acute medical algorithms updated jan.06

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Acute Medical Acute Medical

Algorithms Algorithms

Interim clinical algorithmsInterim clinical algorithms

Web Edition May – November2005



DIRECTORATE OF MEDICINE CLINICAL ALGORITHMS

CONTENTS

CARDIOLOGYAcute Coronary Syndromes without ST elevation ………………. Page 3

Use of Tirofiban in ACS……………………………………….. Page 6 Use of Clopidrogel in ACS……………………………………… Page 6

Acute Left Ventricular Failure ……………………………………….. Page 7Use of Carvedilol………………………………………………… Page 9

Biochemical Investigation of Cardiac Chest Pain ……………….. Page 10Management of Arrythmias………………………………….………... Page 11

Tachycardias………………….………………………………… Page 12

Broad Complex Tachycardia….………………………….…. Page 53 Narrow Complex Tachcardia………………………………… Page 55

Atrial Flutter/Fibrillation (Rescus Council AF)..…………….…. Page 13(54) Bradycardia………………………………………………………. Page 52

ST Elevation /New Left Bundle Branch Block (LBBB)…………… Page 16

DERMATOLOGYAcute Blistering Dermatoses………………………………..……….. Page 18Dermatology Cellulitis ………………………………………………… 0

DIABETESHypoglycaemia in the Adult ……………………………..……..……. Page 22Management of Diabetic Ketoacidosis in Adults ………….……… Page 24

GASTROENTEROLOGYAcute Gastrointestinal Haemorrhage……………………………….. Page 25Acute Gastroenteritis/Colitis………………………………………….. Page 27Jaundice………………………………………………………………..… Page 28

HCOOP & NEUROLOGYStroke …………………………………………………………………….. Page 29Delirium ………………………………………………………………… Page 31Falls …………………………………………………………………….. Page 33Syncope ……………………………………………………………….. Page 35

RENALAcutely Presenting Renal Failure …………………………………… Page 36Hypercalcaemia…………………………………………………………. Page 40Management of Shortness of Breath in Dialysis Patient ……….. Page 41

RESPIRATORYAcute Exacerbation of COPD ……………………………………..…. Page 42Asthma in Accident and Emergency Departments……………….. Page 44Severe Asthma in Hospitalised Patients…………………………… Page 46Suspected Community Acquired Pneumonia …………………….. Page 47Suspected Pulmonary Embolus……………………………..….…… Page 48

RHEUMATOLOGYSingle Hot Joint………………………………………………….….….. Page 50

RESUSCITATION COUNCIL ALGORITHMS…………………… Page 51



This web edition will be maintained as up to date as possible. There will be slight variance from the paperversion which has already been distributed.

Key additions:

Acute Asthma – British Thoracic Society Chart 2 – Acute Severe Asthma in Adults

Appendix – Resuscitation Council UK and European Resuscitation Council Algorithms

THE ALGORITHMS ARE DESIGNED TO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THESECONDITIONS, HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCE FROM THEALGORITHM



CLINICAL ALGORITHM FOR ACUTE CORONARY SYNDROMES WITHOUT ST ELEVATION“UNSTABLE ANGINA – NON STEMI”

ECG

No ECG ST

Acute MI:exit this guideline

ECG ST

Or new LBBB

ECG ischaemicor raised Troponin

Normal ECG+

Troponin

Suspected Cardiac Pain

Suspectedacute coronary syndrome

Confirmedacute coronary syndrome

Normal ECG/Troponin at4 and 12 hours:

Consider discharge

Stress Test

Risk StratificationIntermediate

3

Low4

High2

Medical Rx

Admit CCU/HDUECG Monitor

Aspirin/LMWH/ beta-BlockerClopidogrel6

Stable for 48hr with nohigh risk features

Recurrent symptoms orECG changes or otherindication of high risk

1

Coronary Angiography7

Out atient

Out atient

Out atient

In-Patient

Glycoprotein II B/III A

inhibitor5

IF ANY AREABNORMAL

Revascularisation or medical treatment(as appropriate)

This algorithm is based on national guidance. The algorithm is designed to guide the basiccare of patients presenting with this condition, however, clinical need may require thatthere is variance from the algorithm.Ref: British Cardiac Society Guidelines. Heart 2001; 85: 133-42

3



Other indications of high risk include acute ischaemia associated with hypotension, arrhythmia, or heart failure; impairedLV function; and diabetes.

2Poor exercise capacity & myocardial ischaemia at low workload (<stage II of Bruce Protocol)

3Poor exercise capacity or myocardial ischaemia at low workload.

4Good exercise capacity and no ischaemia at low workload.

5Appendix on Troponin

6Appendix on Clopidogrel

7Patients who fail to settle despite optimal medical therapy or those in the high-risk group should be considered for early

inpatient cardiac catheterisation after discuss with the cardiac team.

The guidelines should not be regarded as the standard for medical care for all patients.Individual care must be managed on the basis of all clinical data available for that care andare subject to change as scientific knowledge advances.

Clinical Guidelines for the Management of Coronary Syndromes (ACS)

The following is an update on the management of patients with unstable angina and non Q-wave myocardialinfarction. It includes risk stratification of patients and the use of low molecular weight heparin.

Patients are risk stratified based on clinical, ECG and cardiac Troponin levels. Those who fall in the intermediateand high-risk groups should be admitted to CCU. Those who fall in the low risk group (normal ECG, negativeTroponin levels at 4 and 12 hours) should be considered for early discharge and exercise test.

5 Consider the use of platelet IIb/IIIA antagonist in the high-risk patients (See appendix on Tirofiban).

6 All patients must receive Aspirin 300mg stat on admission, reduced to 150mg/day for 1 month and then 75-150mg/day thereafter. If contraindicated, consider Clopidogrel (300mg stag, and then 75mg/day) as an alternative.(See Appendix on Clopidogrel).

6 All patients should be commenced on Enoxaparin 1mg/kg bd in the absence of the usual contraindications.

6 Beta-Blockers should be started early. If beta blockers contraindicated and in the absence of heart failure, a ratelimiting calcium antagonist e.g. Diltiazem will be the alternative treatment of choice.



5 APPENDIX - ON THE USE OF TIROFIBAN IN ACUTE CORONARY SYNDROME PATIENTS

The IIB/IIIA inhibitor, Tirofiban, is available for use in addition to Aspirin and Heparin in high-risk acute coronarysyndrome patients presenting without ST-elevation. Such patients are identified by:

The combination of Troponin T rise >0.1mcg per litre and significant ST-depression, particularly where there is:

Recurrent or refractory ischaemia as manifested by further chest pain or ST-segment depressionOrHaemodynamic instability with pulmonary oedema or hypotension on presentation.

The use of Tirofiban identifies a patient as being at high risk and therefore likely to benefit from urgent transfer to aninvasive centre for angiography and possible revascularisation. In parallel therefore, urgent referral to a tertiarycentre for transfer should be made. The use of Tirofiban should be restricted to Coronary Care Unit on the advice ofa consultant or Specialist Registrar in Cardiology.

Dose Regimen

Intravenous infusion on the Coronary Care Unit, initially 400 nanograms/kg/minute for 30 minutes, then 100nanograms/kg/minute for 30 minutes, then 100 nanograms/kg/minute for at least 48 hours, maximum duration oftreatment 108 hours.

Contraindications

Abnormal bleeding within 30 days, stroke within 30 days, haemorrhagic stroke or other intracranial disease, severehypertension, bleeding diathesis, increased PT or INR, thrombocytopenia.

6 APPENDIX – ON THE USE OF CLOPIDOGREL IN ACUTE CORONARY SYNDROME PATIENTS

Clopidogrel is indicated to be used in addition to Aspirin and low molecular weight Heparin as anti-thrombotictherapy in patients presenting with non ST elevation MI acute coronary syndromes where:

1. There is evidence of a rise in Troponin T above 0.1mcg per litre2. There is significant ST depression on the presenting ECG without a Troponin rise3. There is widespread anterior T-wave inversion suggestive of an LAD “syndrome”.

Dose Regimen

The initial loading dose should be with 300mg of Clopidogrel followed by a maintenance dose of 75mg per day.

The duration of treatment has been agreed as nine months, on line with median length of time enrolled in the“CURE” study.

Contra-indications to Clopidogrel

Active bleedingBreast-feeding



CLINICAL ALGORITHM FOR ACUTE LEFT VENTRICULAR FAILURE

ACUTEBREATHLESSNESS

O2Therapy *ECG, CXR, Bloods, ABG

Pulmonary OedemaChest X-Ray

Cardiogenic Shock

Consider:

• Central venous line• Urinary catheter – hourly

output

• Dopamine/Dobutamine IV*

IV Nitrate *

Regular loop diuretic

Echocardiogramduring admission

ACE Inhibitor *

BP < 100systolic

ClinicalRadiologicalImprovement

BP > 100systolic

Loop diuretic, 80mIV Frusemide StatOpiates

Spironolactone *

• Echocardiogram within 24hours

• * Seek Urgent SpecialistAdvice

Carvedilol *

STABLE

DISCHARGE

Cardiologist/Physician

OUT-PATIENT GP Drug DoseTitration

FOLLOW-UP IntermediateSpecialist Nurse

THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM IS DESIGNED TO

GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THIS CONDITION, HOWEVER,CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCE FROM THE ALGORITHM.

