Bendigo SSOU Admission Guidelines

Clinical Resources

Bendigo SSOU Admission Guidelines
Introduction
Bendigo Health ED runs a 12 bed Short Stay Observation Unit (SSOU). Admission to the SSOU is guided by the ED Streaming Model of Care and is in keeping with the Victorian Department of Health Guidelines for Short Stay Units.
Admission Guidelines
Common conditions suitable for admission to SSOU are listed below. Click on each to see our admission guidelines for each of the diagnoses.

DEEP VEIN THROMBOSIS

Definition

Patients presenting with either proven DVT or are awaiting imaging to confirm/ rule out the diagnosis. These patients may be admitted pending investigations or to initiate an appropriate treatment plan and follow-up.

Admission Criteria

DVT most likely below mid-thigh
Awaiting imaging

Exclusion criteria

Negative D-dimer and low pre-test probability excludes the diagnosis
DVT above the inguinal ligament
Evidence of pulmonary embolism
Major comorbidity or complicating social/mobility factors
Neurovascular compromise
Upper limb DVT: likely to require admission on confirmation

Investigations

FBE
UEC
Doppler Ultrasound
Documented weight
Additional as required: INR if on warfarin

Suggested medications

Drug	Dose	Frequency	Route
Enoxoparin (clexane)	1.5 mg / kg to maximum dose 100mg	Daily	SC
Apixaban (CrCl ≥25ml/min)	10mg	BD for 7 days then decrease to 5mg BD	PO
OR Rivaroxaban (CrCl ≥30ml/min)	15mg	BD for 21 days then 20mg daily	PO
Paracetamol	1g	4hourly PRN	PO
Ibuprofen	400mg	TDS	PO

Specific observations

Accurate weight for clexane dosage in kg (note maximum dose is 100mg)

Report immediately to medical staff any of the following

Chest pain – please complete ECG if CP occurring
SOB
Decreased Sa02
Pain not responding to simple analgesia

Discharge Criteria

Suitable home situation
Able to mobilise
Adequate social supports
Patient education and handout
Script for appropriate medications if required

Hospital admission criteria

Inadequate social supports
Ongoing uncontrolled pain
Development of PE symptoms

PYELONEPHRITIS

Definition

Acute pyelonephritis is a bacterial infection causing inflammation of the kidneysand is one of the most common diseases of the kidney.
Pyelonephritis occurs as a complication of an ascending urinary tract infection (UTI) which spreads from the bladder to the kidneys and their collecting systems.

Admission Criteria

Clinical features suggestive of acute pyelonephritis
- Flank pain
- Pyuria (urine MCS or FWT with leukocytes +/- nitrates)
- Loin pain
- +/- fever
- +/- nausea and vomiting
- +/- dehydration

Exclusion criteria

Hypotensive not responding to IV fluids or other signs of severe sepsis
No FWT or MSU done
Pregnancy
Renal insufficiency
Marked debility
Co-morbidities
Known renal tract anomaly or significant pathology e.g. single kidney
Rental tract stent
Rena tract obstruction
Immunocompromised patients

Investigations

FWT
Urine MCS
BHCG urine
FBE
UEC
Additional as required
- Renal USS or CT if abnormal renal function or persistent flank pain

Suggested medications

Drug	Dose	Frequency	Route
Paracetamol	1g	4hourly PRN	PO
Ibuprofen	400mg	TDS	PO
Normal Saline or CSL	100ml	Repeat PRN	IV
Oxycodone IR	5-10mg	4hrly PRN	PO
Metoclopramide OR Ondansetron	10mg 8mg	8hrly	IV or PO
Moderate – Severe Disease
Gentamicin	4-6mg/kg	Single dose	IV
Ampicillin	2g	6hrly	IV
Mild disease
Augmentin DF	875/125mg	BD	PO

Specific observations to be notified to staff

Notify fall in BP to medical staff
Notify ongoing vomiting or rigors

Specific management issues

Second episode of pyelonephritis should have renal tract ultrasound as inpatient

Consultations

Urology if abnormal renal tract investigations
Medical admission if symptoms/ patient not clinically improving

Discharge Criteria

Pain managed by oral analgesia
Systemic toxicity improved
Adequate oral intake
May be discharged to HITH

Hospital admission criteria

Persisting systemic toxicity
Signs of sepsis
Not tolerating oral fluids
Diagnosis unconfirmed on laboratory findings

Discharge follow-up

MIGRAINE

Definition

Migraine is a type of headache characterized by recurrent attacks of moderate to severe throbbing and pulsating pain on one side of the head
Migraine similar to previous established clear diagnosis but not responding to usual treatment

Admission Criteria

Clear diagnosis ie similar recurrent headache in past diagnosed as migraine
Previous normal CT
Long established history of migraines
Required IV hydration
Requires treatment

Exclusion criteria

Fevers unless non-CNS focus is found e.g. UTI/ URTI
Impaired consciousness level (GCS <14)
New focal neurological deficit
Sudden onset of headache indicated SAH (please see SAH pathway)

Investigations:

FBE UEC

Suggested medications

Drug	Dose	Frequency	Route
Normal Saline or CSL	100ml	Repeat PRN	IV
*Analgesia*
Paracetamol	1g	4hourly PRN	PO
Ibuprofen	400mg	TDS	PO
Aspirin OR Aspalgin (with codeine)	900mg	6hrly (max dose 2.4g in 24hrs)	PO
Sumatriptan tablet	50-100mg	Once	PO
Sumatriptan (nasal spray)	20mg	Once	IN
*Antiemetics*
Metoclopramide	10mg	8hrly	PO/ IV
Ondansetron	8mg	8hrly	SL/ IV
Prochlorperazine	5-10mg	8hrly	PO/ IV
Chlorpromazine (Largactil) infusion	12.5mg in 1000ml Nsaline	Over 1hr. can be repeated once	IV

Non pharmacological treatment

Cold packs over the forehead or back of the skull (targeting the supraorbital and greater occipital nerves)
Hot packs over the neck and shoulders (targeting the innervation of the scalp)
Neck stretches and self-mobilisation
Rest in a quiet dark room.

Specific observations

Report drop in GCS by 1 point
Headache/ vomiting not controlled with maximal treatment
Report new onset fever

Discharge Criteria

Pain-free and controlled by oral analgesia
Normal hydration
No vomiting
Appropriate social supports
Diagnosis certain

Hospital admission criteria

Headache not controlled by oral analgesia
Development of new neurological deficit
Impaired level of consciousness
Neurological deficit not resolving
Uncertain diagnosis

PVB IN EARLY PREGNANCY

Definition

Patients presenting with PV bleeding who are <20/40 gestation. These patients may require investigations (including bloods and US scan) and consideration of anti-D treatment (for Rhesus negative mothers).

