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 NICE COPD guidance
Glasgow pancreatitis score NICE head CT guidance (amendment)
Alvarado score NICE head CT guidance
Rectal bleeding differentials Chest pain differentials
Upper GI bleed differentials Breathlessness / hypoxia differentials
Abdominal pain differentials Bradyarrhythmia differentials
Jaundice differentials Tachyarrhythmia differentials
Rockall score (GI bleed) Reversible causes of cardiac arrest
ABCD2 (TIA) ECG interpretation
Severe sepsis criteria New York heart failure classification
Sepsis screening tool Grading of murmurs
Severe sepsis 1
st
hour pathway Headache differentials
Soft tissue antibiotic policy Dizziness differentials
Curb 65 (pneumonia) AMTS
LRTI antibiotic policy Timed get up and go test
Meningitis antibiotic policy Stroke mimics
UTI antibiotic policy falls /collapse differentials
Wells criteria (PE) Pain assessment
Wells criteria (DVT) Confusion differentials
MRC dyspnoea scale Hypotension differentials
ASA grading (anaesthetics) Stages of hypovolemic shock
BTS asthma exacerbation grades CO poisoning






Reversible causes of cardiac arrest
Hypoxia Tamponade
Hypothermia Toxins
Hypovolemia Thromboembolism
Hypo / hype / hypokalaemia Tension pneumothorax
Stroke mimics
Hypoglycaemia
Seizure

Complicated migraine
Hypertensive encephalopathy
Conversion disorder
CURB-65 score for 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
adverse
prognostic
features
Hypoxaemia (SaO2 <92% or PaO2 <8 kPa)
regardless of FiO2
Bilateral or multilobe involvement on CXR
Modified Glasgow Score For Pancreatitis
Parameter score
age >55 1
pO
2
<8.0kpa 1
WCC >15 1
Ca
2+
(uncorr) <2 1
ALT >100 1
LDH >600 1
glucose >10 1
score > 3 indicates severe pancreatitis
Rockall scoring system
(Risk of re-bleeding / death after acute UGIB)
Variable Score 0 Score 1 Score 2 Score 3
Age in years <60 60 79 >80
Shock None SBP
>100, pulse
<100
Tachycardia
pulse >100,
SBP >100
Hypotension
SBP <100,
pulse >100
Co-morbidity Nil major Cardiac
failure, IHD,
other major
co-morbidity
Renal or liver
failure,
disseminated
malignancy
Diagnosis Mallory-Weiss
tear, no lesion,
no stigmata of
recent
haemorrhage
All other
diagnoses
Malignancy of
upper GI tract
NICE criteria for immediate head CT (adults)
GCS <13 on initial assessment in ED
GCS <15 2 hours after injury / ED assessment
Suspected open or depressed skull fracture
Any sign of basal skull fracture
Post-traumatic seizure
Focal neurological deficit
More than one episode of vomiting
Amnesia for events >30 minutes before impact
NICE criteria for immediate head CT
(patient experiencing LOC / amnesia since injury)
>65 years
Coagulopathy / warfarin
Dangerous mechanism of injury

ABCD2 to identify patients at high risk of stroke
following a TIA
Score Description
1 A - Age >=60 years
1 B - Blood pressure at presentation >=140/90 mmHg
2 C - Clinical features of unilateral weakness
1 C - Clinical features of speech disturbance without
weakness
2 D - Duration of symptoms >= 60 minutes
1 D - Duration of symptoms 10-59 minutes
1 Presence of diabetes
Scores range from 0 (low risk) to 7 (high risk)
Wells score for DVT
Score 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 /
CCF)
Yes No
SaO2 <90% Yes No
Changes on CXR Present No
Arterial pH <7.35 >7.35
Arterial PaO2 <7kpa >7kpa
Grading of asthma exacerbations
Moderate Acute severe Life threatening Near fatal
Increasing symptoms PEF 33 50% best
or predicted
PEF <33% best or
predicted
Raised PaCO2
PEFR >50 75%
best or predicted
RR > 25 /min SpO2 < 92% Requiring
mechanical
ventilation with
raised pressures
No features of acute
severe asthma
HR > 110 /min PaO2 <8kpa
Inability to complete
sentences in one
breath
Normal PaCO2
Silent chest
Cyanosis
Feeble respiratory effort
Bradycardia, arrhythmia,
hypotension
Exhaustion, confusion,
coma
Asthma Exacerbation Grades (BTS)
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
I
Normal healthy individual

