Just when you think you had all your patients under control, in through the doors rolls the ambulance crew. And guess whatâ€¦they are not alone.
Here are a few essential points in plotting a new patientâ€™s trajectory through your shift.
ID / Allergy Bands: ALL patients are to have an identification band and Allergy band (if required) placed on arrival. As the shift coarsens up, the ED can quickly deteriorate into some bizarre game of musical beds. Patients are constantly moved around the unit to maximize our resources. Before you administer any medication or intervention, CHECK to make sure you have the right patient.
ECG: All patients who are admitted with chest pain, cardiac history or who are over 40 years must have an ECG.
We like to have all ECGâ€™s checked by registrar/consultant within 2 minutes of obtaining.
Documentation: Itâ€™s all about the ink baby. Your ongoing documentation (known to us as progress notes) must include:
- Brief history of presenting problem.
- Past medical history.
- Current medications.
- Last time of food and/or fluids.
- Next of Kin details.
- Initial set of vital signs including pain score (if indicated).
Vital Signs: must be recorded. Thatâ€™s why they call them vital.
- Initially on presentation.
- Every 30 min. for 1 hour.
- Hourly thereafter.
- If patient is stable observations may be obtained less frequently. This decision should be made in consultation with the senior nurse on the floor.
- Febrile children are to have 1/24 temperature.
Frequency of all observations should be dependent on patientâ€™s clinical condition and may need to be very frequent.
Any patient presenting post head injury or altered state of consciousness must have:
Initially Â½ hourly for 1 hour, then hourly.
Neurovascular observations: should be commenced on:
Any patient presenting with suspected limb fractures or any injury to a limb.
Initially Â½ hourly for 1 hour, then hourly.
Capillary Blood Glucose:
Capillary blood glucose level ( BGL) must be obtained on all diabetic patients on arrival and 4/24 thereafter.
BGLâ€™s are obtained 1/24 on all hypo/hyper-glycaemic patients and those on insulin infusions.
Capillary Ketone levels should be checked whenever a patient has a Capillary BGL > 15.
Oxygen therapy: is to be commenced on all patients with SaO2 less than 95%, any respiratory or cardiac history, any reduced level of consciousness, and those receiving narcotics.
- Febrile children are to have their temperature taken hourly.
- All paediatric patients are to have a urinalysis.
- All paediatric patients are to have an initial blood pressure.
- All paediatric patients are to have their drugs and fluids checked by two nurses. All IV fluids are to be run via an electronic delivery pump.
All narcotic infusions (PCAâ€™s) are to be checked with the nursing team leader.
All insulin infusions are to be checked with the nursing team leader.
A cannula should be placed in the patient if you believe the patient will require blood tests and/or IV fluids. This will be attended by the doctor unless you are proficient at cannulation and have the time to do so.
Any patient having IV fluids delivered in less than 2 hours duration, should have a warmed bag of fluid.
All patients over 70 years and those who have IV fluids with additives must be run via an electronic delivery pump.
After taking bloods use any remainder to obtain a baseline BGL.
Febrile Oncology patients:
ALL febrile Oncology patients are to be worked up ASAP and must have their Antibiotics commenced at least within 1 hour of presentation to ED. These patients are not to be put in the reverse flow (isolation) rooms.
All children are to have their weight recorded on arrival unless they are critically unwell. Weight is the single most important factor in determining correct medication dose, volume replacement and equipment selection.
Neonates and infants up to 6 months should be bare weighed. Infants older than 6 months may have their weight attended in a singlet and nappy.
Children can be weighed with light clothing and barefoot.
All paediatric patients must have a full set of vital signs recorded on arrival.
- Neonates- apical pulse.
- Young infants- apical pulse
- Older infants / children- radial pulse.
The pulse should be palpated for a full minute to allow for normal variations in rhythm.
Bradycardia relative to a childâ€™s age is an ominous sign. Neonates with a pulse < 80 will need active resuscitation. Oxygen therapy is to be commenced on all hypoxic children (ie SaO2 < 95%).
Fontanelle: The anterior fontanelle closes between 6months and 18 months. The fontanelle should be palpated whilst the infant is sitting upright and quiet. A bulging fontanelle may indicate raised intra cranial pressure (ICP); a sunken fontanelle may indicate dehydration.
Monitoring: All paediatric resuscitation patients are to have cardiac monitoring, oximetry and an initial BP. Never ever ever, turn the cardiac monitors alarm parameters OFF.
U-bag: All neonates and infants are to have a urine collection bag applied on arrival. Thoroughly clean the genitalia first with water before applying the adhesive collection bag.
Resuscitation fluids: The dose of fluids for resuscitating volume depletion is: 20mls / kg warmed crystalloid. May be repeated if necessary.
Narcotic Infusion: Morphine is the preferred drug. Load 1mg / kg in 100mls and titrate the infusion from 1-4 mls / hr (10-40 mcg / kg / hr) via pump. A patient controlled analgesia pump (PCA) should be considered in older children.
Intramuscular injections: In neonates and children less than 2 years, use the vastus lateralis or rectus femoris muscle groups of the lateral and anterior thigh. There are no major nerves in this area and it contains a high muscle mass.
Do NOT use the buttocks for IM injections in this age group as the muscle has not bulked up and the sciatic nerve is prominent.