Admission Criteria

Calculated gestation <20/40
PV bleeding with NO PAIN (if pregnancy location not known)
PV bleeding with mild-moderate pain is acceptable if pregnancy is known to be intrauterine
Anti-D arranged for women with Rhesus negative blood type PRN

Exclusion criteria

Significant abdominal pain
Abnormal vital signs
High suspicion for ectopic pregnancy

Investigations:

FBE UEC
Blood group if unknown
Early pregnancy ultrasound
Quantitative BHCG (not required if >10 weeks or previous USS showing foetal HR)
Urine FWT

Suggested medications

Drug	Dose	Frequency	Route
Paracetamol	1g	4hourly PRN	PO
Oxycodone IR	5-10mg	4hrly PRN	PO
Buscopan	10mg	8hrly	PO
Anti-D Immunoglobulin for Rh negative blood group	250 IU if <12/40 625 IU if >12/40	Once	IM
NO NSAIDS in 1^st trimester

Dose and indications for Anti-D as per RANZCOG guidelines 2022

Specific observations

Visualize pad changes, if heavy please weigh
Severe pain

Report immediately to medical staff any of the following

Excessive PV loss (>1 pad every hour) or passage of products of conception
Hypotension
Severe pain not responding to PO analgesia

Consultations

O&G if miscarriage for management options, on DC for EPAS

Discharge Criteria

Bleeding settled and pain free with simple analgesia
USS no concerning features
Follow-up planned
- Early pregnancy assessment service (EPAS)- needs O&G registrar referral and online request
- Private obstetrician
- GP

Hospital admission criteria

Persisting pain and bleeding
Possible ectopic
Lack of adequate social supports

PNEUMOTHORAX (SPONTANEOUS)

Definition

Spontaneous pneumothorax is defined as gas in the pleural space that occurs in the absence of an external event. Spontaneous pneumothorax can be either primary or secondary.
Primary Spontaneous Pneumothorax (PSP) is a spontaneous pneumothorax that occurs in patients with no underlying lung disease
Secondary Spontaneous Pneumothorax (SSP) is a spontaneous pneumothorax that occurs in patients with underlying lung disease
Severity can be defined in terms of size of the pneumothorax as either small or large, and by the patient’s clinical signs and symptoms.
- A small pneumothorax is defined as <2cm distance from the chest wall to the visceral pleural line at the level of the hilum
- Large pneumothorax is defined as a distance of ≥ 2cm from the chest wall to the visceral pleural line at the level of the hilum

Admission Criteria

Spontaneous pneumothorax
If secondary size <2cm (small)
Stable vital signs
No recent trauma

Exclusion criteria

Significant hemodynamic instability
Significant exertional dyspnea
If secondary Spontaneous pneumothorax large >2cm
Recurrent spontaneous pneumothorax
Bilateral spontaneous pneumothorax
Tension pneumothorax
Traumatic pneumothorax
Unstable vital signs
Chronic lung disease or significant comorbidities

Investigations

CXR prior to admission
Repeat CXR at 4-6hours post

Suggested medications

Drug	Dose	Frequency	Route
Paracetamol	1g	4hourly PRN	PO
Ibuprofen	400mg	TDS	PO
Oxycodone IR	5-10mg	4hrly PRN	PO
Metoclopramide	10mg	8hrly PRN	PO/ IV

Specific observations

Apply supplemental oxygen targets to SpO2 ≥ 96% (88-92% for patient at risk of hypercarbia)

Report immediately to medical staff any of the following

Report any increasing shortness of breath/ chest pain

Consultation

AGSU if any deterioration

Discharge Criteria

Repeat CXR done at 4-6hours indicative of stable or resolving pneumothorax
Discharging between 8am and 11pm
Living within 30minutes of the hospital
Patient is competent.
Discharge advice (see below) has been provided.
- PSP FU with GP in 2-4 weeks with repeat CXR prior to review
Patient is able to represent in 12-48 hours for a repeat CXR

Discharge advice

Patients should be advised to:
- Stop smoking, including cigarettes, other tobacco products, marijuana and illicit drugs
- Avoid any air travel for 1 week post complete resolution of the pneumothorax. An undrained pneumothorax is a definitive contraindication to commercial air travel. A small risk of recurrence up to 1 year after a pneumothorax occurs with any air travel
- Gradually re-introduce exercise after two weeks. Contact sports, heavy weightlifting and extreme exercise may need longer periods of avoidance
- Avoid deep sea diving permanently unless the patient has had a pleurodesis and a normal CT chest

Hospital admission criteria

Increase in size of pneumothorax on CXR
Significant symptomatic SOB

Discharge Follow-up

GP
Consider surgical OP
Repeat CXR in 2-4 weeks with GP or to represent to ED if no GP
Clear education that if worsening SOB to represent to ED

SEIZURE

Definition

Observation and management of the post ictal patient that has not fully recovered in ED

Admission Criteria

Single seizure in known epileptic or first seizure
Post 1hr ED observation with improving consciousness state GCS >15
For observation and short term management
For IV rehydration
Requiring anti-convulsant medication level check

Exclusion criteria

Fever/ sepsis
Alcoholic withdrawal seizures
>1 seizure in <24hrs
Pregnancy
Head trauma during seizure unless normal CT
Altered conscious state due to other diagnosis

Investigations

FBE UEC
ECG
BSL
Optional: Anti-convulsant drug level, CTB, CMP

Suggested medications

Drug	Dose	Frequency	Route
Midazolam	2-5mg	Stat for seizure	IV or IM if no IV access
Usual anticonvulsants
OR Levetiracitam	500mg	Stat loading	IV

Specific observations:

Watch for repeat generalized seizure
Note any focal arm/ leg/ facial twitching which may indicate generalized seizure likely to occur

Report immediately to medical staff any of the following

Repeat seizure

Specific management issues

Ensure patient usual anti-epileptics medications are charted and given

Consultations

Austin Epilepsy Registrar (through switch)
GP/ Physician/ Neurologist who usually manages seizures

Discharge Criteria

Resolved post ictal state
Appropriate carer to safe environment
Advice re swimming, driving, dangerous activities
EEG and CT (if not already completed)
Austin 1^st Seizure clinic referral- after discussion with Austin Epilepsy Registrar

Hospital admission criteria

Further seizure
Persisting low GCS or new neurology

Unable to establish safe environment at home

SNAKE BITE

Definition

If suspected snake bite only i.e. no clinical or laboratory signs of envenomation and patient not presenting with significant symptoms, then can be managed in SSOU. SSOU consultant must review/ accept patient prior to transfer.
90% of bites are dry and contain little to no venom
Only approximately 5% of snake bites lead to envenomation
Brown snakes are commonest cause of severe envenoming and fatalities in Australia

Types of snakes and clinical presentation

Category	Venom induced consumptive coagulopathy	Neurotoxicity	Myotoxicity	Other effects
Brown	Always present with significant envenoming	Rare	Not present	Early collapse (335) or cardiac arrest (3%). Systemic symptoms frequently absent (50%) Thrombotic microangiopathy (10%)
Tiger group	Always present with significant envenoming	Uncommon Slow onset over many hours	Uncommon Slow onset over many hours	Systemic symptoms common Thrombotic microangiopathy (<5%)
Black	Not present Mild direct anticoagulant effect. INR/APPT rise but normal fibrinogen	Not present	Common Slow onset over hours to days Can result in renal failure	Systemic symptoms common Local bite site pain and swelling significant
Taipan (uncommon VIC)	Always present with significant envenoming	Common may be rapid onset	Rare	Systemic symptoms common Thrombotic microangiopathy (5%)
Death adders (uncommon VIC)	Not present	Common Slow onset over many hours	Not present	Systemic symptoms common Local bite site pain often present

