Tips for New ED Staff

RED FLAGS - a warning of impending disaster

• Stab wounds anywhere on the anterior trunk may cause delayed cardiac tamponade or occult intra-abdominal injury and should be admitted, after initial resuscitation and negative radiology, under the duty surgical team
• Penetrating wounds of the neck may appear innocuous.  All wounds penetrating deep to platysma should be considered for exploration in theatre by an appropriate specialist (plastic surgeon, vascular surgeon or ENT surgeon).
• The signs of an acute subdural haematoma mimic intoxication.  Almost all patients presenting to the ED with an acute intra-cranial haematoma appear to be intoxicated. Alcoholics are more at risk of SDH as they have bleeding tendencies, fall more frequently and their altered conscious level is wrongly ascribed to alcohol.
• Patients who are “uncooperative” may have intracranial haematomas requiring urgent neurosurgery to prevent deterioration.  If you ever find yourself describing a patient as “uncooperative” in your clinical records, remember this possibility.
• Acute abdominal pain in male children/teenagers/young adults. Testicular torsion can present as acute abdominal pain in young boys; examination of the testes is mandatory. Any dubiety should be discussed with a senior.  As this has been missed several times, all patients under 40 with testicular pain must be examined by a urologist.
• Symptoms suggestive of renal colic in patients over 55. Unless they are known to have calculi, the diagnosis is possibly a leaking abdominal aortic aneurysm!
• Soft tissue injuries to the thumb MCP joint often cause rupture of the ulnar collateral ligament .x-ray the joint to exclude avulsion fractures then test the integrity of the ligament. Local anaesthetic infiltration and stress radiographs may be required. Laxity mandates immediate referral to the hand surgeon for consideration of operative repair. If in doubt arrange follow up at the next hand clinic.
• Wounds over the dorsum of an MCP joint following a punch injury (the so called “fight bite”) often lead to septic arthritis of the joint
  Always obtain an x-ray, looking carefully for tooth fragments. Thoroughly irrigate and clean the wound, prescribe IV or oral augmentin and obtain an immediate hand surgery opinion for all penetrating wounds. Consider BBV.
• Children under 14 who present to the ED after a fall on their outstretched hand are at risk of a greenstick or buckle # of the distal radius If you can’t see the fracture, show a senior doctor the films. Even if a fracture is not seen, supply a wrist splint and refer to the virtual fracture clinic.
• Unable to sleep due to pain? Such patients usually have a fracture requiring immobilisation or pus requiring drainage. In children limb pain keeping them awake may indicate an underlying tumour. In other words, it’s usually serious and active treatment will be required. 
• Head injured patients on warfarin or DOACs – beware!  Unless the injury is really trivial, arrange a CT  (INR > 4 means 10 times as likely to have intra-cranial bleed).
• Cut with glass? A soft tissue x-ray must be obtained No exception to this rule. All glass is radio-opaque (but may occasionally be difficult to see against bone). Surprisingly large pieces of glass have been found in surprisingly innocuous wounds.
• Headache: rule out life threatening causes first. Beware Warfarin.  Sudden onset is a subarachnoid haemorrhage until proven otherwise - be wary of previous headache syndromes. Headache and pyrexia is meningitis until proven otherwise.
• Patients with left or right shoulder / upper arm pain may be having an MI. Get an ECG done quickly.
• Patients with epigastric pain may be having an MI.  Get an ECG done – quickly
• Patients who return to the ED (unplanned) should be discussed with or seen by a senior doctor.  There is a high incidence of missed injury in this group of patients. It is paramount that the injury should not be misdiagnosed or mistreated on the second visit as legal action is likely to ensue (and be successful!)
• Patients with neck of femur fracture may have normal initial x-rays.  Patients who live in Nursing Homes or who can weight bear are therefore sent home. While this may be reasonable, it is most important that instructions are given to the patient or carers that they should return to the ED for repeat x-rays if their symptoms are not resolving in 2-3 days. We are aware of several cases where an impacted sub-capital neck of femur fracture has initially been missed and resulted in avascular necrosis of the head of femur. It has been agreed that patients who cannot be sent home following hip injuries should be admitted under the orthopaedic team.
• Patients with abnormal vital signs (resps, pulse, BP, SaO2, GCS, temp, BM) should not be sent home - unless the abnormality has been corrected or adequately explained.
• Toddlers limp for a reason.  Even a fracture of the tibia from a twisting injury (toddler’s #) can produce minimal signs so the threshold for x-ray should be very low. Check temperature and arrange follow-up if no obvious cause.
• RBBB on ECG - Always check for left axis deviation. If present indicates “bifasicular block” and if symptomatic (e.g. dizziness, syncopal episode) urgent referral is indicated. If PR interval is increased then this is trifascicular block and should be admitted.
• Cauda Equina Syndrome: this can present in the early stages with urinary disturbance and subjective alteration in sensation at the “saddle area” before the full blown complete syndrome develops. If any possibility manage as an orthopaedic emergency.
• Pain out of Proportion: significant pain not responding to analgesia may be a sign of significant pathology e.g compartment syndrome, tendon sheath infection, deep abscess, necrotic or ischaemic tissue. Check bloods and a lactate! 

