GREY BOOK Medical Emergency Protocols

August 2013 – 22nd Edition

ACS - STEMI 1

ACS – Unstable Angina and NSTEMI 2

AKI 3

Arrhythmias 4

Asthma 10

Blood Products 11

Cardiac Pacing 12

Community Acquired Pneumonia 13

Delirium 14

DKA 16

Drug Overdoses - Generic 17

Drug Overdose - Paracetamol 18

Heart Failure – Acute 21

HONK - Hyperosmolar Hyperglycaemic State 22

Hyperkalaemia 23

Massive Blood Loss 24

Needle Stick (HIV) 26

Neutropenic Sepsis 27

Non Invasive Ventilation (CPAP and BIPAP) 28

Pancreatitis – Acute 30

PE 31

Perioperative Anticoagulant Protocol 32

SAH 34

Spontaneuous Pneumothorax 35

Status Epilepticus 36

Stroke/CVA 37

TIA 38

Upper GI Bleed 39

i

ii

The aim of these notes is to advise junior staff on how to deal with some common medical

emergencies and problems of medical management

Please send any comments, reviews and/or suggestions to:

Gail Isted – Clinical Guidelines Co-ordinator

Or

Simon Higgs – CESU Manager

The review and circulation of this document is managed by: The Clinical Guidelines Team 2nd Floor Stillman House St Richard’s Hospital Chichester 01243 831419 ext 1419

Last updated: 07/12

1

Start Basic treatment in A&E prior to transfer  

Aspirin 300mg PO*  

Prasugrel 60mg PO**  

Heparin 5000 units IV*  

GTN T‐TT (400‐800micrograms) SL***  

Diamorphine 2.5mg‐5mg or Morphine 1‐10mg IV  

Oxygen ONLY if SATS< 94% or heart failure (initially 2 ‐4 L/min)  

Consider:  Beta blocker, Anxiolytic, Antiemetic (Metoclopramide 10mg IV)  

*Avoid in active bleeding/allergy. ** Avoid Prasugrel if history of Intracranial Haemorrhage 

If able, IV cannula left arm / hand, thereby leaving right for pPCI access. *** Give GTN BEFORE Opiate 

BLUE LIGHT AMBULANCE TRANSFER for emergency PCI 

Ensure patient fully undressed in a hospital gown, and take direct to Cath Lab. Notes including administered drugs & ECGs to be taken 

directly to cath lab, or fax to CCU in QA on 6243. 

For QAH Portsmouth Fast dial #5123 from SRH 

 In hours: (Mon‐Fri, 0830‐1730) contact cath lab cardiologist on:    

Ext 4648 (cath lab 1)               Or via coordinator bleep 1125 

 Out of hours: contact cath lab cardiologist (not general cardiologist) via QA switchboard.

REFER to cardiology at QAH Portsmouth 

by senior ED clinician (middle grade or above) for emergency PCI 

Initial ECG within 10 minutes of arrival 

 Persistent ST Elevation 

 New (presumed) LBBB 

ST depression V1/V2  –consider posterior STEMI ( Check V7, V8, V9) 

If YES to any one of above  NO ‐ NSTEMI /Unstable Angina guidelines

Patient presenting within 12 hours of onset of cardiac chest pain 

EARLY MANAGEMENT OF STEMI

2

3

AKI

Under construction

Please see senior, or see national guidance

4

ARRHYTHMIAS

Bradyarrhythmia The most important factor influencing treatment is the presence or absence of symptoms. See algorithm on next page. a) Sinus Bradycardia. Asymptomatic - no treatment. Symptomatic - give atropine 500 micrograms IV (recurrent dosage to 3mg may be attempted). If the bradycardia is persistent or recurrent, temporary cardiac pacing should be undertaken. The underlying cause should be determined and treated and any responsible medications stopped. b) Atrioventricular Block. First and second degree AV block found incidentally do not usually require emergency treatment - may require further investigation. Mobitz typeII and Complete Heart Block if symptomatic will require temporary pacing until the underlying cause is determined and/or permanent pacemaker implanted. Treatment such as isoprenaline infusion or external pacing may be required. Patients presenting with asymptomatic persistent complete AV block will require permanent pacing as a planned procedure.

BRADYCARDIA ALGORITHM

(includes rates inappropriately slow for haemodynamic state)

Adverse signs? • Systolic BP < 90 mmHg • Heart rate < 40 beats min-1

• Ventricular arrhythmias compromising BP • Heart failure

Atropine 500

micrograms

Satisfactory Response?

Risk of asystole? • Recent asystole • Möbitz II AV block • Complete heart block with broad QRS • Ventricular pause > 3s

Interim measures: • atropine 500 micrograms IV repeat to maximum of 3 mg • adrenaline 2-10 micrograms min-1 • Alternative drugs OR • Transcutaneous pacing

Seek expert help Arrange transvenous

pacing

Yes

s

No

Ye

Observe

YesoN

5

Bradyarrhythmias 1st Degree Heart block 2nd Degree heart block – Mobitz type I - Wenckebach 2nd Degree Heart block – Mobitz type II – 2:1 3rd Degree / complete heart block

6

7

TACHYARRHYTHMIA The presence or absence of adverse signs will determine treatment pathway. See algorithm on next page. a) Supraventricular Tachycardia. The commonest types are:

a. atrial fibrillation b. atrial flutter and atrial tachycardia c. junctional tachycardia.

Diagnosis: from 12 lead ECG. May be acute paroxysmal or chronic tachycardia. Treatment: Acute AF – IV amiodarone 300mg through large arm vein, may use Betablocker or

diltiazem if patient not compromised to control ventricular rate. Do not use IV adenosine in AF or atrial flutter if known (See AF Guideline)

Acute SVT – Use of vagal manoeuvres / carotic sinus massage Adenosine (6-12mg IV) -- Avoid adenosine in Asthma Adenosine may cardiovert those with accessory pathway such as in Wolff Parkinson White

syndrome Beta blocker (e.g. atenolol, metoprolol) Flecainide - in patients with structurally normal hearts and no coronary or conduction disease. Drug treatment is not appropriate if patient is markedly hypotensive (BP less than 90mmHg) or

poor perfusion. In these circumstances DC cardioversion (under sedation) is treatment of choice.

Chronic AF (to control ventricular rate - use beta blocker, calcium-channel blocker, digoxin). SVT prevention sotolol 40-80mg twice daily. In resistant cases use amiodarone (Avoid flecainide in ischaemic heart disease). b) Ventricular Tachycardia. This is a common arrhythmia in ischaemia or acute myocardial infarction. It may present with few or no symptoms (haemodynamically stable tachycardia) or lead to profound collapse or arrest (haemodynamically unstable tachycardia). Do not be misled into thinking that stability excludes a diagnosis of VT! Features of VT:

a. >3 ventricular complexes @ rate 150, or >5 @rate 120, Broad QRS complexes (more than 0.14 seconds)

b. Indeterminate axis (or extreme left/right axis deviation) c. AV dissociation with capture and/or fusion beats.

Treatment: Determine that patient has a pulse present – if not proceed to immediate CPR and defibrillation. If pulse present assess for adverse signs (as in algorithm). If adverse signs present and patient peri-arrest proceed immediately to DC cardioversion. Stable patient treatment - amiodarone 300mg IV bolus via antecubital vein or centrally over 30 minutes – 1 hour. Continue central or oral loading. Ensure normokalaemia between 4-5mmol/l Alternative drug treatment: procainamide. Polymorphic VT- in patients with long QT on normal ECG, may require temporary pacing and/ or isoprenaline infusion – discuss with cardiologist urgently. Further cardiological assessment is mandatory in all cases of VT not associated with acute ischaemia or infarction.

