City hospitals Sunderland A&E Department
Information Card Pack
Produced by Dr Sarah Frewin
Correspondence to s.e.frewin@doctors.org.uk
Review date: January 2012
Nexus C-spine rules
Glasgow pancreatitis score
Alvarado score
Rectal bleeding differentials
Upper GI bleed differentials
Abdominal pain differentials
Jaundice differentials
Rockall score (GI bleed)
ABCD2 (TIA)
Severe sepsis criteria
Sepsis screening tool
Severe sepsis 1st hour pathway
Soft tissue antibiotic policy
Curb 65 (pneumonia)
LRTI antibiotic policy
Meningitis antibiotic policy
UTI antibiotic policy
Wells criteria (PE)
Wells criteria (DVT)
MRC dyspnoea scale
ASA grading (anaesthetics)
BTS asthma exacerbation grades
NICE COPD guidance
NICE head CT guidance (amendment)
NICE head CT guidance
Chest pain differentials
Breathlessness / hypoxia differentials
Bradyarrhythmia differentials
Tachyarrhythmia differentials
Reversible causes of cardiac arrest
ECG interpretation
New York heart failure classification
Grading of murmurs
Headache differentials
Dizziness differentials
AMTS
Timed get up and go test
Stroke mimics
falls /collapse differentials
Pain assessment
Confusion differentials
Hypotension differentials
Stages of hypovolemic shock
CO poisoning
Reversible causes of cardiac arrest
Hypoxia
Tamponade
Hypothermia
Toxins
Hypovolemia
Thromboembolism
Hypo / hype / hypokalaemia
Tension pneumothorax
Stroke mimics
Hypoglycaemia
Seizure
Complicated migraine
Hypertensive encephalopathy
Conversion disorder
Score
CURB-65 score for pneumonia
Description
1
Age 65+
1
New onset confusion
1
Urea >7mmol/l
1
Respiratory rate >30/min
1
SBP <90mmHg / DPB <60mmHg
Additional
adverse
prognostic
features
Hypoxaemia (SaO2 <92% or PaO2 <8 kPa)
regardless of FiO2
Bilateral or multilobe involvement on CXR
Modified Glasgow Score For Pancreatitis
Parameter
score
age >55
1
pO2 <8.0kpa
1
WCC >15
1
Ca2+ (uncorr) <2
1
ALT >100
1
LDH >600
1
glucose >10
1
score > 3 indicates severe pancreatitis
Rockall scoring system
(Risk of re-bleeding / death after acute UGIB)
Variable
Score 0
Score 1
Score 2
Score 3
Age in years <60
60 – 79
>80
Shock
None SBP
Tachycardia Hypotension
>100, pulse
pulse >100, SBP <100,
<100
SBP >100
pulse >100
Co-morbidity Nil major
Cardiac
failure, IHD,
other major
co-morbidity
Diagnosis
Malignancy of
upper GI tract
Mallory-Weiss All other
tear, no lesion, diagnoses
no stigmata of
recent
haemorrhage
Renal or liver
failure,
disseminated
malignancy
NICE criteria for immediate head CT (adults)
 GCS <13 on initial assessment in ED
 GCS <15 2 hours after injury / ED assessment
 Suspected open or depressed skull fracture
 Any sign of basal skull fracture
 Post-traumatic seizure
 Focal neurological deficit
 More than one episode of vomiting
 Amnesia for events >30 minutes before impact
NICE criteria for immediate head CT
(patient experiencing LOC / amnesia since injury)

>65 years

Coagulopathy / warfarin

Dangerous mechanism of injury
ABCD2 to identify patients at high risk of stroke
following a TIA
Score
Description
1
1
2
1
2
1
1
A - Age >=60 years
B - Blood pressure at presentation >=140/90 mmHg
C - Clinical features of unilateral weakness
C - Clinical features of speech disturbance without
weakness
D - Duration of symptoms >= 60 minutes
D - Duration of symptoms 10-59 minutes
Presence of diabetes
Scores range from 0 (low risk) to 7 (high risk)
Wells score for DVT
Score
1
Description
Active cancer (treatment within last 6 months or palliative)
1
Calf swelling >3 cm compared to other calf (measured 10 cm
below tibial tuberosity)
Collateral superficial veins (non-varicose)
Pitting oedema (confined to symptomatic leg)
Swelling of entire leg
Localized pain along distribution of deep venous system
1
1
1
1
1
1
1
Minus 2
Paralysis, paresis, or recent cast immobilization of lower
extremities
Recently bedridden > 3 days, or major surgery requiring
regional or general anesthetic in past 12 weeks
Previously documented DVT
Alternative diagnosis at least as likely