6



LEFT VENTRICULAR FAILURE – GUIDELINES

Specialist Advice Local or Tertiary Centre, contact for Cardiology Advice on Cardiogenic Shock

IV Nitrates Initiate dose to keep blood pressure greater than or equal to100 systolic

ACE Inhibitor Contraindicated by clinically or echocardiographically significant ASExisting significant renal impairment requires careful monitoring and consider RenalArtery Stenosis

Spironolactone Requires monitoring if used with ACE Inhibitor. Contraindicated in renal failure

Beta Blocker See Therapeutic Guidelines regarding Carvedilol

Dopamine/Dobutamine Consider low dose Dopamine 1 microgram/kg/min via central lineDobutamine 2.5 – 20 micrograms/kg/min to get systolic BP greater than or equal to 100mmHg

Echocardiography Unless already known left ventricular failure

O2 ABGs determine safety of oxygen dosage.



THERAPEUTIC GUIDELINE FOR THE USE OF CARVEDILOL IN SEVERE SYMPTOMATIC CHRONICHEART FAILURE

This guideline has been formulated following the adoption of Carvedilol onto the Trust formulary for the treatment ofcertain patients with heart failure in the light of the COPERNICUS trial.1 This trial showed that in appropriatelyselected patients Carvedilol can reduce the risk of death by 35%. The benefits of Carvedilol (7 lives saved for 100patients treated for 1 year) in these patients may be comparable to ACE Inhibitors. Carvedilol is suitable forpatients with very severe heart failure in whom other ß-Blockers are contraindicated.

This guidance updates and supplements the guidelines regarding the use of Beta-Blockers in Heart failure issued byPRICCE. It complements the guidelines for the use of Bisoprolol (previously issued by Guys & St Thomas’ Trustand adopted by East Kent Hospitals Trusts) which remain unchanged.

SUITABLE PATIENTS FOR CARVEDILOL

Carvedilol is indicated for the treatment of severe (NYHA IV)2 stable chronic heart failure with poor systolic leftventricular function (ejection fraction <25% on echocardiography) as an adjunct to standard therapy.2

It may also be tried in patients considered suitable for treatment with Bisoprolol (NYHA III4 stable chronic heartfailure and ejection fraction of 35% or less) who have been unable to tolerate Bisoprolol.

Carvedilol is indicated in these patients regardless of age and regardless of the aetiology of the heart failure unlessit is due to uncorrected major valve disease.

Patients must be:

• Stable• Euvolaemic i.e. no signs of pulmonary oedema, and no/minimal peripheral oedema or cardiac origin• Systolic blood pressure >85mmHg, heart rate >68/min• Creatinine <247 micromol/l• The COPERNICUS trial also excluded patients who had had calcium antagonists, Beta-Blockers or class I

antiarrhythmics in the last 4 weeks and patients who had had a recent (<2 months) MI,CVA orrevascularisation.

• Conventional contraindications to Beta-Blockers such as asthma, first, second and third degree heart blockapply.

ß-Blockers should not be used in heart failure patients who are already on a combination of both ACE inhibitors andangiotensin II antagonists, but are indicated in patients who fulfil the above criteria and are only on either an ACE

inhibitor or angiotensin II antagonist.

Effect of Carvedilol on Survival in Severe Chronic Heart Failure. New England Journal of Medicine 1651-8, 344, 22 May 2001Dyspnoea at rest

ACE inhibitor or AII antagonist, Spironolactone, other diuretics +/- DigoxinDyspnoea on minimal exertion



DOSING REGIMEN

Warning: Carvedilol treatment in heart failure should be initiated at a low dose and gradually titrated up in a similarfashion to Bisoprolol. If patients are unable to tolerate it in higher doses they should revert to their previous lowerdose. Carvedilol must not be stopped abruptly.

Starting Dose: 3.125mg bd for 2 weeksIncreasing to: 6.25mg bd for 2 weeksThen: 12.5mg bd for 2 weeksFinal target dose: 25mg bd

Patients should be assessed before each increase in dose. If there is a delay in this assessment the patient shouldbe maintained on the current dose until a full assessment is possible. Assessment should include direct questioningabout any change in exercise tolerance (may improve), side effects and cardiovascular examination including bloodpressure. The dose of diuretics may need to be adjusted (either increased or decreased).

SIDE EFFECTS

Patients should be warned about potential side effects. These are essentially the same as occur with Bisoprolol butthere is some suggestion that Carvedilol may be better tolerated.

It is common for patients to feel generally exhausted initially during treatment but if this occurs they should beencouraged to persist with the tablets since this often improves over a few weeks. It often helps to delay increasingthe dose for 2-4 weeks while they get used to the tablets.

Dizziness if it occurs after a dose increase may be self-limiting. Check they are not bradycardic. It may be due toan improvement in the heart failure so that a reduction in diuretics may be needed to avoid dehydration and posturalhypotension. It may also help to take the Carvedilol 12 hourly and take ACE inhibitors and diuretics at a differenttime of day (eg 2 hours later).

Increased fluid retention may occur and patients should be advised to monitor their weight daily and watch forankle swelling and worsening breathlessness. If this occurs they must be assessed to see whether their diureticsneed to be increased or Carvedilol reduced.

Diabetic patients may find that their normal warning symptoms of sweating and shaking during hypoglycaemia aremasked. Hypoglycaemic symptoms of decreased mental alertness and agility are unaffected and should beheeded. Diabetic control may worsen during initiation of treatment with Beta-Blockers so regular monitoring of bloodglucose is advised during the early stages of treatment.



ALGORITHM FOR BIOCHEMICAL INVESTIGATION OF CARDIAC CHEST PAIN

ECG

New onsetST segmentelevation ornew LBBB

Manage patientaccording to TrustGuidelines foracute MI

Single CKmeasurementindicated

Measure Troponin onadmission

Manage patientaccording to TrustGuidelines foracute coronarysyndromes

Troponinincreased

Non-diagnostic ECGchanges

Suspicious cardiac chest painSuggestive history

Troponin normal

Repeat Troponin andCK 12 Hours after onsetof chest pain

Troponinincreased

Consider earlydischarge andarrange exercisetest

Troponin normal

Manage patientaccording to TrustGuidelines foracute coronarysyndromes

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patientspresenting with this condition, however, clinical need may require that there is variance from the algorithm.

Ref: British Cardiac Society Guidelines. Heart 2001; 85: 133-42

10



Management of Tachycardia

TachycardiaHR > 100

Sinus TachycardiaNarrow Complex Tachycardia

Treat underlyinig causeeg sepsis/bleeding

Irregularly irregularAtrial fibrillation

Rate 150 bpmAtrial flutter with 2:1block

RegularRe-entrant SVTAVNRT/AVRT

See algorithm on AF/AFlutter

See algorithm on AF/AFlutter

Vagal manoeuvres/Adenosine 1

Haemodynamically stableConsider Magnesium infusion 3IV lidocaine or IV Amiodarone 4

Synchronised DC Cardioversion ifchemical cardioversion

unsuccessful

Venttachy

Seek senior advice – R

See n

Seek senior advice – Registrar or above

Consider IV adenosine to aid diagnosis

If haemodynamically unstable (systolic BP less than 90 mmHg), or have chest pain, or breathlessness – See

Always check the serum potassium urgently – aim for K > 4.0 mmol/l – 3. If pulseless manage with standard



Also see Resuscitation Council AF Guideline Atrial

Flutter/Fibrillation

Acute < 24 hrs

Synchronised DCcardioversion.Consider TOE

Chemicalcardioversion

Ventricular rate control

& anticoagulation

IV or oral DigoxinOr

IV or oral VerapamilOr

Oral or IV DiltiazemOrOral or IV Beta blocker

Considersynchronised DCcardioversion in

4-6 weeks

Propafenone600 mg PO Stat

orSotalol

80 mg PO StatorAmiodarone

150 mg IV over10 mins. Can be

repeated onceor

IV Flecainide100-150 mg over30 mins – if no

known structuralheart disease.



This algorithm is based on national guidance. The algorithm is designed to guide the basic carepresenting with this condition, however, clinical need may require that there is variance from theRef: European Resuscitation Council Guidelines 2000 for Adult Advanced Life Support Resu(2001) 211–221. See ERC algorithms in appendix.