8

Tachycardia Algorithm (with pulse)

• Support ABCs: give oxygen; cannulate a vein • Monitor ECG, BP, SpO2 • Record 12-lead if possible, if not record rhythm strip

• Identify and treat reversible causes (e.g. electrolyte abnormalities)

Seek expert

Synchronised DC Shock* Up to 3 attempts

Seek expert

Normal sinus rhythm

Probable re-entry PSVT: • Record 12-lead ECG in sinus rhythm • If recurs, give adenosine again & consider choice of anti-arrhythmic prophylaxis

If Ventricular Tachycardia (or uncertain rhythm): • amiodarone 300 mg IV over 20-60 minutes; then 900 mg over 24 hours

If previously confirmed SVT with bundle branch block: • Give adenosine as for regular narrow complex tachycardia

• amiodarone 300 mg IV over 10-20 min and repeat shock; followed by: • amiodarone 900 mg over 24 hours

Is patient stable? Signs of instability include: 1. Reduced conscious level 2. Chest pain 3. Systolic BP < 90 mmHg 4. Heart failure (Rate related symptoms uncommon at less than 150 beats min-1)

Is QRS narrow (< 0.12 sec)?

Broad Narrow

Narrow QRS Is rhythm regular?

Regular

Irregular

Broad QRS Is QRS regular?

• Use vagal manoeuvres • adenosine 6 mg rapid IV bolus;

if unsuccessful give 12 mg; if unsuccessful give further 12 mg.

• Monitor ECG continuously

Irregular Narrow Complex Tachycardia Probable atrial fibrillation Control rate with: • -Blocker IV or digoxin IV If onset < 48 hours consider: • amiodarone 300 mg IV 20-60 minutes; then 900 mg over 24 hours

Irregular Regular

Possibilities include: • AF with bundle branch block

treat as for narrow complex • Pre-excited AF

consider amiodarone • Polymorphic VT (e.g. torsade de pointes - give magnesium 2 g over 10 minutes)

Yes No

Possible atrial flutter • Control rate • (e.g. -Blocker)

*Attempted electrical cardioversion is always undertaken under sedation or general anaesthesia

Stable

Unstable

Tachyarrhythmias Atrial Flutter 2:1 conduction Atrial Fibrillation Supra ventricular tachycardia Ventricular tachycardia Polymorphic /torsades VT Ventricular fibrillation Authors: Drs Wong, Murphy, Reid & Tanner Last updated 07/12

9

10

ASTHMA

Under construction

Please see senior, or see national guidance BTS

11

BLOOD PRODUCTS

TRANSFUSION TESTS Group and Save (G&S) – The identification of the patient’s blood group, Rh D status and the presence (if any) of red cell antibodies. The sample is usually retained for 7 days. A group and save sample can be converted to a crossmatch sample on request. Crossmatch – The issue of compatible red cells. Red cells are usually issued more quickly by electronic crossmatching. The laboratory may request further samples for crossmatching if required. Kleihauer – Will determine the extent of foeto-maternal haemorrhage. Direct Antiglobulin Test (DAT) / Coombs test – Detection red cell antibodies and/or complement that are bound to the surface of red blood cells. This is used to determine evidence of, for example, autoimmune haemolytic anaemia or a haemolytic transfusion reaction. TRANSFUSION REQUESTS The following blood components and products are requested from the Blood Transfusion Laboratory:

Blood component Special

requirements?

Consultant Haematologist to approve request?

Red cells Irradiated / CMV neg No

Platelets (1 unit = 1 adult dose) Irradiated / CMV neg Yes

Fresh-frozen plasma (10-15ml/kg) N/A Yes

Cryoprecipitate (2 units = 1 adult dose) N/A Yes

Blood product Special

requirements?

Consultant Haematologist to approve request?

Anti-D immunoglobulin N/A No

Human Albumin Solution (HAS) N/A No

Prothrombin Complex Concentrate (PCC) N/A Yes

Coagulation factors e.g. FVIIa, FVIII, FIX N/A Yes

Author: Dr P Bevan, Ruth O’Donnell Reviewed: 07/13 Next Review: 07/14

12

CARDIAC PACING (SRH)

Temporary Pacing Temporary cardiac pacing is performed in the ‘pacing room’ on CCU. The x-ray screening can be performed by one of the medical team providing one member of the team has completed a ‘Radiation Core of Knowledge’ course. Otherwise a radiographer must be present. Use full aseptic precautions for temporary wire insertion. All patients should have an x-ray following the procedure. Check temporary wire threshold daily. If sepsis develops check blood cultures, remove infected system and insert new temporary wire if still required. Permanent pacemaker implantation and follow-up Please inform the Cardiac team and Cardiac Department as soon as possible, about patients for permanent pacing who are on the wards. This enables us to plan the number of outpatients to bring in. Pre-pacemaker check 1) Patient consented. 2) Green venflon (18g cannula) in contralateral arm. 3) 1g IV flucloxacillin premedication. (if penicillin allergic use teicoplanin 400mg) 4) Shaved and cleaned skin over implant area. Post pacemaker check 1) Wound (if haematoma develops check if anticoagulants may be responsible and apply firm pressure dressing). 2) Temperature. 3) Chest X-ray. 4) Pacemaker function check – next day. 5) Review medications (these may require altering). If a patient has a suspected pacing fault, please contact Cardiac Department and we will arrange to see them as soon as possible. Authors: Drs Wong, Murphy, Reid & Tanner Last updated 06/12

A Mistry updated 2013 ks

13

Department of Respiratory Medicine

PRACTICAL GUIDELINES FOR THE INITIAL MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA

(This protocol is not designed for patients with exacerbations of COPD or bronchiectasis,

empyema, lung abscess, hospital acquired pneumonia or the immunocompromised)

Clinical features and radiological confirmation of pneumonia

Assess severity

Respiratory Consultants (ADAMS< CONGLETON< STEELE) Reviewed: 07/13

CURB 65 0 - 1 and ≤ 1 additional feature

Mild pneumonia Up to 3% risk of death

Severe pneumonia Risk of Death 15-40%

Could the patient be managed in the community?

CURB 65 2 and no additional features of severity

Moderate Pneumonia Risk of death 9%

Additional featuresTemperature <35°C or >38°C WCC >20 or <4 CRP >50 Multilobar/bilateral pneumonia PaO2 < 8kPA or saturations <92% Age over 50 years Co-morbidity:. IHD, CVA, CCF, CRF

CURB 65 Confusion: new (AMT ≤ 8 or worsening of previous) Urea > 7 mmol/l Respiratory Rate > 30 BP: SBP < 90 and/or DPB ≤ 60 Age ≥ 65

CURB 65 3 – 5 (or 2 + additional features)

May need admission if patient vulnerable or poor social circumstances.

1. Assess oxygenation (ABG, pulse oximetry) and manage appropriately.

2. Give intravenous antibiotics IMMEDIATELY.

3. Send blood and sputum for culture. 4. Intravenous fluids if indicated.

ADMIT

Blood + Sputum cultures if no prior antibiotics

5. Consider urinary legionella and other microbiological investigations

6. Consider involvement of HDU or ITU for imminent transfer to the unit or in case of deterioration later (see below).

Benzylpenicillin 1.2g qds i.v and doxycycline 200mg bd (48 hours) then reduce to od (2nd line levofoxacin 500mg od iv AND teicoplanin 400mg bd 3 doses then od i.v.**)

Amoxicillin 500mg tds po

(2nd line Doxycycline 200mg day 1 then 100mg od or clarithromycin 500mg bd po )

Amoxicillin 1g tds and clarithromycin 500 mg bd po (2nd line doxycycline 200mg od oral or levofloxacin 500mg od oral/ iv)

PRESSURE INJURY.

