlessness / Hypoxia differentials
COPD / asthma
Pneumonia
PE
Pulmonary oedema
MI
Pneumothorax
Pleural effusion
Pain
Sepsis
Metabolic acidosis
Anaemia
Chronic fibrotic lung disease
Upper GI bleed differentials
Peptic ulcer

Oesophagitis

Erosions

Varices

Mallory-Weiss tear

Swallowed blood

Malignancy
Rectal bleeding differentials
Polyps

Diverticular disease

Angiodysplasia

Haemorrhoids

Anal fissure

IBD

malignancy

Upper GI bleed
Abdominal pain differentials
AAA
Infarction / ischemia
Obstruction
Pancreatitis
Appendicitis
Perforation
Strangulated hernia
Torsion
Ectopic
Referred pain
IBD
PID
Constipation
 Jaundice differentials
Paracetamol OD / toxins / drugs
Gall stones
Sepsis
Viral hepatitis
Alcohol
Cholangitis
Pancreatitis
Haemolysis
Gilberts
Dizziness differentials
Shock
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 differentials
Hypoxia

Infection

Drugs

Dural haemorrhage (subdural haemorrhage)

Endocrine

Neoplasm

Metabolic

Alcohol

Psychosis
Falls / collapse differentials
MI
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 armchair

2. Walk 3 meters (in a line)
3. Turn
4. Walk back to chair
5. 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 independence

High scores correlate with poor functional independence and higher risk of falls
 ECG interpretation
Complex What it looks like Changes
P wave 2-3 sq high
1.5-3sq long
R wave 1st positive deflection after P
PR 3-5 sq long
interval
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 Can be negative in AVR, V1,V2
leads
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

Questions
Do 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.)?

Management
Blood for COHb estimation
Oxygen
Do not allow patient to go home to where there are suspect appliances
Contact local HPA