RCEM best practice guidelines Flashcards
1
Q
Which two IM sedative drugs at what doses are recommended for ABD by RCEM 1st line
A
Ketamine 4mg/kg IM and droperidol 5-10mg IM
2
Q
In ABD - what agents are recommended second line IM and at what doses? (2) What circumstances might they be used?
A
Midazolam 5-10mg IM.
Haloperidol 5mg IM +/- 2mg IM lorazpeam
Used if concerned re: sympathethitc increases
3
Q
How can we manage risk to patients being restrained? (5)
A
- Assess capacity
- Least restrictive restraint
- Try verbal de-escalation
- Observations when able
- Safety person - eyes on patient not involved
4
Q
How can we manage risk to staff? (4)
A
- Early security
- Sufficient numbers for restraint
- Police if needed
- Only staff trained for restraint
5
Q
When would we call the police to assist with a difficult patient in the ED? (3)
A
- Staff injured
- Risk of serious injury
- Delay to security
6
Q
How is it best to restrain a patient? (4)
A
- Avoid prolonged
- As least restrictive as possible
- De-escelate ASAP
- NOT prone
7
Q
What makes a good environment to de-escalate? (7)
A
- Many exits
- Doors open outward
- Quiet
- Not too warm
- No furniture
- No ligature points
- Constantly obsverable
8
Q
Re: rapid tranquilisation in the elderly what agents should we use and what should we avoid?
A
- 5mg droperidol safe
- Benzos can prolong delirium
- Avoid droperidol and haloperidol in PD
9
Q
What is the most discriminating factor in aortic dissection?
A
Pain worse at onset
10
Q
What percentage of 1. CXR and 2. ECG are normal in aortic dissection?
A
- 15% normal CXR
- 30% normal ECG
11
Q
What percentage of TTE will miss dissection? How sensitive is TOE?
A
- 30%
- 99%
12
Q
What are the different phases of CTA and what are they for? (3)
A
- Initial non-contrast - assess intramural haematoma
- Post contrast CT shows extent of dissection
- Arterial phase with ECG synchronisation (gated scan) provides motion free images
13
Q
When should we include just the thorax for CT aorta?
A
Low and intermediate risk (may need completing if abnormality found
14
Q
What are the high risk conditions for dissection? (5)
A
- Marfans
- Connective tissue disorders
- FHx aortic disease
- Known aortic valve disease
- Recent aortic manipulation
15
Q
What are the two high risk features for aortic dissection?
A
- Severe and abrupt chest/back/abdo pain
- Ripping/tearing pain or radiating to back
16
Q
1
A
17
Q
What are the high risk findings with regards to aortic dissection? (3)
A
- SBP difference >20mmHg between arms
- Focal neurological deficit
- New aortic regurgitation murmur (early diastolic)
18
Q
When does RCEM recommend requesting CTA?
A
No other cause found and ANY high risk factor
19
Q
How many Joules are there per pulse in CAD (controlled energy device?)
A
0.1 Joules/pulse
20
Q
What injuries is a CAD likely to cause and which two are the most common? (4)
A
- Fall secondary to paralysis
- Forceful muscle contraction and lead to #/dislocations
- Retained barbs and superficial burns most common
21
Q
What can CADs rarely lead to (4)
A
- Arrhythmia
Single case of:
2. Miscarriage
3. Seizure
4. Stroke
22
Q
When should we perform an ECG in CAD discharges? (4)
A
- ICD
- PPM
- Chest pain
- Palpitations
23
Q
With regards to the police and patients with CAD what should we ensure? (3)
A
- Record names of officers in ED and which station they are from
- Discharge letter should have safety netting advice and tx had
- Patient advice leaflet
24
Q
What are the RCEM recommendations for pain management in adults (5)
A
- Pain should be assessed in <15mins arrival
- Mod-severe pain should have analgesia <15mins
- Severe pain should be re-evaluated 15 mins after first dose
- Pain should be recorded like observations
- Annual pain audit
25
What are super strong magnets made out of?