Considerations for HDU/ITU 1. CURB 65 score at least 2 2. Signs of hypoperfusion (SBP<90, oligouria, confusion)

and not responding to therapy 3. Respiratory failure (PaO2<8kPa; PaCO2 ≥ 6kPa) 4. Significant acidosis (pH ≤7.25, base excess <-8)

5. Progressive exhaustion and depressed consciousness

14

PATIENT WITH ACUTE CONFUSION THINK DELIRIUM

HISTORY and PHYSICAL

EXAM

Assessment Identify functional and cognitive baseline

(AMTS/ MMSE)

NB CAM will diagnose delirium Neurological exam Temperature

Sensory impairment Recent medication change Constipation(consider pr) Hallucinations

Level of consciousness Hydration Status Oxygen saturations Infective source

Alcohol/substance

Withdrawal

Nutritional status PAIN

Diagnosis Confirmed Hyperactive 15% Mixed 52% Hypoactive 19%

Investigations: All Patients

FBC/CRP/ESR/U and E

LFT/Ca 2+/Na+ BM ECG Urinalysis TFT

Also consider Blood cultures Haematinics ABG Senior Clinician review: CT Brain LP EEG

Treatment Pathway (overleaf)

Causes Include:

2. Inattention

3. Disorganised thinking (illogical/rambling)

4. Altered consciousness (alert/drowsy/hyper alert)

CAM (If Yes to 1 and 2 and either 3 or 4 then

POSITIVE

1. Acute onset and fluctuating course

(Alone or more likely in combination) Drugs/Polypharmacy Primary neurological

eg stroke seizure Cardiovascular

disease Electrolyte disturbance Metabolic disturbance Immobility Pain Constipation Hypo/hyperglycaemia Hypoxia/hypercapnia Environment Catheterisation

15

If symptoms persist and complex actions required consider:

Is Deprivation of Liberty safeguards application required?

Referral to Older persons Mental Health Team

If known to have a dementia - Dementia Nurse review

Link Geriatrician assessment. Knowing Me Document in place

Author: Dr Katrine Hedges Reviewed: 11/13 Review due: 11/14

TREATMENT

Identify and address precipitating and

predisposing factors

Drugs – Review and withdraw, consider and treat accordingly substance misuse ETOH/Smoking

Premorbid Cognitive Status

Functional status/sensory impairment

Fluid Status Co-existing medical

issues

Interventions in acute episode Consider mental capacity and best interest

Documentation

1st Line Non-pharmacological

Reassuring and calm manner Continuity of care/staff changes to minimum Orientation to environment Reiterate information Use of distractive measures i.e. Music. Consider impact of environment i.e. over or

under stimulating. Adequate Lighting DO NOT USE Bedrails Specific interventions that have been helpful

record in care plans. Pharmacological

ONLY USE IN SEVERE CASES ONLY USE IF Person is at risk to self and /or

others

Treat underlying medical problems

Review Drugs Hydration Sepsis Electrolyte

imbalance Constipation Urinary

retention.

Supportive care Staff

Safety Risk to others Delirium Care plan. Review of:

Sensory aids Pain Bowels Bladder – AVOID

CATHETERS Family/Education

Delirium Leaflet Advice re: visits (spaced apart if

able) Carers passport if appropriate

Keep drug use to the minimum Start slow and titrate carefully Withdraw slowly Review every 24hrs and stop if it resolves Oral administration preferable to I/M/I/V Monitor appropriately and closely if given

1st Line – Oral Haloperidol 0.5mg – 1mg up to 2hrly (Max 5mg/24 hrs.) Peak effect 4 – 6 hrs.Review then and at least evry 24hrs thereafter. Review and consider olanzapine only after senior review. 2nd Line Oral Lorazepam 0.5mg – 1mg Every 2hrs (Max 2mg/24 hrs.)Review at 2hrs at every 24hours thereafter. (Benzodiazepines 1st line for patients with Parkinson’s, Lewy Body dementia, seizures or treatment of alcohol/sedative withdrawal or amphetamine/cocaine intoxication.) 3rd Line – severe delirium consider IM haloperidol/ orodispersable lorazepam

 

Diabetic Ketoacidosis in Adults 

This is an acute life threatening condition characterised by raised blood glucose, metabolic acidosis and elevated ketone levels. This checklist outlines the immediate management of such patients. 

1. Airway, Breathing, Circulation 

 

Investigations:    Do not delay treatment Venous Blood Gas FBC, U&E, LFT, CRP, Lab Glucose Blood/Urine Cultures, Blood Ketones, CXR, ECG 2. Fluid Resuscitation 

 

 

 

 

 

 

 

 

 

 

 

If Systolic BP >90 1L 0.9% Saline     Over 1 hour 1L0.9% Saline & KCl*    Over next 2 hours 1L0.9% Saline & KCl*    Over next 2 hours 1L0.9% Saline & KCl*    Over next 4 hours 1L0.9% Saline & KCl*    Over next 6 hours

If Systolic BP <90  

Give 500ml 0.9% saline stat, if still below 90, give further 500ml stat and request senior r/v 

*Potassium replacement K >5.5    None Added K 3.5 – 5.5  40mmol KCl K <3.5    40mmol KCl & senior r/v Severe hyperkalaemia may require treatment (see guidelines) 

Glucose  

Once Glucose <14mmol/L Add 1L 10% dextrose over 8 hours (Aim to maintain BM > 8mmol/L) 

Caution Fluid replacement may need to be more cautious in the elderly, pregnant, heart failure, renal failure and young, thin adults. If in doubt, seek senior r/v. 

3. Insulin treatment   ‐  After fluid resuscitation has begun 

 

 

 Continue patient’s long acting insulin (e.g. Lantus/Levemir) 

Fixed Rate Insulin infusion   0.1 units/kg/hour (Initial maximum 6 Units/Hour)

4. Review     

 

 

 

 

 

 

Venous Blood Gas @ 1 hour then 2 hourly until resolution/clear trend of improvement and @ 12 hours Hourly Capillary Blood Glucose

Overly Rapid resolution of Glucose/hypoglycaemia should trigger reduced insulin infusion rate  Resolution = pH> 7.30  ‐ Convert to s/c insulin regime           (Pt must be ready to eat. Involve the Diabetic team) 

HDU r/v for worsening MEW Score, or failure to respond to treatment 

If not Increase insulin infusion by 1Unit/hour  

             Glucose decreased by 3mmol/L/hour                            HCO3 Increased by >3mmol/L/hour Targets              Ketones decreased by 0.5mmol/L/Hr

16

5. Referral 

 

DKA Checklist:       tick 

1. ABC        □ 2. Fluids & Potassium                         □ 3. Insulin (fixed rate infusion)  □ 4. Review        □ 5. Referral     □

Refer to Diabetic Team for r/v within 24 hours of admission.

 

 Full national guidelines AUTHORS: Drs Bosman, Laji and Weiss Reviewed: 06/13 Next Review: 06/14

 

Overdose – common principles and initial acute management (SRH) 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BREATHING ‐ If low & an opiate OD is suspected naloxone should be given. (0.4 ‐ 1.2 mg IV stat and repeat twice if ineffective) & call for urgent senior help. ABG to assess hypoxia & acidosis. 

CIRCULATION ‐   IV access & bloods (FBC, U&Es, LFTs, INR, paracetamol & salicylate levels).    Cardiac monitoring & ECG in all overdoses IV fluids as support in initial management

Overdose history What have they taken?  How much have they taken? When?  Was it staggered?  Have they taken paracetamol? (Always ask) Alcohol intake (chronic or acute)

AMPLE history:  Allergies Medications Past Medical History  Last Ate & Drank Events leading up to  

GET TOXBASE INFORMATION & MANAGEMENT FOR THE OVERDOSED DRUG OR DRUGS  

Toxbase (The National Poisons Information Service (NPIS)) www.toxbase.org 

DISABILITY – Temperature, BM, GCS & pupillary response (consider recovery position). IF CONCERNED AND HAVEN’T ALREADY DONE SO, GET URGENT SENIOR HELP

Substances not bound to charcoal: Boric acid; Cyanide; Ethanol; Ethylene glycol; Iron; Lithium; Malathion; Methanol; Petroleum distillates; Strong acids & alkalis

Usual Paediatric Dose 1g/kg – liaise with paediatric team

Usual Adult Dose: 50g; patient should be able to drink it. If not, or if vomiting is a problem, consider NG tube administration +/‐ anti‐emetic. Ensure there is no aspiration risk 

Single toxic doses taken within 1 hour, in an alert patient consider charcoal 

Toxbase also has a backup site: www.toxbasebackup.org The username & password is available in A&E. 

