Moderator ventana Posted December 19, 2014 Moderator Share Posted December 19, 2014 Looking to put together a list of red flag symptoms (with clinical info) for complaints that either need to talk to a provider ASAP - but likely go to ER, along with WHY we need to send. Working on nurse triage training....... two I have recently run across 1) double vision after facial trauma - needs CT to r/o fracture with entrapment 2) testis swelling (pretty much any swelling) after trauma - needs scrotal US to r/o torsion, fracture, rupture...... Anymore? (not every little complaint, but the big one's that we just can not miss) (yup I have to much time tonight so I am playing with font and colors) Link to comment Share on other sites More sharing options...
Joelseff Posted December 19, 2014 Share Posted December 19, 2014 I had a pt withHerpes Zoster Opthalmicus who was referred to me by a psychiatrist colleague who thought "she has severe allergies and a reaction to benadryl." Pt presented with shingles on the right side of her forehead and scalp and her eye was swollen shut with lovely discharge.She also had not seen a provider in years and had a BMI of 61! Yes. 61...i tried to bring her back in after her hospitalization but she never returned our calls. Edit: I meant HZ opthalmicus not Ramsay Hunt-Sorry staying late at the office to finish charting...SMH Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 19, 2014 Moderator Share Posted December 19, 2014 acute onset dizzyness in pt over 50 which is not clearly BPV. could be posterior circ. stroke. needs emergent ED eval for contrast MRI. Vague dyspnea +/- chest pain in woman on birth control to r/o PE Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 19, 2014 Author Moderator Share Posted December 19, 2014 Like these for immediate double vision after facial trauma - needs CT to r/o fracture with entrapment testis swelling (pretty much any swelling) after trauma - needs scrotal US to r/o torsion, fracture, rupture...... Facial Herpes with eye or tip of nose involvement(I added that one for optic nerve involvement) Exposure to Bats - the whole rabies IG and vaccination is only avail through our ER These seem like they need to see a PA to see if they warrant ER visit (remember it is nurses doing the triage, not a provider) age > 50 and new onset dizzy vertigo Dyspnea in female of child bearing age, smoker, OBCP Link to comment Share on other sites More sharing options...
Guest Paula Posted December 19, 2014 Share Posted December 19, 2014 How about a patient who presents to the office stating "I think I'm turning yellow?" The patient is the color of a banana. Took me 2 1/2 hours to work the pt. up and could have been done so much quicker in an ER. Even in rural areas an ER visit is necessary. It's too complicated to explain why I didn't send due to internal politics. Pt. had pancreatic cancer. Was interesting, I must say. Link to comment Share on other sites More sharing options...
winterallsummer Posted December 19, 2014 Share Posted December 19, 2014 syncope > 50 y/o CP in unestablished pts or pts who will need trop/ekg trending trauma w/ LOC do you have Xrays in your office? Link to comment Share on other sites More sharing options...
cbrsmurf Posted December 20, 2014 Share Posted December 20, 2014 How about a patient who presents to the office stating "I think I'm turning yellow?" The patient is the color of a banana. Took me 2 1/2 hours to work the pt. up and could have been done so much quicker in an ER. Even in rural areas an ER visit is necessary. It's too complicated to explain why I didn't send due to internal politics. Pt. had pancreatic cancer. Was interesting, I must say. Is the ER the best place to send this type of patient? Would an urgent abd CT and bloodwork be more appropriate? Link to comment Share on other sites More sharing options...
cbrsmurf Posted December 20, 2014 Share Posted December 20, 2014 acute onset dizzyness in pt over 50 which is not clearly BPV. could be posterior circ. stroke. needs emergent ED eval for contrast MRI. Saw that last year when I was in UC. Said he got a spider bite on his hand then felt dizzy a few hours later. Wife noticed his face looked "different" (I honestly couldn't tell anything looked weird on his face and CN II-XII were equal bil). Hypertensive, Romberg positive. Decided to send him to the ED and ended up being an ischemic CVA. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 20, 2014 Moderator Share Posted December 20, 2014 Is the ER the best place to send this type of patient? Would an urgent abd CT and bloodwork be more appropriate? nope. they turn out bad. what do you do? send to the er for workup and admission....skip the middleman and just send now. Link to comment Share on other sites More sharing options...