Interpretation
2 or higher:- DVT likely (consider imaging leg veins)
<2:- DVT unlikely (consider XDP to further rule out DVT)
Score
1
2
3
4
5
MRC Dyspnoea Scale
Symptom
Not troubled by breathlessness except on
strenuous exercise
Short of breath when hurrying on walking up a
slight hill
Walks slower than contemporaries on the level
because of breathlessness, or has to stop for
breath when walking at own pace
Stops for breath after walking about 100m, or after
a few minutes on the level
Too breathless to leave the house, or breathless
when dressing or undressing
COPD Guidance (NICE)
Factors to be considered when deciding where to manage patient
Factor
Able to cope at home
Breathlessness
General condition
Level of activity
Cyanosis
Worsening peripheral oedema
Level of consciousness
Already receiving LTOT
Social circumstances
Acute confusion
Rapid rate of onset
Significant co-morbidity (IDDM /
CCF)
SaO2 <90%
Changes on CXR
Arterial pH
Arterial PaO2
Favours hospital
No
Severe
Poor /deteriorating
Poor /confined to bed
Yes
Yes
Impaired
Yes
Living alone / not coping
Yes
Yes
Yes
Favours home
Yes
Mild
Good
Good
No
No
Normal
No
Good
No
No
No
Yes
Present
<7.35
<7kpa
No
No
>7.35
>7kpa
Asthma Exacerbation Grades (BTS)
Grading of asthma exacerbations
Moderate
Increasing symptoms
PEFR >50 – 75%
best or predicted
No features of acute
severe asthma
Acute severe
PEF 33 – 50% best
or predicted
RR > 25 /min
Life threatening
PEF <33% best or
predicted
SpO2 < 92%
HR > 110 /min
PaO2 <8kpa
Inability to complete
sentences in one
breath
Normal PaCO2
Silent chest
Cyanosis
Feeble respiratory effort
Bradycardia, arrhythmia,
hypotension
Exhaustion, confusion,
coma
Near fatal
Raised PaCO2
Requiring
mechanical
ventilation with
raised pressures
Grade
1
2
3
4
5
6
Grading of murmurs
Description
Very faint, heard only after listener has "tuned in"
may not be heard in all positions
Quiet, but heard immediately after placing the
stethoscope on the chest
Moderately loud
Loud, with palpable thrill (ie, a tremor or vibration
felt on palpation)
Very loud, with thrill. May be heard when
stethoscope is partly off the chest
Very loud, with thrill. May be heard with stethoscope
entirely off the chest
New York Association Heart Failure Classification
Class
Description
1
2
No Limitation. Ordinary activity does not cause
undue fatigue, dyspnoea, or palpitations
Slight limitation of physical activity. Comfortable at
rest, but ordinary physical activity results in heart
symptoms
3
Marked limitation of physical activities. Comfortable
at rest, but less than ordinary activity causes heart
failure symptoms
4
Symptoms of heart failure are present at rest. If any
physical activity is undertaken, discomfort is
increased
Modified Alvarado score for appendicitis
Score
Description
1
Migratory right iliac fossa pain
1
Anorexia / acetone urine
1
Nausea/vomiting
2
Tenderness right lower quadrant
1
Rebound tenderness right iliac fossa
1
Pyrexia greater than or equal to 37.5°
2
Leucocytosis
Score <5 is not likely appendicitis
5 or 6 is equivocal
7 or 8 is probably appendicitis
9 means patient is highly likely to have appendicitis
ASA Grading (assessment of fitness for anaesthesia and surgery)
Grade
I
II
III
IV
V
Definition
Normal healthy individual
Mild systemic disease that does not limit activity
Severe systemic disease that limits activity but is
not incapacitating
Incapacitating systemic disease which is constantly
life-threatening
Moribund, not expected to survive 24 hours with or
without surgery
Sepsis Screening Tool
Score
Criteria
1
Temperature > 38°C or < 36°C
1
Heart rate > 90 beats/minute
1
Respiration > 20/min
1
WCC >12 or <4
1
Hyperglycaemia in absence of diabetes >6.6
1
Acutely altered mental state
Ask patient about history suggestive of new infection
Sepsis present in patients presenting with 2 or more criteria
PTO for severe sepsis criteria
Severe Sepsis Criteria
SBP <90 or MAP <65
Urine output <30mls/hr for 2 consecutive hours