 An alternative source of information is NPIS Telephone Helpline #5108 (0844 892 0111) 

 Search for the each drug separately (can use trade names if needed: e.g. panadol) Use  the  printable  versions  as  your  guide  for  the  specific  management  of  each  overdose.  It  is useful  to  tick off  the printed  list when  tasks have been achieved & keep  this  record with  the medical notes, with patient’s name and hospital number written on top.  Consider mixed  overdoses, many  drugs  potentiate  each  other  and will  require  longer  periods of monitoring and observation, please discuss with your senior

Adults who  are unwell or  require  specific  treatments  (N‐acetylcystine, naloxone  infusions  etc.) or have ingested cardioactive drugs should be referred to the on call medical team.  Adults who are well, with a GCS 15 & who only require observation should be admitted to the 

Patients may be referred to the psychiatrists once their medical treatment is complete. 

A&E Ward under the care of the A&E Team. All children who have taken an overdose, under the age of 16 and those 16‐18 in full time education should be referred to the paediatric on call. 

AIRWAY – Consider senior departmental & anaesthetists support (SHO: bleep 007) early if concerned about the safety of the airway or respiratory effort. 

Reviewed: 07/13                                                                                                               Next Review: 07/14

17

Paracetamol Overdose in Adults, WSHT Guidelines  In overdose paracetamol  can be  fatal. N‐acetylcysteine  (NAC, Parvolex) has proven benefit  as  the ‘antidote’. If untreated, Liver damage is maximal 3‐4 days after ingestion and can develop into acute liver failure syndrome (hypoglycaemia, coagulopathy, haemorrhage,  jaundice, renal failure, cerebral oedema, encephalopathy) & death. 

Initial ABCDE assessment of the patient

Is it a staggered overdose or unknown time of ingestion or a late presentation (>8 hours)?

If time of overdose is known and within 4‐8 hour window take a post overdose paracetamol level (& INR, Lactate, FBC, U&E, LFT). 

Take bloods: Paracetamol levels, INR, Lactate, FBC, U&Es, LFTS and Start N‐acetylcysteine treatment immediately 

Additional Notes: 1) Some patients may develop hypoglycaemia several hours after Paracetamol – be aware of this  2) Be aware of coexistent poly pharmacy overdose. All patients should be tested for Salicylate levels and questioned about other drug consumption  3) For patients weighing > 110 kg the antidote dose in mg/kg should be calculated using a maximum of 110 kg, rather than actual weight  4) Pregnancy: NAC dose should be calculated using the patient’s actual pregnant weight  5) Beware renal failure may occur either in isolation or as part of the acute liver failure spectrum – this should be managed with a standard AKI approach 

Plot paracetamol level against treatment line (see next page for nomogram) 

Is the paracetamol level plotted above the treatment line, therefore in the toxic range? 

Psych review needed before discharge.  If in doubt, speak to a senior about further management. n.b Be aware of concealed overdose. Even if below treatment line if any disturbance to LFT/INR may need to consider empirical treatment. 

100 mg/kg over the next 16 hours (max dose 11g) Bag 4 (1000ml 5% Dextrose): IV N‐acetylcysteine (PARVOLEX) 

50 mg/kg over the next 4 hours (max dose 5.5g) Bag 3 (1000ml 5% Dextrose): IV N‐acetylcysteine (PARVOLEX) 100 mg/kg over the next 16 hours (max dose 11g) 

Bag 1 (200ml 5% Dextrose): IV N‐acetylcysteine (PARVOLEX) 150 mg/kg over 1 hour (max dose 16.5g) Bag 2 (500ml 5% Dextrose):IV N‐acetylcysteine (PARVOLEX) 

Treatment Regime: NAC infusions are weight based and should be prescribed according to the adult dosage table shown below. All infusions are to be diluted with 5% Dextrose. 

YES

NO 

INR >1.3 OR transaminase activity has x2 since admission level OR the transaminase activity is >3x ULN 

1. Continue to repeat the 16 hour bags until the INR <1.3 

2. Seek specialist advice (Working hours – Drs Philipose, Thomson, OOH ‐ Liver unit)

Re‐check INR, creatinine, bicarb, LFT activity (ALT/AST) after Bag 3; 

 While awaiting results repeat 16 hour dose 

(Bag 4) 

INR <1.3 (& transaminases <3x Normal &<2x admission level)  

1. Can stop N‐Acetylcysteine administration 

2. If all other medical issues treated & patient well, then needs psychiatric referral

NO YES

18

Paracetamol Overdose Treatment Line Nomogram 

19

20

 

N‐acetylcysteine (PARVOLEX) reactions:  Can occur in up to 15% patients, usually within first 30 minutes of the infusion starting.  Symptoms:    Nausea,  vomiting,  flushing,  urticarial  rash,  angioedema,  tachycardia,  hypotension, bronchospasm, respiratory depression and collapse. n.b mild symptoms are relatively common and are not a reason to completely withhold NAC, severe reactions are rare (~1%).   Management of clinically significant reactions: 

1) Stop infusion (is usually all that is required) and repeat all observations. 2) Antihistamine for rash 3) Nebulised salbutamol, if respiratory symptoms 4) Once reaction settled, recommence at infusion rate of 50 mg/kg over 4 hours (slower rate) 5) For  severe  reactions  please  contact  toxbase  (national  poisons  information  service)  for  further 

management 

  

Background to the changes  These  changes  are  intended  to  simplify  treatment  decisions  and  reflect  the  findings  of  the commission on human medicines  (CHM),  that  the  evidence base  to  support  the practice of  risk factor assessment was poor and inconsistent, and that many of the risk factors were imprecise and difficult to   determine with sufficient certainty in clinical practice. By removing the need to assess risk  factors  for  hepatotoxicity,  the  approved  indication  for NAC  is  greatly  simplified  to  a  single treatment line on the paracetamol nomogram. In order to reduce the potential for hypersensitivity and simplify prescribing the  initial  infusion dose has been extended from 15 minutes to 1 hour. A substantial  number  of  spontaneous  reports  of  administration  errors  with  IV  NAC  were  also considered, some of which had the potential to cause significant harm. CHM recommends a range of risk minimisation measures to reduce the  incidence of administration errors, most notably the introduction of weight‐based dosage tables to remove the need to calculate the dose.  

 

 Reviewed 07/13                                                                       Review due: 07/14    

21

HEART FAILURE - ACUTE

Under construction

Please see a senior, or see national guidance

 

  

22

 Hyperkalaemia 

Diagnosis      ECG changes                  Symptoms   

  

  

 Management (monitor ECG, check Blood Glucose)  

                   

Ongoing Management          

     

Mild  K+ 5.5 – 6.0 

Moderate  K+ 6.1 – 6.9 

Severe  K+ ≥7  

May be asymptomatic 

Paraesthesia 

Muscle weakness 

Palpitations 

Flaccid paralysis 

Tall ‘tented’ T waves 

Flat P waves 

Increased PR interval 

Widening QRS → sinusoidal pattern → VF/VT 

1. 10ml calcium gluconate 10% IV over 2 mins ‐ Protects cardiac membrane o If ECG changes present there should be improvement in 1‐3 mins o Repeat every 10 mins until ECG normalises (up to 50mls) o If on digoxin give slowly over 20 mins in 100mls 5% glucose 

 

2. 50ml 50% glucose with 10 units Actrapid into large vein over 30 mins – Drives K+ intracellularly o Reduces K+ by 0.6‐1.0mmol/L o Effects observed in 15 mins, last 4‐6 hrs o If glucose ≥15 no need for glucose with insulin o Monitor for hypoglycaemia: check BM at 30 mins, then hourly up to 6 hrs  

3. Nebulised Salbutamol 2.5‐10mg ‐ Drives K+ intracellularly o Reduces K+ by 0.5‐1.0mmol/L o Effects observed in 15 mins, last 2 hrs  

4. Calcium Resonium – Prevents K+ absorption from gut o 15g/6‐8h in water PO or o 30g enema followed by colonic irrigation after 9hrs to remove K+ from colon 