II Mild systemic disease that does not limit activity
III
Severe systemic disease that limits activity but is
not incapacitating
IV
Incapacitating systemic disease which is constantly
life-threatening
V
Moribund, not expected to survive 24 hours with or
without surgery

Sepsis Screening Tool
Score Criteria
1 Temperature > 38C or < 36C
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
cultures
Also consider other microbiology samples (urine /
sputum /swabs)
IV
antibiotics
As per trust guidelines (contact microbiology for
advice)
Fluid Bolus of Hartmans / N/saline @20ml/kg. Further
boluses @10ml/kg
Lactate /
FBC
Also ensure Hb >7 / do other bloods as
appropriate
Catheterise Commence 1 hourly urine output

Discuss with senior to asses if escalation in care is needed
Antibiotic policy for soft tissue infection
Less severe More severe notes
1
st
line Flucloxacillin PO
500mg 1g QDS
Flucloxacillin
IV 1-2g QDS
Treat for 5,7, 10
days according to
response
Penicillin
allergy
Clindamycin PO
300 600mg QDS
Clindamycin IV
600mg QDS
Treat for 5,7, 10
days according to
response
Caution in elderly
due to risk of C-diff
MRSA
suspected
Doxycline PO 100mg
BD
Plus either
Sodium fusidate PO
500mg TDS
Or
Rifampicin PO 300mg
BD
Contact
microbiology
Antibiotic policy for acute meningitis infection
Antibiotic Notes
Standard Cefotaxome IV 2g
QDS
Or
Ceftriaxone IV 2g
BD
Add amoxicillin IV 2gQDS if
aged > 55to cover listeria
Additional Acyclovir IV
10mg/kg TDS

For suspected HSV
Antibiotic policy for UTI (non catheterised)
Patient
condition
Treatment
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 1
st
line 2
nd
line 3
rd
line
Bronchitis
/ COPD
Doxycycline PO 200mg loading
dose then 100mg OD for 5 days
Amoxicillin 500mg
1g TDS for 5
days (IV or PO)
Moxifloxacin PO
400mg OD for 5
days
Systemic
Sepsis
Cefuroxime 750mg 1.5g IV
TDS (switch to co-amoxiclav PO
625mg TDs to complete 5 days
ASAP)
Contact
microbiology
CAP
CURB-65
2
Amoxicillin 1g TDS (initially IV)
Plus either
Clarithromycin IV 500mg BD
Or
Erythromycin PO 500mg QDS
Or
Clarithtomycin PO 250 500mg
BD
All for 5 7 days
In penicillin allergy
Clarithromycin IV
500mg BD
Or
Erythromycin PO
500mg QDS
For 5 7 days
Moxifloxacin PO
400mg OD for 5
days (up to max
of 10 days
CAP
CURB-65
3
Cefuroxime 750mg 1.5g IV
TDS
Plus
Clarithromycin IV 500mg BD
Stages of hypovolemic shock
Grade 1
Up to 15% blood volume loss (750mls)
Blood pressure maintained
Normal respiratory rate
Pallor of the skin
Grade 2
15-30% blood volume loss (750 - 1500mls)
Increased respiratory rate
Blood pressure maintained
Increased diastolic pressure
Narrow pulse pressure
Sweating
Grade 3
30-40% blood volume loss (1500 - 2000mls)
Systolic BP falls to 100mmHg or less
Marked tachycardia >120 bpm
Marked tachypnoea >30 bpm
Decreased systolic pressure
Grade 4
Loss greater than 40% (>2000mls)
Extreme tachycardia with weak pulse
Pronounced tachypnoea
Significantly decreased systolic blood pressure of 70 mmHg or less
Nexus C-spine rule
Score Parameter
1 Midline c-spine tenderness
1 Evidence of intoxication
1 Altered consciousness
1 Focal neurology
1 Distracting injuries
Score >1 indication for c-spine imaging
Wells criteria for 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 3
rd
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
Addisons / 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
UTI
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 1
st
positive deflection after P
PR
interval
3-5 sq long
QRS 5-15 sq high, up to 3 small sq long
ST Should be isoelectric
Max height= -0.5 - +1 sq
T Height= 0.5-10 sq depending on
leads
Can be negative in AVR, V1,V2
QT 9-10 sq long
RBBB Prolonged QRS, RSR (rabbits ears) with T wave inversion in V1, wide S
and upright T in V6
LBBB Wide QRS in all leads, slurred R and T wave inversion in V6, may have
ST depression / elevation
Suspected CO poisoning
PC:- Headache, N&V, drowsiness, dizziness, dyspnoea, chest pain
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