Private clinic and A&E: the interface

Private clinic and A&E: the interfaceDr TSUI Sik Hon 徐 鍚 漢 ,FRCP Edin, FRCS Edin, FHKCEMConsultant & Chief of ServiceAccident & Emergency DepartmentQueen Mary HospitalHong Kong1

Contents• Discussion on emergency cases that mayturn up in private clinics• What will happen to such patients afterthey are referred to A&E?• How private doctors help to improvepatients’ outcome by providing theappropriate initial management?• Follow up of cases that are referred backto your clinic3

Medical conditionsHypertension• A 45 year old lady presented with URTIand high BP was found: 200/120• Patient is referred to A&E• What will be her journey like?4

A&E Triage System• Patient will be triaged by the nurses afterregistration• To established priority of care• Base on patient’s general condition, vitalsigns, brief history and referral notes (ifavailable)• According to disease urgency and severity• Nurse initiated investigations andtreatments5

Triage CategoriesTriage Category Patient condition Target response time1. Critical危 殆Suffering from a life threateningconditionWith unstable vital signs requiringresuscitationImmediate2. Emergency危 急3. Urgent緊 急4. Semi-urgent次 緊 急5. Non-urgent非 緊 急Suffering from a potentially lifethreatening conditionBorderline vital signs with risk ofrapid deteriorationSuffer from a major condition withpotential risk of deteriorationSuffer from acute but stableconditionSuffer from minor and stablecondition

Hypertension• BP in A&E: 220/120, P: 92/min• Patient had mild dizziness• Triaged as Cat 3• The key to manage this case:– Establish if this case is hypertensiveemergency or hypertensive urgency7

• Hypertensive emergency:– Severe elevation in BP with complicated byevidence of progressive target organdysfunction• Hypertensive urgency:– Severe elevation in BP without target organdysfunction8

Target organ dysfunction• Coronary ischaemia• Acute pulmonary oedema• Acute renal failure• Aortic dissection•Stroke• Hypertensive encephthalopathy9

Evaluation• CNS: headache, vomiting, impairedconscious level, seizure, neurologicaldeficit, coma• CVS: chest pain, SOB• Renal: haematuria, proteinuria, decreasedurine output• Retina: haemorrhage, exudates,papilloedema10

Investigations•ECG•CXR• Urinalysis•RFT• +/- CT brain11

Management• HT Emergency– Manage in CCU/ICU/Stroke Unit– Rapid and smooth BP control by parentaltherapy12

Management• HT Urgency (much more common)– Rest and repeated BP measurement– Not very urgent actually– Start oral anti-HT as indicated– Monitor response to resting or treatment inObservation Ward or EM Ward– Nifedipine SL NOT recommended because ofrapid drop in BP followed by rebound13

Case 2• A 55 years old gentleman presented toyou with retrosternal dull aching chest painfor 1 hour• Chronic smoker, good past health• You perform ECG in your clinic……14

Can you identify anyabnormality?15

AMIActions for you:• Call ambulance (27353355) and give clearinformation to ambulance controller• Advise against self-transport to hospital• Drugs you can consider to give whilewaiting:– Aspirin ~300mg (check allergy and contraindications– Morphine IV, maxalon IV– TNG (check contra-indications)16

What happens next?• Ambulance equipped with defibrillator willsoon arrive• Rapid transfer to hospital• Alert A&E en-route• Triage Cat 1, immediate attention•Aim for early PPCI or thrombolysis;depending on availability of expertise andindications17

A&E Management of STEMI• Patient evaluation: focused Hx and PE• Define symptom onset time• Establish diagnosis; rule out AMI mimics• Ix: ECG 12 leads, right side, post leads• Ix: CBP, LRFT RG, AP/APTT, type &screen• Set IV access•Tx: MONA• Communication: activate AMI pathway 18

ECG ED R side leads

ECG ED posterior leads

Reperfusion therapyChance of survival• Better with early reperfusion therapy (timeis muscle)• Better with PPCI than thrombolytics• International bench mark:– DNT ≤ 30min–DBT ≤ 90min• Consider PPCI if DBT-DNT < 60min• Also depends on availability of expertise21

No Left SystemTotal Blocked LADMechanical VentilationShock, IABPBalloon time : 13:35 3/11/07Door-to-Balloon Time : 87minNormal FlowRe-establishedPt in ICU ARF 6wFull recovered22