Stop exacerbating factors: o Drugs: K+  supplements (Sando‐K), ACE‐i/ARBs, K+  sparing diuretics (spironolactone, 

amiloride), K+ containing laxatives (Movicol, Fibogel), NSAIDs, digoxin, beta blockers o Foods: fruit juice, fruits, chocolate, biscuits, potatoes, coffee o IV fluids containing K+  

Continue monitoring: o U&E, glucose at regular intervals o ABG if appropriate 

Treatment‐refractory hyperkalaemia

K+ remains ≥7 despite treatment, or  

Persistent ECG changes 

May require Haemodialysis/filtration 

Liaise with Renal Team (QA) and/or ICU team 

Treat if K+ >6.5 or if ECG changes/symptoms Urgent repeat K+ if possible pseudohyperkalaemia 

e.g. haemolysis, prolonged tourniquet time

For further reading click here                                                                                         Last reviewed: 07/12

23

24

                                                                                                                                                     

MASSIVE BLOOD LOSS Massive Transfusion can be defined as the replacement of a patient’s total blood volume (approximately 5 litres in an adult) in less than 24 hours. Management requires early recognition, rapid and effective restoration of an adequate blood volume and securing normal haemostasis. Massive transfusion requires good communication between surgeon, anaesthetist, the transfusion laboratory and haematologist. It is essential that Transfusion staff be notified immediately when a massive bleed occurs or is anticipated. Blood Component Therapy Red Cells Group specific red cells should be given in emergency cases and can be made available within minutes. The only exception to this is in extreme emergencies where it may be necessary to use the two O Rh D neg ‘flying squad’ red cell units. Pharmacological Agents in Massive Blood Loss

Tranexamic Acid Intravenous tranexamic acid (anti-fibrinolytic) can be very useful in uncontrolled bleeding. Cautions: massive haematuria (can precipitate ureteric obstruction); not for use in DIC. Contra-indications: severe renal impairment By slow intravenous injection, dose1g up to 4 times daily Recombinant Factor VIIa (Novoseven) Trials have not shown this to be very useful in the general surgery setting, and there are significant thrombotic risks in older patients. Discuss with the Consultant Haematologist. This is not kept on St Richard’s site, but if high risk patients are anticipated (eg patients refusing blood products) please discuss before surgery with Consultant Haematologist.

Reversal of Anticoagulation Warfarin: see reversal of anticoagulation Unfractionated Heparin - Reversed with protamine (1mg protamine reverses 100u heparin) Excess protamine induces a coagulopathy. Low Molecular Weight Heparin - Poorly reversed with protamine Fondaparinux and new oral anticoagulants do not have specific reversal agents

Quick Reference: Management of Massive Blood Loss

Goal Procedure

Arrest bleeding Pressure / elevation / tourniquet / haemostatic dressings Early surgical/radiological intervention

Restore circulating volume

Establish venous access / monitoring Give warm crystalloid / colloid Aim for systolic >90 mmHg and urine output >30ml/hr

Clinical Liaison Contact key personnel

Call the following: Anaesthetist on call & ODP Consultant Haematologist Surgeon on call Porters Contact Transfusion Laboratory giving estimated rate of bleeding

and patient details. Adults order 4-6 red cell units, 1L FFP, 2 platelet units Children weight related Seek Advice

25

Goal Procedure

Coordinate on-going treatment with theatre, ITU and lab

Send lab tests (Ensure correct patient ID)

G&S, FBC, PT, APTT, Fibrinogen, Chemistry profile Send second G&S on advice of lab. Repeat FBC, PT, APTT, Fibrinogen every 4 hrs if oozing, or every

8-10 units if bleeding. Use results to guide replacement.

Maintain Hb >8 g/dl

Administer high flow FiO2 Consider cell saver Use blood warmer if giving > 4 units of red cells stat.

Maintain Plts >75 × 109/l

If multiple or CNS trauma or abnormal platelet function maintain >100 × 10 9/l Allow for delivery time of approx 2-3 hours

Maintain PT <18s. APTT <40s/<1.5 ratio

FFP 15 ml/kg guided by tests. Anticipate need for FFP after 1–1·5 × blood volume replacement. Platelets and FFP may be needed earlier if DIC or liver failure present.

Maintain Fibrinogen > 1·5 g/l

If not corrected by FFP give cryoprecipitate Adult –order 2 packs of pooled cryoprecipitate Children weight related Seek Advice

Avoid complications Hypothermia – warming blankets DIC - address underlying cause, correct any coagulation defect

Arrest Ongoing Bleeding

Discuss further blood products and pharmacological agents with Consultant Haematologist

Order more platelets

Keep Consultant Haematologist and the Transfusion Laboratory Informed

Author: Dr S. Janes, SRH

Reviewed: 08/13 Next Review: 08/14

Needle stick/Sharps Injury Hotline The Trust now has a single Occupational Health Hotline number for all sharps injuries and contamination incidents: The number is St. Richard’s ext (73) 2405

(73) 2405 

For the full Blood Borne Virus (BBV) Policy (including management of sharps exposure incidents) please click here

Updated 07/13

26

Guideline for the management of

27

suspected neutropenic sepsis in Adults

Door-to-needle time (first dose of antibiotics) should be within one hour. Take baseline Observations; Temperature, pulse, respiratory rate, blood pressure and O2 saturations Take peripheral and central (via Hickman/PICC line) aerobic and anaerobic blood cultures, and urgent bloods for FBC, LFT’s CRP, Calcium and U&Es. If haemodynamically unstable take venous lactate and bicarb . Consider MSU, stool, skin, wound, Hickman and PICC line swabs for Culture & Sensitivities as indicated by examination. Do not perform chest X-ray unless clinically indicated

SIRS=Systemic Inflammatory Response Syndrome IMPORTANT — IF NEUTROPENIC SEPSIS SUSPECTED DON’T WAIT FOR BLOOD RESULTS START

ANTIBIOTICS

Neutropenia = ( < 1.0 x 109 )cells)

Remember, symptoms may be vague and there is often no obvious focus of infection

Reference: Western Sussex Hospitals NHS Trust Antimicrobial Formulary Created by: Ann Maloney (Lead AOT, Caroline Boxall (Lead Pharmacist Cancer Services), Santosh Narat (Consultant Haematologist Neutropenic sepsis lead) Review: April 2015.

Suspected neutropenia – Has the patient received recent IV or oral chemotherapy (within the last 4 weeks) and has a

Temp >38.0°C or < 35.50°C or any symptoms of infection?

All patients that are admitted need to be referred to the Consultant Haematologists and Acute Oncology Team

H E A T

Any signs of SIRS ? give first line antibiotics immediately SIRS = Fever 38.0 °C or Hypothermia <35.5°C Shaking / chills Tachycardia >90 bpm Tachypnoea >20 bpm Hypotension <90 mmHg

HISTORYAt risk groups Haematology Breast Cancer Post chemotherapy Palliative patients Pts with CVADs

EXAMINE

ACTION

TREAT

Is the patient on chemotherapy?Do they have any SIRS?

FIRST LINE ANTIBIOTICS Tazocin▲ 4.5g QDS IV

OR IF PENICILLIN ALLERGIC Ceftazidime▼ 2g TDS IV

and Single dose Gentamicin● 5mg/kg LBW IV* STAT

Bloods required FBC, LFT, U&E CRP, Calcium blood cultures, venous lactate and bicarb clotting studies

Monitor daily bloods and 4 hourly Observations or 1 hrly if hypotensive

* 5mg/kg lean body weight. Closely monitor BP, renal function, fluid balance and U&Es. Monitoring required - see guidelines on StaffNet.

▲ Contains a penicillin. Do not use with patients known to be penicillin-allergic. ▼ Suitable for use in patients with a known non-severe penicillin allergy (e.g. rash). Do not use in patients known to have anaphylaxis to penicillins - discuss these with a Microbiologist. ● Suitable for use if any penicillin allergy.