Admission Criteria

Snake bite (true or suspected).
Pressure bandage
First set of blood tests
Anti-venom given to patient with signs of

Exclusion criteria

Significant neurotoxicity (Eg. respiratory distress).
Post-circulatory collapse / cardiac arrest.
Haemo-dynamically
Profuse

Investigations

Bloods on presentation to ED with pressure immobilization bandage insitu
If normal and no features of envenomation remove bandage
- Re-apply if any signs of envenomation
Bloods 1hour post bandage removal
Can go to SSOU if bloods normal
Repeat bloods at 6hours and 12 hours post bite
Bloods
- FBE
- UEC- AKI secondary to rhabdomyolysis or thrombotic microangiography
- Coagulation studies- INR, APTT, fibrinogen
- D-dimer
- CK
Urine FWT for protein / microglobinuria
***Snake venom detection no longer recommended

Evidence of envenomation

Clinical
- Neurotoxicity- ptosis generally 1^st sign, extra-ocular ophthalmoplegia (diplopia), blurred vision
- Myotoxicity- muscle pain and tenderness, weakness, elevated CK
- Coagulopathy – bleeding from gums, IVC site
- Nonspecific symptoms e.g. NV, headaches
- Early CV collapse
Lab evidence
- INR >1.2
- Prolonged APTT
- Low or undetectable fibrinogen concentration
- Raised D-dimer (at least 10x the assay cut off or >2.5mg/L)
- CK> 1000 units/L
- Raised creatinine
- Evidence of thrombotic microangiography

Suggested medications

Drug	Dose	Frequency	Route
Paracetamol	1g	4hrly PRN max 4g	PO
Ibuprofen	400mg	6hrly PRN	PO
Metoclopramide	10mg	8hrly PRN	PO/ IV
Ondansetron	8mg	8hrly PRN	SL / IV

Specific observations

Report signs of respiratory
Report
Report new neurological symptoms (Eg. ptosis, ophthalmoplegia, limb weakness).
Report

Specific management issues

Coagulopathy may not begin to improve until about 12 hours.
Persistent coagulopathy is not an indication for additional anti-venom.
Repeat blood tests every 12 hrs until coagulopathy resolved if coagulopathy persists at 12

Consultations

Call toxicologist on call (Poisons Information Centre 13 11 26)
- If any signs of envenomation are present.
- For all potential snakebites in paediatric patients.
- If the patient was bitten by a snake in a location other than Victoria or Tasmania.
- If the patient is a snake handler or the bite was from an exotic snake.
- If there is any doubt about treatment.

Discharge Criteria

Hospital admission criteria

Respiratory distress requiring ventilatory
VICC resulting in clinically significant
Post cardiac arrest / circulatory

TIA

Definition

Neurological dysfunction caused by focal brain or retinal ischaemia lasting <1hr
- Typical duration 2-15min

Admission Criteria

Rothwell ABCD2 score

Components
- Age >60 =1 point
- BP> 140/90 = 1 point
- Clinical features
  - Unilateral weakness = 2 points
  - Speech impairment without weakness= 1 point
- Duration of symptoms
  - >60min = 2 points
  - 10-59 min= 1 point
- Diabetes= 1 point
Scoring
- >5= high risk
  - 7 day stroke risk 25-30%
  - Admit medical
- 4-5= moderate risk
  - 7 day stroke risk 20-25%
  - For SSOU to complete investigations as inpatient
- Score 0-3=-3 low risk
  - 7 day stroke risk 0-15%
  - Safe for home or SSOU. Investigations can be completed as outpatient

Exclusion criteria

If present refer to medical team for admission

Investigations

CTB +/- angiography +/- stroke protocol
ECG
FBE
UEC
Fasting lipids
BSL
HbA1c if diabetic
Additional as required
- Carotid Doppler- for anterior circulation
- TTE if AF
- MRI in selected patients

Suggested medications

Drug	Dose	Frequency	Route
Antiplatelet
Aspirin	300mg if loading required then 100mg daily	Daily	PO
OR Clopidogrel (if already on aspirin)	75mg	Daily	PO
Antihypertensives
Consider ACE inhibitor
Lipid lowering agent
Atorvastatin	80mg	Daily	PO
Or increase current to max dose

Specific observations

Telemetry

Report immediately to medical staff any of the following

Notify if any irregularity in pulse rhythm e.g. new AF

Discharge Criteria

Responsible carer to observe
Follow-up arrangements made
Adequate explanation and understanding
Education regarding stroke risk, risk factor management and signs and symptoms of stroke
- Stopping smoking- 66% relative risk reduction from cessation
- Low fat and salt diet
- Increasing regular exercise
- Avoiding excessive ETOH- no more than 2 STD per day
Advice re driving
Appropriate medications changes with script

Hospital admission criteria

Neurological deficit persists
Evolving causative pathology- consider transfer
Abnormal CT or critical Doppler abnormality
- >80% stenosis risk decreased by 50% with endarterectomy/ stenting and 25% for 70-80% stenosis
- Patients with lesser stenosis do not benefit from surgery
Unable to establish safe discharge environment

Follow-up

Medical TIA clinic as OP

URINARY RETENTION

Definition

Urinary retention is the acute or chronic inability to voluntarily pass an adequate amount of urine. The condition predominantly affects men. The most common causes are obstructive in nature, with benign prostatic hyperplasia accounting for 53% of cases.
Causes
- BPH/ prostatitis
- Urethral strictures- post trauma, infection, radiation, surgery, clot retention
- Prostate cancer/ penis cancer
- Phimosis/ paraphimosis
- Acute prostatitis/ urethrities
- Pharmacology
  - Anticholinergics
  - Sympathomimetics
  - CCB
  - TCA
  - Antihistamines
- Neurogenic causes
  - MS
  - Parkinsons
  - Diabetic perihperal neuropathy
  - Spinal trauma
  - Strokes
- Infection/ inflammatory
  - Genital herpes
- Constipation

Admission Criteria

Exclusion criteria

Failed urethral catheterization
Significant co-morbidities
Patient unlikely to cope with leg bag/ management at home
Trauma
Neurological cause for obstruction
Post urological surgery e.g. clot retention

Investigations

FBE
UEC
Urine FWT / MCS
Bladder scan prior to IDC insertion
+/- CTAP

Suggested medications

Drug	Dose	Frequency	Route
Alpha blockers e.g. Tamsulosin	AFTER DISCUSSION WITH UROLOGIST
Apperients if due to constipation
Paracetamol	1g	4hrly PRN max 4g	PO
Normal saline	1000ml- to match urine output if post obstructive diuresis	As required	IV

Specific observations

Urine output >200ml/hr following drainage
- Requires referral to urology for post obstructive diuresis
Haematuria- except from initial insertion if traumatic
Report increasing abdominal discomfort
Report fever

Consultations

Discussion with urology

Discharge Criteria

Catheter education
Referral to district nursing if required
Clear follow-up plan with patient aware of plan

Hospital admission criteria

Development of fever
Development of haematuria
Systemic toxicity

Follow-up

Trial of void clinic

VERTIGO

Definition

Illusion of motion, rotatory or otherwise
Important to distinguish peripheral vertigo (caused by lesions of the vestibular nerve and inner ear) from central vertigo (caused by lesions of the CNS)
Peripheral vertigo
- approximately 90% of cases
- may be very sudden onset when due to benign positional vertigo
- nystagmus usually present
  - horizontal or horizontal-rotatory
    - not vertical, unless following Dix-Hallpike test
  - unidirectional
    - never direction changing
  - initially toward affected ear
- Causes
  - Meniere’s disease
  - labyrinthitis
  - benign paroxysmal postural vertigo (BPPV)
  - acoustic neuroma
- Central vertigo
  - approximately 10% of cases
  - may be sudden in onset when caused by stroke
  - usually slow in onset when due to other causes (tumour, demyelination etc)
  - is usually less severe and causes less nausea and vomiting than peripheral causes
  - nystagmus
    - usually absent
    - vertical nystagmus may occur without vertigo

Admission Criteria

Acute vertigo with peripheral aetiology as per HINTS exam

Exclusion criteria

Severe headache
Significant ataxia e.g. cannot walk
Recurrent or worsening vertigo
Fever
Cranial nerve abnormalities
Cerebella dysfunction
ANE long tract neurological signs
Examination findings suggestive of central cause - indication for medical admission.

