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Online Conference Topic: Overview of Same Day Emergency Care Pathway and Common cases Encountered Date: 16 November 2024 Time: 09:00 BST Presenters: Dr Mst Hiramoti [Medical Registrar] Dr Archana Benny [Clinical Fellow] Dr Oluwatosin Ige [Clinical Fellow] Understandthestructureandfunctionof theSame Day Understand EmergencyCarePathway(SDEC)intheNHStoefficientlynavigate emergencycareprocesses. Identifycommon casesencounteredinSDECandunderstand Identify howtheyare generallyhandledwithinthis particularpathway. Learning objectives Enhancediagnosticandtreatmentplanningskillsforcommon Enhance casesencounteredinSDEC,utilisingthebestevidence-based practices. Increaseconfidenceindecision-makingandproblem-solving Increase abilitieswithinthecontextof fast-pacedSame DayEmergency Careenvironments.Definition ❑ Same DayEmergency Care (Ambulatory care/Unscheduled care) ❑ Setting in whichmedical treatment is offeredforconditionswhichare not immediately life-threateningbut could worsen ifleftuntreated. ❑ Average length ofstay- 4-6 hours ❑ Bridge between Emergency Medicine alternative to admissionas an Mostly run as an outpatient servicefrom morning to evening but may run for 24 Hours Servicescan bedifferent with on calldoctorsas from hospital to hospital many patients require an overnightstay/hospital admission Services SDEC also allows patients who otherwise would have been Providersadopt a admittedto be seen by standard approach to specialists for decidingexclusion assessment and critreferralsDEC treatment on thesame dayBenefitsofambulatory caresetting ❑ Patientare assessedand treatedthe same day,reduce unnecessaryhospital admissions. ❑ Shortstay,solowrisk of nosocomial ❑ Saves costsforNHS.CriteriaforSDEC • Patientwho 1. Are Ambulatory 2. Don’t need support for ADL 3. Don’t need any organ support such as oxygen/IV fluid 4. Primarily with medical problems • Pleasedonot relyon assessmentdoneinitially by someoneelse.Illnessesevolveovertimeand examinationfindingsmighthave changedbeforeyou seethepatientSo thinkaboutotherspecialialities problemsas well—specificallysurgicalproblems,rarely gynaecologicalproblems.SourcesofreferraltoSDEC: Following Referral from streaming 111 from ED Investigation centres likeCT Urgent GP/GP scan,USS surgeries Surgical pre- assessment clinics unit ED- for followup Setting MOSTLYCHAIRS COUCHFORASSESSMENT VERYFEW BEDSINCASEOF SERVICESPROVIDEDBY POSSIBLEADMISSION RESIDENTDOCTORS, NURSES,PAS, HCASAND SPECIALISTS- NURSE SPECIALISTSAND CONSULTANTS Chestpain Fit for SDEC Fit for A&E Pneumonia ACS MSK :(Trauma/Costochondritis) GORD Aortic dissection PE Pneumothorax Angina and MIs in Stable pts Pericarditis Acutechestsyndrome (SCA)Pneumonia Hx: Cough,productivewith colouredsputum, fever,Pleuriticchestpain Examination: Febrile, coarsecrepitations (usuallyunilateral), dullto percussion, reduce air entry NB: CURB-65- Determines planfor discharge,ward admissionor ITUadmission Ix: Bloods: high WCCand CRP. CXR:Consolidation Rx: Antibiotics: Amoxicillin,Co-Amox.If Pen-Allergic,considerDoxycycline/Clary • For atypical organisms, consider adding Clarithromycin. Destination: Home ifstable - MostSDECpatientCardiacChestpain ✓ Hx: Exertional squeezing/pressure-like chest painrelieved with rest/GTN -Stable angina. ✓ Cardiac-soundingchest painwithvery minimal exertion/at rest -Unstable angina ✓ Associated Sx includes SOB, Palpitation, nausea/vomiting, profuse sweating ✓ Ix: ECG + Troponin ✓ ECG doneat triage andusually givento a doctor to review immediately ✓ Ifnormal or with ischaemic