What do we do about X?

It is impossible to be prescriptive - to protocol level - about management because we may see anything at all here; and your management will depend on your diagnosis, your judgement and the patient's wishes, amongst other variables. What follows however is a series of "checklists", or points to consider, in the context of various typical presentations. Links to standard sources of information and clinical protocols can be found thru my webpage, with the NHS Highland Intranet being the first listed. Leo Murray

Abdo pain in female

HPT? History? Exam? Hernias? Rectal? PV? Differential? Send now or hold for observation? IVI? FBC [HB AVAIALBLE HERE]? Biochem [K U Cr Amylase CK available here]? BG? Cefuroxime? Metronidazole? Morphine? Antiemetic?

Abdominal pain?

History? Exam? Send now or hold for observation? Hernias? Rectal? PV? Differential? IVI? FBC [HB AVAIALBLE HERE]? HPT? G&S? Amylase? Biochem [K U Cr Amylase CK available here]? BG? Cefuroxime? Metronidazole? Morphine? Antiemetic?AbscessHistory? Exam? Able to provide local anaesthesia? Need to arrange GA? Happy to drain adequately? Usually elliptical excision of prominence not "lancing". Sometimes aspiration may be appropriate. Dressing? Review plans? Needs antibiotic? Breast abscesses [not just skin infection over breast] often need formal surgical drainage under GA] Careful with facial abscesses - remember underlying clockwork.

AF

Really af? Infarcted? Atherosclerosis risks lipids/obesity/smoking/diabetes. Hyperthyroid? Respiratory disease? Clexane? Warfarin? For cardioversion? Rate control with beta blocker? Digoxin?

Alcohol intoxication

Alcohol intoxication is only one cause of altered consciousness - is it just alcohol? ABCDEDDT differential.

Alcohol withdrawal

History? Exam? Diplopia? Peripheral Neuropathy? Memory? Admit? Previous withdrawal fits? Support at home? Involve CPN? Need iv sedation? Oral sedation? IV vitamins before dextrose? Vitamin B? Thiamine at 50 tid? Omeprazole for gastritis? AnaemicHistory? Examination? FBC [HB AVAIALBLE HERE]? ESR? Biochem [K U Cr Amylase CK available here]? B12? Folate? Ferritin? TSH? CXR? FOB? Urinalysis?

Anaphylaxis

Cannula oxygen Adrenaline? IVI? Hydrocortisone? Chlorpheniramine? [www.resus.org.uk]

Ankle oedema

History? Examination? Bloods? ECG? CXR? Renal? Hepatic? Cardiac? Traumatic/Rheumatic? Domestic violence? SW? Police?

Assaulted female? Back pain History?

Exam? Reflexes? Sphincters? Abdomen? FBC [HB AVAIALBLE HERE]? ESR? Biochem [K U Cr Amylase CK available here]? Electrophoresis? Analgisia? Admit?

Catheter

[urinary] stuck Balloon deflated? Overinflate with air? Do not cut catheter!

Chest infection?

History? Examination? Sats? ECG? Cardiac failure? CXR? Sputum? A&AFB? PFR? Hold here? Keep here? Send on?

Chest pain

History? Exam? Could it be ihd? Cannula? Bleed? Morphine?Oxygen? Nitrates? Aspirin?; ECG? CXR?

Clopidogrel? Beta blocker? Clexane? Throbolyse? Atherosclerosis risks - lipids/obesity/smoking/diabetes. Keep here? Send on now? Send on later?

Collapse in aged patient

ABCDE Oxygen IV Access History? Examination? BM AEIOU DDT differential diagnosis. ECG? FBC [HB AVAIALBLE HERE]? ESR? Biochem [K U Cr Amylase CK available here]?Lipids? TSH? CXR?

Colles fracture

All will need POP. Full POP? Backslab? Needs mua? Do we have someone available manipulate? Someone to sedate? Last ate? Safe to sedate here? Fit to sedate here? Try here? Analgesia and evacuation?Do here? Refer on? Follow up here? Refer on?

CVA

Differential dx of altered consciousness - is it a CVA? ABC care. Needs evacuation for acute work up ? SAH ? tumour? Atherosclerosis risks - lipids/obesity/smoking/diabetes.

Dental problem

History? Examination? Is it really dental pain? Nsaid? Simple analgesia? Antibiotic? See dentist

Dislocated total hip?

History? Examination? X-ray. Analgesia. Do we have someone available to reduce the hip? Someone to sedate?Last ate? Safe to sedate here? Fit to sedate here? Try here? Analgesia and evacuation? DVT risk. Consult with orthopods.

Disturbed Psychiatric patient?

Other causes of altered mental state? How to sedate? Police needed? Send now or hold for observation pending team from New Craigs

Dog bite

NV? Suture or not? Antibiotic or not? Review?

DVT?

