GEMS - WDWLT?

What did we learn today?

Audit Presentation: Adult pain management in the ED

Click here to access the poster.

Areas of good practice:

1. majority of patients in SEVERE pain received their initial pain assessment within 20 minutes
2. majority of patients arriving in ED with pain had a documented pain score / group

Areas for improvement

1. all patients should have a pain assessment within 20 minutes of arrival to the ED
2. administration of correct analgesia for pain assessment
3. Reduction in the use of Oramorph

• we are using a lot of Oramorph - why?
  • difficult managing severe pain in minors (IV medication neccesetate trolley and a dgree of monitoring; it is not always practical / possible to move a patient to majors for this reason due to overcrowding)
  • can we look at other options?
    • PR diclofenac
    • IM morphine
    • INTRANASAL opioids?  ...watch this space...

Useful links:
RCEM Pain in Adults Best Practice guideline
Oxford analgesia league table

Burns in the ED

Plymouth is a burn facility.

5 criteria to guide referral decisions

• TBSA - Total Body Surface Area 
• Depth - The depth of burn injury
• Site - Anatomical site of the burn injury
• Mechanism - The etiology of the burn injury 
• Other Factors / Parameters that may impact on the severity/complexity of burn injury

Minimum threshold for REFERRAL to a burn centre (via Plastics Team)

• All burns ≥2% TBSA in children or ≥3% in adults
• All full thickness burns
• All circumferential burns
• Any burn not healed in 2 weeks
• Any burn with suspicion of non-accidental injury should be referred to a Burn Unit/Centre for expert assessment within 24 hours

Indications for DISCUSSION with Plastics Team

• All burns to hands, feet, face, perineum or genitalia
• Any chemical, electrical or friction burn
• Any cold injury Any unwell/febrile child with a burn
• Any concerns regarding burn injuries and co-morbidities that may affect treatment or healing of the burn

Essential documentation

• Age
• DOI (date of injury)
• TOI (time of injury)
• First aid
• MOI (mechanism of injury)
• TBSA
• Depth
• Suspicion on NAI
• Dressings = non-adherent (Mepitel)
• FU plan

Useful links:
Burns assessment
National burn care referral criteria
Burns and Scalds leaflet for Parents

Knee examination

In the assessment of ACL injuries, the history is often the most important aspect in diagnosis.

In the assessment of patella dislocations, look out for these groups who will present with patellar instability.
1. Trochlear dysplasia

• "J sign" - refers to lateral patellar deviation during terminal knee extension
• video

2. Patella alta 

• Insall-Salvati ratio

3. lateralisation of the tibial tuberosity

• ​Q angle

Other interesting eponymous knee injuries

• Segond fracture : very frequently (~75% of cases) associated with disruption of the anterior cruciate ligament.
• Pellegrini-steida lesion (avulsion injury of the medial collateral ligament at the medial femoral condyle)
• o'donohues unhappy triad (ACL, MCL, medial meniscal tear)

Hand anatomy

Boutonniere Deformity
Jersey Finger
Guyon tunnel syndrome