Patient with chestpain/discomfort• A common presentation to A&E• Long list of differential diagnosis• History is the KING, ECG is a MUST• First is to exclude life threatening causes:– Acute coronary syndrome (ACS)– Aortic dissection– Pulmonary embolism– Tension pneumothorax23

Chest pain protocol• After brief history, PE, vital signs; identifythe group of patients with:– Atypical chest pain– Stable angina with non-specific or normalECG• Consider risk factors for ACS• Low to moderate risk: admit EMW orObservation ward for monitoring, serialECG and Troponin24

Rationale for chest pain protocol• A normal ECG does not exclude ACS• Elderly patients and diabetics are more prone to atypicalor silent presentation of ACS• Epigastric or upper abdominal pain may be apresentation of inferior myocardial ischaemia• Response to GI cocktail does not rule out ACS• Reproducible chest wall pain does not rule our ACS• Patient with chest pain and an abnormal ECG should notbe sent home before further assessment25

Neurological Problem• A 71 year old gentleman with history ofDM presented to your clinic in the morningwith facial asymmetry and slurring ofspeech• Is this a case of stroke?26

Acute Stroke• Stroke is a syndrome characterized by asudden neurological deficit caused byintracranial haemorrhage or ischaemia• In the era of thrombolytic therapy, timelydiagnosis and appropriate therapyrequires close collaboration of variousparties27

Chain of optimal recovery of acute stroke patientsEarlyrecognitionEarly EMSactivationFamily doctor has a role hereEarly EDevaluationandinterventionEarly accessto neurologyexpertise

Chain of optimal recovery of acute stroke patientsEarly ED evaluation and interventionInter-department collaboration to shorten:Door to Triage timeEarlyoptimalsupportivecareDoor to Doctor timeDoor to CT timeDoor to Stroke Unit timert-PA30

Respiratory case• A 25-year old man with history of asthmawho appears very dypsnoeic comes toyour clinic• You detect a lot of wheeze on PE• You decide to refer him to A&E• What treatment will you give in your clinic?32

Unfavorable historyBritish ThoracicSociety Guidelines201233

Severity Assessment34

Discharge arrangement36

Blood sugar• 73 year old man, known DM on Diamicron80mg OM• Presented to you with mild dizziness anddry mouth• RG by bedside glucometer: 22 mmol/L• Would you like to refer to A&E or managethis patient yourself?37

A&E Approach• Hyperglycaemia with minimal or nosymptom• Rule out life-threatening complications:– DKA: clinical, urine/blood ketones, ABG– Hyperosmolar hyperglycaemic non-ketoticsyndrome: clinical and blood test– Underlying diseases: ACS, infection…38

Hyperglycaemia• Manage in EMW/Observation Unit forselected cases– Check diet compliance– Check drug compliance– Await investigation results– Input from DM nurse, Dietitian etc if serviceavailable– Dosage adjustment and FU39

Allergy• A 23 year old lady with low back painreceived a shot of diclofenac injection inyour clinic• She has no history of drug allergy• She comes back to you 15 min later withgeneralised urticarial rash, peri-oralswelling, SOB and dizziness40

Are you worried?• PE: BP 80/30, Pulse 120/minchest: wheeze noted• Yes, this is a severe presentation of drugallergy: acute anaphylaxis• Need to call for help41

Urgent Treatments to begiven in A&E• IV fluid replacement• Adrenaline is the main stay of treatment;IV is needed for such presentation,otherwise SC for milder cases• Anti-histamine• Steroid• Salbutamol• Expected response will be fast42

The worst scenario for you….• While you are busy seeing patient in yourclinic, your assistant called you for help: apatient collapses suddenly in your waitingarea• You find an old gentleman, unconsciouswith no spontaneous respiration and nopulse• What should you do?43

Don’t forget to call for help• Update on American Heart Associationguidelines 2010 on CPR– Emphasize on chest compression (C-A-Binstead of A-B-C)– High quality: at least 5cm depth, at least100/min– Allow chest compression alone CPR foruntrained bystander– Chest compression alone is much better thannothing44

For trained personnel• Delay of chest compression is to beavoided• Look, listen and feel for breathing• Briefly check for no response and nobreathing• Activate EMS• Spend no more than 10s to check pulse• Chest compression and rescue breath– 30:2 45

• Get a defibrillator if available• Some malls in HK have installedAutomated External Defibrillator (AED)• Easy to operate46

Use of Automated ExternalDefibrillatorsPads, thenPlug in CableAutomatic AnalysisNeed to PRESS to shock if advised to Do So.47