History? Exam? Signs of embolism? Underlying local causes? Underlying systemic causes? Needs ecg? Needs cxr? Needs fbc [Hb avaialble here]? Biochem [K U Cr Amylase CK available here]? Inr baseline? Treat with clexane? Arrange u/s? Admit here or send on? History? Past history? Examination? PR? FOB +ve? IV access? Bloods? Hold here? Keep here? Send on? Arrange UGIE here? Examination? Flexion and extension. Supination and pronation. NV status? X-ray? Effusions? Fractures?

Dysphagia

Elbow injury in adult History?

Epistaxis

History? Exam? Need IVI? On Warfarin? On Aspirin? Adrenaline and Lignocaine and inspect ? cauterise with silver nitrate. If fails Merocel pack. Epistaxis balloon in reserve. Keep here? Send on?

Exac asthma?

Diagnosis? Is it Asthma? Familiar with national guidelines? Admit here or send on? Antibiotic? Need CXR? Aminonophylline? IV salbutamol? IV magnesium sulphate? History? Exam? Medication? PFR? Sputum? CXR? Sats? FBC [Hb available here]? ESR? Biochem [K U Cr Amylase CK available here]? Associated LVF? Admit here or send on? Antibiotic? Ventolin? Atrovent? Oxygen? Steroids? Aminophylline?

Exac COPD

Facial fractures

ABC. History? Exam? Remember neck and brain if enough force to make you consider facial fracture. Sensation? Bite? Eye movements? Often will not require x-ray ooh especially if intoxicated/obtunded - need to cooperate to get good pictures. Compound fractures will need antibiotic prophylaxis.

Fall onto hand Fall

Wrist #? Scaphoid#? Radial head #? Supracondylar #? # Surgical neck humerus? Clavicle? Was it a fall? Syncope?

FB in wound?

X-ray if ? glass ? metal; ?? u/s for wood; think about adjacent structures; To explore or not?

FB sensation eye? History? Examination? Slit lamp

exam?VA? Upper lid? Staining? Traumatic ulcer? Viral ulcer? Need xr for ? iofb?

Febrile child

Younger they are the more difficult to assess and to localise. History? Examination? Rash? Ent? Chest? Urine? Meningitis? Admit? Evacuate? Treat as septicaemic?

Finger in door Fit

History? Exam? NV? X-ray? Trephine nail? Avulse nail? Repair nail bed? ABCDE Oxygen IV Access History? History from others? New event? Previous fits? Examination? BG? BM AEIOU DDT differential diagnosis. ECG?

Fitting?

History? Exam? ABC. Blood Glucose? Diazepam rectal? IV Diazepam or Lorazepam?; Repeat? Paraldehyde? Phenytoin? Ventilate?

Fracture demonstrated

Discuss by teleradiology? Splintage how? Review here? If one fracture ? more? ? other injury?

Fracture nof? GI Bleed

Why did they fall? Other pathology? AP and lateral. Femoral block? Splintage? History? Examination? FOB +ve? IV access. IVI? FBC [hb avaialble here]? ESR? Biochem [K U Cr Amylase CK available here]? X-match? Group and save? O negative blood? PPI? Hold here? When can we get scoped? Keep here? Send on?

Head injury

Neck? Aware of SIGN guidelines? Aware of NICE Guidelines? On warfarin? History? Exam? Evacuate for CT? SXR? Observe here? Observe at home?

Headache Hypo?

Most headaches do not come to hospital - take seriously. SAH? Sinusitis? Really a hypo? IV dextrose? Glucagon? Why did it happen? Silent MI or other as yet undiagnosed illness? Send thru or hold here?

Hypothermia

History? Exam? Investigation? Needs ecg? Needs cxr? ? Amylase Warming machine? Warm IV fluids? Keep here? Send on?

Ingrown toenail?

History? Examination? Antibiotics only? Avulsion? Wedge Excision? Today? Soon in any event? Dont just prevaricate with antibiotics

Ketoacidosis Diabetic

Almost always initial ABC considerations and resuscitation with saline and commencement of Insulin via syringe driver - and evacuation appropriate. We are not in a position to to the lab monitoring needed. Remember

aggressive fluid loads in kids can cause cerebral oedema - take advice.

Knee pain

Is it referred? History? Exam? Effusion? Haemarthosis? Aspirate? Inject?

Leg ulcers

Familiar with SIGN guideline? Venous? Arterial? Malignant? Dopplers? Antibiotics for cellulitis? Flamazine topically? Rest? DVT risk? Lesser toe #? History? Exam? X-ray ? Teach patient how to garter strap? Review at all? Review here?

Mallet finger

History? Exam? X-ray ? avulsion. Refer acutely if #. Importance of patient understanding. Mallet splint. Review here.

Mandibular fracture

History? Exam? Extra and intraoral. X-ray ? we cannot do opts here machine at Portree so difficult to read standard views are all we have. Max fax at Raigmore for advice.