GSCF Solid tumours patients age >60 years with neutrophil <1.0, Give GSCF until neutrophil >1.0 For Haematology patients please seek advice from Haematologist

NIV in acute respiratory failure in Adults

Consider in patients with • COPD with pH 7.25-7.35, raised pCO2

• Chest wall deformity, neuromuscular disorder, decompensated OSA

• Cardiogenic pulmonary oedema, unresponsive to CPAP

Premorbid state • Potential for recovery to quality of life acceptable to the patient • Patient’s wishes considered

Decide if invasive ventilation is appropriate if NIV fails

Optimise medical Rx including FiO2

Not improving

Transfer to Ford/CCU/HDU

Trial of NIV

Reassess after 30-45 mins

Improving

Continue

Not improving (See box)

Improving

Medical treatment

Deteriorating; pH < 7.3

ITU

British Thoracic Society Guidelines

28

Refer for long term NIV if: Chest wall/ neuromuscuar disease

Spinal cord problems Failure to wean 3 admissions with AHRF in COPD

Monitoring Clinical: pulse, RR, BP, MEWS Transcutaneous O2

Chest wall movement Accessory muscle use Coordination with NIV Comfort, mental state

Inx: ABGs 0,1,4 hours transcutaneous CO2 & O2

Failure to improve?

Setting up NIV - Explain NIV to the patient. - Select a mask to fit the patient and hold it in place to familiarize the patient. - Set up the ventilator - Attach pulse oximeter to patient. - Commence NIV, holding the mask in place for the first few minutes. - Secure the mask in place with straps/headgear. - Reassess after a few minutes. - Adjust settings if necessary - Add oxygen if SpO2 <85%. - Instruct the patient how to remove the mask and how to summon help. - Clinical assessment and check blood gases at 1–2 hours. - Adjust settings/oxygen if necessary.

Typical initial ventilator settings For acute respiratory failure in COPD Mode: Spontaneous/timed EPAP 4–5 cm H2O IPAP 12–15 cm H2O (to be increased as tolerated to 20 cm H2O) Triggers: set to optimise synchronization Back up rate: 8 breaths/min Back up Ti 1.00 sec

Contraindications • Facial trauma/burns • Recent facial, upper airway, or upper

gastrointestinal tract* surgery • Fixed obstruction of the upper airway • Inability to protect airway* • Life threatening hypoxaemia* • Haemodynamic instability* • Severe co-morbidity* • Impaired consciousness* • Confusion/agitation* • Vomiting • Bowel obstruction* • Copious respiratory secretions* • Focal consolidation on CXR • Undrained pneumothorax* . acute asthma *NIV may be used, despite the presence of these contraindications, if it is to be the “ceiling” of treatment.

• Consider a pneumothorax, aspiration pneumonia, etc Paco2 improves but Pao2 remains low • Increase FiO2 • Consider increasing Epap Paco2 remains elevated • adjust O2 to maintain SaO2 between 88-92% • Is there excessive leakage - check mask fit

- If nasal mask, consider chin strap or full-face mask • check the circuit set up - check connections, leaks • Is re-breathing occurring – is expiratory valve patent - consider increasing EPAP (if bi-level pressure support) • Is the patient synchronising with the ventilator

- check inspiratory and expiratory trigger - consider increasing EPAP (in COPD)

• Is ventilation inadequate - observe chest expansion - increase target pressure (or IPAP) or volume - consider increasing inspiratory time - consider increasing resp rate (increases minute ventilation)

• Consider a different mode of ventilation/ventilator

Have any complications developed?

Is the treatment of the underlying condition optimal?

• Check medical treatment and that it has been given • Consider physiotherapy for sputum retention

29

- British Thoracic Society Guidelines AUTHOR: Dr D. Ross Reviewed: 06/13 Next review: 06/14

Setting up NIV - Explain NIV to the patient. - Select a mask to fit the patient and hold it in place to familiarize the patient. - Set up the ventilator - Attach pulse oximeter to patient. - Commence NIV, holding the mask in place with the cpap valve off for the first few minutes and then attach valve. - Secure the mask in place with straps/headgear. - Reassess after a few minutes. - Adjust settings if necessary - Add oxygen if SpO2 <85%. - Instruct the patient how to remove the mask and how to summon help. - Clinical assessment and check blood gases at 1–2 hours. - Adjust settings/oxygen if necessary.

NOTE IF USING CPAP VIA THE VITAL SIGNS WHISPER FLOW CIRCUIT A NON VENTED MASK MUST BE USED AND THE BRIDGE OF THE NOSE MUST BE PROTECTED AGAINST

Monitoring Clinical: Pulse, RR, BP, MEWS Transcutaneous O2 Chest wall movement Accessory muscle use Comfort, Mental State Inx: ABGs 0,1,4 hours transcutaneous CO2 & O2

Contraindications Facial trauma/burns Recent facial, upper airway, or upper

gastrointestinal tract* surgery Fixed obstruction of the upper airway Inability to protect airway* Life threatening hypoxaemia* Haemodynamic instability* Severe co-morbidity* Impaired consciousness* Confusion/agitation* Vomiting Bowel obstruction* Copious respiratory secretions* Focal consolidation on CXR Undrained pneumothorax Acute asthma

*NIV may be used, despite the presence of these contraindications, if it is to be the “ceiling” of treatment.

NIV in acute respiratory failure in Adults CPAP

Consider in patients with Type 1 Respiratory Failure PaO2 < 8kpa with normal PCO2

Decide if CPAP is appropriate

Optimise medical Rx including FiO2

Not improving

Transfer to Ford/CCU/HDU

Trial of CPAP

Reassess after 30-45 mins

Improving

ContinueNot

improving (see box)

Improving

Medical treatment

Deteriorating Fall in PaO2

HDU/ITU

• Patients requiring high concentrations of oxygen > 60% • Acute Lung Injury Cardiogenic pulmonary oedema and LVF To Mobilise secretions

Premorbid state • Potential for recovery to quality of life acceptable to the patient • Patient’s wishes considered

Failure to improve?

Is the treatment of the underlying condition optimal?

• Check medical treatment and that it has been given • Consider physiotherapy for sputum retention

Have any complications developed?

• Consider a pneumothorax, aspiration pneumonia, etc PaO2 remains low • Is there excessive leakage – check mask fit Check the circuit set up • Increase EPAP/CPAP incrementally by 2.5cms H2O If EPAP raised to 10cm and not improving, anaesthetic advise should be sought Increase FiO2 to maintain saturations >94%

• I f PaO2 remains low and evidence of increased work of breathing consider BIPAP

Typical initial CPAP settings for Acute Type I Respiratory Failure Mode: CPAP IPAP: 5-10 CMS H2O

Management of Acute Pancreatitis (SRH only)

30

Initial Assessment Airway, Breathing, Circulation

Initial Investigations Bloods (FBC, U&Es, LFTs, Amylase, CRP, Glucose, LDH, Calcium, Coagulation) Imaging (AXR + Erect CXR) ECG ABG (may not be necessary if pt appears well) Initial Management

Fluid resuscitation to maintain adequate urine output (>0.5mls/kg/hr) with regular fluid status assessment as likely hypovolaemic Analgesia (Morphine) Consider catheterisation with hourly measurement of urine output O2 to maintain sats >95% Sips clear fluid as tolerated NG tube if constant vomiting Caution: Beware aggressive fluid resuscitation in elderly, CCF, CKD. If in doubt contact senior for advice

On admission Investigate for aetiology i.e. USS Repeat assessment of severity daily Consider nutritional support (enteral preferred) Consider contrast CT scan if diagnosis in doubt or to assess for complications in severe pancreatitis i.e. necrosis Therapeutic ERCP for severe gallstone pancreatitis if evidence of jaundice, biliary obstruction, cholangitis within 72 hours of onset of pain Definitive management of gallstone pancreatitis during same admission

Assessment of Severity Glasgow Score APACHE II

Mild pancreatitis

<3 <8

Severe pancreatitis

≥3 ≥8

CRP >150 is an indicator for severe pancreatitis ITU/HDU Referral

Severe Pancreatitis Organ failure (ALI, renal failure)

Glasgow Scoring System PO2 (<8kPa) Age (>55) WCC (>15 x109/L) Calcium (<2mmol/L) Urea (>16mmol/L) LDH (>600units/L) Albumin (<32g/L) Glucose (>10mmol/L)

No firm evidence antibiotics are indicated for prophylaxis against complications, however if started should not be given for more than 14 days. NG tube is not indicated unless there is constant

vomiting or evidence of paralytic ileus. Hypoxia, hypocalcaemia and hypoalbuminaemia are poor prognostic factors.