changes, Give aspirin andsend BloodsforTroponin ✓ OLDECGs -Always check ifavailableCardiacChestpain • Other investigations - D-Dimer, CRP,FBC, U&Es, Lipase (epigastric pain), LFT,Lipid profile, CXR,CBG • Raised Trop: STEMI or NSTEMI action for PCI at the nearest Cath-lab - Could be local or another hospital (Blue light). Notify cardiologist immediately • If NSTEMI:ACS Protocol, Cardiology review ASAPynamic ECGchanges: Serial ECGs-Cathlab • Ongoing pain: ISDN infusion +/- Angio ASAPPulmonaryEmbolism Hx:Breathlessness,pleuriticchest pain,haemoptysis PERiskfactors:Long haulflight, unilateralcalf swelling/pain,hormonaltherapy,recent surgeries,immobilization,personal/FHxofDVT orPE,thrombophilia,Trangengeronoestrogenor testosterone,historyofcancer especiallyonactivetreatment,pregnancy Exam:Tachycardia, evidenceofDVT, tarchypnoea, lowBP-thinkmassive/bilateralPE (thrombolysis+ITU) ECG: Sinustachy (mostcommonECG finding);S1Q3T3(mostspecific,butinjust a fewpatients) • WELLSCORE: To assessthe riskof PEor DVT. • Ix: D-Dimer:Raisedin PEand DVT • CTPA goldstandard • VQ ScanIf contrastallergyor inpregnancy (butexplainthe riskof breastcain motherif CTPA,andriskof childhoodcancer- if VQ scan) Pulmonary • Treatment:Anticoagulation- DOAC now Embolism recommendedin most patients.Exceptin kidneydysfunction(use heparininfusion),Pte withmechanicalheartvalves.Weight>120kg, LMWHis preferred. • ForprovokedPE(known RF pptingfactor) - anticoagulation for3months • Forunprovoked PE(no known RF ppting factor) -Anticoagulation for6months Pulmonary • Anticoagulation followup Embolism • RepeatPE orPEwithpreviousDVT orPEin Pt onprophylaxis anticoagulation, consider haematology opinion -might suggestLMWHor Warfarin as the case may bePericarditis • History of viral-like illness, followed by pleuritic chest pain, worse on lying down and relieved by sitting up • Pericardial rub on examination • Ix: Raised inflammatory markers; troponin might be raised is there is associated epicardial damage or involvement of myocardium • ECG:saddle shaped ST elevation • Rx:NSAICD +/- Colchicine • Cardiology review; may suggest OP Echo • Hx: Lifting ofheavyobject,recent unaccustomedexerciseinvolvingupperbody; • Pleuriticchestpain worsewithpalpation and/or bodymovement Musculoskeletal palpationor passivebodymovement;other chestpain systemicexamination normal • Ix:ECGnormaland bloodsare normal • Rx: Optimalpain killersPneumothorax • Hx: Sudden-onsetpleuriticchest pain in a tallthin patient; +/- trauma, BGofCOPD • Exam: unequalair entryand expansion;hyperresonanceto percussion • Ix:Pleuralseparated fromribson CXR;otherIx oftennormal • Rx: Oxygentherapy,needle aspiration, chestdrain • Hx: Sudden-onset tearing pain between the scapulae, SOB,limb weakness • Exam: Low BP or very high BP, difference in brachial pulse and BP Aortic Echo or CTened midiastinum on CXR, Aortic dilatation on dissection • CT aortogram- gold standard emergencye A: affects ascending aorta; cardiothoracic • Type B: affects descending aorta; conservative Rxwith strict BP control • Hx: Sudden-onset tearing pain between the scapulae, SOB, limb weakness • Exam: Low BP or very high BP, difference in brachial pulse and BP Aortic • Ix: Widened midiastinum on CXR, Aortic dilatation on Echo or CT • CT aortogram- gold standard dissection • Rx: Type A: affects ascending aorta; cardiothoracic emergency conservative Rx with strict BP control 1touch patient’s chest to see any tenderness. Tipsand tricksduring 2pleuritic or cardiac sound pain evaluationof 3can be cardiac pain as wellst pain chestpain specifically women, diabetes