A Manual for New Staff by Dr. LA Mckinney

© L.A. McKinney 1995

ACCIDENT & EMERGENCYMEDICINE

A Manual for New Staff by Dr. LA McKinney

Accident & Emergency Department Aitnagelvin Area Hospital

Dear

On behalf of the existing members of the A& E team, welcome to the A&E Department.

Most of us on arrival in A&E have felt somewhat overwhelmed by the change of pace and range of conditions found here. I feel sure that you will soon settle in and that you may actually enjoy your time here. There is a range of help available s.:> please make use of all of us who got here before you and who know What its like in! the` first week or two.

This booklet is intended to provide you with information on the normal practice in this Department to assist you in the initial settling in period. It is not exhaustive and is for general guidance only. Individual circumstances may diet,-)'e that the management. of a specific problem follows different lines, but this should hopefully no t occur regularity.

Please consult with other members of the A&E team and myself for additional help.

Good luck!

Admissions

Contact the SHO on call for the speciality to which you wish to admit. He/She may wish to examine the patient in A&E prior to admission, but patients should not be detained for long periods in the department waiting for second opinions. Patients whose GP has already arranged admission should be directed to the appropriate ward: If a ward SHO has arranged to assess a patient for a GP prior to admission, the SHO concerned should be advised of their attendance. The A&E SHO need not see these patients.

Investigations in A&E should be limited to those that are necessary for immediate patient management.

Alcohol

Blood alcohol samples taken by SHOs are not generally admissible in subsequent legal proceedings. If the RUC require samples from patients suspected of alcohol related offences these should be taken by the Police Surgeon. They require the consent of the patient and of the attending Doctor: Your consent should not be withheld unless there are sound clinical reasons (€g the delay will be prejudicial to the proper care or treatment of the patient.)

In RTAs where personal injury has occured, the RUC have established a routine of interviewing drivers early to obtain breath sample alcohol measurement. Their interview should not be allowed to interfere with medical care.

Asthma

Treatment of Asthma should follow the 1992 guidelines of the BPA, a copy of which is available for consultation in the Department. All should receive Oxygen and nebulised Salbutamol. Consider Oral or IV steroid. Check PFR and consider ?cause of attack. As estimate of attack severity can be obtained from the ratio of actual vs expected PFR. The patient may know what his usual PFR is.

Asthma Severity assesment

Asthma Admission

For Children admission should be arranged when there is:

•Failure to respond or early deterioration following bronchodilator

(Peak flow < 50% expected 10 mins after Rx),

•GP request for admission,

•Severe breathlessness or tiredness,

•or difficulty at home with Rx.

For Adults admit where there are

•Residual signs of acute severe asthma (P>1 10/min, Resp rate >25/min, PEF<50% pred. or cannot talk)

•or if life threatening featurespresent.(particularily PEF<33%)

The departmental workload is constantly being assessed in order to gauge and improve quality of patient care. Patient management is scrutinised daily by the A&E Consultant, who may identify areas of concern to you. There will be regular monthly audit meetings, which you will be expected to attend, and general audit related issues will be raised at these. To assist in the audit process please ensure that your notes are legible and that times are inserted in the appropriate places on the A&E chart.

Burns

Not covered here but important

Chest Pain

All patients with chest pain where a cardiac cause is suspected should have an ECG performed and CVS Observations recorded. For acute infarction/crescendo angina give oxygen and suitable pain relief. (Try Nitrate, Nifedipine then Opiates)

Note Suitable IV access and ECG monitoring should be performed whilst admission is arranged with the Cardiac SHO. Cardiac patients should be closely observed whilst in the A&E department and during transfer to the ward. Where myocardial infarction has been diagnosed, patients will normally be commenced on Streptokinase by syringe pump infusion in A&E prior to transfer to CCU, unless it has been contraindicated. The Cardiac SHO will advise on this in an individual patient basis.