Neodymium
26
When are we concerned particularly about the ingestion of super strong magnets? (2)
1. When there are more than one
2. When patient is symptomatic (50-75% perforate)
27
What imagining do children with ingestion of superstrong magnets need? (3)
1. CXR
2. AXR
3. If single magnet needs lateral XR to ensure not 2
28
What discharge criteria are there for children following super strong magnet ingestion (6) and what follow up do they need?
1. Single magnet
2. Accidental
3. No co-morbidities
4. Tolerating PO intake
5. <24 hour ingestion
6. Care giver to observe
Needs follow up XR 6-12 hours - not progressing needs d/w paeds surgeons
29
At what population prevalence dose RCEM recommend routine HIV testing?
> 2/1000
30
What is a:
1. Body packer
2. Body stuffer
3. Parachuting
4. Pusher
1. Swallowed drugs, well wrapped
2. Concealed drugs in cling film in mouth, can be swallowed to avoid detection.
3. Recreational drug technique, treat as a stuffer
4. Insert into anus/vagina
31
With police and suspected internal drug traffickers what do we need to keep in mind? (2)
1. Police must stay with patient and they must remain under arrest
2. Patient has the right to talk to a doctor without police
32
Do the police have the legislative powers to authorise intimate search?
Yes but ED physicians do not have to comply and it is not recommended (rupture, can be missed)
33
What is recommended imaging for suspected internal drug traffickers and what do we need to tell the patient (3)?
Low dose CT abdomen and pelvis
1. Need consent
2. Need to know it may not change management
3. Need to know that could be used as evidence
34
If patient with suspected internal drug trafficking is in cardiac arrest what should we keep in mind?
Prolonged resusitation up to an hour can have good outcomes
35
What is the management including observation times for body stuffers/parachuting? (3)
1. Signs/symptoms needs >8 hours observation and follow toxbase
2. Need at least 8 hours observation even if refuse tx
3. LDCT will allow earlier discharge
36
What is the management of body pushers including observation time? (4)
1. Signs/symptoms needs >8 hours observation and follow toxbase
2. Need at least 8 hours observation even if refuse tx
3. LDCT will allow earlier discharge
4. If unwell must way up risk/benefit of intimate search
37
What is the management of body packers who are symptomatic and have positive CT?
1. Urgent surgical removal
2. Benzo/nitrates for HTN
3. Bicarbonate if acidotic
4. Endoscopy can lead to rupture of packaging
5. CT with contrast can help plan surgery but should not delay tx
38
How should body packers with positive imaging who are aymptomatic be managed?
Can be observed and managed in custody
39
How should body packers with positive imaging and mild symptoms be managed? (2)
Observed in hospital
Consider laxatives/bowel irrigation but isotonic (klean-prep or movicol) as theoretical risk of rupture
40
How should body packers who are asymptomatic and refusing imaging be managed?
Discharge back to custody
41
What are the considerations with respect to confirmation of clearance from body packers? (3)
1. If not passed after 48 hours unlikely to
2. If LDCT performed number of packages passed should be counted against those on CT
3. LDCT may need to be used to confirm clearance
42
How should we give discharge advice to patients going back to custody following internal drug trafficking? (3)
1. Sealed envolope FAO custody HCA
2. Number of packages removed .remaining
3. Thorough documentation of triggers to return/safety netting
43
What does RCEM recommend about FIBs in ED? (7)
1. Available all EDs
2. Done ASAP
3. Clinicians performing should have completed competency assessment
4. Observed closely for 1 hour
5. Intralipid should be easily available
6. Departments should have policy
7. Invasive procedure checklist 'stop before you block'
44
What are the advantages of FIB over femoral block in ED (2) ?