Notes:

1. This algorithm applies in the absence of heart failure or haemodynamic instability. If these areappendix.

2. Always have the serum potassium result available – ideally this should be > 4.0 mmol/l

3. Patients who are haemodynamically unstable ie systolic BP < 90 mmHg, chest pain, or are in tachycardia and should be managed on the Coronary Care Unit and should be considered for Senior advice.

4. TOE = transoesophageal echocardiography.

5. IV Amiodarone should be administered via a long peripheral line or a central line.

6. Verapamil and Diltiazem are not to be used in patients already on Beta blockers.



CLINICAL ALGORITHM FOR ST ELEVATION / NEW LEFT BUNDLE BRANCH BLOCK (LBBB)

Aspirin 300mg stat,02, Analgesia5 Min

Early Beta-Blocker4

CK Measurement 6-12 Hours

Statin5

Day 1 – Continue 150mg Aspirin/Day

ACE Inhibitor – Day 26

Thrombolysis WITHIN 20 minutes

of arrival2 / 3

ADMIT CCU

ECG – ST ELEVATIONNEW LBBB

2

CHEST PAIN

CARDIACREHABILITATION

DISCHARGEDAY 5-6

ETT/ANGIOGRAPHYFOR RISK STRATIFICATION

his algorithm is based on national guidance. The algorithm is designed to guide the basic care ofatients presenting with this condition, however, clinical need may require that there is variance from thelgorithm. Ref: National Service Framework: Coronary Heart Disease



GUIDELINES

1 Thrombolysis:

1mm elevation in two or more limb leads2mm elevation in two or more consecutive chest leads

2 If thrombolysis is considered appropriate for a patient presenting with LBBB then it should be administered withinthe time stated in the hospital protocol. It is not acceptable to delay thrombolysis in order to track old ECGs orawait Troponin results if the history supports a diagnosis of acute myocardial infarction.

3 Patients under the age of 70 with an anterior MI presenting within 4 hours of onset of chest pain should receiveaccelerated tPA or Retaplase. tPA should also be used in any patient who has previously receivedStreptokinase.

4 Early use of Beta-Blockers is advised in the absence of the usual contraindications. They should be prescribed after theadministration of thrombolytic agent has been completed usually in the CCU setting. Beta-Blockers should be continuedlong-term and the agents of choice are Atenolol, Metoprolol and Bisoprolol.

5 Patients should be commenced on a statin (Pravastatin or Simvastatin at starting doses of 40mg and 20mgrespectively).

6 All patients with MI should be commenced on an ACE inhibitor (if no contraindications) on day 2 and continuedlong-term . This is in view of the recent findings of the HOPE study. Routine echocardiography of all MIpatients is not recommended, as it will not alter their management. Use of echo should be restricted to thosepatients with suspected complications e.g. valvular dysfunction, VSD, left ventricular thrombus (esp. largeanterior MIs). The recommended ACE inhibitors are Lisinopril and Ramipril at maximum tolerated dose.

The main indications for urgent transfer to a tertiary centre for cardiac catheterisation are continuing myocardialischaemia or a catastrophic complication such as VSD or acute mitral regurgitation. All proposed emergencytransfers should be discussed with a consultant cardiologist.

At discharge, a copy of the final page of the MI integrated care pathway must accompany the routine dischargesummary to the GP. The information included on this page must include diagnosis, thrombolysis (and door toneedle times), any complications, list of discharge medication in particular the reasons for absence of any of the key medication. This data should also be entered on a database at the time of patient discharge to facilitate futureaudit. The patients should receive a booklet with a list of their medication and a timetable of further appointmentsand investigations.

All MI patients are reviewed in the “MI clinic” run by the cardiac rehabilitation nurses at 2 to 4 weeks. Their

symptoms and medication (in particular dosages) will be reviewed. Their assessment will include a treadmillexercise test that will be reviewed by a consultant cardiologist who will decide whether cardiac catheterisation isindicated. This will lead to “fast-tracking” of high-risk patients.



THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM IS DESIGNED TOGUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THIS CONDITION, HOWEVER,

CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCE FROM THE ALGORITHM.

Presentation:

Blistering can have a large number of causes. The blistering process can be localised or generalised. The patientmay have generalised symptoms and signs either associated with or independent of the blistering disease processitself. One needs to consider all aspects of the patient history and their disease presentation, in order to formulate adifferential diagnosis and active management plan.

Cause:

During the clerking process, it should become apparent from a combination of the accurately taken history andexamination what the likely diagnostic possibilities are. Think about the age of the patient, their medication history,recent events and possible infections as potential contributing or causative factors. Other causes of blisteringinclude some eczemas, bullous impetigo, herpes simplex virus, T.E.N., autoimmune bullous diseases andphytophotodermatitis.

Management:

It is likely that the Dermatologist will be required to be involved in the investigation and management of all but themildest cases, including the possibility of skin biopsies. Please advise the Dermatologist early in the day should youneed their input.



CLINICAL PATHWAY FOR DERMATOLOGY: CELLULITIS

CELLULITIS

History & Examination Nursing Observations:• Temperature• Pulse• Blood Pressure• Mark edge of advancing

erythema with pen

• Pain Chart/Assessment

Initial Investigations: • FBC, U&E’s, LFTs, ESR, blood

cultures• Skin swabs• Consider skin scrapings for

mycology

(For mild cases)

NO

(For More Severe Cases)

YES

Treatment:• Refer back to community care (GP,

District Nurse) as appropriate• Treat with oral antibiotics (See

below) for 10 days minimum• Gentle compression/elevation

• Treat underlying cause/trigger

Improvement:

Discharge when stable

Immediate Treatment:

• Admit and elevate limb• Analgesia as appropriate• IV antibiotics (see chart below) for at

least 5 days

• Encourage oral fluids

ASSESS THE NEED FOR ADMISSION

No Improvement/Deterioration:

Seek Specialist advice

Route: Medication: Dose: Duration:

Intravenous 1. Flucloxacillin 500mg 6 hourly At least 5 days or until pyrexia settles

Plus 2. Benzylpenicillin 1.2g 6 hourly At least 5 days or until pyrexia settlesOral 1. Amoxycillin 500mg 8 hourly For a further 10 days

or 2. Erythromycin 500mg 6 hourly For a further 10 days Can be started orally

or 3. Clarithromycin 500mg bd For a further 10 days in a penicillin allergic Patient from day 1

Plus Flucloxacillin 500mg 6 hourlyFor a further 10 days

Medication Guide: Both the IV antibiotics shown below must be started in combination to cover the likelyorganisms, unless there is an allergy to penicillin. If positive cultures are obtained, then one can alter the regimeas appropriate. When oral therapy is subsequently commenced, any of those suggested can be used, asappropriate.

Presentation:

This algorithm is based on national guidance. The algorithm is designed to guide thebasic care of patients presenting with this condition, however, clinical need may requirethat there is variance from the algorithm. Ref:.



Cellulitis is an inflammation of subcutaneous tissues in which an infective cause is assumed or proved. The patientis normally unwell and pyrexial often with flu-like symptoms. The affected area is red, hot and swollen. It isfrequently tender to touch and localised pain can restrict movement. Cellulitic areas may present with blistering andskin necrosis in association.

Cause:

The usual cause of cellulitis in immunocompetent individuals is a group A Streptococcus, but other Lancefieldgroups have also been implicated. Occasionally Staphylococcus aureus is implicated either alone or in association

with the Streptococcus. In children under the age of 2 with facial cellulites, consider Haemophilus influenzae type b.In immuno-compromised patients, other organisms may need to be considered, such as Pseudomonas aeruginosaand Campylobacter jejuni.

Medication:

Beta haemolytic Streptococci are sensitive to penicillin with IV Benzylpenicillin being the treatment of choice.Patients allergic to penicillin can be given erythromycin (or Clarithromycin). This can be given via the oral route fromthe outset, as its bioavailability is high, and with IV erythromycin being very irritant to the veins leading to rapidtissueing of the venflon. Treatment must be continued for at least 2 weeks otherwise relapse is very likely. Assuggested in the table above, the oral antibiotics should be continued after at least 5 days of IV therapy. If apositive culture is obtained, antibiotic therapy can be altered if sensitivities indicate that this is appropriate.

Local Treatment:

Gentle cleansing with an antibacterial soap substitute can be beneficial. Particular attention to foot hygiene isimportant.

If there is significant blistering or erosions, a daily soak or wash with diluted potassium permanganate can help, asthis is a good antiseptic and drying agent.

Topical therapy is limited to bland emollients that can help to soothe. Blistered or eroded areas may be dressedwith simple non-adherent dressings with or without an absorbent dressing over, such as Allevyn or Lyofoam, if thereis significant ooze.

Topical antifungals can be used when there is associated fungal infection.

Leg ulcers should be managed conventionally, except that the compression bandaging should be discontinued untilthe acute, painful phase of the cellulitis has settled.