Investigations

Suggested medications

Drug	Dose	Frequency	Route
Paracetamol	1g	4hrly PRN max 4g	PO
Prochlorperazine	12.5mg	6hrly	IV/ IM
Prochlorperazine	10mg	6hrly	PO
Nasline	1000ml	Maintain hydration	IV
Consider Eply maneuver

Specific observations

Monitor for altercation in conscious state

Specific management issues

Bed rest and supervised mobilization until physio review
Report any of
- Worsening vomiting or vertigo
- Altered conscious state- GCS falling by 1 point or more
- Severe headache
- Facial or motor asymmetry
IVF until tolerating oral

Consultations

Medical if symptoms persist or new neurological changes develop
Physiotherapy if required

Discharge Criteria

Symptoms resolved, passed mobility test
Appropriate carer
Follow-up arranged
Consider discharge medication

Hospital admission criteria

Persisting symptoms
Dehydration not resolved
Development of new neurological symptoms

WARFARIN

Definition

High INR awaiting normalization to safe therapeutic level

Admission Criteria

INR >5.0 on warfarin therapy
Minor bleeding only and controlled in ED
Drug interaction considered/ eliminated
Systolic BP <180mmHg

Exclusion criteria

Uncontrolled bleeding any site
Falls risk
Significant bleeding, non compressible e.g. GIT, intracerebral, haemoptysis

Risk factors for bleeding- 2 or more suggest HIGH risk

Age > 65yrs
Uncontrolled hypertension
History of GI haemorrhage, active peptic ulcer, hepatic insuffi ciency
Haematogical: platelet count < 50 109/L OR dysfunction, coagulation defect, malignancy
History of stroke, cognitive or psychological impairment
Renal insuffi ciency
Trauma: recent trauma, > 3 falls within previous treatment year, recurrent or injurious falls
Excessive alcohol intake
Medications: Asprin, NSAIDs, COX-II, “ natural remedies”

Investigations

INR
FBE
UEC
LFT
Additional as required
- Repeat INR 6hrs and 12hrs after initial treatment if not normalized

Suggested medications

INR	Bleeding risk YES/ NO	Risk of bleed	Reversal agent
5-9	No	Low	Consider 1mg vitamin K
5-9	No	High	Vit K 1-2mg orally OR 0.5-1mg IV
>9	No	Low	Vit K 2.5-5.0mg PO OR 1mg IV
>9	No	High	Vit K 1mg IV OR Prothrombinex 25-50 units OR FFP 150-300mls IV

Specific observations

Any new bleeding/ malena

Specific management issues

Stop warfarin for 24hrs and restart next night at ½ usual dose

Discharge Criteria

INR < 5 and no bleeding
Repeat INR in 24 hours after discharge
Any drug interaction resolved
Patient understands cause of toxicity
Review need for ongoing warfarin
Restart WARFARIN AFTER 24 HOURS at ½ dose

Hospital admission criteria

Development of significant haemorrhage
INR > 5
Failure to control minor haemorrhage or recurrence

PARACETAMOL OVERDOSE

Definition

Intentional or non-intension potential dangerous ingestion of paracetamol
Risk assessment
- Dose
- Formulation ingested
- Acute vs staggered vs repeated supratherapeutic
- Time of ingestion
- Symptoms- abdo pain, N/V
Clinical features
- Usually asymptomatic
- Abdominal pain, vomiting
- Late toxicity- liver failure, coagulopathy, encephalopathy
Refer to Austin Toxicology clinical practice guidelines and call Poisons Information Centre as required on 13 11 26 for clinical advice

Admission Criteria:

Overdose paracetamol
Cleared ECAT or likely DC home rather than Psychiatry admission
4hour ED observation or a clear period in which physiological stability is assessed and documented

Exclusion criteria

Known ingestion of potentially lethal material
Patient on Assessment Order
Abnormal neurological examination inc seizures, hallucinations, confusion, or GCS 14-15
Unstable respiratory or cardiovascular status
Abnormal LFTs/ Coagulation profile
Cardiac arrhythmias
Need for ongoing decontamination procedures
Ingestion of corrosives
Ongoing suicidal intent and uncooperative with treatment

Investigations

1^st paracetamol level (4hrs from ingestion)
LFTs
Blood Alcohol level
ECG
Additional as required
- FBE
- INR / coagulation
- BSL
- Repeat bloods

Paracetamol nomogram

Management

4hrs post ingestion- Paracetamol level and LFTs
Plot paracetamol level on nomogram and if above treatment line treat with 20hour NAC course
2 hours prior to completion of 20-hour NAC course
- Measure ALT
- Paracetamol level
If ALT is abnormal or paracetamol level onc >10mg/L continue NAC and refer to medical team for admission

Suggested medications

Drug	Dose	Frequency	Route
Metoclopramide	10mg	8hrly PRN	IV/ PO
Ondansetron	8mg	8hrly PRN	SL/ IV
Pink mix	10ml/20ml	PRN	PO
Loratadine	10-20mg	Once PRN	PO
NAC (Acetylcysteine) ADULT
1^st dose:	200mg/kg in 500ml 5% glucose	Over 4hrs	IV
2^nd dose:	100mg/ kg in 1000ml 5% glucose	Over 16hrs	IV

Specific observations

Report evidence of allergic reaction to NAC (rash, itch, orofacial swelling, dyspnoea)

Consultations

ECATT

Discharge Criteria

Return of non toxic/ normal laboratory results
Stable vital signs/ neurological exam
ECATT assessment completed and deemed safe for discharge
Safe psychosocial environment with appropriate care

Hospital admission criteria

Abnormal laboratory results
Deterioration in neurological state or GCS
Cardiac/ respiratory instability
Unsafe psychosocial environment
Persistent suicidal intent

Discharge follow-up

Mental health team
GP

MINOR HEAD INJURY

Definition

Mild head trauma related to transient neurological or systemic dysfunction

Admission Criteria

GCS 14-15
Age 16-65
Mild head injury without dangerous mechanism, requiring period of observation (4-6hours)
LOC <5min
Isolated injury
Normal CTB (Canadian Head CT rules for indications)
Mild headache
Mild nausea/ single vomit
No cpsine collar

Canadian Head CT rule (Indications for head CT in minor head injury)

