EMERGENCY DEPARTMENT

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Dual antiplatelet use in NSTEMI / STEMI

Message from Matt Jackson, cardiologist

Just a quick update following on from the change to the NSTEMI pathway.

It is now the Tees-wide agreement that NSTEMIs do NOT get loaded with a second antiplatelet prior to angiography. For once, CDDFT blazed the trail and Middlesbrough have been forced out of procrastination (which is nice).

For ED/AMU purposes, this is as discussed in the ED governance meeting recently and translates to:

• Suspected NSTEMI – Aspirin / Fondaparinux ONLY
• Suspected NSTEMI on anticoagulation – Aspirin ONLY. Continue regular anticoagulation

After a bit of additional discussion, this advice now also applies to STEMIs.

The ATLANTIC trial showed no benefit in preloading with Ticagrelor in the ambulance on the way from the patient’s house to the cath lab compared to loading post procedure. There is no evidence that giving Ticagrelor in an ED cubicle THEN getting in the ambulance is any more effective!

So the STEMI advice is:

• Aspirin
• Analgesia
• Ambulance ASAP
• NO SECOND ANTIPLATELET OR FONDA
• Heparin IV 5000IU if you have it easily to hand and it is not going to delay transfer. Not essential.

JCUH is our ‘go to’ tertiary centre and have agreed this. I can check what the current Freeman policy is but (from experience) they load patients at the CCU door on the way into the cath lab so I would not see this as a deal breaker to a blanket policy of NOT loading in out ED.

For clarity, the ‘no DAPT’ rule is only in the acute setting after numerous studies showing pre-loading before angiography makes no difference to outcomes. In the post-MI period, DAPT has a definite long-term benefit with the standard of care remains 12 months followed by lifelong single antiplatelet (with an increasing use of Prasugrel now evidence suggests it might be a little bit better than Ticagrelor as well as cheaper).

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Cardiology follow up

Summary:

• There is no access to a rapid access chest pain clinic from ED / AMU / SDEC.
• Do not ask GP to refer to RACPC.
• Discuss early with cardiology team / outreach nurses for queries
• Send an e-mail with copy of notes to below e-mail address if discharging - cardiology service will triage and contact patient. Make clear in notes to GP that cardiology have been mailed for an opinion and they will review the case

cddft.cardiologyuhnd@nhs.net

ED (and others) do not have access to a rapid access chest pain clinic (RACPC) - when this was available, there was reportedly a 0% hit rate for cardiac issues.

Most frequently, when a patient attends the Emergency Department or SDEC, it is due to prolonged episode of chest pain or with atypical features. In this instace, the predominant question being asked is "is this a heart attack?". Following the chest pain algorithm, will either result in admission for assessment or NSTEMI ruled out. In the latter instance, the advice to be given is: "Advice: You have not had a heart attack. You only need to see your GP if you have ongoing concerns or symptoms. Your GP will then decide if you should be referred for further tests."

In the instance that a patient attends with a suspected diagnosis of typical angina, or the patient is already under a cardiologist with some change in the existing problem and you want to let cardiology know about it (e.g., known coronary artery disease with a further presentation with chest pain / angina), then contacting the cardiologist of the day / cardiac outreach nurses in hours, or sending an e-mail with a copy of the notes to the above e-mail address is an appropriate course of action.

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Diabetic foot clinic referral

If a patient needs follow up in diabetic foot clinic after discussion with ED SDM/speciality, please email:

• cddft.diabetesadmin@nhs.net

Please send the symphony notes and reason for referral. Please document the same in the medical notes that a referral has been sent. The Diabetic team will follow up the patient.

NOTE: Please don’t ask primary care physician to do the referral in the discharge letter.

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House-Brackmann Facial Paralysis Scale

• Grade I: Normal
• Grade II: Slight facial weakness or other mild dysfunction. Normal tone and symmetry at rest. Complete closure of the eye without effort. Slight asymmetry of the mouth when facial movements occur.
• Grade III: Assigned to patients dealing with moderate dysfunction; these patients generally do not display any noticeable facial weakness with synkinesis, they maintain complete eye closure and good forehead movement with effort.
• Grade IV: Assigned to patients dealing with severe dysfunction. Obvious facial weakness. Incomplete eye closure, no forehead movement, asymmetrical mouth movement, and synkinesis.
• Grade V: Assigned to patients who have little to no ability to smile, frown or make other facial expressions. The closure of the eye is incomplete, and there is no forehead movement.
• Grade VI: No facial motion.

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Urology clinic referrals for stones or retention

Following a discussion with the urology secretaries at Sunderland, they have agreed that for both urinary retention and stone clinic referrals, we simply need to email our secretaries to ask them to please send a copy of the notes to the urology secretaries. We no longer need to complete any referral forms.

For this to work it is important that the notes contain all of the relevant details, including:

• Urinary Retention – PR examination, mls drained when catheter inserted, Blood results including WCC, CRP, U&Es
• Stone Clinic – CT findings, Blood results including WCC, CRP, U&Es
  • Transfer CT KUB AND plain XR-KUB to Sunderland PACS
  • The plain XR KUB has been agreed with radiology and urology and allows urology to track progression of the stone if radiopaque

Do NOT send the referral directly to urology, but to the ED secretaries to allow tracking of the referral.

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Suspected cancer referrals

There are two options of referral for suspected cancer:

• 2 Week Week (2ww) - for those with symptoms suggestive of malignancy
• 1 Week Wait (1ww) specifically for ED for those with imaging suggestive of malignancy

Guidance

1. Suspected diagnosis of malignancy: fill in one of the referral forms
2. Inform the patient and the leaflet in the same form/ link to be handed out.
3. Request CT TAP as outpatient under 2 WW if not already done and inform the same to patient.
4. Also record this in the ED EPR notes, a copy of which can be posted to GP so that the primary care team are aware.
5. The completed form and EPR notes should be sent to
   • cdda-tr.cancer2WWBookingteam@nhs.net AND
   • cddft.aos@nhs.net AND
   • also CC to UHND ED secretaries cddft.eduhndsecretaries@nhs.net
   This can be uploaded onto EPR as a proof.

Note: with the transition to EPR, the forms may make reference to Symphony

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Prothrombin Complex Concentrate (PCC / Beriplex) Guide