Mild compression bandaging can be introduced during the healing phase, especially when mobilising the patient.

In uncomplicated cases of lower leg cellulitis, consider class 2 compression below knee support hosiery for 4 to 6months, following resolution of acute phase.

References: Rook, Wilkinson, Ebling. Textbook of Dermatology. 6th Edition. (1998). Blackwell Science LtdHughes and van Onselen. Dermatology Nursing: a particle guide. (2001). Churchill LivingstoneLeppard and Ashton. Treatment in Dermatology. (1995). Radcliffe Medical Press



Clinical Algorithm Hypoglycaemia in the Adult:

Altered Consciousness,altered behaviour orneurological signs

Mild Hypoglycaemiawithout alteredconsciousness

Admission with Hypoglycaemia

(Check finger prick blood glucose& also take blood for laboratoryglucose for later analysis. If notknown diabetic take blood forInsulin & C-Pe tide

Symptomatic recovery

• Maintain normoglycaemia• Organise meal• If type 2 diabetic on Sulphonylurea will

need continuous IV glucose 10% for24 hours

• Identify Cause

Give oral glucose solution• Give 25-50 ml 50% GlucoseIV

• Give Glucagon 1mg IM or SC

if no venous access(NB glucagon relatively ineffective inchronic hypoglycaemia, Type 2 diabetes,alcohol induced hypoglycaemia )

Identify Cause: Excess insulin/oral hypoglycaemic. Malnutrition, starvation,alcohol, liver disease, other drugs (aspirin OD, ACE), hypoadrenalism,hypopituitarism, insulinoma, reactive (e.g. post gastrectomy)

Discharge Arrangements:Patient should not drive.Notify Diabetic Nurse to contact patient and review(K&C & QEQM only)Organise review by normal medical Supervisor

This algorithm is based on national guidance. The algorithm is designed toguide the basic care of patients presenting with this condition, however,clinical need may require that there is variance from the algorithm.Ref:



CLINICAL ALGORITHM FOR THE MANAGEMENT OF DIABETIC KETOACIDOSIS IN ADULTS

Clinical History: • Polyuria• Polydipsia• Abdominal Pain• Weakness• Vomiting

• Confusion

Clinical Signs: • Assess dehydration• Deep sighing respiration

(Kussmaul)• Smell of Ketones

• Lethargy

Confirmed Diagnosis

Diabetic Ketoacidosis

• Shock• Reduced Conscious

level• Coma

• Vomiting

• Dehydration• Clinically Acidotic

Resuscitation:• Airway/ NG Tube• Breathing (100% 02)• Circulation IV Colloid/

Crystalloid) until circulation

restored

Intravenous Therapy: • Correct fluid balance over 24-48

hours tailored to individual needs• 0.9% saline - with KCL – may need

between 10 to 30mmol K per hour – MONITOR – see below

• 6 unit IV insulin / hour• (IV bicarbonate very rarely indicated

and only after discussion withregistrar/Consultant)

Therapy:• Start with sc insulin• Give oral fluids• Contact diabetic nurses to

enable same day dischargeand communitymanagement

• No Dehydration

• Clinically Well

• Tolerating fluid orally

Biochemical Signs: • Ketones in Urine• Elevated Blood Glucose• Acidaemia• Take blood also for electrolytes & urea• Perform other investigations as

indicated

Identifying Underlying Cause:SepsisMI Should notStroke beGastroenteritis dismissedAbdominal Pain

Amylase may be elevated

Observations:• Hourly blood glucose• Neurological status at least hourly• Hourly fluid input/output (ensure input

exceeds output until fluid deficitcorrected, avoid over-rapid correction offluid deficit).

• Electrolytes 2 hours after start of IVtherapy, then 4-hourly – hypo-kalaemiakills

• Monitor ECG for T-wave changes• NG Tube if impaired consciousness• Bladder catheter if doubt about urine

No Improvement?• Check insulin infusion

connected viadedicated line

DeterioratingNeurological Status?

• Meningitis?• Cerebral Oedema

Good Progress (Blood Glucose reduction ~ 1-2 mmol/hour, Good urine output and vital signs normal)• Continue standard insulin infusion (see drug chart overleaf)• Ensure serum potassium always remains within normal range• Change to dextrose containing fluids when Blood glucose <10 mmol/l

• Commence S/C insulin (Actrapid QDS) when tolerating oral fluid (may still have urinary ketones)• Continue insulin infusion for 1 hour after s/c insulin



CLINICAL ALGORITHM FOR THE MANAGEMENT OF DIABETIC KETOACIDOSIS

GUIDELINE NOTES

For newly diagnosed Type 1 or 2 Diabetic, admission is rarely necessary, confirm diagnosis of diabetes and type and

refer to Diabetic nurse to initiate protocol for management of Newly Diagnosed type 1 Diabetes and to commence

outpatient insulin. The Diabetic physicians will be happy to give advice on further management and follow up.

HYPEROSMOLAR COMA

More common in elderly and mortality greater

Fluid depletion greater.Fluid resuscitation should be slow over 48-72 HoursInsulin sensitivity greater and may only need 1-2 units/hour of IV insulin. Discharge on oral hypoglycaemic or dietmay be possible.High risk of thrombotic events. Fully anticoagulate with LMWH if not contraindicated.

IV SLIDING SCALE INSULIN REGIME FOR GENERAL USE:

Add 50 units of human Actrapid Insulin to 50mls of 0.9% Saline in a Syringe Driver. Give Insulin as below.

Capillary Blood Glucose (mmol/l) IV Human Actrapid (U/Hr)<4 0.5

4.1-7 17.1-11 211.1-15 315.1-20 5

>20 6

If BM remains persistently above 20 mmo/l inform Doctor. Hypoglycaemia is corrected by giving carbohydrate andnot being discontinuing insulin. If hypoglycaemia develops it must be corrected quickly.

Fluids:

If BM>12 give 0.9% saline 1L with 20mmol/l KCL over 6hours

If BM<12 give 5% Dextrose 1L with 20mmol/l KCL over 6hours

Return to subcutaneous Insulin:

Once patient eating normally and not vomiting, switch back to normal daily insulin regime. Ensure this overlaps withthe insulin infusion. ie. Give S/C injection at mealtime, 60 min before insulin infusion is discontinued. If notpreviously on insulin use 24-hour insulin requirement when stable on sliding scale regime to estimate dose.

This algorithm is based on national guidance. The algorithm is designed to guide the basic careof patients presenting with this condition, however, clinical need may require that there isvariance from the algorithm.Ref: Evidence-based On-call. NHS National Electronic Library for Health and is adapted from

the Diabetes UK Guideline on DKA in Children and Adolescents (09-02-2002).



CLINICAL PATHWAY FOR ACUTE GASTROINTESTINAL HAEMORRHAGE

History: Haematemesis/Melaena.NSAID’s/Aspirin/Warfarin.Previous peptic ulcer disease.Alcohol intake.

Examination: Features of chronic liver disease.Heart rate/Blood pressure.Lymphadenopathy/Abdominal masses.

If liver disease suspected:Clotting studies/LFT’s

Avoid normal salineIf varices suspected:Consider Terlipressin

Management: Full blood count/Urea and electrolytes.Stop NSAID’s/Aspirin.

Group and save/cross-match IV fluidsLarge bore intravenous cannula.

If patient unstable & Pt stable &Hb < 10g Hb >10g

High risk of re-bleeding,stabilise + surgical review

Contact surgeons

Urgent OGD

Endoscopy following morning

Calculate Rockall score*

If low risk of re-bleeding,

Early discharge

Surgery/Discharge

22

THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM IS DESIGNEDTO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THIS CONDITION,HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCE FROM THEALGORITHM.



Notes: Initial Management of Upper GI Bleeding

1. Coagulation screening is not required for all patients with suspected upper GI bleeding. However, the test should be

requested in the following situations:

Patient on warfarin (INR only) or heparin (APTR only)

Known coagulation abnormality

Known/ suspected chronic liver disease or jaundice

Massive bleeding requiring large volume transfusion

2. The following are strong indicators of the need for immediate fluid resuscitation:

Systolic Hypotension (<100mHg)Tachycardia (>100)

Postural drop in blood pressure of >20mmHg

However remember:

‘Normal’ range of BP for individual patients may vary (BP 90 systolic is normal for some patients

Drugs (eg betas blockers), anxiety, and arrhythmias (eg paroxysmal AF) may influence heart rate irrespective of degree of blood

loss. Postural hypotension may have other causes. Therefore always interpret haemodymamic indices in the context of the

amount of blood loss.