Unexplained metabolic acidosis pH<7.35
Acute change in mental state
New need for O2 to keep SPO2 >90
Plasma lactate >2
Platelets <100
Creatinine >177
Oxygen
Severe Sepsis First Hour Pathway
Target SPO2 >94% / COPD target 88-92%
Blood
cultures
Also consider other microbiology samples (urine /
sputum /swabs)
IV
antibiotics
As per trust guidelines (contact microbiology for
advice)
Fluid
Bolus of Hartman’s / N/saline @20ml/kg. Further
boluses @10ml/kg
Lactate /
FBC
Also ensure Hb >7 / do other bloods as
appropriate
Catheterise
Commence 1 hourly urine output
Discuss with senior to asses if escalation in care is needed
Antibiotic policy for soft tissue infection
Less severe
More severe
1st line
Flucloxacillin PO
500mg – 1g QDS
Flucloxacillin
IV 1-2g QDS
Penicillin
allergy
Clindamycin PO
300 – 600mg QDS
MRSA
suspected
Doxycline PO 100mg
BD
Plus either
Sodium fusidate PO
500mg TDS
Or
Rifampicin PO 300mg
BD
notes
Treat for 5,7, 10
days according to
response
Clindamycin IV
Treat for 5,7, 10
600mg QDS
days according to
response
Caution in elderly
due to risk of C-diff
Contact
microbiology
Antibiotic policy for acute meningitis infection
Antibiotic
Standard
Notes
Cefotaxome IV 2g Add amoxicillin IV 2gQDS if
QDS
aged > 55to cover listeria
Or
Ceftriaxone IV 2g
BD
Additional
Acyclovir IV
For suspected HSV
10mg/kg TDS
Antibiotic policy for UTI (non catheterised)
Treatment
Patient
condition
Asymptomatic
Needs no treatment
Symptomatic
Trimethoprim PO 200mg BD for 5-7 days
Or
Cefalexin PO 500mg TDS for 5 – 7 days
Clinically unwell
Co-amoxiclav IV 1000/200mg TDS for 5 – 7 days
Or
Cefuroxime IV 750mg – 1.5g TDS for 5 – 7 days
Or
Aztreonam IV 1g TDS for 5 – 7 days
Septic
Single dose of IV gentamicin 5mg/kg (await culture)
Antibiotic policy for LRTI
Condition
1st line
Bronchitis
/ COPD
Doxycycline PO 200mg loading
dose then 100mg OD for 5 days
Systemic
Sepsis
CAP
CURB-65
≤2
CAP
CURB-65
≥3
2nd line
3rd line
Amoxicillin 500mg Moxifloxacin PO
– 1g TDS for 5
400mg OD for 5
days (IV or PO)
days
Cefuroxime 750mg – 1.5g IV
Contact
TDS (switch to co-amoxiclav PO
microbiology
625mg TDs to complete 5 days
ASAP)
Amoxicillin 1g TDS (initially IV) In penicillin allergy Moxifloxacin PO
Plus either
Clarithromycin IV 400mg OD for 5
Clarithromycin IV 500mg BD
500mg BD
days (up to max
Or
Or
of 10 days
Erythromycin PO 500mg QDS
Erythromycin PO
Or
500mg QDS
Clarithtomycin PO 250 – 500mg
For 5 – 7 days
BD
All for 5 – 7 days
Cefuroxime 750mg – 1.5g IV
TDS
Plus
Clarithromycin IV 500mg BD
Grade 1
Grade 2
Grade 3
Grade 4
Stages of hypovolemic shock
Up to 15% blood volume loss (750mls)
Blood pressure maintained
Normal respiratory rate
Pallor of the skin
15-30% blood volume loss (750 - 1500mls)
Increased respiratory rate
Blood pressure maintained
Increased diastolic pressure
Narrow pulse pressure
Sweating
30-40% blood volume loss (1500 - 2000mls)
Systolic BP falls to 100mmHg or less
Marked tachycardia >120 bpm
Marked tachypnoea >30 bpm
Decreased systolic pressure
Loss greater than 40% (>2000mls)
Extreme tachycardia with weak pulse
Pronounced tachypnoea
Significantly decreased systolic blood pressure of 70 mmHg or less
Nexus C-spine rule
Score
Parameter
1
Midline c-spine tenderness
1
Evidence of intoxication
1
Altered consciousness
1
Focal neurology
1
Distracting injuries
Score >1 indication for c-spine imaging
Score
Wells criteria for PE
Parameter
3
Clinical signs of DVT
3
Alternative diagnosis less likely
1.5
HR>100
1.5
Immobility / surgery in last 4 weeks
1.5
Previous DVT / PE
1
Haemoptysis
1
Malignancy
Low risk = 1 – 2.5 points
Moderate risk = 3 – 6 points
High risk = 6.5 – 12.5
1
1
1
0
1
1
1
1
1
1
1
AMTS
What is your age
What is your date of birth
What is the year
Please remember “42 West Street”
What is the time to the nearest hour
What is the name of this hospital
Can patient recognise 2 people (Dr / nurse)
What year did World War II end (1945)
Name the present monarch
Count backwards from 20 to 1
Recount the address you were asked to remember