pt, elderly people can present with epigastric pain. systemic causesg swelling – think • kidney/liver/heart failure Leg • manage accordingly and involve the specialty responsible swelling +/-pain redness + warmthg swelling + pain + • Cellulitis • DVT• DVT • Usually presents withcalf pain • ClinicalExamination • Measure mid-calfcircumferenceusing a tapemeasure • Assess risk using WELL’s scorefor DVT • Ix : D-Dimer- if raised- Dopplerultrasound of deep leg veinsTreatment– Anticoagulation– DOAC (Apixaban)/ LMWH(Tinzaparin) Duration- dependingonifit is provoked orunprovoked. DonotforgetanticoagulationreferralCELLULITIS Unilateral leg swelling + pain + redness + warmth Mostly unilateral but can be bilateral; may have fever Assessment: Measure mid-calf circumference; mark the area affected with a skin marker to check if spreading Raised inflammatory markers i.e. CRP Antibiotics: 1 line FlucloxacillinTips and tricks for any leg pain: Please think aboutanyarterial Patient can gohome with IV insufficiencywhich is purely abx ifneeded with hospital at vascularsurgery problem—so home service or SDEC askaboutintermittent service. So no need admission claudication alwaysfor patients who are requiring IV AbxAbnormalbloods • LowHB • Hypo-&Hypercalcaemia, • Hyponataemia, • Hypo-&hyperkaleamiaHyponatremiacommon causes Euvolemic - SIADH, Hypothyroidism,ACTH deficiency,Primary polydipsia Hypervolemic - CHF, Cirrhosis, NephroticSyndrome Hypovolemic- Vomiting, Diarrhoea, Dehydration, DiureticsLowHb • Hx:Bloodloss: Menorrhagia, GI bleed (darkstool),ask for bleeding from other body sites • Dietery(iron,folate orB12deficiency) • Hemolysis - sickle cell/thalassemia/hereditaryspherocytosis • Symptomatic? SOBon exertion, exercise intolerance • Ix: FBC(check MCV too), Ironstudies-Iron,ferritin,transferrin, folateand B12, consider peripheral smear Rx: Ifasymptomatic,replacethedeficientnutrient – iron/folate/B12. IfsymptomaticandHbistoo low(usually<70) considerbloodtransfussion, becarefulaboutSCD/autoimmunehaemolyticanaemia pt Transfusionthreshold : LowHb Hb – 70g/L-80g/Lin stableadults. Higherthresholdforindividulaswith activebleedingor cardiovasculardisease. Explorecauses foranemia •Gynae referral,USS Pelvisif menorrhagia •FIT test, OGD/ Colonoscopy if? UGIB •CoeliacScreen •Heamatology referralifsickle celldisease/thalassaemia/pancytopenia •CT TAP if?malignancy • Features: Bone pain, abdo pain, polyuria, polydipsia, confusion, constipation • Ix: Bone profile, PTH, Hypercalcaemia • Rx: Generous IV fluids, may need Bisphosphonates after IVF • Patient may need cancer screen as hypercalcaemia may be due to PTHrp releasedby lung cancer, or a feature of bone metastasis • NICE definesneutropenicsepsis in peoplehaving 109/L or lower andeither a fever of> 38°C oranyx symptoms and/orsigns ofsepsis • The rule is that, in any patient onanticancer treatment havingany ofthe features ofinfection, full septic workup andstart treatment within1 hour Neutropaenic ofhospitalattendance. Sepsis • Most ofthem havepre-prescribed IV antibiotics, so that they dontneedto have seen a doctor before getting treatment. Trusts give Tazocin +/-Gentamycin to Trust; SomeArrhythmia: • stable AF patient commonly referred to SDECafter T achy or incidentalfindingsinECG Brady • RelevantHistory: symptoms of arrhythmia underlyingcausestoms of • MS-mitralstenosis • IHD,Infection Most • Thyrotoxicosis common • HTN Causes of •syndrome—holiday heart AF: • IdiopathicWhatisthemainworry? complicationifdon’ttreat properly Tachycardiomyopathyand HF,StrokeECG interpretation in AF: • P wave: Represents