3. Suspect variceal bleeding if:

History of, or clinical evidence of chronic liver disease

Evidence of portal hypertensionPrevious varices or variceal bleeding

4. CVP lines provide a means of monitoring fluid requirements and early identification of rebleeding, particularly where other

haemodynamic indicators may be unreliable (eg elderly patients or patients on beta blockers). CVP insertion should be

considered in the following situations:

Patients with known renal or cardiac failure

Patients who have brisk / ongoing bleeding

Patients with suspected / proven variceal bleeding

Patients at high risk of rebleed (Rockall score 6 or more)

Rockall Score is a means of assessing risk of rebleed and mortality following non-variceal upper GI bleeding. Reference:

Rockall TA, Logan RF, Devlin HB, et al: Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 38: 316-

321

0 1 2 3

Age <60 60-79 >=80

Shock Systolic >100

Pulse <100

Systolic >100

Pulse >100

Systolic <100

Co-Morbidity None Heart Failure

IHD

Major Comorbidity.

Renal Failure

Liver failure

Disseminated Malignancy

Diagnosis Mallory-weiss tear

Normal (and no blood seen)

All other diagnoses Upper GI Malignancy

Stigmata of

Haemorrhage

None (or dark spot only) Fresh Blood seen;

Adherent clot;Visible

Vessel;Spurting vessel

Total score Death %(95% CI)

Rebleeding(95% CI)

8+ 40% (30% to 51%) 37% (27% to 47%)7 23% (15% to 31%) 37% (28% to 46%)

6 12% (6.3% to 17%) 27% (20% to 34%)5 11% (6.3% to 15%) 25% (19% to 31%)4 8.0% (4.0% to 12%) 15% (10% to 21%)3 1.9% (0.0% to 3.9%) 12% (6.8% to 17%)

0 to 2 0.0% (0.0% to 0.93%) 5.9% (3.3% to 8.5%)



CLINICAL PATHWAY FOR ACUTE GASTROENTERITIS/COLITIS

History: Travel/Symptoms

History of inflammatory bowel disease.

Other people affected, bleeding ?.

Antibiotic therapy.

Examination: Features of inflammatory bowel disease.- Joints/Eyes/Skin.

- Evidence of circulatory compromise.

Presumed

Gastroenteritis

Full blood countUrea andElectrolytesStool cultures

if had antibioticsc.diff toxinif vomiting -> I.V.fluids

Presumed relapse

IBD or newdiagnosis IBD

Full blood countU&E’s/CRPStool cultures +/-c.diff toxinI.V fluids

Sigmoidoscopy +/-rectal biopsy

Infection unlikely – start Hydrocortisone 100mgIV tds +/- oral steroids (eg Prednisolone 40 mg)Consider 5-amino salicylates if IBD likely afterdiscussion with Gastroenterologist.

?Colonoscopy ?Surgical procedureDischarge when stable.

Discharge

THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM ISDESIGNED TO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THISCONDITION, HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCEFROM THE ALGORITHM.



CLINICAL PATHWAY FOR JAUNDICE

History: Drugs/Alcohol.Sexual partners/Contacts.Family history.Pruritis/Fever.Dark urine/Pale stools.

Examination: ?Alcohol.Stigmata of chronic liver disease.Masses/Stigmata of malignant disease.Lymphadenopathy/Hepatomegaly.

?Haemolysis

?Ascending cholangitis/sepsis – antibioticsas per antibiotic policy

Investigations: FBC, U&E’s,LFT’s, clottingstudies & bloodcultures

Ultrasound Dilated ductsERCP +/- PTC

Non-dilated ductsConsider: Hepatitis A&C serology.

Auto-immune profile.Drugs/Alcohol.Metastases.Liver biopsy.

THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM ISDESIGNED TO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THISCONDITION, HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE ISVARIANCE FROM THE ALGORITHM.



Has there been an acute onset of a focal neurological deficit?

Have the symptoms

resolved within 24 hours

TIA

Start Aspirin 75mg od

Neurovascular clinicappointment

DISCHARGE

STROKEFBC, U+E’S,

Glucose,

Cholesterol, ECGExit Algorithm

Consider alternative diagnosisDoes the

patient require

urgent CT @

YES NO

CT SCAN Is survival likely?

ADMIT STROKE

UNIT

NO

Palliative care, decision re: CPR.

Exit Algorithm

YES

YES

NO

CT WITHIN 48 HRS IF NOT

ALREADY DONE

Is Bp <

140/90

NO

Check

4o

YES

Is Temp

<37.5 C

Check 4 o

NO

Evidence of infection

NOYESOnly lower acutely

if evidence of

accelerated

hypertension

Paracetamol

1g 6o

Can patient swallow?

YES NO

Normal dietNBM

IV fluids

SALT

Normal diet

Modified dietNG Feed

DIETICIAN

Are O2 SATS

<93%

YES

O2 24%

Is BM

>11

YES

IV insulin sliding scale

NO

Treat

appropriately

Is haemorrhage

unlikely/excluded

NO

Await

CT

YES

Aspirin 75mg

od

Is pt mobile?

YES

Physio/OT

assessment

Is pt safe to

discharge

YESNO

REHABILITATION

Is there

evidence of

PVD or DM

NO

Compression

stockings

Discharge CART/FDH/stroke

OPD



ACUTE MANAGEMENT OF STROKE

– a check list for the first 3 days

Prompt appropriate care saves lives and improves outcome

Once presumptive diagnosis is made initiate following care:Monitor neurological state:

• vital signs Pulse 4 hrly cardiac monitor if irregular or rate >100

Respiration 4 hrly

BP 4 hrly )

O2 Saturation 4 hrly ) manage as below

Temperature 4 hrly )

• conscious level Glasgow coma scale 4 hrly

Assess

• History: obtain as detailed a history as possible from patient/relatives/carers.

• Examine: including full neurological assessment

• Investigate: FBC, U&E, LFTs, Glucose, ESR, Clotting if on Warfarin, ECG, CXR.

• CT – with in 48 hours. @ urgent (same day) if potential bleed (on warfarin, recent trauma, possible sub-arachnoid) or worsening neurological state.

• Other specialised tests – see guidelines.

Maintain homeostatic control

• Temperature if above 370

- Paracetamol. If above 37.5 look for infection and add antibiotics.

• Oxygenation if O2 saturation < 95% - provide 2 – 4 l O2 by nasal cannulae.

• Blood pressure systolic 180 – 220 and/or diastolic 105 – 120 mm Hg - Do not treat

systolic > 220 on three or more readings, or diastolic 120 – 140 mm Hg or both Treat

diastolic > 140 Urgent treatment

• Glucose if blood glucose > 10mmol/l maintain normoglycaemia with insulin

• Hydration maintain normal hydration with iv/subcut fluids. Fluid balance chart• Metabolic status check and monitor electrolytes daily. Correct as required

Antithrombotic therapy

• Aspirin 300mg immediately, ideally after haemorrhage has been excluded on CT

Management of stroke impairment

• Swallowing Assess, including bedside water test if appropriate. If swallow unsafe or

possibly unsafe, make nil by mouth and review at 6 hours, repeat after 24 hours, if continues to

be unsafe refer to SALT

• Paralysis Ensure good positioning and pressure relieving bed/mattress

• Continence Avoid catheterisation unless in retention or skin at risk

Prevention/treatment of complications

• DVT/PE Ensure full length TED stockings are provided.• Pneumonia ensure swallow assessment and swallow guidelines are followed. Good

positioning and changes in position to facilitate chest movement.

Monitor for signs of infection

• Pressure sores ensure good positioning and regular changes in position

• Epilepsy iv diazepam or clonazepam

followed by oral valproate, carbamazepine or phenytoin

This algorithm is based on national guidance. The algorithm is designed to guide the basic care ofpatients presenting with this condition, however, clinical need may require that there is variance

from the algorithm. Ref: National Clinical Guidelines for Stroke RCP 2000 ; European StrokeInitiative Recommendations for stroke management Cerebrovasc Dis 2000;10 : 335 - 351



CLINICAL ALGORITHM FOR THE MANAGEMENT OFDELIRIUM

Specific/empiricalantibiotic treatment

Cultures, UrinalysisFBC, ESR

CXR

Infection

Follow up

Monitor with AMTAvoid sedatives/restraint

Multidisciplinary discharge planning

Continue

Improving

Seek expert helpConsultant Old Age Psychiatry/

Geriatrician

Review diagnosis

Worsening

Progress

Discontinue likely drugsCaution with benzodiazepine

withdrawal

Review all drug treatmenteg drugs with anticholinergic activity,

benzodiazepines, other CNS depressants

digoxin, antihypertensives

Drugs

Treat cause found

U&E, LFT, GlucoseECG

Other tests

Other

Investigate andidentify underlying causes

DELIRIUM

yes no

is there a change fromthe normal mental state?

possible delirium

<8/10

delirium unlikely -

consider other diagnoses

eg dementia, depression

8+

AMT

Features of Delirium

1. Disturbance of consciousness with reduced ability to focus, sustain or shift attention

2. A change in cognition or development of perceptual disturbance not better accounted for by pre-existing orevolving dementia

3. Disturbance develops over short period of time (hours or days) and fluctuates during course of day

Reference: The Guidelines are based on those developed by Dr Lesley Young and Dr Jim George, Cumberland Hospital, Carlisle and the

American Psychatric Association Practice Guidelines, 1998.