Differential diagnosis to consider

If in doubt , contact seniors for advice at all times! Last updated 07/12

- Perforated ulcer - Mesenteric ischaemia - Ruptured AAA - Myocardial infarction - Ectopic pregnancy

31

PE

Under construction

Please see a senior, or see national guidance

32

 

PERIOPERATIVE ANTICOAGULANT PROTOCOLS All patients should be discussed with the Haematologists prior to any surgical procedure. For elective cases, the Anticoagulant Clinic will give written advice if informed of the proposed operation and the date at least one week before. More detailed guidance is available on the Trust Intranet under Clinical resources: VTE and anticoagulation. Management of the warfarinised patient during surgery depends on two main factors: 1. The level of haemostasis required for surgery,

e.g. dental extraction INR 2.0-3.5 neurosurgery INR 1.0-1.3

2. The thrombotic risk of the patient’s underlying condition. Low risk: The risk of thrombosis occurring in these patients if they have an INR < 2.0 for several days is very low.

e.g. AF Cardiomyopathy Previous CVA Single episode DVT, > 3months previously Peripheral vascular disease.

High risk: These patients have a significant risk of thrombosis/embolism if they are not adequately anti-coagulated at all times. Consider whether surgical procedure is absolutely necessary.

e.g. Recent DVT or PE (within 3 months) Thrombophilic tendency with recurrent thromboses Prosthetic heart valve Antiphospholipid syndrome Arterial embolic disease

(1)Dental extraction Advice to dentists from the BDA has recently been revised. Single extractions can be performed with no correction of INR provided the INR is below 4. Tranexamic acid is not available to dentists and is not recommended routinely. (2) Full reversal of anticoagulation not required, e.g. minor skin lesions In all patients, stop warfarin 2 days prior to the procedure. Ideally, and if bleeding complications could ensue, the INR should be checked on the day of the procedure (INR < 2.5). Recommence warfarin, at the patient’s normal dose, on the evening of the procedure, provided haemostasis has been achieved. Some patients with prosthetic heart valves, especially Starr-Edwards, severe thrombophilia,

or antiphospholipid syndrome, may have had previous problems when their INR fell below 3.0. These patients will require a more formal anticoagulant regime, and must be discussed with the Haematologists.

(3) Low thrombotic risk patients requiring full reversal of anticoagulation. Patients with AF etc should stop their warfarin 3-5 days prior to surgery, and can be admitted the day of the operation. Allow 5 days if possible before spinal anaesthesia. On admission, start prophylactic dalteparin 5000U in the evening, unless bleeding risk exceptionally high. Check INR prior to surgery, to ensure warfarin cleared. Recommence warfarin, at double the normal dose on first day then normal dose thereafter, as soon as haemostasis is achieved. Do not reload. Continue heparin until the INR >2.0. (4) High risk patients requiring full reversal of anticoagulation. Stop warfarin 3-4 days pre-operatively. Check INR daily, and introduce therapeutic dose of dalteparin, as single daily sc injection (dose based on weight of patient) once INR <2.5. This may be able to be done as an outpatient. Last dose to be given at least 24h before surgery.

Check INR and APTR pre-operatively. Post-operatively, if very high bleeding risk or poor renal function, start continuous IV heparin 6 hours post-operatively, or as soon as the surgeon is satisfied that haemostasis is adequate, aiming for an APTR of 1.5-2.0. (suggested starting dose 1000 units/h). The IV loading dose should be omitted. In major surgery, it may be best to give sc heparin 5000units at 6pm on the day of operation, and start IV heparin by 10am the following morning. Check APTR daily. Once risk of bleeding low, IV heparin can be replaced by dalteparin at therapeutic dose. (5000 units on evening of operation followed by therapeutic dose the next day). Restart warfarin at the normal dose when considered safe. Heparin must be continued to cover the re-introduction of warfarin, until the INR is >2.0. Check APTR and INR daily while patient on iv heparin. Continuous IV heparin is preferred to LMW heparin where there is significant risk of post-

operative bleeding, as the half-life is much shorter, and anticoagulation more readily reversed.

Do not start warfarin if re-operation is a possibility. Reversal of anticoagulation using Vitamin K, Beriplex or FFP carries a risk of thrombo-

embolism, and is only permissible if emergency surgery is required. Anticoagulated patients run a small risk of thrombosis when their anticoagulation is stopped,

and so every effort should be made to avoid cancelling the operation at the last minute, and exposing them to this risk unnecessarily.

LMWH e.g. dalteparin, does not usually alter the APTR or INR, but the patient on treatment doses is still fully anticoagulated, with a similar bleeding risk to IV heparin. Therefore patients on LMWH should not be presumed to have normal clotting, e.g. safe for epidurals, until 24 hours after the last injection. This will be longer in patients with renal impairment.

Aspirin and Clopidogrel It is difficult to give firm advice, but some patients on these drugs do bleed excessively. If there are no contra-indications, it is probably advisable to stop them about two weeks before elective surgery but this is usually not recommended with coronary artery stents. In these cases, seek advice from the cardiologists. New oral anticoagulants (Apixaban, Dalteparin, Rivaroxaban) ∫These drugs generally have a short half-life except in renal impairment. Guidelines are available on the Trust Intranet (under Clinical resources: VTE and anticoagulation), and advice can also be sought from the Anticoagulant clinic and Haematology Consultants.

Guide to INRs for particular “day case”

procedures (These are for guidance only: the haemostasis required

will depend on the surgeon and the procedure).

Tooth extraction: single 2.0-4.0 multiple 1.5-2.0

Tooth restoration 2.0-2.5 Root canal filling 1.5-2.0

Cystoscopy 2.0-2.5 Removal of dermatological lesion: on face/ vascular/ skin graft <1.5 non facial/ less vascular 2.0-2.5

Author: Dr S. Janes, SRH Reviewed: 08/13 Next Review: 08/14

33

34

SAH

Under construction

Please see senior, or see national guidance

35

36

STATUS EPILEPTICUS (SRH)

Status epilepticus may be defined as a generalised seizure lasting more than 30 minutes or several distinct seizures without restoration of consciousness. In practice, however, convulsions persisting more than five minutes warrant treatment. Approximately 50% of cases occur in patients with chronic epilepsy, usually on antiepileptic drug withdrawal, or during intercurrent illness. About 25% are associated with acute neurological or metabolic disorders, including drug or alcohol abuse, CVA, encephalitis or tumour. In about 25% a cause may not be established. Some of these may have pseudo status, which may be suspected if the patient appears to be aware while convulsing, has previous hysterical illness or recovers abruptly between convulsions. Initial Management 1. Remove false teeth, turn to semi-prone position and prevent the patient injuring him/herself.

Administer high flow oxygen. 2. Give lorazepam 0.1mg/kg (diluted 1:1 with normal saline over 2 minutes) or diazepam 10-

20mg IV (0.15-0.25mg/kg) at a rate of 5mg per minute. Repeat once after 3-5 minutes if seizures continue, watching for respiratory depression.

3. Take blood for urgent urea, electrolytes, calcium, glucose and FBC. Put a drop of blood on a

BM stick. Save blood for anticonvulsant levels, alcohol, and a toxicology screen. 4. If the BM stick suggests a low blood glucose give 50% glucose 25mls IV. Give 2 pairs of IV Pabrinex 8 hourly if alcohol is a possible cause. 5. If the patient is not known to be taking phenytoin, or if it has been recently withdrawn, follow

the diazepam immediately by IV phenytoin (otherwise seizures may recur when diazepam wears off) at 15-18mg/kg, no faster than 50mg/minute. Only give as the neat solution, or diluted in 0.9% saline, through a peripheral vein, (see Injectable Medicines Policy for more details).