GOLDEN RULES (these instructions must be followed to avoid error)

• All patients with non traumatic chest pain have a treatable MI until proven otherwise. An immediate ECG must be obtained to “rule in” MI. If negative, unstable angina, PE, aortic dissection and oesophageal rupture must be considered and rapidly “ruled out” 
• Do not send patients with chest pain home unless: 
  • the pain is atypical and not associated with dyspnoea, sweating or nausea
  • there are no significant risk factors
  • the ECG and troponin are normal
  • the case has been discussed with a senior
• Never close pre-tibial lacerations with tight sutures.  Careful apposition with steristrips is the appropriate treatment, but ensure that the flap edges are not “rolled under”.
• Always follow up limping children within a few days. Non weight bearing children should be referred.
• Don’t write “drunk” in your clinical records. Consider the following descriptive terms – smells of alcohol, speech slurred, dysarthria, ataxia, garrulous, euphoric, etc. 
• Patients who have scaphoid tenderness require scaphoid x-rays, scaphoid immobilisation even if x-rays are negative (splint without thumb extension or occasionally POP) and MRI booked with follow up in the VFC (see protocol). 
• Non weight bearing patients must be supplied with a walking aid (ie crutches or a stick) on discharge.  No patients should be seen hopping out of the ED. Patients who require an aid should all be followed up. Soft tissue injuries should be encouraged to weight bear early and use crutches only for first few days
• If the elbow does not fully extend following trauma, a haemarthrosis +/- radial head # may be present. An x-ray must be obtained in all such cases. If an elevated fat pad is noted, look very carefully for subtle fractures of the radial head.
• In head injured patients with drowsiness or disorientation (i.e. GCS 14), failure to improve is an indication for CT scan-There is no point in observing patients until they deteriorate: subsequent surgery is unlikely to be successful. We must be proactive and act on those patients who fail to improve after a period of observation 
• Head Injury?– sometimes looking isn’t enough on the scalp. Look and palpate for abnormalities, swellings, and haematomas.
• All patients with a periorbital injury require to have their visual acuity assessed and documented - Failure to do so may be considered negligent
• Patients who cannot open their eye after periorbital injury require careful assessment often by ophthalmology and admission. Consider CT scan of orbits. Check & record light appreciation through the closed lid . Complete rupture of the globe of the eye has been missed before in a patient who was discharged with such an injury.. 
• Don’t suture bites - They get infected – thoroughly irrigate, prescribe antibiotics according to the guidelines and arrange review in 48-72 hours. Delayed primary closure of wounds can be carried out if necessary but if a cosmetic problem is anticipated, refer to plastics.
• Always test the integrity of the Achilles tendon in injuries of the lower leg / ankle.  Palpate the tendon and squeeze the calf observing normal plantar flexion of the foot.
• Always rewrite the Nursing Obs (vital signs) in your records.  It proves that you noticed them and makes it much less likely that you will overlook significant abnormality. Note the time that they were taken and repeat if appropriate.
• Check for tenderness of the 5th metatarsal base, navicular, os calcis and proximal fibula in ankle injuries - Memorise the Ottowa Ankle rules
• Always x-ray dislocations pre and post dislocation.  It is important on follow up to see the nature of the initial dislocation (and your notes may not be sufficient) and to ensure that it is completely reduced on discharge. It may redislocate prior to review and in addition fractures may only be evident on one of the views (exception is recurrent episodes with spontaneous dislocation). The exception to this rule is when the skin or neurovascular compromise (most often in angulated bimalleolar ankle fractures) in which case reduction should be achieved without delay before x-ray.
• Don’t put labels on blood transfusion bottles, they must be handwritten and include name, DOB and ideally CHI number - This is because there have been numerous incidents where the wrong label was stuck on the bottle.
• Don’t admit patients to GRI with infective diarrhoea – Call the Infectious Diseases Unit first to see if they could be more appropriately admitted there.
• Always check the doses of IV infusions in the infusion guide in resus.  To reduce K+, the dose of insulin is 8u in 100ml 20% dextrose; In DKA the dose of insulin is 50u in 50ml N Saline. It’s safer to confirm it each time.
• When admitting patients try to ensure that they are “pink” before leaving the ED.  Grey or blue patients need further resuscitation! White ones probably need to go straight to theatre with resuscitation en route! Don’t ignore abnormal observations, treat them and escalate to a senior if no improvement.
• IV analgesia with morphine does not routinely require the co-administration of an anti-emetic. It makes no difference to nausea and vomiting. Titrate analgesia to effect..
• Trampoline Injuries– often result in a broken bone – default is an x-ray! 
• Drugs ~ for majors/resus patients record all drug on Kardex not the ED card.
• Anticoagulant & Headache = normally warrants a CT scan.

