OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Emergency Medicine Published and upcoming Oxford Handbooks Oxford Handbook for the Foundation Program 3e Oxford Handbook of Acute Medicine 3e Oxford H andbook of Anesthesia 3e Oxford Handbook of Applied Dental Sciences Oxford Handbook of Card iology 2e Oxford Handbook of Clinical and Laboratory Investigation 3e Oxford Handbook of Cl inical Dentistry 5e Oxford Handbook of Clinical Diagnosis 2e Oxford Handbook of Clinical Ex amination and Practical Skills Oxford Handbook of Clinical Hematology 3e Oxford Handbook of Clinical Immunology and Allergy 2e Oxford Handbook of Clinical Medicine - Mini Edition 8e Oxford Handbook of Clinical Medicine 8e Oxford Handbook of Clinical Drugstore Oxford Handbo ok of Clinical Rehabilitation 2e Oxford Handbook of Clinical Specialties 8e Oxford Handbook of Clinical Surgery 3e Oxford Handbook of Complementary Medicine Oxford Handbook of Critic al Care 3e Oxford Handbook of Dental Patient Care 2e Oxford Handbook of Dialysis 3e Oxford Handbook of Emergency Medicine 4e Oxford Handbook of Endocrinology and Diabetes 2e Oxford H andbook of ENT and Head and Neck Surgery Oxford Handbook of Expedition and Wilderness Medic ine Oxford Handbook of Forensic Medicine Oxford Handbook of Gastroenterology & Hepatology 2 e Oxford Handbook of General Practice 3e Oxford Handbook of Genetics Oxford Handbook of Gen itourinary Medicine, HIV and AIDS 2e Oxford Handbook of Geriatric Medicine Oxford Handbook of Infectious Diseases and Microbiology Oxford Handbook of Key Clinical Evidence Oxford Han dbook of Medical Dermatology Oxford Handbook of Medical Sciences Oxford Handbook of Medical Statistics Oxford Handbook of Nephrology and Hypertension Oxford Handbook of Neurology Oxf ord Handbook of Nutrition and Dietetics Oxford Handbook of Obstetrics and Gynecology 2e Oxf ord Handbook of Occupational Health Oxford Handbook of Oncology 3e Oxford Handbook of Ophth almology 2e Oxford Handbook of Pediatrics Oxford Handbook of Pain Management Oxford Handboo k of Palliative Care 2e Oxford Handbook of Practical Drug Therapy 2e Oxford Handbook of Pre -Hospital Care Oxford Handbook of Psychiatry 2e Oxford Handbook of Public Health Practice 2 e Oxford Handbook of Reproductive Medicine & Family Planning Oxford Handbook of Respiratory Medicine 2e Oxford Handbook of Rheumatology 3e Oxford Handbook of Sport and Exercise Medic ine Oxford Handbook of Tropical Medicine 3e Oxford Handbook of Urology 2e Oxford Handbook of Emergency Medicine Fourth edition Jonathan P. Wyatt Consultant in Emergency Medicine and Forensic Physician Royal Cornwall Ho spital, Truro, UK Robin N. Illingworth Consultant in Emergency Medicine St James \200\231s University Hospital, Leeds, UK Colin A. Graham Professor of Emergency Medicine Chinese Univ ersity of Hong Kong, Hong Kong SAR, China Kerstin Hogg Clinical Research Fellow, The Ottawa Hospital, Ottawa, Canada with senior international advisors: Michael J. Clancy Consultant in Emergency Medicine Southampton General Hospital, Southampto n, UK Colin E. Robertson Professor of Emergency Medicine Royal In \201 rmary, Edinburgh, UK 1 1 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the Univer sity \200\231s objective of excellence in research, scholarship, and education by publishin g worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico Cit y Nairobi New Delhi Shanghai Taipei Toronto With of \201 ces in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan P oland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York Oxford University Press, 2012 The moral rights of the authors have been asserted Database right Oxford University Press ( maker) First edition published 1999 Second edition published 2005 Third edition published 2006 Fou rth edition published 2012 All rights reserved. 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S.p.A. \200\224Lavis TN ISBN 978 \200\2230 \200\22319 \200\223958956 \200\2232 10 9 8 7 6 5 4 3 2 1 Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and c linical procedures with the most up-to-date published product information and data sheets p rovided by the manufacturers and the most recent codes of conduct and safety regulations. T he authors and publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherw ise stated, drug dosages and recommendations are for the non-pregnant adult who is not brea stfeeding. Dedicated to Dr Robin Mitchell (1964 \200\2232010) Emergency Physician in Christchurch, Edi nburgh and Auckland. Outstanding clinician and teacher, tremendous colleague and friend. This page intentionally left blank vii Contents Abbreviations and symbols ix Normal values xvii Acknowledgements xix 1 41 62 179 219 253 271 319 401 503 533 545 563 601 630 1 General approach 