This algorithm is based on national guidance. The algorithm is designed to guide thebasic care of patients presenting with this condition, however, clinical need may requirethat there is variance from the algorithm. Ref: The Guidelines are based on thosedeveloped by Dr Lesley Young and Dr Jim George, Cumberland Hospital, Carlisle and theAmerican Psychiatric Association Practice Guidelines, 1998.

Summary of Carlisle guidelines for management of delirium

In all stages during the hospital admission, ensure good communication with the patient and carer and between professionals caring for the patient.

1. Identification of delirium using established diagnostic criteria (see over).

2. Recognition of delirium can be increased by the routine assessment of cognitive state, e.g. using the AMT (see

over). Repeated use of the AMT may help to determine recovery or onset of delirium in those not delirious onadmission.

3. Assessment of patients pre-admission cognitive, functional and social status. This information may need to beclarified with the carer.

4. Identification of risk factors such as dementia, severe illness, sensory impairments, alcohol use.

5. Identification of underlying cause (commonly infection or drugs).

6. Treatment of underlying cause or removal of offending drugs.

7. Avoidance of physical restraints.

8. Avoidance of major tranquillizers, where possible, but if necessary use only one drug and in the lowest dosepossible (e.g. haloperidol 0.5-3mg orally up to QDS). Review drug treatment regularly.

9. Multi-disciplinary team involvement in treatment and discharge planning.

10. Create optimum environment for care (e.g. single room, good lighting).

11. Use reality orientation techniques and rehabilitative care models.

12. Ensure adequate discharge and follow up to avoid unnecessary readmissions and to provide support to patient

and carers.



FALLS ALGORITHM

Patient present to A&E/CDU having falls

HISTORYCan you remember falling?

Did you slip/trip on something?

Any preceding symptoms?

Do you know why you fell?

EXAMINATIONFull medical examination

Remember L+S BP

Rule out fractures/other fall related injury

DRUG HISTORY>4 drugs leads to increased risk of falling

Look for drugs causing postural hypotension

Look for sedatives, eg Benzodiazepine

DECIDE ON CAUSE OF FALL – The common causes are

Osteoporosis preventionSeparate Guidelines exist locally and from NICE (2005)

1. Acute illness Treat as appropriate and falls screening tool 2

2. Blackout/dizzy spell/cause unknown ECG – Normal ) refer to falls clin

Abnormal 24 hour ECG ) investigate as in3. Simple slip/trip Falls screening tool 2

4. Frail older person often with cognitive impairment Falls screening tool 2

DECIDE ON NEXT STEP1. Admit (a) Acute medical ward 2. Discharge (a) No further input needed

(b) Rehab ward (b) CART

(c) Orthopaedic ward (c) Rapid response

FOLLOW UPIf dizzy spell/blackout or cause of fall unknown – ask nurses to do screening tool 2 and refer to falls clinic

Otherwise follow up as usualRefer to falls service as advised in screening tool 2.

Stabilise medically



Acute Assessment Syncope (One of causes Transient Loss of Consciousness = T-LOC)

Is loss of consciousness attributable tosyncope or not?

Is heart disease present or absent? Are there important clinical features in

the history that suggest the diagnosis?

When to admit for observation/Consultant levelreview (most of rest have low morbidity and/or noneeded immediate treatment so can be discharged

from A&E or CDU) o Any nausea/ vomiting/ abdominal

pain (unless suspect partial complexseizure)

o patient pallor aftero no prolonged confusion after

Suspected or known significant heart disease ECG shows

o Bifascicular block (defined as either left bundle

branch block or right bundle branch block combinedwith left anterior or left posterior fascicular block) Avoid common diagnostic errors

o TIAs do not have loss ofconsciousness

o Tonic clonic convulsion <15 secondsafter loss of consciousness isconsistent with syncope, longerthan this => epilepsy

o Drop attack diagnosis

o Other intraventricular conduction abnormalities (QRSduration _0·12 s)

o Mobitz I second degree atrioventricular blocko Asymptomatic sinus bradycardia (<50 beats/min) or

sinoatrial blocko Pre-excited QRS complexeso Prolonged QT intervalo Right bundle branch block pattern with ST-elevation

in leads V1-V3 (Brugada syndrome)Do not waste investigations in T-LOC.A proper history is worth any number of

tests (History from witness, bytelephone etc).CT/MRI head scan without neurologyEEG is not for syncopeDizziness is not syncopeThink of Driving (below for basic license)

Simple Vasovagal faint: No restrictionProbable Syncope(low risk): At least 4 weeks off

Probable Syncope(high risk): 4 weeks off after Rx, or 6months free

Other T-LOC no seizure pointers: At least 6 months offT-LOC with seizure pointers: 1 year off

o Negative T waves in right precordial leads, epsilonwaves and ventricular late potentials

o suggestive of arrhythmogenic right ventriculardysplasiao Q waves suggesting myocardial infarction

Syncope occurring during exercise Syncope causing severe injury Family history of sudden death Discuss patients without heart disease but with sudden

onset of palpitations shortly before syncope, syncope insupine position and patients with frequent recurrentepisodes, patients with minimal or mild heart diseasewhen there is high suspicion for cardiac syncope

Cardiac arrhythmias as cause of syncope Syncope due to cardiac ischaemia

Relevant East Kent Services

Tilt Table evaluation is usually throughCardiologist or Care of Elderly Physicianinterested in Falls/Syncope. Any ECGabnormality like AF, LVH or ectopics is anabnormal ECG and needs 24hr tape first !

Syncope secondary to the structural cardiopulmonarydisease

Stroke or focal neurologic disorders Cardioinhibitory neurally-mediated syncope when urgent

pacemaker implantation is planned Ref: Guidelines on management (diagnosis and treatment)

of syncope E uropean Heart Journal (2001);22:1256–1306



CLINICAL ALGORITHM – ACUTELY PRESENTING RENAL FAILURE

Small KidneysNormal or big kidneys(excluding amyloidosis andpolycystic kidney disease

Rate of rise SCr <50umol/l/day

Rate of rise SCr >50 umol/l/day

PreviousSCr normal

PreviousSCr increased

Urea/SCrIncrease

CRF

Rate of rise SCr > 50umol/l/day

Flare of previousdisease

Acute-on-chronicrenal failure

Renal Ultrasound

Normal

Normal

Urinary tractdilatation

ARF

No Prerenalfactors?

Parenchymatousglomerular orsystemic ARF

Yes Data indicatingglomerular or

systemic disease?

No Improvementwith specific

treatment

Yes

PrerenalARF

Vascular ARFYes Great or small No

Acutetubulointerstitial

nephritis

Yes Data indicatinginterstitial disease?

No

No

Acutetubularnecrosis

No

Crystals or tubulardeposits?Yes

Tumour IysisSulfonamides

Amyloidosis Other

ObstructiveARF

Yes

30



THIS ALGORITHM IS BASED ON NATIONAL GUIDANCE, THE ALGORITHM ISDESIGNED TO GUIDE THE BASIC CARE OF PATIENTS PRESENTING WITH THISCONDITION, HOWEVER, CLINICAL NEED MAY REQUIRE THAT THERE IS VARIANCEFROM THE ALGORITHM.

Diagnostic Approach to Acutely Presenting Renal Failure

Step 1

History (including drug history and recent changes in drug therapy), notes review for evidence of pre-existingdisease and previous renal function, physical examination, urinary bladder catheterisation (if oligoanuric)

3 crucial assessments: volume status, urinalysis, renal ultrasound

Step 2

Consider whether the presentation is acute renal failure, acute on chronic renal failure, or acutely presentingend stage renal failure.

Refer acutely presenting end stage renal failure to the renal service

Step 3

Consider whether acute/acute on chronic renal failure is prerenal, renal or postrenal.

Refer suspected renal causes of acute/acute on chronic renal failure to the renal service

Step 4

Consider simple therapeutic measures for prerenal and postrenal failure (volume expansion, relief ofobstructive uropathy).

If no response to simple measures for prerenal failure refer to the renal service.

If no response to simple measures for postrenal failure refer to urology unless either biochemistry or volume status is life-threatening in which case refer to the renal service.