6. If the patient is definitely taking a standard dose of phenytoin and is compliant give

phenobarbitone as stated below. 7. Once seizures are controlled, establish maintenance therapy, using nasogastric tube if

required. Drug Resistant Status Epilepticus 1. Refer urgently to an anaesthetist and neurologist. Transfer to intensive care usually

necessary. Arrange an urgent phenytoin level and EEG. 2. In the presence of an anaesthetist phenobarbitone 10mg/kg IV diluted 1 in 10 with water for

injection at 100mg/min (700mg over 7 minutes in an adult, with a maximum of 1000mg). Ensure that any existing antiepileptic drugs are not omitted. Maintenance dose of phenytoin is 100mg tds (oral or I.V), phenobarbitone is 60-120mg per day. Continued fitting requires consideration of thiopentone or lignocaine infusions. Diagnosis of cause Many patients will require a CT and/or MR scan and lumbar CSF analysis to exclude meningitis and encephalitis or other intracranial lesion. Author: Dr S. Hammans, SRH Last updated 07/12

Author: Dr S. Ivatts Stroke: Acute management Reviewed: 07/12 This is a medical emergency requiring urgent assessment and rapid referral where appropriate

1. Assessment: ROSIER Score Ring all that apply YES NO

Loss of consciousness / syncope -1 0 Seizure activity -1 0 New acute onset (or from sleep):

37

Asymmetrical facial weakness 1 0 Asymmetrical arm weakness 1 0 Asymmetrical leg weakness 1 0 Speech disturbance 1 0 Visual field defect / ophthalmoplegia 1 0 TOTAL SCORE _______ (-2 to 5) Stroke is unlikely, but not excluded if total score is ≤ 0

Avoid Do not insert a urinary catheter Do not insert NG tube Do not prescribe antiplatelets for 24 hours Do not prescribe anticoagulation Do not perform Arterial puncture

Immediate Management: Call 3482 to alert CT of likely urgent CT Brain Move the patient to ED Resus room Intravenous access (insert 2 cannulae) Oxygen to keep saturation ≥ 95% Take blood for FBC, U&E, LFT, Clotting, Glucose, G&S ECG

Call switchboard and ask for the Stroke Team

2. Is patient a candidate for Thrombolysis?

Yes No Does the patient have a suspected stroke? Is the time since onset of symptoms less than 4.5 hours?

Is the ROSIER score more than 0? Is BM >3.5mmol/L if not treat and reassess

If the answer to any of the above 4 questions is NO then the patient is not suitable for

thrombolysis and you do not need to call the Stroke Team immediately. Please assess the patient as normal and use this Acute Stroke Pathway from page 7 onwards

Yes to all 5 criteria: Possibly for thrombolysis No to any of the 5 criteria

Stroke team will assess patient, and decide if suitable for thrombolysis. Thrombolysis will be performed following the procedure set out in the full Acute Stroke Pathway, available on the intranet.

Do not delay the CT scan – move patient as soon as CT ready

Not for Thrombolysis: Do not need to call Stroke team urgently Assess the patient as normal and use Acute Stroke Pathway from page 7 onwards

CT Brain to be performed within 24 hours

Hypertension – Only treat in hypertensive emergency (D/W senior if in doubt) Consider all patients for treatment at 2 weeks post stroke Ace inhibitors, thiazide diuretic, calcium channel blocker are first line choice.

Immediate CT Brain if: On anticoagulants Known bleeding tendency GCS < 13 Unexplained progressive or fluctuating symptoms Papilloedema, neck stiffness or fever Severe headache at onset

Antiplatelets: (once haemorrhage excluded) Aspirin 300mg od (or clopidogrel 75mg od if intolerant/allergic to aspirin) PPI in dyspepsia/risk of GI bleeding LMWH should NOT be routinely prescribed for CVA patients.

Assess swallow – prescribe IV fluids if necessary

Thrombolysis is performed 9am - 5pm Monday to Friday NOT outside these hours currently

If a patient presents outside these times, please follow Transfer Protocol

Transient Ischaemic Attack (TIA) A sudden onset of focal neurological signs/symptoms lasting <24 hours.

The majority will last minutes and resolve within one hour

38

Assess

ABCD2 score Score

Age > 60 1 point

BP Systolic>140 or diastolic≥90 1 point

Clinical Features: Speech disturbance (no weakness) Unilateral weakness

1 point 2 points

Duration 10-59 mins >1 hour

1 point 2 points

Diabetes 1 point Total

Total Score Risk Approx CVA risk within 7 days

≤ 3 Low

4 Low <1%

5 High >10%

>6 Very high >20%

For further information click here: TIA Guideline Author: Dr S. Ivatts Reviewed: 07/12

Management

ABCD2 score ≤ 3 or presenting more than 1

week after assessment should be booked into a TIA slot within the next 7

days.

ABCD2 score ≥ 6-7 out of hours i.e. mon –fri 5pm – 9am, weekends and bank

holidays should be admitted under the on-call medical

team and moved to Petworth ward when a bed is available.

Complete referral form (and ABCD2 score section if presenting within 7 days of TIA). Fax completed form to fax number 01243 831427

Start daily aspirin 300mg immediately. If aspirin intolerant consider clopidogrel 75mg od

ABCD2 score ≥ 4 should be seen in next available TIA clinic slot ideally within 24 hours

NB ANY residual focal weakness/neurological signs should be treated as a CVA

Patients with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke even if they have an ABCD2 score of 3 or below. These

patients should also be seen in the next available TIA clinic slot.

Acute Upper GI Bleeding/Variceal Bleeding (SRH)

1. Assess:

39

Airway, Breathing, Circulation Investigations FBC, U&E, LFT, Clotting, X-Match (G&S if less severe bleed)

Rockall Score* Blatchford Score

Erect CXR, ECG (do not delay treatment) Large Bore IV Access (x2)

2. Fluid Resuscitation: Keep Patient Nil by Mouth

Rapid Infusion IV crystalloid for shocked patients (up to 1L immediately) Blood transfusion if remains shocked Otherwise slow IV crystalloid infusion Catheter and monitor UO

3. Drug treatment:

Reverse Clotting Defects Any clinical evidence of Chronic Liver

Disease: Terlipressin+ 2mg IV and Do NOT give PPI pre-endoscopy (Endoscopist will decide if PPI needed post endoscopy)

Augmentin 1.2g IV TDS

4. Interventional Treatment

Endoscopy (OGD): within 24hrs: referral form to consultant in endoscopy suite

Immediate/urgent OGD for:

In hours: D/W consultant in endoscopy suite (ext. 5050/5051)

Profound/treatment refractory shock Out of hours: D/W consultant on call for endoscopy via switch Profound/treatment refractory bleeding

Notify Surgical team of these patients

Balloon Tamponade for exsanguinating Variceal Bleeds Sengstaken Blakemore tube - Found in fridge in ICU and Endoscopy suite. Should be passed by an experienced person. This is usually only performed on intubated patients due to high risk of aspiration

+Terlipressin *Rockall Score (pre-endoscopy) Blatchford Score - Continue QDS for 48 hours in

confirmed variceal bleeds 0 1 2 3

- Caution in IHD and HTN. GTN infusion may be necessary for severe coronary side effects

< 60 60-79 >80 Age

HR<100 HR>100 HR>100 Shock SBP>100 SBP>100 BP<100 Consider for discharge:

Rockall/BlatchfordComorbidity None HF, IHD, other

major comorbidity

Liver failure, renal failure,

disseminated malignancy

score 0, and No witnessed haematemesis/

PR Bleed, and Not a current inpatient

Total score = _/7 If in doubt, d/w senior colleague

Reviewed: 06/13 Next Review: 06/14

40