1. Decrease risk of intraneural and intravascular injection
2. Lateral cutaneous nerve gives block to thigh
45
What patient group should not have FIB and which group are relatively c/i ? (1 + 1)
1. Obtunded patients - unable to report signs LA toxicity
2. Anticoagulated patients - follow local guidance
46
How does RCEM recommend making FIB safer? (3)
1. US guidance
2. 5ml then aspirate
3. 1 hour observation post block
47
What does RCEM recommend doing to prevent absconding?
1. Prioritise assessment of those at risk absconding and consider direct referral to psych or concurrent management
2. Assess capacity at triage
3. Physical description at triage
4. Inform them of likely wait time
5. Observe every 15 mins or continually
48
What principles do RCEM recommend with regards to restraint? (4)
1. EPs requesting restraint should be clear with legal justification and in notes
2. Should be proportionate
3. Should be as least restrictive as possible
4. Should have written agreement with security re: restraint
49
What period of physical restraint does RCEM say is the maximum before moving to chemical restraint?
10 mins
50
What are the 4 legal justification for restraints?
1. MCA 2005
2. MHA 1983 - if not under section consider requesting section 4 or 136
3. Common law doctrine of necessity - not assessed capacity but significant risk to life. Needs to be most senior decision maker and escalate to consultant ASAP.
4. Duty to protect life - article 2 European Convention on Human Rights
51
What steps should we undertake if patient absconds? (5)
1. Search ED
2. Ask security to search and use CCTV
3. Call patient
4. Call NOK
5. Call police if appropriate
52
Under what circumstances should the police be called if a patient absconds (6)
1. Real threat to life
2. Proportionate response
3. Patients vulnerability taken into account (LD/child)
4. All other efforts have failed
5. No other services can help
6. Discussion had between most senior nurse and doctor
53
Do police have the power to bring patient back to ED at request of ED?
No -must be under arrest or section 136 (if police feel this is appropriate)
This should be clarified by police
54
What are the age RCEM recommends age cut offs for paeds ketamine sedation in ED? (2)
1. Not <1
2. 2-5 years should be clinician with significant experience with ketamine
55
What conditions are mandatory for paediatric ketamine sedation? (4)
1. Full AAGBI monitoring
2. Resus area
3. Minimum 3 members of staff
4. Needs adequate senior nursing and doctor cover in rest of ED
56
What two bits of paperwork should be done for paediatric sedation?
1. Pre-sedation assessment
2. Written consent
57
What are the common side effects of ketamine sedation in paeds and %? (4)
1. Mild agitation (20%)
2. Hypersalivation/lacrimation (10%) - no evidence for anti-cholingergics)
3. Vomiting in recovery phase (5-10%)
4. Involuntary movements/ ataxia (5%)
58
What are the complications, methods to reduce them and % of ketamine in paeds? (4)
1. Emergence (1.6%) - rare under 10, positive psych +/- benzo
2. Airway misalignment (<1%) - basic airway maneuvers
3. Apnea (0.3%) - push over 60 secs decreased chance
4. Larygnospasm (0.3%) - increased if has URTI or simulation posterior pharynx therefore avoid
59
Should methadone be given if dose not checked?
No - not according to RCEM
60
What does RCEM recommend for use of urine tox?
Not supported - expensive and misleading
61
In suspected ruptured AAA
if hypotensive but normal US what is the next reccomended course of action and where best should this be done?
CT in vascular centre
62
What are the 3 most important clinical signs in deciding with a patient is suitable for transfer for AAA?
1. GCS
2. BP
3. Any LOC
63
What 3 clinical factors make transfer for AAA likely to be unsuitable?
1. Cardiac arrest
2. I+V
3. Vasopressor/ionotrope
64
What 3 criteria should mean direct referral to vascular centre from ED without local surgical review?
1. Mild/moderate systemic disease
2. <85
3. Alert
65
When is investigation not required to confirm rAAA diagnosis if it is suspected?
Known AAA
66
What is the evidence based treatment for rAAA?