8 or higher is normal for an elderly patient
Pain assessment
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating /relieving factors
Score
Chest pain differentials
MI
ACS
Angina
Aortic dissection
Pericarditis
PE
Pneumonia
Pneumothorax
GORD
Sickle cell crisis
PUD
Musculoskeletal
Tachyarrhythmia differentials
Sinus tachycardia
Fast AF
SVT
Atrial flutter
VT
Re-entrant tachycardia (WPW)
Bradyarrhythmia differentials
Sinus bradycardia
Complete or 3rd degree AV block / other heart blocks
MI
Drugs (beta-blockers, digoxin etc)
Vasovagal
Hypothyroidism
Hypothermia
Cushings reflex
Hypotension differentials
Hypovolemia
Cardiogenic shock
Septic shock
Neurogenic shock
Anaphylaxis
Dysrhythmia
Postural hypotension
Vasovagal
Addison’s / adrenal failure
Drugs
Breathlessness / Hypoxia differentials
COPD / asthma
Pneumonia
PE
Pulmonary oedema
MI
Pneumothorax
Pleural effusion
Pain
Sepsis
Metabolic acidosis
Anaemia
Chronic fibrotic lung disease
Upper GI bleed differentials
Peptic ulcer
Oesophagitis
Erosions
Varices
Mallory-Weiss tear
Swallowed blood
Malignancy
Rectal bleeding differentials
Polyps
Diverticular disease
Angiodysplasia
Haemorrhoids
Anal fissure
IBD
malignancy
Upper GI bleed
Abdominal pain differentials
AAA
Infarction / ischemia
Obstruction
Pancreatitis
Appendicitis
Perforation
Strangulated hernia
Torsion
Ectopic
Referred pain
IBD
PID
Constipation
Jaundice differentials
Paracetamol OD / toxins / drugs
Gall stones
Sepsis
Viral hepatitis
Alcohol
Cholangitis
Pancreatitis
Haemolysis
Gilberts
Dizziness differentials
Shock
Arrhythmia
Postural hypotension
Anxiety / hyperventilation
Syncope
Epilepsy
Hypoglycaemia
Vertigo
BPPV
Menieres
Drugs
Headache differentials
Haemorrhage
Meningitis
Encephalitis
Raised ICP
Temporal arteritis
Glaucoma
Dehydration
Tension
Migraine
Extracranial (sinuses etc)
Hypertension
hypoglycaemia
Acute confusion differentials
Hypoxia
Infection
Drugs
Dural haemorrhage (subdural haemorrhage)
Endocrine
Neoplasm
Metabolic
Alcohol
Psychosis
Falls / collapse differentials
MI
Arrhythmia
Shock
Sepsis
CVA
Seizure
Hypoglycaemia
PE
Postural hypotension
Mechanical
Syncope
TIMED GET UP AND GO TEST
Patient wearing regular footwear, using usual walking aid, and sitting back in a
chair with armrest.
Ask patient to do the following:
1. Stand up from the armchair
2. Walk 3 meters (in a line)
3. Turn
4. Walk back to chair
5. Sit down
Observe patient for postural stability, steppage, stride length and sway
Scoring:seconds
Normal:Abnormal:-
Completes task in < 10
Completes task in >20 seconds
Low scores correlate with good functional independence
High scores correlate with poor functional independence and higher risk of falls
Complex
ECG interpretation
What it looks like
P wave
2-3 sq high
1.5-3sq long
R wave
1st positive deflection after P
PR
interval
3-5 sq long
QRS
5-15 sq high, up to 3 small sq long
ST
Should be isoelectric
Max height= -0.5 - +1 sq
T
Height= 0.5-10 sq depending on
leads
QT
9-10 sq long
Changes
Can be negative in AVR, V1,V2
RBBB
Prolonged QRS, RSR (rabbits ears) with T wave inversion in V1, wide S
and upright T in V6
LBBB
Wide QRS in all leads, slurred R and T wave inversion in V6, may have
ST depression / elevation
Suspected CO poisoning
PC:-
Headache, N&V, drowsiness, dizziness, dyspnoea, chest pain
Questions
Do you feel better away from home or work?
Does anyone else in the house have the same symptoms?
Have you recently had a heating / cooking appliance installed?
Have all cookers / heaters been service in the last year?
Do you ever use your oven / stove for heating purposes?
Has there been any change to the ventilation in your home (eg double glazing)?
Have you noticed any soot / increase condensation around appliances lately?
Does your work involve exposure to smoke / petrol fumes?
What type of home do you live in (detached / semi / hostel etc.)?
Management
Blood for COHb estimation
Oxygen
Do not allow patient to go home to where there are suspect appliances
Contact local HPA