High risk (for neurological intervention)
- GCS score <15 at 2 h after injury
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture (haemotympanum, ‘racoon’ eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, Battle’s sign)
- Vomiting ≥ two episodes
- Age ≥ 65 years
Medium risk (for brain injury on CT)
- Amnesia before impact >30 min
- Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or five stairs)

Exclusion criteria

Abnormal CT
Repeated/persistent Vomiting
Focal neurological sign
Skull fracture
Facial fractures
LOC > 5 minutes
Deterioration in GCS> 1 point
Pre injury debility or non ambulant
Risk of cervical spine injury / collared
Age > 65
Intoxicated / Drug affected

Investigations

CTB as per NUTS Head Injury Guidelines
CTB if coagulopathy present inc NOAC, clopidogrel
BSL
BAL

Suggested medications

Drug	Dose	Frequency	Route
Paracetamol	1g	4hrly PRN max dose 4g 24hrs	PO
Ibuprofen	400mg	6hrly PRN	PO
Oxycodone IR	5-10mg	4hrly PRN	PO
Metoclopramide	10mg	8hrly PRN	PO/ IV
Ondansetron	8mg	8hrly PRN	SL/ IV

Specific observations

Abbreviated Westmead Post traumatic amnesia scale if any amnesia
Report persistent vomiting, increasing headache, falling GCS, developing neurology

Consultations

Neurosurgery or surgical if symptoms not improving or deteriorating

Discharge Criteria

Normal neurological exam at discharge with GCS 15
Clinically improving
Passed A-WPTAS if required
Normal CTB or NO indication for CTB
Appropriate carer and able to return if condition deteriorates
Able to take & tolerate oral fluids
Head injury information supplied and understood

Hospital admission criteria

Development of exclusion criteria
Persisting abnormal mental state
Uncontrolled headache, vomiting
Lack of appropriate carer

PERITONSILAR INFECTION

Definition

A peritonsillar abscess (also called paratonsillar abscess or quinsy) is a collection of pus in the space between the tonsil and the superior pharyngeal constrictor muscle.
Tonsillitis is inflammation and infection of the tonsils

Admission Criteria

Severe pharyngotonsilitis
Systemic toxicity
Dysphagia, unilateral sore throat
Dehydration
Difficulty opening mouth (trismus)

Exclusion criteria

Airway compromise
Stridor
Uncertain site
Abscess needing intra-operative drainage
Immune-compromise

Investigations

FBE
UEC
Additional as required
- EBV screen- monospot/ serology
- Throat MCS
- Consider need for aspiration/ formal I&D

Suggested medications

Drug	Dose	Frequency	Route
0.9% Nasline	1000ml	4-12hrly	IV
Benzylpenicillin	1.2g	6hrly	IV

Dexamethasone	8mg	12-24hrly	IV
Paracetamol	1g	4hrly PRN max dose 4g	PO or IV
Ibuprofen	400mg	6hrly	PO
Aspalgan (aspirin/ codeine) gargle	900/30mg	BD	Gargle
Lignocaine viscous	10-20ml	TDS prior to meals	PO

Specific observations

Report stridor or worsening dysphagia to medical staff
Pain score hourly and give analgesia until pain adequately controlled

Specific management issues

If abscess aspirated diet as tolerated

Discharge Criteria

Adequate hydration/ tolerating oral fluids
Normal vital signs
Pain controlled

Hospital admission criteria (TF to Melbourne as no ENT service at Bendigo)

Inadequate hydration or ability to tolerate oral fluids
Persisting toxicity
Requiring formal I&D of abscess

HYPEREMESIS GRAVIDARUM

Definition

Nausea and vomiting is the most common medical condition in pregnancy, affecting up to 90% of women.
Persistent vomiting that leads to weight loss of greater than 5% of pre-pregnancy weight occurs in 1% of pregnancies and is referred to as hyperemesis gravidarum. This is associated with electrolyte abnormalities and dehydration

Admission Criteria

Presumed normal pregnancy
Vomiting requiring IV hydration
No evidence of miscarriage
No evidence of pre-eclampsia
Other diagnosis unlikely (e.g. UTI, surgical abdomen)
Normal urinalysis

Exclusion criteria

Diagnosis unclear
Abdominal pain/ tenderness unrelated to vomiting
Urinary symptoms
PV bleeding
Fever
>20 weeks gestation
BP >140/90 and proteinuria or symptoms of possible pre-eclampsia (seizure, headache, blurred vision, abdominal pain)

Investigations

FBE
UEC
Glucose
CMP
LFT
Urine FWT
Consider
- USS if pregnancy not yet sited
BHCG is NOT indicated unless pregnancy has not been sited- as grossly elevated levels may suggest molar pregnancy

Suggested medications

Drug	Dose	Frequency	Route
Pyridoxine	25mg	TDS	PO
Doxylamine (restavit)	12.5-25mg	Nocte (TDS if tolerated)	PO
Metoclopramide	10mg	TDS	IV/ PO
Prochlorperazine	5-10mg 12.5mg	TDS TDS	PO IV
Ondasnetron	4-8mg	TDS	SL/ IV
Hartmann’s (CSL)	1000ml	2-8hrly PRN	IV

Consider review RWH guidelines for ‘Nausea and vomiting- Pregnancy’

Nausea and Vomiting - Pregnancy (worldssl.net)

Specific observations

Report any
- PV bleeding
- Increasing abdominal pain and or vomiting
- Increased BP
- Altered conscious state, headache, blurred vision

Specific management issues

Bland diet
Consider laxatives if constipation also present

Consultations

Gynaecology

Discharge Criteria

Nil vomiting for 6 hours
Normal hydration
Able to tolerate fluids
Adequate social support and carer
Follow-up arranged
Script for regular/ PRN antiemetics
RWH Patient handout for ‘Coping with Nausea and vomiting in Pregnancy’
- Coping with nausea and vomiting in pregnancy (worldssl.net)

Hospital admission criteria

Vomiting persisting
Unable to tolerate oral fluids and antiemetics
PV bleeding or increasing abdominal pain

Discharge Follow-up

GP
Private obstetrician

CELLULITIS

Bendigo ED/SSOU Cellulitis Guideline

PURPOSE AND SCOPE

To assist ED and SSOU staff in the diagnosis and management of cellulitis

To reduce the length of ED/SSOU stay of patients with cellulitis, and to reduce the rates of unsuccessful SSOU admissions

To assist in making early and appropriate disposition decisions

KEY POINTS

Consider key differential diagnoses

Most uncomplicated cases of cellulitis do not require investigation

Oral antibiotics are suitable for most patients. Intravenous antibiotics should only be used for those with evidence of severe infection, uncontrolled comorbidities, failure of oral antibiotics or specific circumstances that may limit oral therapy

Spreading erythema, ongoing fever and lymphangitis <72 hours after commencing appropriate antibiotics does not necessarily constitute failure of oral therapy. Consider a longer course or higher dose of oral antibiotics

Rest, elevation and splinting/immobilisation of any affected limb in order to reduce lymphatic spread are just as important as antibiotics in the successful treatment of cellulitis

Under certain circumstances, patients may need investigation and management by units other than ED/SSOU

OVERVIEW

Cellulitis is a spreading bacterial infection of the skin. There may be associated lymphangitis, lymphadenopathy, fever or haemodynamic compromise.