CPR should be performed using the Resuscitation Council Guidelines. A copy of the most recent European guideline is attached to the wall in Resuscitation. The essential point is that defibrillation should not be delayed, and the patient must he oxygenated using the ABC principles of assessment.

Child Abuse

If you suspect a non-accidental injury, examine the child and arrange the child's admission with a Senior Paediatrician. Do not confront parents. If the child is removed from the department, inform Social Worker and GP immediately of your suspicions. There is a WHSSB document (Child Protection Policy & Procedures) which explains your role in the management of NAI more fully. A Copy is available for you to read and you should be familiar with it. If you wish to check whether a child is listed on the Social Services At Risk Register you may obtain this information from the Social Worker on call. Alternatively the information can be obtained from the staff of Harberton House. As this register is strictly confidential and contains extremely sensitive' information, your request for information from it is routinely recorded. It is hoped that direct access to the SOSCAREcomputer database on which this register is held will be available via an A&E Computer Terminal.

The Health Visitor can also act as a useful community liaison and may have local knowledge of the family and of previous episodes of illness or injury. Remember too that the family GP has a continuing responsibility for his patients and should be kept informed of any development as soon as possible.

Computers

There is a Computer link to the NHS Poison Information Service situated in the Nurse Triage Room. This computer also contains a program to assist in the identification of unknown tablets and there is a Word Processor that you may use (Word star 2000). The A&E record system is shortly to become Computerised and this work may commence during your term in the department. You will be involved in the computer system at a number of levels, and will be responsible for assisting with diagnostic coding of patients you have seen. 'Ordercoms' which applies to investigations arranged in other departments does not apply to A&E.

Consultant

The Consultant is responsible for overall departmental management and audit, recruitment, training and supervision and for the investigation of complaints etc. He will also liase with hospital management and attempt to assure charter targets are met,and that the department is adequately resourced. These roles involve the examination of X-Ray reports, referrals, admissions, deaths, complaints, A&E records, etc. From this analysis you may be made aware of potential areas of improvement or policy may be clarified: This process is a Quality Control, not a witch-hunt. The Consultant is available to you for advice and help on any matter including patients in whom you are uncertain about diagnosis or management.

Department

This A&E department has an annual attendance figure of approximately 38,000 new patients with approximately 8,000 reviews. Five SHOs provide 24 hour care on a full shift rota for all patients whoattend.The staff also includes one Consultant, a Senior Registrar and Staff Grade, a Nurse manager and two Sisters. The Department has a Resuscitation room, theatres, children's, private and ophthalmic examination rooms together with minor and major examination cubicles and a decontamination room. There is a bereaved relatives room beside Resus.

The X-Ray department is alongside A&E and can handle most radiology.

Disasters

Please read and become familiar with the contents of the Major Emergency Plan. This provides information on when a major alert should be called, and the roles of the various members of staff. There are copies of the Major Incident Plan in Sisters' and in Mr. McKinney's' Offices. In most circumstances the SHO would continue in his normal role, and would be assisted by additional members of medical staff. Triage would be performed by a Senior doctor, and patients and staff allocated to particular areas of the department. The principles of ATLS should be used in prioritising and in treating victims. It may become necessary in some circumstances to dispatch a 'Flying Squad' to the scene of the incident, and Medical equipment and protective clothing is available for this purpose. The disaster plan is currently being revised and this will be discussed with you during your stay in the department.

Please ensure that Sister has a copy of your contact telephone number so that you can be accessed in the event of a disaster.

Dispensing

Try to ensure that patients have an initial supply of necessary medication (particularily analgesia, antibiotics etc) as it may take some time for them to obtain prescriptions.

To dispense drugs complete the dispensary section of the A&E chart with drug, dose, frequency etc. A starter pack of these drugs can then be given to the patient before discharge. You should also complete a Request for prescription letter to the GP with details of your recommended choice.

Due to costs, lack of space and hospital policies, the choice of some drug categories for dspensing may be restricted. Permanent staff members can offer advice.