2 Life-threatening emergencies 3 Medicine 4 Toxicology 5 Infectious dise ases 6 Environmental emergencies 7 Analgesia and anesthesia 8 Major trauma 9 Wounds, fractu res, orthopedics 10 Surgery 11 Ophthalmology 12 Ear, nose and throat 13 Obstetrics and gyne cology 14 Psychiatry 15 Pediatric emergencies Index 737 This page intentionally left blank ix Abbreviations and symbols 8 +ve \200\223ve i d ABC ABG AC ACE ACTH ACS AF AIDS AIO AIS ALS ALT ALTE AP APLS AP TT ARDS ARF AST ATLS AV bd BKPOP BKWPOP BLS BMG BNF BNFC degrees approximately positive negative plus or minus increase(d) decrease(d) airway, breat hing, circulation arterial blood gas acromio-clavicular angiotensin-converting enzyme adren ocorticotropic hormone acute coronary syndrome atrial \201 brillation acquired immune de \201 ciency syndrome Ambulance incident of \201 cer abbreviated injury scale advanced lif e support alanine aminotransferase apparently life-threatening event antero-posterior Advan ced Pediatric Life Support activated partial thromboplastin time adult respiratory distress syndrome acute renal failure aspartate transaminase advanced trauma life support atrio-ven tricular twice daily below knee Plaster of Paris below knee walking Plaster of Paris basic life support bedside strip measurement of venous/capillary blood glucose British National F ormulary British National Formulary for Children x ABBREVIATIONS AND SYMBOLS BP BTS BZP CBRN CCU CK cm CMV CN CNS CO CO 2 COHb COPD CPAP CPR CRF CRP CSF CT CTPA CVP CVS CXR DIC DIPJ DKA dL DPL DPT DSH DVT EBV ECG ECT ED EEG EMLA ENT EPAP blood pressure British Thoracic Society benzylpiperazine chemical, biological, radiological , nuclear critical care unit creatine kinase centimeter(s) cytomegalovirus chloroacetopheno ne central nervous system carbon monoxide carbon dioxide carboxyhaemoglobin chronic obstruc tive pulmonary disease continuous positive airways pressure cardiopulmonary resuscitation c hronic renal failure C-reactive protein cerebrospinal \202 uid computed tomography comput ed tomography pulmonary angiography central venous pressure cardiovascular system chest X-r ay disseminated intravascular coagulation distal interphalangeal joint diabetic ketoacidosi s decilitre diagnostic peritoneal lavage diphtheria, pertussis, and tetanus deliberate self -harm deep venous thrombosis Epstein \200\223Barr virus electrocardiogram electroconvulsive therapy emergency department electroencephalogram eutectic mixture of local anesthetics ea r, nose and throat expiratory positive airway pressure xi ABBREVIATIONS AND SYMBOLS ESR ET ETCO 2 FAST FB FBC FFP FG FiO 2 FOB G6-PD g G GA GCS GFR GI GHB GMC GP GTN GU 5HT HA TI Hb HCG HCM Hct HDU HHS HIV HONK hr HTLV ICP ICU IDDM IHD IM INR erythrocyte sedimentation rate endotracheal end-tidal carbon dioxide focused assessment wit h sonography for trauma foreign body full blood count fresh frozen plasma French Gauge insp ired oxygen concentration fecal occult blood glucose 6-phosphate dehydrogenase gram(s) gaug e general anesthetic Glasgow Coma Score glomerular \201 ltration rate gastrointestinal ga mmahydroxybutyrate General Medical Council general practitioner glyceryl trinitrate genitou rinary 5-hydroxytryptamine human anti-tetanus immunoglobulin hemoglobin human chorionic gon adotrophin hypertrophic cardiomyopathy haematocrit high dependency unit hyperosmolar hyperg lycaemic state human immunode \201 ciency virus hyperosmolar non-ketotic hyperglycaemia ho ur/s human T-cell lymphotropic virus intracranial pressure intensive care unit insulin depe ndent diabetes mellitus ischaemic heart disease intramuscular international normalized rati o (of prothrombin time) xii ABBREVIATIONS AND SYMBOLS IO IPAP IPg IPPV ISS ITP IUCD IV IVI IVRA IVU JVP KE kPa KUB L LA LAD LBBB LDH LET LFTs LMA LMP LMWH LP LSD LV LVF LVH m MAOI MAST max MC MCA MCPJ MDU MI min intra-osseous inspiratory positive airway pressure interphalangeal intermittent positive pr essure ventilation injury severity score idiopathic thrombocytopenic purpura intrauterine c ontraceptive device intravenous intravenous infusion intravenous regional anesthesia intrav enous urography jugular venous pressure kinetic energy kiloPascal(s) pressure X-ray coverin g the area of kidneys, ureters and bladder liter(s) local anesthetic left axis deviation le ft bundle branch block lactate dehydrogenase lidocaine epinephrine tetracaine liver functio n tests laryngeal mask airway last menstrual period low molecular weight heparin lumbar pun cture lysergic acid diethylamide left ventricular left ventricular failure left venticular hypertrophy meter(s) monoamine oxidase inhibitor military anti-shock trousers maximum meta carpal Mental Capacity Act metacarpophalangeal joint Medical Defense Union