the electrical activity in the atria, or upper heart chambers • Irregularly irregular rhythm • No P waves • Variable ventricular rate • QRS complexes: narrow <3 small squares • Fmay not be present and can be fine or may or coarse. • If you don’t want to remember all above findings then just remember rhythm and whether you can see P wave • Ix: Mx of AF • and electrolytes, TFTsy inflammatory markers • 24h tape: persistent/paroxysmal and in a stable whether patient symptomatic with that. • Echo: Heart valve problem patient: • CT coronary angiogram: IHDTreatment: • 1st line: Bisoprolol2.5mg thenif HR >70 can increase to 5mg • DigoxinifHF • 2ndline: Amiodarone/fleicanide • Anti-coagulation based on CHA₂DS₂-VASc score • Eventually all newlydiagnosed patient need Cardiologyinputwith the aboveresults in view oftreat underlyingconditionsand preventcomplications • Usually AFrelated all tachycardiomyopathy/heart failure patient needeither elective cardioversion or Ablasion irrespective ofageHeadache • Seeing the headache patient can be a real headache for you, one of the puzzles areas everywhere either in SDEC/ED as it relates with life threatening conditions which can lead to a life-threatening condition if do not diagnose and treat properly. Timeof onset: Location: unilateral/bilateral/occipital/temporal Progression:when wasthe peaktimeforpain oncestarted—fewminutes/anhour How to evaluate? Severity: Relievingfactors—darkroom/silent Exacerbatingfactors—light/noise Associatedsymptoms—neckstiffness/any neurologicalsymptoms- speech/vison/weakness/confusion/seizure Migraine Tension headache SAH Differential HTN diagnosis Meningi-encephalitis Idiopathic intracranial HTN for SDEC: Cerebral venous thrombosis if pregnant/on OCP GCA Viral infection: now headacheInvestigation • Depends on your differential diagnosis • If SAH/hemiplegia migraine: CT head • For SAH: ideally within 6h, maximum within 24h as Clot is seen in the subarachnoid space in 92 percent of cases if the scan is performed within 24 hours of the bleed. • LP after 12h from the onset of pain • Migraine treatment: combination of following medications: 1.Simple analgesia-combination of paracetamol and high dose NSAIDs (Aspirin 900mg/Ibuprofen 800mg/naproxen 500mg/ diclofenac 50mg) 2.Anti-emetic: metochlopromide/ prochlorperazine/domperidobe) Treatments 3.Triptan: rapid acting sumatriptan/zolmitriptan 4.Consider preventive medication (they occur frequently (more than once a week on average) or are prolonged and severe despite optimal acute treatment.): 1st line: propranolol/atenolol, 2nd line: amitryptuline/ topiramate/Na valproateTips and tricks if any headache • See at a glance before patient noticed that you are seeing them to see any obvious distress • Don’t forget to ask exacerbating or relieving factors and time of onset • if hemiplegic migraine please refer to neurologist • really worried then give telephone consultation next day to evaluate symptoms • Still concern/ now you are feeling headache headache your senior and give them SDECis anemergencysamedayservice—-priorityto sendhomesafely.If not safethenneedadmission. If foradmissionthenthink really needadmission:?IV Abx/IVfluid/oxygen/unwellneedclosemonitoring If discharge thenwhat youcan do orspecialistcan doto makeasafedischargeplan. Conclusion Eventually Allpatientsneed—- Safedischargeplan Safetynet advice Specialistreferral/telephoneconsultationappointment inSDECif relevantto avoidbringthembackReference https://www.england.nhs.uk/urgent-emergency-care/same-day- emergency-care/ Oxfor Handbook of Clinical Foundation 5ed.