Duties

SHOs are responsible for the assessment and management of all patients attending the department. Appropriate investigations should be performed and arrangements made for the patient's continuing care. You should be familiar with the equipment necessary for the monitoring and resuscitation of patients, and the practical procedures involved.

ROTA

The arrangement of the SHO working rota is managed by Dr. Dunn. SHOs should ensure that the department is staffed at all times. It is important to reach early agreement on holidays with the rota organiser, so that the department is staffed and everyone is fairly treated.

Please ensure that your leave card is completed for signature by Mr McKinney.

Emergencies

Ask for help if you are faced with a situation where you are unhappy to proceed.

Depending the circumstances, time of day etc, consult a more senior A&E collegue (Staff Grade, SR or Consultant) or the Registrar or SHO from relevant specialty. Senior A&E Nursing staff may also be able to offer guidance.

ENT Problems

Epistaxis

If persistent will require nasal packing or cautery and patient may therefore require admission.

Inhaled FBs

If you suspect inhalation of a FB from a history of transient choking/ coughing after ingestion of nuts etc., arrange admission so that bronchoscopy can be arranged.

? # Nose

Nasal deformity is the important sign and radiology is therefore not normally indicated. ENT review for nasal deformity assessment should be when ST swelling is reducing at approx. day 4.

Septal haematoma

This would require evacuation ASAP.

Nasal FB

FBs may be difficult to remove particularly if the patient is unable to co-operate. Beads can sometimes be pushed further in by the wrong technique or instrument.

An ENT SHO is available for consultation re: ENT problems

Eyes

All patients presenting with eye injuries should have Visual Acuity recorded at each visit. The examination cubicle has an ophthalmoscope and a Slit Lamp and you will receive instruction in the use of this. Patients with painful eye conditions should be prescribed oral Analgesia, Not Local Anaesthetic drops. Where the eye may have suffered penetration by a FB X-Ray of the Orbits should be performed.

Chemical Burns of the eye should be treated by copious irrigation of the conjunctival sac until the pH becomes and remains neutral. Particulate debris (e.g.. Cement dust) should be removed. Alkaline burns can be particularily troublesome as they tend to be deeper and more extensive than others.

There is an agreed protocol for the management of Welders Flash injury. This involves the use of Voltarol drops. These patients will need to be reviewed.

An SHO in ophthalmology is available for advice about specific problems.

Fracture Referrals

Please refer significant fractures to the Fracture Clinic for review and rehabilitation, after primary treatment in the A&E department. You should specify how long the interval to the appointment should be, and ensure that the initial management has been adequate for this period.

Fractures of toe phalanges and finger terminal phalanx tuft fractures could be reviewed in A&E.8

When referring undisplaced Greenstick fractures please record this on the A&E notes, so that appointments in # Clinic can be arranged

All requests for # Clinic Appointments are vetted after X-rays are reported, and some will be cancelled being replaced with A&E Review or alternative arrangements.

PLEASE ENSURE THAT YOU HAVE MARKED THE DISPOSAL SECTION OF THE A&E CHART CLEARLY WITH YOUR REQUEST FOR A FRACTURE CLINIC APPOINTMENT (e.g. by writing # in large letters adjacent to the box)

Fractures Treatment

Where reduction is necessary, this should be done as soon as possible in A&E or following admission. Painful injuries should be treated with analgesia.

The following pages contain general guidelines for the treatment of some common fractures. However if you are in any doubt about management, you should seek advice from the A&E Consultant, SR or Staff Grade, or members of the hospital's orthopaedic team.

Ankle

Most ankle injuries require X-Ray particularly where there is tenderness over malleoli, or where the patient is over 55 yrs.

(a) Mild Strains & Sprains require only support bandaging or strapping for 10 days. Encourage stretching exercises and normal gait. Review not normally necessary. Advise: Rest Icepaks Compression & Elevation

(b) Moderate sprains: Consider discussion with Physiotherapist re: Haematoma dispersal, proprioceptive re-education etc. Strapping + crutches. Review may be necessary after 10-14 days

(c) Partial Ligamentous Rupture: SL POP with heel + Crutches; Refer to Fracture Clinic.