Quick diagnosis and transfer
SBP 90-120
67
What is recommended by RCEM with regards to transfer rAAA?(4)
1. Ideally paramedic but not essential
2. Doctor should rarely accompany
3. Blood should usually not go with patient that isn't running already
4. Should go to critical care environment and be met with most senior surgical decision maker
68
What features make valid consent (4)
1. Voluntarily given
2. Without pressure of influence
3, By an appropriately informed person
4. Who has capacity
69
Is restraint purely physical?
No - using force or threat of using force, whether or not patient resists is still restraint
70
Who can give consent for an adult patient? (3)
1. Patient
2. LPA
3. Court appointed deputy
71
What 3 parts of law describe consent in children and what ages?
1. Childrens Act 1989 <18
2. Family Law Reform Act 1969 < 16
3. Gillick competence - no set age
72
Who can consent for a child (3)
1. Child if competent
2. 1x parent
3. Court
73
What happens if a child (competent) and parent disagree on refusing treatment?
Parents can't refuse treatment for their child who is competent
Reverse more complicated
74
Where can a section 136 not be used?
Home or garden of the patient in question
75
In what circumstances can police force entry to somewhere with regards to 136? (2)
1. Needs to be a constable?
2. Needs to be somewhere a `136 can be applied
76
Can police officers search patients under 136?
Yes if reasonable grounds they may have something that can hurt themselves or others
77
How long does a 136 last and when dose it begin?1
24 hours from arrival to ED (regardless of whether they then go to 136 suite) therefore should have mental health assessment ASAP
78
What information should be shared with CSP (community safety partnership) (3)
1. Date and time of assualt
2. Location
3, Any weapons used
79
Are we allowed to share information with Community Violence Partnership (CSP)
Yes but anonomyised
80% assaults presenting to ED not reported
80
What constitutes a frequent attender?
>5 attendances / year
81
What 5 ways does RCEM recommend to decrease frequent attenders?
1. ED care plans
2. Case management - detailed assessment of patients needs
3. MDT
4. Primary care - may need more assertive approach
5. Psychological support for patients with medically unexplained symptoms
82
What does RCEM give as targets for mod-severe pain in children? (2)
Analgesia within 20mins
Re-assesed within 60 mins of first dose
83
Who are we required to ask about FGM?
Those is higher risk groups
84
What should we do if FGM disclosed in >18 years?
Document in notes
Supported and offered follow up
85
What should we do if discover or suspect FGM <18 years (3)
1. Inform police
2. Safeguarding
3. Share with GP and health visitor
Failure to do so is illegal
86
If a patient is in custody what 2 things should be done to better manage them?
1. Prioritise within their triage category
2. Senior ED clinician
87
What should we ask police bringing in a patient in custody? (2)
1. In what capacity are they with you? (136/arrest/accompany)
2. Which station are you from and contact details?
88
What should the police ensure at all times if they bring a patient in custody?
2 officers at all times (1 who can remove restraint)
89
3 principles when discharging patient back into custody?
1. D/c summary in sealed envelope to custody HCP
2. Same threshold as discharging home
3. Ideally liase directly with custody HCP - clear safety netting.
90
What is an EPs forensic role?
None but should discuss chain of evidence with police ie. clothes in bags etc
91
What is offered by a SARC? (5)
1. Forensic examination
2. Emergency contraception
3. PEP
4. Counseling
5. Legal advice
92
Under what circumstances should ED perform intimate exam on patient following sexual assualt?
Heavy bleeding
93
What advice should be given to patient going to SARC with regards to evidence? (3)
No shower
No brushing teeth
Preserve clothes
94
What is the role of an EP post sexual assault? (7)
1. Careful hx
2. Thorough exam
3. Most senior doctor and choice of gender
4. Consider pregnancy
5. Consider STI
6. Consider BBV
7. Consider safguarding
95
Post sexual assault what is recommended with regards to Hep B?