MI

Follow Raigmore protocol - see Intranet/Clinical Governance/Cardiology; Tenecteplase in drug cabinet on A&E wall; Heparin in ward area, Clexane in Big Drug Cupboard, Atenolol injection ward area

Miscarriage

History? Exam? HPT? Cannulate? Needs fbc [Hb available here]? Arrange u/s? Bleed for serology? Need Anti D? Discuss with Gynae? Admit here or send on?

Neck injury?

Cspine management? Pull arms for xr? XR? Can you read a cspine x-ray?

Needlestick

History? Examination? Risk of sepsis? Risk of tetanus? Risk of HepB? Vaccinated? Needs Ig? Needs Vaccinated? Risk of HIV? Sample for storage? Sample from source patient? HIV prophylaxis kit in DDA cupboard?

Overdose

Poisons computer for info. Supportive rx - ivi and airway care always correct. Specific rx rare except for parvolex for paracetamol. Safe rx so treat on suspicion ahead of [delayed] blood results. Unreliable historians. Calculated risk in admission here.

Pain in calf?

History? Exam? DVT? Gastrocnemius tear? Ruptured Tendo achilles? Leak from knee bakers cyst

Patient intubated

Monitor ECG Sats Capnometry CXR NG tube? Suction ET tube, Arterial line. Disposal. Continuing sedation ? Drug Continuing paralysis ? drug; Use of syringe driver Use of Oxylog

Post Op problem?

History? Exam? If in doubt discuss with the surgeon responsible [on a Monday night in a hotel locally] and failing that with the duty surgeon at Beford or Raigmore as appropriate.

Pretibial lac

History? Examination? To suture? To steristrip? Watch tension devitalising the flap. Admit and elevate? Remove flap and apply as graft? Keep here? ATT?

Prolapsed piles

True piles? To reduce? Thrombosed external pile? To incise? Arrange rv?

Rectal Bleeding History?

Examination? PR? FOB +ve? IV access? Bloods? Rigid siggy? Admit? X-match? Group and save? O negative blood? Hold here? Keep here? Send on?

Renal colic?

History? Exam? Urinalysis? Plain Abdo? U/s? IVP? Remember dissecting aneurysms cause loin pain. Send now or hold for observation? Differential? IVI? Biochem [K U Cr Amylase CK available here]? Urate? Sieve urine? Analgesia? Antiemetic? Obstruction is the urological emergency, not just colic. Beware fever and colic ? obstructed kidney.

Request for an opinion on anything? Retention of urine

See and assess anything but then - do you need further advice? History? Exam? Rectal; Prostate. U&E and PSA. Catheterise. If fail - suprapubic. Use bonanno or addacath. We should no be sending patients to Raigmore as an emergency in retention. If in doubt use the small ultrasound machine. Antibiotic rx if suspect infection or a traumatic catheter or a suprapubic.

Ring stuck

History? Examination? Circulation? Sensation? Remove. Wound needs dressing? Review?

Serious Trauma

Initial ATLS AcBCDE. Cspine management? Need rapid iv infusion? Need chest drain? Conscious level? Get Stripped off. Do you need neck chest and pelvis xrs? Secondary survey. Documentation? Admit? Transfer on?

Shoulder injury?

History? Exam? NV? X-ray? Of Shoulder? Of AC? For scapula?

Smiths fracture

Always put films up with thumb mc down to avoid Smiths/Colles confusion. Not for mua here. Often internal fixation. Sprained ankle? Familiar with Ottawa rules? DTG? Backslab? Crutches? Review? Nsaid? Physio?

Syncope

History? Exam? History from others? IV access. Bloods? ECG? Keep here? Send on?

Tetanus prophyaxis

High risk wounds - heavy anaerobic contamination - get Tetanus Immunoglobulin [in fridge] and tetanus toxoid at separate site. Low risk wounds - if had 5 shots of tetanus toxoid in life - get no toxoid , otherwise give tetanus toxoid - [which now contains diptheria and pertussis automatically - central DOH decision.]

Tonsillitis?

Quinsy? Admit? Choice of antibiotic? Admit here? Monospot?

Wound any

History? Examination? What parts are injured? What deeper structures might be injured? Risk of Infection? ATT status? Are you happy to explore and repair? Could there be glass - x-ray or document decision not to x-ray. Dressing? splintage?

Wound infection?

Why? Open wound up? Able to provide local anaesthesia? Need to arrange GA? Happy to drain adequately? Discuss with surgeon? Choice of antibiotic? Local dressing? Admit here? Refer on?

Wound of finger

History? Examination? What parts are injured? What deeper structures might be injured? FDS FDP Extensor tendons. Risk of Infection? ATT status? Are you happy to explore and repair? Dressing? splintage?

Wrist injury

History? Exam? NV? X-ray? Of wrist? Scaphoid series? Happy to read wrist and scaphoid series? Perilunate dislocation? Triquetral avulsion? [fall on hand = wrist or scaphoid or radial head or humeral neck or clavicular fracture]