Pearls of Wisdom - top tips to improve your management of patients

• More mistakes are made from not caring than from not knowing . Unhappy patients may have undiagnosed or badly treated injuries. 
• Off legs / Total body pain, numbness or weakness- Think of central cord syndrome (especially in older patients). CVAs don’t really produce bilateral neurology.
• Abdominal Pain as primary complaint - refer to surgeons (or gynaecology). This includes alcoholic gastritis – see the Specialty Triage document.
• Understand the relationship between serum osmolality and alcohols - The difference between the calculated osmolality [(2 x Na) + (2 x K) + urea + glucose] and the measured osmolality, equates to the alcohol level in mmol/l. Multiply this by 4.6 to convert to mg/dl. The legal limit for driving is 50mg/dl or 11mmol/l. (Methanol and ethylene glycol can produce a similar osmolar gap.) 
• Hyperextension injury of the finger usually results in volar plate injury at the PIPJ.  Tiny avulsion fractures may be seen at the base of the middle phalanx. Buddy strapping and hand clinic follow up is important to avoid fixed flexion deformity.
• A “laceration” is a wound caused by blunt force - Avoid looking foolish under cross examination in court by restricting the use of the term laceration to wounds caused by blunt force. A wound caused by a sharp object is described as “incised”. A slash wound is longer than it is deep and a stab wound is deeper than it is long.
• Describe wounds accurately for legal / forensic purposes- Always record the length of wounds and the number of sutures used in closure. 
• Stab wounds of lateral thigh frequently injure the profunda femoris artery Distal pulses are normal and swelling may not be evident for several hours. Such cases should be admitted under the duty surgical or vascular team and may require angiography.
• Alcoholics with an altered conscious level are often hypoglycaemic - ALL patients with an altered conscious level require a BM stick assessment of blood glucose. This may be overlooked in alcoholics, despite the fact that they are prone to hypoglycaemia, as they are assumed to be intoxicated or post ictal. Remember to give IV thiamine / pabrinex as well as glucose to avoid encephalopathy
• Swelling may not be obvious in young children’s fractures - So don’t assume that there is no fracture just because there is no swelling – and the parent thinks it is swollen… see below
• Parents are always (usually) right - If a parent says their child is ill, the child is ill. Parental concern is a legitimate indication for admission at the Royal Hospital for Children.
• Some patients who think they are “going to die” after stab injuries have been proved right- Call a surgeon NOW and get the patient to theatre!
• Intoxicated individuals/alcoholics may not remember they have fallen or sustained an injury! Always consider the possibility of injury in such patients who present with “unexplained” pains e.g. cervical spine # !
• Self-harm patients often have both a “medical” and psychiatric issue.Don’t dismiss, downplay or overlook one aspect and focus on the other.
• Difficult “intravenous” access.  If you are having problems getting a venflon in… remember there are many routes and methods of access to the circulation – e.g. central lines, midlines and even intraosseus (EZIO for adults and children). Don’t persevere if the patient is critically unwell – get help. 
• Thoraco-lumbar fractures are common after falls >2m (especially if axial loading) and MVAs. There are frequently distracting injuries. All such patients should be assessed immediately and have spinal immobilisation instituted or maintained until logroll and senior review. Clinical examination is insensitive but if signs are present they are highly specific for fracture. Thoraco-lumbar imaging should therefore be obtained in such clinical presentations if any of the following are present: 
  • back pain / mid-line tenderness 
  • local signs: bruising / step 
  • neurological signs 
  • cervical spine fracture discovered 
  • GCS <15 (including significant alcohol / drug intoxication) 
  • significant distracting injury 
• ECG abnormality remember old ECGs are usually available on the Clinical Portal
• Sudden Onset of Pain– think of vascular causes.
• Emergency Care Summary – put a patient sticker on all printouts.