myocardial infar ction minute/s xiii ABBREVIATIONS AND SYMBOLS MIO mL mmHg mmol MMR MRI MRSA MS MSU MT MTPJ MUA NAC NAI ND NG NHS NIV NO NSAID NSTEMI NWBP OP O 2 OA OCP od OPG ORIF ORT PA PACS PAN PCI pCO 2 PCR PE PEA PEEP PEFR PGL medical incident of \201 cer milliliter(s) millimeters of mercury pressure millimoles mump s, measles, and rubella magnetic resonance imaging meticillin resistant Staphylococcus aure us multiple sclerosis mid-stream specimen of urine metatarsal metatarsophalangeal joint man ipulation under anesthetic N -acetyl cysteine non-accidental injury noti \201 able disease nasogastric National Health Service non-invasive ventilation nitrous oxide non-steroidal a nti-in \202 ammatory drug non-ST segment elevation myocardial infarction non-weight-bearin g Plaster of Paris oxygen osteoarthritis oral contraceptive pill once daily orthopantomogra m open reduction and internal \201 xation oral replacement therapy postero-anterior pictu re archiving and communication system polyarteritis nodosa percutaneous coronary interventi on arterial partial pressure of carbon dioxide polymerase chain reaction pulmonary embolus pulseless electrical activity positive end-expiratory pressure peak expiratory \202 ow ra te persistent generalized lymphadenopathy xiv ABBREVIATIONS AND SYMBOLS PICU PID PIPJ PO pO 2 POP PPE PPI PR PRF PRN PSP PV qds RA RAD RBBB RBC Rh ROSC RR RSI RSV rtPA RTS RV SA SARS SC SCIWORA sec SIDS SIGN SIRS SL SLE SpO 2 SSP SSRI STD pediatric intensive care unit pelvic in \202 ammatory disease proximal interphalangeal joi nt per os (orally/by mouth) arterial partial pressure of oxygen plaster of Paris personal p rotective equipment proton pump inhibitor per rectum patient report form pro re nata (as re quired) primary spontaneous pneumothorax per vaginam four times a day rheumatoid arthritis right axis deviation right bundle branch block red blood cells Rhesus restoration of sponta neous circulation respiratory rate rapid sequence induction/intubation respiratory syncytia l virus recombinant tissue plasminogen activator revised trauma score right ventricular sin o-atrial severe acute respiratory syndrome subcutaneous spinal cord injury without radiogra phic abnormality second(s) sudden infant death syndrome Scottish Intercollegiate Guidelines Network systemic in \202 ammatory response syndrome sublingual systemic lupus erythematos us arterial oxygen saturation secondary spontaneous pneumothorax selective serotonin re-upt ake inhibitor sexually transmitted disease xv ABBREVIATIONS AND SYMBOLS STEMI SVT T T 3 T 4 TAC TB tds TFTs TIA TIMI tPA TSH u/U U&E URTI USS UTI V VA VF VHF V/ Q VT WB WBC WCC WHO WPW ST segment elevation myocardial infarction supraventricular tachycardia temperature tri-iod othyronine thyroxine tetracaine, adrenaline and cocaine tuberculosis three times a day thyr oid function tests transient ischaemic attack thrombolysis in myocardial infarction tissue plasminogen actvator thyroid stimulating hormone unit(s) urea and electrolytes upper respir atory tract infection ultrasound scan urinary tract infection volts visual acuity ventricul ar \201 brillation viral hemorrhagic fever ventilation/perfusion (scan) ventricular tachy cardia weight-bear(ing) white blood cells white cell count World Health Organization Wolff Parkinson White (syndrome) This page intentionally left blank xvii Normal values Note that \200\230normal \200\231 values in adults may vary slightly between labs. Normal values in pregnancy are shown in b The pregnant patient, p.576. Arterial blood gas analysis H + pH pO 2 (on air) pCO 2 bicarbonate base excess 35 \200\22345 nanomol/L 7.35 \200\2237.45 >10.6 kPa, 75 \200\223100 mmHg 4.5 \200\2236.0 kP a, 35 \200\22345 mmHg 24 \200\22328 mmol/L 2 mmol/L Biochemistry alanine aminotransferase (ALT) albumin alkaline phosphatase amylase aspartate transaminase (AST) bicarbonate bilirubin calcium (total) calcium (ionized) chloride creatin e kinase (CK) creatinine C-reactive protein (CRP) glucose (fasting) G glutamyl transpeptida se (4) (5) magnesium osmolality potassium sodium urea urate (5) (4) 5 \200\22335 iu/L 35 \200\22350 g/L 30 \200\223300 iu/L 0 \200\223180 Somogyi U/dL 5 \200 \22335 iu/L 24 \200\22330 mmol/L 3 \200\22317 micromol/L 2.12 \200\2232.65 mmol/L 1 \200 \2231.25 mmol/L 95 \200\223105 mmol/L 25 \200\223195 iu/L 70 \200\223150 micromol/L <10 mg/ L 3.5 \200\2235.5 mmol/L 11 \200\22351 IU/L 7 \200\22333 IU/L 0.75 \200\2231.05 mmol/L 278 \200\223305 mosmol/kg 3.5 \200\2235.0 mmol/L 135 \200\223145 mmol/L 2.5 \200\2236.7 mmol/L 150 \200\223390 micromol/L 210 \200\223480 micromol/L xviii NORMAL VALUES Hematology RBC (women) (men) Hb (women) (men) Hct (women) (men) MCV WCC neutrophils lymphoc ytes monocytes eosinophils basophils platelets