Author: Charlotte Davies / Editor: Hannah Bell / Codes: HMP1-5, CMP1-5 / Published: 31/07/2018
We all work in the Emergency Department because we think there’s going to be lots of “emergencies”. We quickly realise that some things are more time critical and need a prompt response. You should know how to deal with everything; after all, you did complete medical school but here’s a handy revision list of the things we think you need to know!
1. Go to the Toilet
OK, so we’ve started with a non-medical emergency first but if you need to urinate, then you will not be giving 100% to your patient. It’s not tough to “hold it” and “wait” but its not cool to have not peed for the whole shift. Drink and then wee when needed. Your patients can (mostly) wait 5 minutes for you to relieve yourself.
You’ve all heard of HALT mistakes are more likely if you are Hungry, Angry, Late or needing the Loo, or Tired going to the loo is the easy one to resolve. So, if you need to micturate – just do it!
2. Cardiac Arrest
Most of the time, our patients are brought in to the department in cardiac arrest but occasionally, you will see a patient who has deteriorated unexpectedly. Remember your basics first call for help the emergency buzzers are a good place to start! Be systematic. If no signs of life, start CPR and follow the resus council UK algorithm. In some places the patient will move to resus for arrest care, in other places a crash trolley will come to the patient. Find out what happens in your hospital and find out where your emergency buzzers are.
This weeks medical infographic is my take on the Adult Advanced Life Support Algorithm. Let me know what you think and if you want other sizes and formats you can find them here https://t.co/O7bfLgvv4q Another one coming next Monday #foamed #Infographic pic.twitter.com/sqEVKts2TZ
Strata5 (@Nrtaylor101) March 26, 2018
In peri-arrest patients, start assessing the patient with an ABCDE approach and follow the principles you would on a ward. Let your registrar or consultant know but don’t stop doing anything, you’re still a Doctor, and can still manage unwell patients! If the patient is under the care of a specialty team, make sure someone is informing the specialty their patient is unwell but don’t stop resuscitating them!
After a cardiac arrest or dealing with an unwell patient you may need some time to stop, pause and think. Speak to the boss, and say “I need a break because dealing with that patient has taken it out of me”, they’ll be understanding.
Anaphylaxis or allergic reaction? Often difficult to know but the general feeling is “if it’s more than skin, get the epi in”. Follow the resus council algorithm (you can get this as an app on your phone too) stop the trigger (if you can identify it), and give 500mcg (0.5 ml of 1:1000) intra-muscular adrenaline. Then move the patient to resus for further monitoring! Often these patients will get better but sometimes they won’t, it’s difficult to predict which is which. The adrenaline dose we’d expect you to know, Chlorpheniramine and Hydrocortisone, you should know too!
4. Severe Shortness of Breath
Lots of patients have severe shortness of breath but if you think systematically, you can always manage to stabilise them until help arrives. After you’ve called for help, be reassuring and calming. Don’t lie to the patient but always avoid nocebo and say something like; “I’m here to help, you’re in the right place. We’re going to do everything we can to make you better”. Sit the patient up and give the patient high flow oxygen. Make sure you pinch the metal strip over their nose. If they’re really hypoxic, turn the dial up to above 15 lpm! It really goes up high! Listen to their chest if they’re wheezy give some nebs. If they could have a pneumothorax and you think it’s tensioning perform a needle thoracocentesis.
We’ve talked about shortness of breath in our first induction blog remember, you don’t need to know the cause of shortness of breath to be able to treat it properly!
Seizures can be frightening. I remember the first time I actually saw a patient fit was in the Emergency Department. I’d done ward cover but they’d always stopped by the time I saw them! This patient in the ED started fitting, and I didn’t know what to do but I called for help (always important) and a burly paramedic responded to my plea, rolled the patient on their side (to protect their airway) and suggested I put some oxygen on them. I suctioned their airway, and then gained IV access. By the time we’d done all that, the patient had stopped fitting! If your patient hasn’t stopped fitting, benzodiazepines are the first line treatment and there’s a nice flowchart to follow in the NICE guidelines.
Even if you know what to do, you’re unlikely to have enough hands to manage seizures, don’t forget to call for help!
6. The Unconscious Patient
Unconscious patients are always tricky, as there are so many reasons why a patient could be unconscious. Remember to follow your ABCDE approach if their airway isn’t maintained; do a head tilt chin lift or jaw thrust (airway reminder here) and shout for some help. Sometimes, a good jaw thrust wakes these patients up and your problem is solved! If your senior doesn’t know that you have an unconscious patient, alert them quickly so they can help you hone down your differential.
We have an e-learning module on this if you’d like to learn more!
7. The STEMI
“Can you look at this ECG for me” is a frequent occurrence in the ED. If you think the patient is having a STEMI, ask the person who performed the ECG to alert a senior. Whilst they are alerting a senior, stop what you are doing, go and see the patient. Nothing frustrates me more than an ECG tech waiting for me to finish discussing a patient, to say the doctor in minors asked me to show you this. Its only by seeing these patients you’ll get good at them!
If the patient is having a STEMI, give them Aspirin and the antiplatelet of your trust’s choice, arrange PCI as per your local guidance, write some notes, photocopy the notes, bingo, STEMI treated. Back to what you were doing and you’ve scored some resus experience.
If there are ischaemic changes and youre not sure, go and have a look at the patient. Don’t let them wait with their chest pain for two hours until they’re seen. Their ischaemic changes may then have changed into a STEMI! There’s loads of resources on ECGs, but obviously our induction blog is the best!
8. The Hyperkalaemia
We have a podcast and e-learning module on this already. The key thing is look at the ECG! If the ECG suggests hyperkalaemia, get the patient treated ASAP. If the ECG is normal, review the clinical history. If hyperkalaemia is possible, and the result is unlikely to be spurious, get the potassium treated. If you are unable to do this straight away yourself, speak to a senior.
9. Stroke Thrombolysis
If you have a patient with any symptoms suggestive of a stroke that started within four hours, get the patient seen as soon as possible – they may be suitable for thrombolysis. Don’t assume their symptoms started an hour ago, we’ve still got three. Because the quicker thrombolysis is performed, the better the outcomes, and even if you’re in a thrombolysis centre, getting the patient to CT isn’t as quick as all that. Some of these patients may be missed by the ambulance service or triage so don’t assume “triage didn’t think it was a stroke, so it can’t be a stroke”. Always alert your senior.
If you’re not sure about the evidence for lytics in stroke, read the evidence, but follow your Trust guidelines.
10. End of Life
Some patients are allowed to die. Sometimes this conversation has been had with the relatives already. Sometimes it hasn’t but the relatives know what’s happening. It’s really, really important that we recognise these patients early, so we can appropriately manage their symptoms and expectations. If you have a patient likely to die in the next four hours, spending two of those hours struggling to get IVs for their fluids isn’t going to help. Speak to your patient, the family and your senior. Don’t wait until the patient arrests to make decisions.
This is such an important topic, we’ve had another blog on it!
COTE Bangor (@COTEBangor) May 13, 2017
We hope that’s a useful overview to some of the top 10 emergency presentations. Manage these well, and the majority of your work is done! We’re not saying nothing else is important but get these right, and you may save lives.