Impetigo is a highly contagious infection of the epidermis, particularly common in young children (hence known as “school sores”), often notable for its characteristic honey-coloured crust.

Common aetiology:

Streptococcus spp or Staphylococcus aureus
Purulent cellulitis is caused by Staphylococcus aureus
Cellulitis associated with animal bites (Capnocytophagia, Pasteurella, Eikenella), fresh water exposure (Aeromonas spp) or salt water exposure (Vibrio spp) require specific antibiotic regimes – refer to eTG for the most up to date recommendations
Cellulitis caused by MRSA is uncommon but is associated with penetrating trauma or ulcerated wounds
In immunocompromised patients, there are many possible causes which may include Gram negative bacteria, fungi or mycobacteria

Many conditions can present similarly to cellulitis, and are therefore often not treated appropriately. Consider the following differential diagnoses:

Necrotising fasciitis is a rare but life-threatening infection causing necrosis of subcutaneous tissues and fulminant sepsis. It can be caused by Group A streptococcal species, Clostridium species spp, or be polymicrobial. It presents as rapidly spreading erythema, severe pain +/- gas in tissues (crepitus) and haemodynamic compromise, mostly in diabetic and immunosuppressed patients. It requires urgent IV antibiotics and source control through surgical debridement by the Plastics team. Fournier’s gangrene is an acute necrotising infection of the perineum or genitalia and should be referred urgently to Urology
Lipodermatosclerosis is a chronic, often bilateral inflammatory condition of the lower limb associated with venous insufficiency causing oedematous brown-red discolouration of the skin. It does NOT respond to antibiotics. Bilateral lower limb cellulitis is rare and more likely to be lipodermatosclerosis
Varicose eczema
Joint pathology: septic arthritis, gout/pseudogout, inflammatory arthritis
DVT
Hypersensitivity reaction
Pyoderma gangrenosum

Predisposing factors to cellulitis include any skin breech, IV drug use, lymphoedema, chronic venous insufficiency, peripheral vascular disease, diabetes, obesity, tinea, fissured dermatitis and CCF.

Local audits and published studies have shown that patients with cellulitis have relatively long admissions to SSOU, high rates of unnecessary SSOU admission, and high rates of unsuccessful SSOU admissions. These factors demonstrate a need to identify the likely trajectory of the patient’s illness, and to admit/refer appropriately and early. The rates of necessary admission with cellulitis have been estimated at less than 10%, however this rate increases significantly in patients 55 years or older.

CLINICAL PRESENTATION

Acute onset of skin erythema, warmth, tenderness and swelling +/- lymphangitis, lymphadenopathy or systemic features.

Severe cellulitis is defined by the presence of cellulitis AND hypotension, or cellulitis plus two or more of the following:

Temperature >38.0 or <36.0
HR >90
RR >20
WCC <4 or >12 (or >10% bands)
Risk factors: IV drug use, immunocompromise, diabetes

Violaceous colour or the presence of bullae are highly suggestive of severe or systemic infection by organisms such as Vibrio or Streptococcus pneumoniae, and should be treated as such.

Pain out of proportion to clinical findings, palpable crepitus, hypotension and rapid spread of cellulitis should raise concern for a necrotising infection and an urgent surgical consult should be sought.

INVESTIGATIONS

Most uncomplicated cases of cellulitis DO NOT require investigation.

FBE, UEC, LFTs, CRP and blood cultures are only required if the patient is systemically unwell, is immunosuppressed, has significant comorbidities (including valvular heart disease, prosthetic heart valve) or where liver/renal dysfunction may affect the dose or choice of antimicrobials.

Blood cultures should not be routine; only in patients with sepsis or where atypical organisms are suspected.

US should be utilised if a foreign body is suspected, and to identify and quantify abscesses for surgical drainage.

MANAGEMENT

Patients are commonly referred to hospital for IV antibiotics after “failure of oral therapy”.

Rest, elevation and splinting/immobilisation of any affected limb in order to reduce lymphatic spread are just as important as antibiotics in the successful treatment of cellulitis.

Non-adhesive dressings should be applied to eroded skin.

Do NOT draw around the edge of cellulitis (see note below*).

Incision and drainage is the definitive treatment for abscesses – only patients with signs of systemic infection, or cellulitis extending beyond the abscess require antibiotic therapy.

Oral antibiotics are suitable for most patients.

Intravenous antibiotics should only be used for those with evidence of sepsis, uncontrolled comorbidities, failure of oral antibiotics (see note below*), or under specific circumstances (see section “Inpatient Management”)

* Spreading erythema, ongoing fever and lymphangitis <72 hours after commencing appropriate antibiotics does not necessarily constitute failure of oral therapy. Erythema often progresses after treatment is initiated and bacterial toxins are released. If otherwise clinically improving and no evidence of sepsis, oral antibiotics should generally be continued, and the need for rest/elevation/immobilisation reiterated. Consider increasing the dose of oral antibiotics (see outpatient management below).

Cellulitis associated with bites (either human or animal) should be referred to AGSU for consideration of washout +/- surgical debridement under general anaesthesia.

OUTPATIENT MANAGEMENT

Rest, elevation and splinting/immobilisation if a limb is affected is imperative to treatment.

Consider a tetanus booster (if not up to date) if cuts, bites or abrasions are suspected to be the cause of cellulitis.

Impetigo can be treated with topical mupirocin ointment, or cephalexin if widespread or large lesions.

1. Mupirocin ointment 2% to affected areas TDS for 5 days

2. Cephalexin 33mg/kg (max 500mg) PO BD for 5 days

Oral flucloxacillin is considered first-line treatment for adults with cellulitis due to its narrow spectrum of activity against Staphylococcal and Streptococcal species. Cephalexin has broader activity against Gram negative organisms, which can alter intestinal flora and lead to antibiotic resistance in these organisms. There is emerging resistance against erythromycin and roxithromycin in Staphylococcus and Streptococcus species. Cephalexin is preferred for use in children with mild cellulitis due to the poor palatability of flucloxacillin. Note the reduced frequency of dosing in children.

1. Flucloxacillin 500mg PO QID for 5 days

2. Cephalexin 500mg PO QID (paediatrics: 33mg/kg (max 500mg) TDS) for 5 days

Clindamycin is the antibiotic of choice for patients with severe hypersensitivity to penicillins or cephalosporins. Be mindful though that there is an increased risk of antibiotic-associated diarrhoea and Clostridium difficile colitis. Note the increased frequency of dosing in children.

1. Clindamycin 450mg PO TDS (paediatrics: 10mg/kg (max 450mg) QID) for 5 days

MRSA is an uncommon cause of cellulitis but may be associated with penetrating or ulcerated wounds. Risk factors include:

Residence in an area with a high prevalence of MRSA (NT, remote communities in northern Queensland, some areas of WA)
Patients of ATSI or Pacific Island descent
Previous colonisation or infection with MRSA
Frequent hospital stays, especially if associated with surgery
Residence in an aged-care facility, especially if the patient has had multiple courses of antibiotics

For proven or suspected MRSA infections, use clindamycin or trimethoprim/sulfamethoxazole.