prothrombin time (factors I, II, VII, X) APT T (factors VII, IX, XI, XII) International Normalized Ratio (INR) therapeutic targets 2.0 \200\2233.0 2.5 \200\2233.5 3.0 \200\2234.5 3.9 \200\2235.6 \227 10 12 /L 4.5 \200\2236.5 \227 10 12 /L 11.5 \200\22316.0g/dL 13.5 \200\22318.0g/dL 0.37 \200\2230.47 0.40 \200\2230.54 76 \200\22396 femtoL 4.0 \200\22311.0 \227 10 9 /L 2.0 \200\2237.5 \227 10 9 /L (40 \200\22375 % of WCC) 1.5 \200\2234.0 \227 10 9 /L (20 \200\22340 % of WCC) 0.2 \200\2230.8 \227 10 9 /L (2 \200\22310 % of WCC) 0.04 \200\2230.40 \227 10 9 /L (1 \200\2236 % of WCC) <0.1 \227 10 9 /L (<1 % of WCC) 150 \200\223400 \227 10 9 /L 12 \200\22315sec 23 \200\22342sec (for treating DVT, pulmonary embolism) (embolism prophylaxis for AF) (recurrent thrombo-emb olic disease, arterial grafts & prosthetic valves) < (age in years+10) / 2 mm/hr < (age in years) / 2 mm/hr ESR (women) (men) Metric conversion Length 1m = 3 feet 3.4 inches 1cm = 0.394 inch 1 foot = 0.3048m 1 inch = 25.4mm Weight 1kg = 2.20 pounds 1g = 15.4 grains 1 stone = 6.35kg 1 pound = 0.454kg 1 ounce = 28.4g Volume 1 L = 1.76 UK pints = 2.11 US liquid pints 1 UK pint = 20 \202 uid ounces = 0.568 L 1 US liquid pint = 16 \202 uid ounces = 0.473 L 1 teaspoon 8 5mL 1 tablespoon 8 15mL Te mperature T in C = ( T in Fahrenheit \200\223 32) \227 9 5 \200\223 Pressure 1kPa = 7.5mmHg xix Acknowledgements A number of people provided comments, help and moral support. Special thanks are due to Dr Phil Munro. We also wish to thank: Miss Sehlah Abassi, Mr David Alao, Dr Matt Baker, Dr Joan Barber, Dr Ruth Beach, Mr Dewald Behrens, Dr Ash Bhatia, Dr Angela Bonnar, Dr Rachel Broadley, Dr Chris Brown, Mrs Debra Cla yton, Mr Jon Davies, Dr Kate Evans, Dr James Falconer, Miss Paula Fitzpatrick, Mrs Jennifer Flemen, Dr Adrian Flynn, Dr Debbie Galbraith, Mr Blair Graham, Dr Catherine Guly, Mr Chris Had \201 eld, Dr Steve Halford, Mr Andrew Harrower, Miss Emily Hotton, Mr Jim Huntley, Mr s Eileen Hutchison, Mr Nicholas Hyatt, Dr Karen Illingworth, Mr Ian Kelly, Mr Jacques Kerr, Dr Alastair Kidd, Dr Paul Leonard, Mr Malcolm Lewis, Mr AF Mabrook, Dr Simon Mardel, Dr Ni ck Mathiew, Ms Carolyn Meikle, Dr Louisa Mitchell, Dr Claudia Murton, Dr Louisa Pieterse, D r Stephanie Prince, Dr Laura Robertson, Miss Katharine Robinson, Dr Andrew Sampson, Mr Tom Scott, Dr Simon Scott- Hayward, Ms Karen Sim, Mr Toby Slade, Dr Timothy Squires, Mr Ashleig h Stone, Dr Luke Summers, Dr Rob Taylor, Dr Ross Vanstone, Ms Fiona Wardlaw, Dr Mike Wells, Mr Ken Woodburn, Mrs Polly Wyatt. This page intentionally left blank 1 Chapter 1 General approach The emergency department Note keeping Radiological requests Triage Discharge, referral, and handover Liaising with GPs Telephone advice Liaising with the ambulance crew Coping as a j unior doctor Inappropriate attenders The patient with a label The patient you dislike Speci al patient groups Discharging the elderly patient The patient with learning dif \201 culti es Patient transfer Breaking bad news What to do after a death Medicolegal aspects: avoidin g trouble Medicolegal aspects: the law Infection control and prevention What to carry in yo ur car At the roadside Major incidents 2 4 6 7 8 10 11 12 14 16 17 18 19 20 21 22 24 26 28 30 32 34 36 38 2 CHAPTER 1 General approach The emergency department The role of the emergency department The emergency department (ED) occupies a key position in terms of the interface between primary and secondary care. It h as a high public pro \201 le. Many patients attend without referral, but some are referred by NHS Direct, minor injury units, general practitioners (GPs), and other medical practiti oners. The ED manages patients with a huge variety of medical problems. Many of the patient s who attend have painful and/or distressing disorders of recent origin. Priorities are: \200 To make life-saving interventions. \200 To provide analgesia. \200 To identify relevant issues, investigations, and commence treatment. \200 To decide upon need for admission or discharge. ED staff work as a team. Traditional roles are often blurred, with the important issue being what clinical skills a member of staff is capable of. ED staff include: \200 Nurses (including nurse practitioners, nurse consultants, health c are assistants). Doctors (permanent and \201 xed-term). \200 Reception and administrative staff (receptionists, secretaries, managers). Radiographers, including reporting radiographers. \200 Other specialist staff (eg psychia tric liaison nurses, plaster technicians, assistants, physiotherapists, paramedic practitioners, physician occupational therapists, clinic/ED war d staff). Supporting staff (security, porters, cleaners, police). Physical resources A principal focu s of the ED is to provide