Resuscitation drugs and equipmentyou may wish to stock• For discussion– IV drugs: adrenaline, piriton, hydrocortisone– ?ATP, atropine– Aspirin, ?morphine– Dextrose, Salbutamol (Neb/Puff/IV)– IV Antibiotics, your choice?48

Orthopaedic Cases• A young man sprained his ankle whileplaying football• He walks with limping gait, withtenderness and swelling around ankle• He does not want to have XR or bereferred to A&E49

Ottawa Ankle Rule50

Another Orthopaedic Case• F/56, known DM• Presents to you with left leg swelling andpain• There is fever• You see this• Are you worried?51

• Don’t mistaken this case as cellulitis• Features that suggests NecrotizingFasciitis:– Systemic symptoms– Disproportionate pain and tenderness over theclinical signs– Purplish discoloration– Blister formation52

TreatmentPrognosis depends on• High index of clinical suspicion ofattending doctor• Early diagnosis• Early involvement of O&T, ICU andMicrobiology Team• Early surgical treatment53

A case of head injury• 61 year old man with IHD and PTCAperformed 2 months ago• On aspirin and pravix• He had syncope after micturition and felllast night, sustained head injury, brief LOC• See you in the morning• You note a 2cm haematoma on occiput• Will you refer this case to A&E?54

Decision for CT Brain55

High Risk HistoryHigh Risk PE• Mechanism of injury• LOC• Amnesia• Anticoagulants (Pravix)• Coagulopathy• Vomiting• Seizure• Focal neurologicalsigns• Asymmetric pupils• Distracting injuries• Intoxication• Large extra cranialhaematoma• Signs of skull #56

Paediatric case• A 6 years old girl presented to you withfever for 2 days• She developed rash this morning• Temp: 39C, patient looks lethargic• This rash is notblanchable57

MeningococcaemiaYour action• Personal protection• Call ambulance• Give one dose of antibiotics beforesending patient away: Cefotaxime(Claforan) or Ceftriaxone (Rocephin)50mg/kg IV• Early antibiotics saves life58

Traffic light system for identifying risk of serious illnessfor children with feverColour• Pale/mottled/ashen/blueActivityRespirationHydrationOthers• No response to social cues• Appears ill to a HCP• Unable to rouse or if roused does not stay awake• Weak, high-pitched or continuous cry•Grunting• Tachypnoea: RR > 60 breaths/minute• Moderate or severe chest indrawing• Reduced skin turgor•0–3 months: ≥ 38˚C;3–6 months: ≥ 39˚C•Non-blanching rash• Bulging fontane• Neck stiffness• Status epilepticus• Focal neurological signs• Focal seizures•Bile stained vomitus

Traffic light system for identifying risk of serious illnessColour• Pallor reported by parent/carerActivity • Not responding normally to social cues• Wakes only with prolonged stimulation• Decreased activity• No smileRespirationHydrationOthers•Nasal flaring• Tachypnoea:RR > 50 breaths/minute age 6–12 monthsRR > 40 breaths /minute age > 12 months• Oxygen saturation ≤ 95% in air• Crackles• Dry mucous membrane• Poor feeding in infants• CRT ≥ 3 seconds• Reduced urine output•Fever ≥ 5 days•Swelling of a limb or joint•Non-weight bearing/not using an extremity

Traffic light system for identifying risk of serious illnessColourActivityRespiration•Normal colour of skin, lips and tongue•Responds normally to social cues•Content/smiles•Stays awake or awakens quickly•Strong normal cry/not crying•NormalHydration•Normal skin and eyes•Moist mucous membranesOthers•None of the amber/ red symptoms orsignsNICE clinical guideline 47 : Feverish illness in children: Assessment andinitial management in children younger than 5 years

Last case• 16 year old girl repeated presented to youfor UTI symptoms• Several courses of antibiotics have beengiven• This time she also C/O epigastric pain withis quite severe; cramping in nature62

Ketamine associated cystitisnormal ketamine abuser x 4 yrs Ketamine abuser x 7 yrsABCourtesy of Dr Peggy Chu, TMH63

Ketamine Associated AbdominalPain• Onset a few hours after taking ketamine• Lasted for 1 to a few days• Epigastric pain, dull and persistent or cramping– Associated nausea and vomiting• Partial relief by buscopan / opioid, but notantacid• Abnormal LFT (~15% HKPIC cohort)

The endThank you for your attention!Questions are welcome65