1. Clindamycin 450mg PO TDS (paediatrics: 10mg/kg (max 450mg) QID) for 5 days

2. Trimethoprim/sulfamethoxazole 160/800mg (paediatrics 8/40mg (max 320/1600mg)) PO BD for 5 days

Patients with persistent skin changes after 5 days of oral therapy, but who are otherwise systemically well, should be considered for a longer course of oral antibiotics (10-14 days in total), or a higher dose of oral antibiotics (e.g. flucloxacillin 1000mg QID for 5 days OR cephalexin 1000mg QID for 5 days).

It should be noted, however, that prolonged or high dose treatment with flucloxacillin has been associated with rare cases of severe cholestatic hepatitis. The incidence of this reaction has been estimated to be between 1 in 12,000 and 1 in 100,000. The risk is predominantly in patients who are greater than 55 years of age, or who are treated for more than 14 days. Consider the patient’s individual circumstances, changing to another agent if longer or high dose therapy is required (e.g. cephalexin), and careful monitoring of liver function during treatment.

INPATIENT MANAGEMENT

This can occur in SSU (if anticipated stay is <24 hours), HITH, AMU or other inpatient specialty units depending on location, comorbidities and likely duration of treatment. Paediatric patients not requiring surgical input should be referred to the Paediatrics team.

Patients requiring hospital admission for IV antibiotics:

Sepsis or significant comorbidities (IV drug use, immunosuppressed, chronic heart/lung/liver/renal disease, diabetes) – SSOU or AMU
Not tolerant of oral intake
Genuine failure of oral antibiotics
Suspected necrotising infections – urgent AGSU (Plastics) referral (or Urology in cases of Fournier’s gangrene) plus IV antibiotics as per eTG and allergy history
Diabetic foot ulcer with associated cellulitis – AMU, may need discussion with a Vascular service
Cellulitis complicating penetrating injuries and retention of foreign bodies – AGSU (Plastics)
Hand cellulitis – consider AGSU (Plastics) referral
Cellulitis of finger/hand with concern for tenosynovitis – AGSU (Plastics)
Orbital cellulitis – transfer to a Melbourne-based service with an ENT/Ophthalmology service
Cellulitis associated with an abscess that requires inpatient incision and drainage (AGSU (Plastics))
Cellulitis associated with either animal or human bites – AGSU (Plastics) for consideration of washout under general anaesthesia
Social issues that will significantly impact upon care – SSU or AMU

Figure 1: Disposition for patients with cellulitis

When systemic features have resolved, switch to oral therapy – this may occur as rapidly as 1 or 2 doses of IV antiobiotics. A total of 5-10 days duration of treatment is recommended.

Antibiotic choice:

1. Flucloxacillin 1-2g (paediatrics: 50mg/kg (max 2g)) IV QID

2. Cephazolin 1-2g IV TDS

Clindamycin can be used in patients with severe cellulitis who have either an immediate or severe allergy to penicillins/cephalosporins, or if MRSA infection is suspected or proven and the organism is considered susceptible (based on sensitivity testing and local strain susceptibility)

1. Clindamycin 600mg (paediatrics: 10mg/kg (max 600mg)) IV TDS

For proven or suspected MRSA infections, use vancomycin or clindamycin (depending on sensitivities if proven to be the cause of infection)

1. Vancomycin IV (refer to eTG, AMH Handbook and RCH website for dosage and principles of use)

2. Clindamycin 600mg (paediatrics: 10mg/kg (max 600mg)) IV TDS

If community-based IV treatment is appropriate, please discuss with the Hospital In The Home (HITH) team as soon as possible. Patients typically suitable for their service have risk factors for severe disease, extensive areas of cellulitis or are not responding to appropriate oral antibiotics. They must meet the following criteria:

resolution of systemic features
no associated abscess (may require US to exclude)
no concern for limb compromise
exclusion of other diagnoses (where appropriate) prior to acceptance of care (e.g. DVT or abscess)
must live within a 30km radius of Bendigo, or be able to reside somewhere within this radius (e.g. with a relative or friend); patients outside of this area may be accepted for brokerage following review and in consultation with HITH nursing staff
must have access to a phone and carer in the event of an emergency
patient or appropriate medical decision maker must provide consent to treatment
patient and their home environment (e.g. pets) must not pose a threat to the safety of staff

The antibiotic of choice for HITH patients with cellulitis is cephazolin (due to its less frequent dosing), with or without probenecid (see below).

1. Cephazolin 2g IV daily

PLUS

Probenecid 1g PO daily

2. Cephazolin 2g (paediatrics 50mg/kg (max 2g)) IV BD

Probenecid is a medication that increases the excretion of uric acid into the urine. It is typically used in the treatment of gout and hyperuricaemia. Studies have also shown that probenecid increases the serum concentration of penicillins and cephalosporins by inhibiting their renal excretion, making once or twice daily dosing possible in the community via HITH.

It is not used in paediatric patients with cellulitis.

It should not be used when gout is active and can sometimes precipitate liver dysfunction and uric acid kidney stones so should be used cautiously in these instances.

OTHER

Fungal infection of the toes and their interspaces can provide a portal of entry for bacterial invasion – patients with lower extremity cellulitis (particularly if recurrent) may require antifungal therapy in addition to antibiotics

Patients with cellulitis associated with chronic wounds and other chronic conditions (such as lymphoedema, diabetes or peripheral vascular disease) may benefit from referral to a number of available community-based services:

High risk foot clinic
Lymphoedema service
Wound clinic
RDNS (now known as Bolton Clarke)

REFERENCES

Electronic Therapeutic Guidelines (eTG) - Cellulitis and erysipelas [Internet]. Melbourne, Australia: Therapeutic Guidelines Ltd; April 2019 [amended August 2021, accessed January 2021]. Available from https://tgldcdp.tg.org.au.acs.hcn.com.au/viewTopic?topicfile=cellulitis-erysipelas&guidelineName=Antibiotic&topicNavigation=navigateTopic#MPS_d1e491

Abetz JW, Adams NG, Newnham H, Smit V, Mitra B. Transfer of care and overstay in the management of cellulitis in the emergency short stay unit: A retrospective cohort study. Emerg Med Australas. 2017 Apr;29(2):143-148. doi: 10.1111/1742-6723.12731. Epub 2017 Jan 22. PMID: 28111931.

Cox VC, Zed PJ. Once-daily cefazolin and probenecid for skin and soft tissue infections. Ann Pharmacother. 2004 Mar;38(3):458-63. doi: 10.1345/aph.1D251. Epub 2004 Jan 23. PMID: 14970368.

Long B, Gottlieb M. Diagnosis and Management of Cellulitis and Abscess in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med. 2022 Jan;62(1):16-27. doi: 10.1016/j.jemermed.2021.09.015. Epub 2021 Oct 14. PMID: 34657784.