immediate resuscitation for patients who present with emergency c onditions. In terms of sheer numbers, more patients attend with minor conditions and injuri es, often presenting quite a challenge for them to be seen and treated in a timely fashion. Different departments have systems to suit their own particular needs, but most have a res uscitation room, an area for patients on trolleys, and an area for ambulant patients with l ess serious problems or injuries. Pediatric patients are seen in a separate area from adult s. In addition, every ED requires facilities for applying casts, exploring and suturing wou nds, obtaining X-rays, and examining patients with eye problems. Discharge from the ED To work ef \201 ciently, the overall hospital system needs to enable easy \202 ow of patients out of the ED. Options available for continuing care of patient s who leave the ED, include: \200 Discharge home with no follow-up. \200 Discharge home with GP and/or other community support/follow-up. \200 Discharge with hospital clinic fo llow-up arranged. \200 Admission to hospital for further investigation and treatment. \200 Transfer to another hospital with more specialist facilities. 3 THE EMERGENCY DEPARTMENT Emergency department staff beyond the emergency department In addition to their roles in pr oviding direct clinical care in their departments, many ED staff provide related clinical c are in other settings and ways: \200 Short stay wards (sometimes called clinical decision units) where emergency care can be continued by ED staff. The intention is for admissions to these units to be short: most of the patients admitted to such wards are observed for re latively short periods (<24hr) and undergo assessments at an early stage to decide about th e need for discharge or longer-term admission. Outpatient clinics enable patients with a variety of clinical problems (eg burns, soft tiss ue injuries, and infections) to be followed up by ED staff. \200 Planned theater lists ru n by ED specialists are used by some hospitals to manage some simple fractures (eg angulate d distal radial fractures). Telemedicine advice to satellite and minor injury units. Emergency medicine in other settings As the delivery of emergency care continues to develop , patients with emergency problems are now receiving assessment and treatment in a variety of settings. These include minor injury units, acute medical assessment units and walk-in c enters. Traditional distinctions between emergency medicine, acute medicine, and primary ca re have become blurred. 4 CHAPTER 1 General approach Note keeping General aspects It is impossible to over-emphasize the importance of note keep ing. Doctors and nurse practitioners each treat hundreds of patients every month. With the passage of time, it is impossible to remember all aspects relating to these cases, yet it m ay be necessary to give evidence in court about them years after the event. The only refere nce will be the notes made much earlier. Medicolegally, the ED record is the prime source o f evidence in negligence cases. If the notes are de \201 cient, it may not be feasible to defend a claim even if negligence has not occurred. A court may consider that the standard of the notes re \202 ects the general standard of care. Sloppy, illegible, or incomplete n otes re \202 ect badly on the individual. In contrast, if notes are neat, legible, appropr iate, and detailed, those reviewing the case will naturally expect the general standards of care, in terms of history taking, examination, and level of knowledge, to be competent. The Data Protection and Access to Medical Records Acts give patients right of access to the ir medical notes. Remember, whenever writing notes, that the patient may in the future read exactly what has been written. Follow the basic general rules listed below. Layout Follow a standard outline: Presenting complaint Indicate from whom the history has been obtained (eg the patient, a re lative, or ambulance personnel). Avoid attributing events to certain individuals (eg patien t was struck by \200\230Joe Bloggs \200\231). Previous relevant history Note recent ED attendances. Include family and social history. An elderly woman with a Colles \200\231 fracture of her dominant hand may be able to manage a t home with routine follow-up provided she is normally in good health, and has good family or other support, but if she lives alone in precarious social conditions without such suppo rt, then admission on \200\230social grounds \200\231 may be required. Current medications Remember to ask about non-prescribed drugs (including recreational, her bal, and homeopathic). Women may not volunteer the oral contraceptive pill (OCP) as \200 \230medication \200\231 unless speci \201 cally asked. Enquire about allergies to medicati ons and document the nature of this reaction. Examination \201 ndings As well as + ve features, document relevant \200\223ve \201 nd ings (eg the absence of neck stiffness in a patient with headache and pyrexia). Always docu ment the side of the patient which has been injured. For upper limb injuries, note whether the patient is left or right handed. Use \200\230left \200\231 and \200\230right \200\231 , not \200\230L \200\231 and \200\230R \200\231. Document if a patient is abusive or aggr essive, but avoid non-medical, judgemental terms (eg \200\230drunk \200\231). Investigation \201 ndings Record clearly. Working diagnosis For patients being admitted, this may be a differential diagnostic list. Sometimes a problem list can help. 5 NOTE KEEPING Treatment given Document drugs, including dose, time, and route of administration (see curr ent British National Formulary ( BNF ) for guidance). Include medications given in the ED, as well as therapy to be continued (eg course of antibiotics). Note the number and type of sutures or staples used for wound closure (eg \200\2305 \227 6/0 nylon sutures \200\231). Advice and follow-up arrangements Document if the patient and/or relative is given preprint ed instructions (eg \200\230POP care \200\231). Indicate when/ if the patient needs to be reviewed (eg \200\230see GP in 5 days for suture removal \200\231) or other arrangement (e g \200\230Fracture clinic in one week \200\231). Record advice about when/why the patient should return for review, especially if there is a risk of a rare but serious complication (eg for low back pain \200\230see GP if not bette r in 1 week. Return to the ED at once if bladder/bowel problem or numb groin/bottom \200 \231 that might be features of cauda equina syndrome). Basic rules \200 Write legibly in ballpoint pen, ideally black, which photocopies well. \200 Always date and time the notes. \200 Sign the notes, and print your name and status below. \200 Make your notes concise and to the point. \200 Use simple line drawings or preprinted sheets for wound/injury descriptions. Avoid idiosyncratic abbreviations. \200 Never make rude or judgemental comments . \200 Always document the name, grade, and specialty of any doctor from whom you have received advice. When referring or handing a patient over, always document the time of referral/handover, to gether with the name, grade, and specialty of the receiving doctor. Inform the GP by letter ( b Liaising with GPs, p.10), even if the patient is admitted. Most EDs have computerized systems that generate such letters. In complex cases, send also a co py of ED notes, with results of investigations. Pro formas Increasing emphasis on evidence-based guidelines and protocols has been associat ed with the introduction of protocols for many patient presentations and conditions. Bear i n mind the fact that, for some patients, satisfactory completion of a pro forma may not ade quately capture all of the information required. Electronic records In an electronic age, there has been an understandable move towards tryi ng to introduce electronic patient records. The potential advantages are obvious, particula rly in relation to rapidly ascertaining past medical history. When completing electronic re cords, practitioners need to follow the same principles as those outlined above for written records. Access to old records can make a huge contribution to decision making. One potential advant age of electronic records is that they can be accessed rapidly (compared with older systems requiring a porter to search through the medical records store and retrieve paper-based no tes). 6 CHAPTER 1 General approach Radiological requests \200\230I am glad to say that in this country there is no need to ca rry out unnecessary tests as a form of insurance. It is not in this country desirable, or i ndeed necessary, that over protective and over examination work should be done, merely and purely and simply as I say to protect oneself against possible litigation \200\231 \200 \224 Judge Fallon, quoted by Oscar Craig, Chairman Cases Committee, Medical Protection Soci ety. Requesting investigations The Royal College of Radiologists \200\231 booklet \200\230 Maki ng the Best Use of a Department of Clinical Radiology: Guidelines for Doctors \200\231 (6t h edn, London, RCR, 2007) contains very useful information and is strongly recommended. General aspects \200 An X-ray is no substitute for careful, thorough clinical examination . It is usually unnecessary to request X-rays to con \201 rm the clinical diagnosis of unc omplicated fractures of the nose, coccyx, a single rib, or toes (other than the big toe). If in doubt about the need for X-rays or the speci \201 c test required, consider relevant guidelines (eg Ottawa rules for ankle injuries, b p.484) and/or discuss with senior ED sta ff or radiologist. When requesting X-rays, describe the indication/mechanism of injury, clinical \201 ndings , including the side involved (right or left \200\224 spelled out in full, not abbreviated ) and the suspected clinical diagnosis. This is important for the radiologist reporting the \201 lms without the advantage of being able to examine the patient. Do not worry about specifying exactly which X-ray views are required. The radiographer will know the standard views that are needed, based on the information provided (eg AP + simpli \201 ed apical oblique views for a patient with suspected anterior shoulder dislocation). In unusual cases, discuss with senior ED staff, radiographer, or radiologist. Always consider the possibility of pregnancy in women of child-bearing age before requestin g an X-ray of the abdomen, pelvis, lumbar spine, hips, or thighs. If the clinical indicatio n for X-ray is overriding, tell the radiographer, who will attempt to shield the fetus/gona ds. If the risks/ bene \201 ts of X-rays in pregnant or possibly pregnant women are not ob vious, consult senior ED or radiology staff. X-ray reporting system Many hospitals have systems so that all ED X-rays are reported by a specialist within 24hr. Reports of any missed abnormalities are returned with the X-rays to the ED for the attention of senior staff, so that appropriate action can be taken. System for identifying abnormalities In addition to the formal reporting system described a bove, a system is commonly used whereby the radiographer taking the \201 lms applies a st icky \200\230red dot \200\231 to hard copy X-ray \201 lms and/or request card or to the equivalent electronic image if they identify an abnormality. This alerts other clinical sta ff to the possibility of abnormal \201 ndings. 7 TRIAGE Triage The nature of ED work means that a sorting system is required to ensure that patient s with the most immediately life-threatening conditions are seen \201 rst. A triage proce ss aims to categorize patients based on their medical need and the available departmental r esources. One most commonly used process in the UK is the National Triage Scale (Table 1.1 ). Table 1.1 National Triage Scale Color Time to be seen by doctor 1 Immediate Red Immediately 2 Very urgent Orange Within 5 \200\22310 min 3 Urgent Yellow Within 1 hr 4 Standard Green Within 2 hr 5 Non-urgent Blue Within 4 hr As soon as a patient arrives in the ED he/she should be assessed by a dedicated triage nurs e (a senior, experienced individual with considerable common sense). This nurse should prov ide any immediate interventions needed (eg elevating injured limbs, applying ice packs or s plints, and giving analgesia) and initiate investigations to speed the patient \200\231s jo urney through the department (eg ordering appropriate X-rays). Patients should not have to wait to be triaged. It is a brief assessment which should take no more than a few minutes. Three points require emphasis: \200 Triage is a dynamic process. The urgency (and hence t riage category) with which a patient requires to be seen may change with time. For example a middle-aged man who hobbles in with an inversion ankle injury is likely to be placed in t riage category 4 (green). If in the waiting room he becomes pale, sweaty, and complains of chest discomfort, he would require prompt re-triage into category 2 (orange). Placement in a triage category does not imply a diagnosis, or even the lethality of a condi tion (eg an elderly patient with colicky abdominal discomfort, vomiting, and absolute const ipation would normally be placed in category 3 (yellow) and a possible diagnosis would be b owel obstruction). The cause may be a neoplasm which has already metastasized and is hence likely to be ultimately fatal. Triage has its own problems. In particular, patients in non-urgent categories may wait inor dinately long periods of time, whilst patients who have presented later, but with condition s perceived to be more urgent, are seen before them. Patients need to be aware of this and to be informed of likely waiting times. Uncomplaining elderly patients can often be poorly served by the process. 