1. Assailant not known Hep B - vaccine and 2 further doses from GP
2. Assailant high risk - also give immunoglobulin
96
What prophx abx regime is recommended post sexual assault?
PO cefixime 400mg + azithromycin 1g + metronidazole 2g
97
In what circumstances should sexual assault be reported to police against patients wishes? (4)
1. Child
2. Concerns re: welfare child of victim
3. Lack of capacity and unlikely to regain
4. Guns/knives used
Ideally d/w another consultant
98
What should EP consider once domestic abuse disclosed (6)
1. Information gather
2. Assess immediate safety
3. Children - safeguarding
4. Photo injuries
5. IDVA
6. Off police and advise local shelters
99
What is a MARAC?
Multi-agency risk assessment conference
Information on attendances can be shared here and protected by Galdicott principles
If information shared about perpetrator this should go in the notes
100
Describe the 5 levels of sedation
1. Minimal - responds to commands, entonox
2. Moderate/conscious - responds to commands with light touch, benzo/opoids
3. Deep sedation - will respond to repeated or painful stimulation
4 GA
5. Dissociative
101
What is needed for minimal sedation? (3)
1 physician/ENP
ILS/ALS
Oximetry
102
What is needed for moderate/conscious sedation? (5)
1. 1 sedationist, 1 operator and 1 nurse
2. ILS/ALS
3.Level 1 sedation training
4. Resus
5. ECG/BP/oximetry, CO2 recommended
103
What are the requirements for deep and dissociative sedation? (4)
1. 3 staff
2. Anaesthetic competency
3. Resus
4. Full AAGBI
104
How should a patient be observed post sedation? (2)
1. In same facilities as sedation under back to pre-sedation state
2. Recovery nurse as defined by AAGBI
105
What are the discharge criteria post sedation? (4)
1. Baseline GCS
2. Normal obs
3. No resp compromise
4. Pain/nausea addressed
106
What are the recommended fasting times?
> 2 hours clear fluid
> 6 hours food
107
What can be done to reduce aspiration risk? (5)
1. Delay
2. RSI
3. Regional block
4. Decrease depth and length of sedation
5. Ranitdine/PPI/metoclopramide
108
What is required for a doctor to provide a witness statement? (2)
1. Written patient consent
2. Judicial request
109
What are the 3 levels of witness statement, with time to respond? (3)
1. Emergency - < 12 hours, rare and must be inspector or higher to request
2. Urgent - < 72 hours to meet prosecution dealine
3. Standard < 2 weeks
110
When can a witness statement be given without a patients consent?
If very serious crime and in public interest
D/w another consultant +/- Galdicott Guardian
111
In suspected serotonergic toxicity what agents should be used to sedate ABD?
25-50mg IV chlorpromazine + a benzo
112
When should haloperidol/olanzepine be avoided?
PD/lewy body dementia
113
What should be used for GHB withdrawal?
Baclofen
114
Which sedative agents increase QTc?
Haloperidol and droperidol
115
How should HTN be managed in patients symptomatic with internal drugs?
Nitrates and benzos
Surgical removal
116
What is poor R wave progression defined as?
R wave <3mm in V3
117
In how many days should a complaint be acknowledged according to the NHS constitution?
< 3 days
118
What is the 'sit up and squat test'? Describe its components
- RCEM recommended test for anorexia
- Get patient to lie on floor then sit up and then do a squat. Measured separately
0 - unable to do
1 - able to do but needs hands
2. Can do without hands but appears to struggle
3 - no difficulty
Score of 2 or less is a red flag
119
Between which layers are we infiltrating LA in FIB and which is the top layer?
1. Fascia Lata (top)
2. Fascia Iliaca (bottom)
120
Which nerves are affected by FIB?
Femoral
Obturator
Lateral cutaneous
121
What is the landmark for FIB?
Draw imaginary line between ASIS and pubic tubercle and aim proximal 1/3 and aim 1cm below this