Favours Acute Favours Chronic

No past history Past history of renal diseaseHistory of systemic illness No history of systemic illnessStigmata of systemic disease No stigmata of systemic diseaseNormal sized kidneys Small kidneys (<8 cm on renal USS)



Management of Acute Renal Failure

Acute fall in GFR leading to rising urea and creatinine

sometimes associated with oligo/ anuria

Initial investigations: Renal unit profile (1) (urgent)

Arterial Blood gases

(2)ECG

Urine dipstick / microscopy / Sodium content

Insert urinary catheter

Measure urine output hourly

Maintain BP >120/80

Consider CVP line (3)

Maintain CVP 8-10 cm

Once fully resuscitated: Fluid restrict previous hours output plus 30 ml/hr

Arrange urgent renal ultrasound (4)

Immunological screen (5) if urinalysis positive

CK +/- myoglobin the lab will not process myoglobin

requests next am

Hepatitis screen if dialysis likely

Refer to renal team (6) if creatinine either >250 or rising by > 50 μmol/L/day

or persistent oligo/ anuria despite fluid resuscitation.or for further advice if diagnosis uncertain



Notes : Acute Renal Failure

1. Treat Hyperkalaemia If ECG is abnormal give 10 mls 10% calcium gluconate or calcium chlorideby slow intravenous injection over 5 minutes . Follow with 10 units intravenous Actrapid, plus 50 ml50% glucose (watch BM stix and give further glucose as required), and then with calcium resonium(30g od rectally or 15g tds orally with lactulose ). Insulin and Glucose can be repeated if necessarydepending on response and insulin infusion may be necessary.

Watch potassium intake (especially IV fluids). Treat acidosis first. (see below)

2. Metabolic Acidosis should be treated if base deficit >5. If there is space to give fluid, 1.4%bicarbonate solution can replace normal saline as crystalloid infusate until fluid resuscitation iscomplete. If no ‘fluid space’, give more cautiously and obtain advice from renal team.

NB higher bicarbonate concentrations risk sodium overload and can precipitate heart failure.

3. CVP lines should be considered to guide fluid requirements, particularly if JVP is not visible, or infrail / elderly patients.

4. Ultrasound of renal tract should be undertaken urgently if the patient is anuric or deteriorating -if obstruction is confirmed bleep on-call urology SpR for further advice.

5. Immunological Screen should include: AIP / ANCA / anti-GBM ; Immunoglobulins; C3/ C4;ESR/CRP

6. To contact renal team:

Bleep 504 for the on call renal SHO, switchboard for renal registrar or renal consultant



CLINICAL ALGORITHM FOR HYPERCALCAEMIA

• Full history and Examination

• Investigations: ECR, LFT,bicarbonate, PTH level, TFT, proteinelectrophoresis, urine BJP, CXR,(ACE level, Vit D may be indicated – D/W Consultant Biochemist)

Mild chronicasymptomatichypercalcaemia (Calcium2.6-2.8mmol/l)

Moderate-severe,symptomatichypercalcaemia (Calcium2.9-3.5mmol/l)

• IV Rehydration (up to 4-6litres/24hrs)N/Saline

• Monitor electrolytes and volume status• Catheterise• Consider CVP in elderly or impaired

renal function• Consider loop diuretic once

hypervolaemia induced diuresis occurs• Consider steroids in steroid sensitive

cases*

Hypercalcaemia persists:• IV Pamidronate See BNF for

dosage and administration• Continue rehydration• Check Ca

2+after 48hrs

• Treat underlying cause

Check corrected Ca+

in 24hrs

Severe hypercalcaemia (Calcium above 3.5mmol/l)

Hypercalcaemia (Corrected Ca2+ of > 2.60mmol/l

If Calcium >4.5mmol/l andneurologicsymptoms

Outpatient Management

Considerhaemodialysis

Treatunderlyingcause

• * Steroid sensitive cases – myeloma, sarcoid,• Patients whose primary disease cannot be cured e.g. disseminated malignancy, oral

bisphosphonates, phosphates, steroids and aggressive oral hydration may be tried afteracute therapy. Repeated infusions of IV Pamidronate at 2-3week intervals may berequired.

• Patients in renal failure who present with severe hypercalcaemia may require urgentdialysis

This algorithm is based on national guidance. The algorithm is designed to guide thebasic care of patients presenting with this condition, however, clinical need may requirethat there is variance from the algorithm.

Ref: Evidence Based on call. NHS National Electronic Librar for Health.



CLINICAL ALGORITHM – MANAGEMENT OF SHORTNESS OF BREATH IN A DIALYSIS PATIENT

On presentation document baseline observations:Pulse / Blood Pressure / Temperature / RespiratoryRate / Oxygen Saturations

Inform dut doctor

Obtain history from patient or witness:• Is the patient on dialysis?• Is the patient on Haemodialysis or Peritoneal Dialysis (CAPD)?• When and where did the patient last receive dialysis treatment?• When did episode of SOB begin?• Any associated symptoms such as chest pain, cough, frothy sputum etcWith a CAPD Patient:• Ask whether any recent problems with drainage of dialysate, use of high concentration bags.

Differential Diagnosis: Examine Patient:

Common problems includepulmonary oedema and fluidoverload.

• Immediate assessment of patient with breathlessness to includebaseline observations as above.

• Assess level of distress/dyspnoea/sweating/cyanosis• Examine for signs of fluid overload such as raised JVP, leg/sacral

oedema/ raised BPBUT CONSIDER:• Examine chest for signs of pulmonary oedema, pleural effusion,

consolidation, bronchospasm or pneumothorax.• Myocardial ischaemia• Pneumonia• Pulmonary embolus• Asthma/COPD

• Pneumothorax Investigations:• ECG and CXR

• Routine Bloods/CRP/Cardiac Enzymes if cardiac aetiology suspected• Consider Arterial Blood Gases

Treatment: • Discuss patient with a senior member of renal team. This may be on-call SpR at KCH or on-call Renal Consultant (contact via KCH

switchboardHaemodialysis Patient:

• Inform the on-call renal SpR or Consultant. Inform the dialysis unit early since patient may require urgent fluid removal by ultrafiltration(“UF”)

• Give Oxygen – if patient clearly fluid overloaded, then treatment can be commenced prior to receiving treatment on the dialysis unit.NB The dialysis patient will NOT respond to Frusemide

• Commence patient on GTN infusion. Stop GTN if systolic blood pressure <100mm/Hg. Commence infusion at 0.8mls/min

• Discontinue GTN before patient begins treatment on dialysis machine since blood pressure will drop following UF.

• If patient is “in extremis” then consider venesection of between 300-400mls of blood.• If not able to be transferred safely to Dialysis Unit contact ITU for ventilatory support and haemofiltration.

CAPD Patient• In general, the approach is the same however, fluid overload again will require specialist input.

• Inform on-call Renal SpR or Consultant

This algorithm is based on national guidance. The algorithm is designed to guide the basic careof patients presenting with this condition, however, clinical need may require that there isvariance from the algorithm. Ref:



CLINICAL ALGORITHM FOR ACUTE EXACERBATION OF COPD

ACUTE EXACERBATIONOF COPD

NO YES

IMPROVEMENT PATIENT DETERIORATES

Discharge when stable Seek specialist adviceSee Table 1 Consider HDU / ITU admission

This algorithm is based on national guidance. The algorithm is designed to guide the basic care ofpatients presenting with this condition, however, clinical need may require that there is variancefrom the algorithm. Ref: BTS Guidelines for the Management of Chronic Obstructive PulmonaryDisease. Thorax 1997;52 (Suppl 5): S1-S28

NURSING OBSERVATIONS:HISTORY ANDEXAMINATION

IMMEDIATE INVESTIGATIONS:

• ABG (Note inspired O2 conc.)• PEF / FEV• CXR• O2 SATS• FBC, U+E.• Temp, Pulse, BP,RR

ASSESS THE NEED FOR ADMISSION: (See Table 1 Overleaf)

IMMEDIATE TREATMENT:

• Controlled Oxygen to achieve Pa O2 of 8.0 kPa (Sats= 92%)

REFER TO COMMUNITYSPECIALIST RESPIRATORYTEAM

• If Pa CO2 > or = 6.5 and pH <7.35 consider referral forNIV (See Table 2) / ITU

(K+CH, QEQMH only)

• 01227-594640 • Nebulised Bronchodilators: Salbutamol 2.5-5mg qdsand/or Ipratropium 0.25-0.5mg qds(If PaCO2 elevated drive nebuliser on air)

• Prednisolone 30-40mg PO / day

• Antibiotics if evidence of infection (2 out of :increasing sputum volume, purulent sputum, orincreasing dyspnoea) If severe treat as severe CAP.