8 CHAPTER 1 General approach Discharge, referral, and handover Most patients seen in the ED are examined, investigated, treated, and discharged home, either with no follow-up, or advice to see their GP (for sutu re removal, wound checks, etc.). Give these patients (and/or attending relative/friend) cle ar instructions on when to attend the GP \200\231s surgery and an indication of the likely course of events, as well as any features that they should look out for to prompt them to s eek medical help prior to this. Formal written instructions are particularly useful for pat ients with minor head injury ( b p.367) and those with limbs in POP or other forms of cast immobilization ( b Casts and their problems, p.424). The referral of patients to an inpatie nt team can cause considerable anxiety, misunderstanding, and potential con \202 ict betwe en ED staff and other disciplines. Before making the referral the following should be consi dered. Is it appropriate to refer this patient to the inpatient team? Usually, this will be obviou s. For example, a middle-aged man with a history of crushing chest pain and an ECG showing an acute MI clearly requires urgent management in the ED, and rapid admission for further i nvestigation and treatment. Similarly, an elderly lady who has fallen, is unable to weight- bear and has a fractured neck of femur will require analgesia, inpatient care and surgery. However, dif \201 cult situations occur where the clinical situation is less clear; for ex ample, if a man experienced 4 \200\2235min of atypical chest pain, has a normal ECG and che st X-ray (CXR), and is anxious to go home. Or a lady has no apparent fracture on X-ray, but cannot weight-bear. Is there appropriate information to make this decision? This requires a balance between ava ilability, time, and appropriateness. In general, simple investigations which rapidly give the diagnosis, or clues to it, are all that are needed. These include electrocardiogram (EC Gs), arterial blood gas (ABG), and plain X-rays. It is relatively unusual to have to wait f or the results of investigations such as full blood count (FBC), urea & electrolytes (U&E), and liver function tests (LFTs) before referring a patient, since these rarely alter the i mmediate management. Simple trolley- side investigations are often of great value, for exam ple, stix estimations of blood glucose (BMG) and urinalysis. If complicated investigations are needed, then referral for inpatient or outpatient specialist care is often required. Has the patient had appropriate treatment pending the admission? Do not forget, or delay, a nalgesia. Treat every patient in pain appropriately as soon as possible. A patient does not have to \200\230earn \200\231 analgesia. Never delay analgesia to allow further examinati on or investigation. Concern regarding masking of signs or symptoms (for example, in a pati ent with an acute abdomen) is inhumane and incorrect. 9 DISCHARGE, REFERRAL, AND HANDOVER How to refer patients Referral is often by telephone, and this can create problems: \200 Introduce yourself and ask for the name and grade of the specialist. \200 Give a clear, c oncise summary of the history, investigations, and treatment that you have already undertaken. Early in the discussion say clearly whether you are making a referral for admission or a re quest for a specialist opinion. With ever increasing pressure on hospital beds, inpatient t eams can be reluctant to come and see patients, and may appear to be happier to give advice over the phone to avoid admission. If, in your view, the patient needs to be admitted, the n clearly indicate this. If, for whatever reason, this is declined, do not get cross, rude, or aggressive, but contact senior ED medical staff to speak to the specialist team. When the specialist team comes to see the patient, or the patient is admitted directly to a ward, the ED notes need to be complete and legible. Make sure that there is a list of the investigations already performed, together with the available results and crucially, a list of investigations whose results remain outstanding. The latter is essential to ensure cont inuity of care and to prevent an important result \200\230falling through the net \200\231 . Similarly, summarize treatment already given and the response. In an emergency, do not de lay referral or treatment merely to complete the notes, but complete them at the earliest o pportunity. \200 Encourage inpatient specialists who attend patients to write their \201 ndings and management plan in the notes, adding a signature and the time/date. Handing over patients Dangers of handing over Handing over a patient to a colleague, becaus e your shift has ended and you are going home, is fraught with danger. It is easy for patie nts to be neglected, or receive sub-optimal or delayed treatment. It is safest to complete to the point of discharge or referral to an inpatient team every patient that you are seein g at the end of a shift. Occasionally this may not be possible (eg if there is a delay in o btaining an X-ray or other investigation). In these situations, hand over the patient caref ully to the doctor who is taking over and inform the nursing staff of this.