(d) Complete Ligamentous Rupture: Discuss with Orthopaedic SHO re: admission for repair.

(e) Fracture: If undisplaced malleolar # SL-POP Non-weight bearing, Refer # clinic 2 Wks. Malleolar tip fractures may weight bear when the POP is set. If you wish the patient to have a walking heel applied to their POP on their Day 1 POP check, please record this in the notes.

(f) Displaced Fractures: These require reduction and should be admitted for this and for elevation.

Carpal

These occur with falls onto the hand. Scaphoid fracture

Diagnose clinically by tenderness in ASB and over palmar scaphoid tubercle. An X-ray should be performed to exclude other injuries and abnormalities. Apply Scaphoid POP and arrange fracture clinic referral.

Most other carpal fractures are rare, except for avulsion of dorsal aspect (with forced wrist flexion) Treat these in neutral POP

Beware Lunnate dislocation and trans-scaphoid perilunar wrist dislocation.

Clavicle

Check neurovascular status of ipsilateral arm. A figure of 8 bandage or Clavicular brace should be applied. Fracture clinic 2 wks approx.

Elbow

(a) Supracondylar Fractures. Admit all Supracondylar fractures for Neurovascular observation.

Collar & Cuff sling +/- backslab.

Never use a completed LA-POP in these patients.

(b) Radial Head Fractures. Displaced fractures may need internal fixation. Obtain orthol_paedic advice. Undisplaced # may not be visible. You should look for a + Fat-pad sign indicating Haemarthrosis.

Treat with sling. Review # Clinic 2 weeks.

(c) Pulled Elbow. e.g. Small child pulled by arm axially (e.g. in a shop).

X-Ray often unhelpful.

Reduce by pronation \ supination of elbow flexed to 90 degrees with axial compression. Normal function should return within 5¬10 mins. No review necessary.

Finger Fracture

Check for rotational deformity which is particularily likely in fractures of proximal phalynx. Following reduction check X-Ray in splint. Splint hands with MCP Flexion and IP Extension. If reduction is unstable or not possible (eg due to interposition of soft tissues) get orthopaedic advice re? admission for internal fixation. See section on Hand Injuries.

Mallet fingers

These should be kept in extension in a mallet splint for 6 weeks with 4 weeks night splintage thereafter if successful. Instruct patient to keep splint on and dry. Refer to fracture clinic.

Finger tip Injury:

In Children treat these conservatively with Steristrips and Occlusivedressings (e.g. Flammazine). Suturing is normally not necessary.

In adults use Digital Nerve Block to ensure wound is cleaned thoroughly. Where bone is protruding this would usually require trimming to obtain soft-tissue cover.

A&E review would be appropriate. Prophylactic antibiotics are not usually necessary.

Fracture Humerus

Check radial nerve function.

Numeral neck fractures -Sling Refer # clinic Midshaft fracture- Bohlar U POP and sling.

Knee

Record mechanism of injury. Check for intact extensor mechanism (active extension), and ligamentous stability. Aspirate haemarthroses only if very tense. Treat with Robert Jones type bandage and advise NWB with Crutches. # clinic review @ 2 weeks or A&E for less serious.

Knee Fractures in which cruciate ligament avulsion occurs will require admission and possible open fixation or ligamentous repair. Consult Orthopaedic staff.

Tibial Plateau Fractures will require immobilisation in a POP Cylinder.

Very severe knee injuries may not develop joint swelling (when the capsule is ruptured), but are likely to display instability (eg of MCL or cruciates). This may occur in RTAs in which a pedestrian is struck by the bumber of a vehicle.

Lumbar Spine

For minor compression fractures (<10% Vertebral height) bed rest and analgesia at home if circumstances permit, depending on pain severity. Advise to avoid stooping and lifting for 4-6 weeks should be given. Orthopaedic Fracture Review should be arranged. More significant compression fractures should be admitted for bed rest etc.