Clinical Practice Guidelines: Cellulitis and other bacterial skin infections [Internet]. Melbourne, Australia: Royal Children’s Hospital; March 2020 [accessed February 2022]. Available from https://www.rch.org.au/clinicalguide/guideline_index/Cellulitis_and_skin_infections/

Hospital In the Home (HITH) Admission and Referral Protocol [Bendigo Health Intranet]. Bendigo, Australia: Bendigo Health; 2017 [accessed February 2022]. Available from https://app.prompt.org.au/search

Original Author: Dr Scott Taylor

Publication Date: July 2022

Amendment Date: January 2023

Review Date: July 2025

ISCHAEMIC CHEST PAIN PATHWAY

Definition

Chest pain can be caused by a number of different pathologies which may include
- Ischaemic chest pain
- Pulmonary embolism
- Pneumonia
- Pneumothorax
- Gastritis
- Pericarditis
- Aortic dissection
- Among many others
Ischaemic chest pain may be stable angina, unstable angina, NSTEMI and STEMI

Admission Criteria

Pain/ other symptoms resolved
Risk stratification intermediate or low requiring investigations
Serious non cardiac cause clinically unlikely
Stable rhythm
Stable vital signs
No acute ischaemic ECG changes
1^st troponin expected to be in normal range in low risk patients

Exclusion criteria

Persistent symptoms e.g. pain, dizziness, dyspnoea
Unstable or abnormal vital signs
Risk stratification high
Unstable cardiac rhythm
Abnormal ECG
Cardiac enzyme rise

Scoring system

EDACS Emergency Department Assessment of Chest pain score

Calculate EDACS score via MDCALC
- https://www.mdcalc.com/calc/1858/emergency-department-assessment-chest-pain-score-edacs#use-cases
Chest pain present for >6hrs = single troponin
EDACS <16 repeat troponin 2hrs
EDACS >=16 repat troponin 3hrs

Investigations

FBE
UEC
Troponin
12 lead ECG
Consider
- CXR- this may not always be required, consider when patient has last had a CXR and if this is clinically indicated
- D-dimer- if requesting this please refer to “Pulmonary Embolism Pathway”
Additional
- Requested repeat troponin with appropriate time to be taken
- Repeat 12 lead ECG with second troponin

Suggested medications

Drug	Dose	Frequency	Route
Aspirin	300mg	Once	PO
GTN	300-600mcg	PRN 5min	SL
Paracetamol	1g	PRN 4hrly	PO
Oxycodone IR	5-10mg	PRN 4hrly	PO
Ondansetron	4-8mg	PRN 8hrly	SL/ PO
Metoclopramide	10mg	PRN 8hrly	PO

Specific observations

Cardiac monitoring
Report any chest/ arm/ jaw discomfort or shortness of breath to SSOU HMO. Please complete a repeat ECG.
Repeat ECG to be reviewed by senior SSOU doctor

Consultations

Consider discussion with cardiology

Discharge criteria

Resolved pain, no further symptoms
Unchanged ECG
No troponin rise
Follow-up arranged

Admit to hospital if any of the following apply

Recurrent chest pain or significant symptoms
ECG changes/ arrythmia
Troponin rise

Discharge follow-up

Follow-up testing is not required if patient is <50yo AND has <3 risk factors AND no previous CAD or MI

PULMONARY EMBOLISM

Definition

A pulmonary embolism (PE) is a blood clot that develops in a blood vessel elsewhere in the body (often the leg) and travels to an artery in the lung, causing a sudden blockage of blood flow to part of the lungs
Annual incidence of 0.31 per 1000 in Australia

Admission Criteria

Stable vital signs
No O2 requirement
No increased WOB
ECG- no signs of right heart strain
Low or Very Low Risk PESI score
PERC score >0 (as if 0 will rule out PE)

Exclusion criteria

PERC 0
PESI score risk class 3-5

Scoring system

Calculate Wells score to determine need for d-dimer and CTPA
- If patient low risk calculate PERC score
  - If PERC 0 <2% chance of PE indicating no need for further work-up for PE
  - If PERC >=1 D-dimer is required
- If patient Intermediate or high risk consider CTPA or VQ scan
Calculate PESI score to determine mortality risk if patient has PE
- If Very Low Risk or Low Risk PE – can go to SSOU
- If risk class 3-5 requires medical admission

PERC Score

Criteria	Point
Age >= 50 years	1
Heart rate >= 100bpm	1
SaO2 on room air <95%	1
Haemoptysis	1
Current oestrogen use	1
Surgery or trauma requiring hospitalization within 4 weeks	1
Prior DVT or PE	1
Unilateral leg swelling	1

Score

0 points or No to all = <2% risk of PE
>=1 or yes to any= cannot rule out PE

WELLS Score

Criteria	Points
Clinical signs/ symptoms of DVT	3
PE most likely diagnosis	3
Tachycardia (>100bpm)	1.5
Immobilisation/ surgery in previous 4 weeks	1.5
Prior DVT/ PE	1.5
Haemoptysis	1
Active malignancy (treatment within last 6months)	1

Score

Low risk <2 points- 2-4% probability of PE
Intermediate risk 2-6 points- 19-20% probability of PE
High risk >6 points – 50-67% probability of PE

PESI score

Predictors	Points
Demographic Characteristics
Age (yr)	1pt/ yr
Male sex	+10
Comorbid Disease
Cancer	+30
Heart failure	+10
Chronic lung disease	+10
Clinical Findings
Pulse >110/min	+20
SBP <100mmHg	+30
RR >30/min	+20
Temp <36C	+20
Altered Mental status	+60
Arterial O2 sat (PaO2) <90%	+20

Severity index

The PESI score predicts 30-day all cause mortality
- Very low risk- Risk class 1 (PESI <66) = 0.8%
- Low risk- Risk class 2 (PESI 66-85) = 2.5%
- Risk class 3 (PESI 86-105) = 4.3%
- Risk class 4 (PESI 106-125) = 9.9%
- Risk class 5 (PESI >125) = 27.1%

Investigations

FBE UEC
D-dimer if requires as per flowchart
ECG- looking for signs of right heart strain
CXR to rule out other causes of chest pain or respiratory symptoms prior to CTPA
CTPA
Consider
- pro-thrombotic screen if PE present and unprovoked.
- troponin

Suggested medications

Drug	Dose	Frequency	Route
Paracetamol	1g	PRN 4hrly	PO
Oxycodone IR	5-10mg	PRN 4hrly	PO
Ondansetron	4-8mg	PRN 8hrly	SL/ PO
Metoclopramide	10mg	PRN 8hrly	PO
Apixaban
If CrCl ≥25mL/min	5mg	BD	PO
If CrCl <25mL/min or Any 2 of the following weight <60kg, age >80yo, Cr >133micromol/L	2.5mg	BD	PO
Therapeutic Enoxaparin
If CrCl ≥ 30mL/min	1mg/kg	12hrly	SC
If CrCl <30mL/min	1mg/kg	24hrly	SC

Specific observations

Cardiac monitoring
Report any chest pain or worsening shortness of breath to SSOU HMO.
If chest pain present please complete ECG and

Consultations

Discussion with haematology if PE present, patient <45yo and unprovoked PE or if pregnant
Obstetrics if patient pregnant

Discharge criteria

If PE present
- Low and Very Low risk PESI score
- Discharge after 4-6hours observation in ED/ SSOU total
- Ensure first dose of DOAC given in ED
- Ensure that patient is discharged with therapeutic DOAC script for 3 months
- Education / counselling for ALL patients commences on anticoagulation either via pharmacy or medical staff
- Refer to haematology clinic
Symptoms resolved/ much improved
Observations within normal range
Follow-up organised

Admit to hospital if any of the following apply

O2 required
Submassive or massive PE present
Troponin rise

Discharge follow-up

GP
Haematology if PE present and unprovoked

Clinical Resources