Sunshine ED Fast Track

see also:

• Western Health ED main page
• Western Health ED medical orientation
• nurse initiated ED treatment

• patients with tonsillitis, peritonsillar abscess (quinsy), or uncomplicated epistaxis can generally be admitted to EOU for ENT reg review
• see:
  • ears, nose and throat surgery (ENT)

• based at Footscray
• there is no OPG machine at Sunshine - only at Footscray, thus at SH may need to do plain films +/- CT as per faciomax.
• refer patients with dental abscesses, fractured mandibles, etc.
• see also:
  • faciomaxillary
  • facial trauma
  • non-traumatic facial swelling / oedema

• The febrile adult presenting to the ED
• cellulitis
  • most febrile patients with cellulitis should be admitted to EOU for initial IV antibiotics
  • patients with co-morbidities (eg. bariatric, diabetic, chronic leg oedema, etc) should be admitted as inpatient under gen med
• venous leg ulcers
• needlestick injury
• intravenous iron Rx (ferric carboxymaltose) at Western Health
• referrals for blood transfusion without acute bleeding:
  • if not appropriate for blood transfusion:
    • print out the WH blood transfusion policy at WH blood transfusion guidelines (pdf) for the patient to give to the GP
    • consider intravenous iron Rx (ferric carboxymaltose) at Western Health if applicable
  • if appropriate for blood transfusion
    • iv cannula, Xmatch, FBE, U&E, admit to EOU (BUT admit to inpatient unit instead if complex issues or ongoing bleeding)
• patient with possible DVT and no clinical features of PE:
  • if Wells score = 0, no cancer, no PH DVT, a negative D-Dimer is sufficient to exclude a DVT
  • if Wells score > 0, need an USS - if there are delays to US then s/c enoxaparin until result of USS
  • if proven DVT then stat s/c enoxaparin and start DOAC (eg. rivaroxaban)
• patient with possible PE:
  • if very low probability PE (PERC negative and Wells < 2) then no need to Ix for PE
  • if low probability PE (Wells 2-4) then negative D-Dimer adequate to exclude PE (consider admit to EOU)
  • if mod-high probability PE (Wells > 4) then D-Dimer not useful, admit to EOU and just do CTPA or V/Q
  • if proven PE and no compromise features, consider outpatient Mx with stat s/c enoxaparin and start DOAC (eg. rivaroxaban), otherwise admit under resp. unit

• low to medium risk patients with undifferentiated abdominal pain / suspected diverticulitis or appendicitis, etc who need further investigations in ED should be considered for work up or review by surg reg in EOU
• patients who have clear cut surgical admission indications should preferably be admitted to a ward bed ASAP if they are stable - may require interim admission orders to be completed if there are delays in surg team reviewing in ED - there is usually no need to await a CT abdo prior to admission
• don't forget to exclude ectopic pregnancy!
• see:
  • general surgery
  • the patient with acute abdominal pain in the ED
  • ano-rectal pain

• don't forget to have a low index of suspicion for ectopic pregnancy in all females of childbearing age with abdo pain, PV bleeding or syncope, even if they have just had a menses
• hyperemesis gravidarum - usually admitted to EOU
• vaginal bleeding in early pregnancy
  • Western Health early pregnancy assessment service (EPAS) referral process
• pelvic inflammatory disease (PID)
• ovarian cysts and other cysts in the adnexae
  • consider admit to EOU if awaiting serum HCG or pelvic USS that day to determine need for admission under gynae

• see:
  • neurology
  • headache
    • if sudden onset headache or other flags for subarachnoid haemorrhage (SAH) then EARLY CT brain (preferably within 6hrs of onset)
    • if possible meningitis then early iv antibiotics
    • headache + fever + cough in winter is likely to be influenza - apply resp. precautions
    • Mx of acute migraine
      • if migraine patients are vomiting or not responding to analgesics then admit to EOU for iv largactil
  • ED Mx of vertigo and BPV
    • most patients can be admitted to EOU
    • don't forget posterior circulation stroke - especially in older patients with risk factors such as diabetes
  • facial weakness
    • stroke vs Bell's palsy

• ED pathway for Mx of suspected or confirmed cancer and other oncology related links

• Eye injuries
• ophthalmology
• there is a slit lamp in the procedure room near EOU at Sunshine
• consider referral to Western Eye Clinic for follow up review of corneal FBs, etc
  • Private clinic at Suite 210, Level 2, 1 Thomas Holmes Rd, Maribyrnong
  • All patients require a referral letter with the patient’s bradma sticker and a provider number (please fax this to the clinic and ask patient to phone clinic for an appointment), and the patient will be billed
  • ph: 9317 8930 fax: 9912 2306

• orthopaedics in the ED
• Western Health Orthopaedics and Fractures
• Western Health Virtual Fracture Clinic and also the Falls and Fracture Prevention Clinic
• adult orthopaedics is only at Footscray
• patients with an obvious dislocated ankle MUST have this relocated ASAP - within minutes of arrival - and before x-ray to reduce risk of serious morbidity due to skin necrosis
• fractures of the hand distal to the carpal bones are managed by plastics NOT orthopaedics
• sciatica
  • patients not able to mobilise should be considered for EOU
  • disc prolapses or those with red flags of spinal disease needing surgical Mx are managed by neurosurg not orthopaedics

• plastics is only at Sunshine
• open wounds with possible joint involvement (excluding hands) are generally managed by orthopaedics not plastics
• Achilles tendon injury are managed by orthopaedics not plastics
• see plastic surgery

• see vascular surgery at Western Health
• based at Footscray
• at Sunshine, contact the vasc reg at WH
• see:
  • abdominal aortic aneurysm (AAA)
  • peripheral vascular disease (PVD or PAD)