1. Co-amoxiclav 625mg TDS PO2. Cefixime 200mg BD PO3. Doxycycline 100mg BD PO

• Consider prophylactic s/c heparin

• Avoid sedatives



TABLE 1

Accept onto Community

Specialist Respiratory Team

Admit to Hospital

Respiratory Rate * <25 per minute >25 per minuteBlood Pressure Normal for patient Abnormal for patientPulse <110 beats per minute >110 beats per minuteTemperature * <37.9C >37.9CChest X-Ray No changes from previous Abnormal/new changesPO2 * >8kPa <8kPaPCO2 * <6.5kPa >6.5kPaPH * >7.35 <7.35Confusion * No DisorientatedSocial * Coping Live alone/no phoneUrea and Electrolytes Normal AbnormalCardiac Status * Stable UnstableECG * Normal for patient Abnormal / new changesI/V Therapy I/V Antibiotics only I/V Fluids & Bronchodilator

• Essential to meet criteria for acceptance onto CRT

TABLE 2

INDICATIONS FOR NIV CONTRAINDICATIONS FOR NIV(Consider referral to ITU)

• PaCO2 > 6.5 pH < 7.25

• pH < 7.35 uncooperative/decreased conscious level

Inability to clear secretions/co-existent pneumonia

Facial abnormality (eg trauma /burns)Vomiting / bowel obstruction

Haemodynamically unstable / Respiratory arrest

N.B: CPAP is not recommended for patients with respiratory failure due to acute exacerbations ofCOPD (Use only after specialist advice).



CLINICAL ALGORITHM FOR SUSPECTED COMMUNITY ACQUIRED PNEUMONIA (CAP)

SUSPECTED COMMUNITY ACQUIRED PNEUMONIA (CAP)

INITIAL OBSERVATIONS:

YES NO

YES

NO

DISCHARGE• Outpatient management • Amoxicillin 500mg-1g tds PO

• Temp / PR / BP/RR• O2 Saturations

INITIAL INVESTIGATIONS

•

CXR

FBC, U+EsSputum (C+S) [+/- Gm stain]Blood CultureDIAGNOSIS OF CAP CONFIRMED ? :Clotted serum for store• Symptoms and signs of LRTI

• New radiographic shadow

ASSESS SEVERITY: EXITPATHWAY• New mental confusion

• Urea > 7mmol/l• RR > 30/min• BP < 90/60 mmHg

None Present 1-2 Features Present 3-4 Features Present

Pre-Existing AdverseFeatures Present

Non-Severe Pneumonia Severe Pneumonia

• Age > 65 Years

• Co-Existent Chronic Disease ADMIT ADMIT • Consider HDU/ITU

INITIAL PREFERRED ANTIBIOTIC: INITIAL PREFERRED ANTIBIOTIC:• Amoxycillin 1g tds PO • Co-amoxiclav 1.2g TDS IV (if allergic to

Pen (rash) Cefuroxime 1.5g TDS IV)(no clarithromycin)plus• OR Moxifloxicin 400mg OD PO for

Penicillin allergy • Clarithromycin 500mg bd IV

If allergic to Penicillin (anaphylaxis)• Levofloxacin 500mg BD IV for Penicillin

allergy (change to Moxifloxacin after 3days)

INITIAL MANAGEMENT: • Check ABG if O2 Saturations < 92%• Continuous O2 to maintain pa O2 >8kPa (Sats > 92%)

• IV Fluids if volume depleted• Pleural Aspiration (M,C&S) if fluid present

If Severe or selected non-severe:• Pneumococcal Antigen (urine, blood or sputum)• Legionella Antigen (urine)

• Atypical and viral serology

SPECIFIC PATHOGENIDENTIFIED

• Review Antibiotic Choice

IMPROVEMENT:• Review Antibiotic duration and route

• Change to PO when apyrexial for 24hr

FAILURE TO IMPROVE/COMPLICATIONS: • Seek Specialist Advice

DISCHARGE• 6 Week F/U CXR if persistent symptoms/signs

and/or hi her risk of underl in mali nanc

This algorithm is based on nationalguidance. The algorithm is designed toguide the basic care of patients presentingwith this condition, however, clinical need

may require that there is variance from thealgorithm. Ref: BTS Guidelines for the

management of Community Acquired

Pneumonia in Adults

www.bit.Thorasic.org.uk



CLINICAL ALGORITHM FOR SUSPECTED PULMONARY EMBOLUS

SUSPECTED PULMONARY EMBOLUS

Start Enoxa arin & Warfarin (see rescri tion) stickers

YES NO

This algorithm is based on national guidance. The algorithm is designed to guide the basic care ofpatients presenting with this condition, however, clinical need may require that there is variancefrom the algorithm. Ref: Suspected Acute Pulmonary Embolism: A Practical Approach. Thorax ;52 (Suppl 4): S1-S24

Nursing ObservationsTemp/PR/BP/O2 sats

Initial investigationsFBC/ECG/CXR/D-Dimer

Clinical Probability of PE

See Table 1

Collapse or hypotensionpresent

VQ ScanUrgent spiral CTSee guidelines for

interpretation

NormalIndeterminate

(low/intermediateProbability)

High Probability

PECONFIRMED

PE EXCLUDEDConsider

alternativediagnoses

D-DimerResult

Anticoagulate(+/- thrombolysis)

-ve & lowclinicalrobability

-ve & interim orhigh clinical

robability

+ve

Spiral CT Ultrasound ofLegs

AnticoagulateNo DVT DVT



Note:

• Once PE is suspected the patient should be started on Enoxaparin and warfarin pendinginvestigations unless anticoagulation presents higher than acceptable risks.

• All patients should have a VQ scan unless a large PE is suspected in which case a spiral CT shouldbe arranged.

• When the VQ test is indeterminate (low/intermediate Probability) further investigations are requiredas shown in the algorithm.

• Further details are available via the hospital intranet.

Clinical Probability:

There is no well validated clinical scoring systems for PE but an estimate of clinical probability(low/intermediate/high) should be made from presenting clinical features and basic tests before the VQscan result is known.

Table 1 covers the important positive features:

• Previous history of DVT/PE

• Current DVT

• Active cancer

• Recent immobility/surgery

• Known inherited or acquired thrombophilic condition

• Family history of venous thromboembolism

• Heart rate of over 100

The following features are more consistent with infection:

• Productive cough

• A white cell count above 15,000/microlitre

• High fever

• Extensive radiological shadows on CXR



CLINICAL PATHWAY FOR SINGLE HOT JOINT

SEPSIS DISCOUNTED SEPSIS SUSPECTED/CONFIRMED

GOUTNSAID OR COLCHICINE OR INTRA-ARTICULAR STEROID

REVIEW NEED FOR ALLOPURINOLAT FOLLOW UP. DO NOT STARTALLOPURINOL DURING ACUTEATTACK

REVIEW MEDICATION FOR SECONDARY CAUSES

REACTIVE ARTHRITIS? GUM OPINIONCULTURE THROAT/ URINE/STOOLNSAID’sINTRA-ARTICULAR STEROIDPHYSIOTHERAPY

PSORIATIC ARTHRITISNSAID/INTRA-ARTICULAR STEROID

POSSIBLE PRESENTATION OFPOLYARTHRITISCONSIDER IF OTHER JOINTSBECOMING INVOLVED

ADMIT

IV ANTIBIOTICS

FLUCLOXACILLIN 1g QDS ALONE

IF PENICILLIN SENSITIVE USE CLINDAMYCIN (D/W

MICROBIOLOGY)

IF PATIENT IS KNOWN MRSA CARRIER USE VANCOMYCIN

DISCUSS WITH RHEUMATOLOGIST/ORTHOPAEDIC CONSULTANT

WITHIN 24 HOURS

BED REST/PHYSIO

REVIEW DIAGNOSIS AT 48 HOURS

(AS SOON AS MICROBIOLOGY AVAILABLE)

CULTURE NEGATIVEREVIEW DIAGNOSIS

(Consider AFB)

SEPSIS CONFIRMED

CONTINUE IV FOR 7DAYS

HISTORY

Enquire for:EXPOSURE TO INFECTION (? Recent antibiotic)

INTERCURRENT ILLNESS

PAST HISTORY

RASH / PSORIASIS

? IS THE PATIENT ON STEROIDS (THIS COULD MASK INFECTION)

? PROSTHETIC JOINT

EXAMINATIONOTHER JOINT INVOLVEMENT

SKIN

TOPHI

MUCOSAL ULCERATION

FEVER

INVESTIGATION

ASPIRATION OF JOINT --- GRAM STAIN – ENSURE SAFE & RAPID TRANSIT TO LABORATORY

(POLARISED MICROSCOPY IF GOUT/PSEUDO GOUT SUSPECTED)

BLOOD CULTURE

ORAL ANTIBIOTICS X 6WEEKS INCONSULTATION WITHMICROBIOLOGIST

This algorithm is based on national guidance. The algorithm is designed to guide the basic care of patients

presenting with this condition, however, clinical need may require that there is variance from the

algorithm. Ref: Journal of the Royal College of Physicians of London – Vol 26 1 January 1992



APPENDIX

RESUSCITATION COUNCIL UKAND

EUROPEAN RESUSCITATION COUNCIL

ALGORITHMS

acute medical algorithms updated jan.06

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