Guest Paula Posted December 20, 2014 Share Posted December 20, 2014 Is the ER the best place to send this type of patient? Would an urgent abd CT and bloodwork be more appropriate? I worked him up with blood work, called a surgeon for consult, he immediately said it's probably pancreatic cancer and the ERCP is the choice diagnostic tool. Told him to go on his weekend fishing trip, which he did. It took wrangling the system to find which health care facility had the person who does ERCP, (2 hours away), was set up after fishing trip. ERCP was complicated. Mass was hard to get to. Had at least 2 of them. Now undergoing chemo in another state close to family. I don't expect I will ever see him again. BTW...he already had history of prostate cancer. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted December 20, 2014 Moderator Share Posted December 20, 2014 Low back pain associated with leg weakness (not pain) and urinary/bowel difficulty and/or chills/nightsweats- needs emergent imaging for cauda equina and/or epidural abscess Increasing pain a few days/week after an injury to a limb, confined to a particular region (such as upper arm, forearm, thigh, calf, etc)- possible compartment syndrome (remember this is also one of those "pain out of proportion to exam findings") Pain behind eye after recent "viral" URI, +/- slight periorbital swelling- possible cavernous sinus thrombosis Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 20, 2014 Author Moderator Share Posted December 20, 2014 How about a patient who presents to the office stating "I think I'm turning yellow?" The patient is the color of a banana. Took me 2 1/2 hours to work the pt. up and could have been done so much quicker in an ER. Even in rural areas an ER visit is necessary. It's too complicated to explain why I didn't send due to internal politics. Pt. had pancreatic cancer. Was interesting, I must say. Sorry, I disagree - the worst place for him to go is the ER - these are the ones that you tell your office staff to work on, getting urgent labs, CT chest, abd plevis (single dye load) in the same day, then ONC refferral. He has been growing his CA for a number of months - agreed with the comment to tell him to go enjoy life while the work up gets done. syncope > 50 y/o CP in unestablished pts or pts who will need trop/ekg trending trauma w/ LOC do you have Xrays in your office? Confirmed syncope - yes CP - have a younger population (mostly 20's 30's into early 40's so not sure if this would be a mandatory send out - more of a triage nurse talking to them on the phone to figure out Trauma with LOC - yes - sending out Low back pain associated with leg weakness (not pain) and urinary/bowel difficulty and/or chills/nightsweats- needs emergent imaging for cauda equina and/or epidural abscess Increasing pain a few days/week after an injury to a limb, confined to a particular region (such as upper arm, forearm, thigh, calf, etc)- possible compartment syndrome (remember this is also one of those "pain out of proportion to exam findings") Pain behind eye after recent "viral" URI, +/- slight periorbital swelling- possible cavernous sinus thrombosis humm low back pain - >50% of my clients claim this - not sure I would want this population going to the ER urgently with out me seeing them. Nursing exam skills are not that great and waiting to the next day (as long as they are not toxic appearing would seem prudent with the population I am dealing with) Hum compartment syndrom - yes that would be ER send out - have to capture that in the protocol for pain out of proportion Eyes- yes that is a good one - might be tough to distinguish from the complaints of occipatial neuritis head ache for a non-provider, but get me thinking of the displaced eye, double vision, acute glaucoma complaints.... good one Link to comment Share on other sites More sharing options...
SocialMedicine Posted December 20, 2014 Share Posted December 20, 2014 i think the lower back pain case was describing a caudal equine syndrome scenario and not a typical low MSK back pain/pyelo/sciatica/stone etc. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted December 20, 2014 Moderator Share Posted December 20, 2014 i think the lower back pain case was describing a caudal equine syndrome scenario and not a typical low MSK back pain/pyelo/sciatica/stone etc. Basically, this- I would never encourage the routine everyday "my lower back hurts" with no other associated symptoms to set foot anywhere near an ER. Although those associated symptoms can be a little hard to differentiate over the phone with a nurse, so it's understandable. Want to hear something scary? EmCare, being one of if not the largest ER provider subcontractor, keeps very close tallies of their "top ten" malpractice misdiagnoses. One of the three fastest-rising diagnoses- for reasons they can't figure out- is a missed spinal hematoma with permanent neurologic dysfunction. It certainly scares me with the vague complaints we sift through daily of "my back hurts and my leg feels numb" that has a normal exam that you can so easily write off as sciatica or a herniated disc. So you can add that in as a sort of "triple threat" of cauda equina/epidural abscess/spinal hematoma as back pain etiologies associated with neurologic symptoms that need emergent evaluation Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 20, 2014 Author Moderator Share Posted December 20, 2014 Basically, this- I would never encourage the routine everyday "my lower back hurts" with no other associated symptoms to set foot anywhere near an ER. Although those associated symptoms can be a little hard to differentiate over the phone with a nurse, so it's understandable. Want to hear something scary? EmCare, being one of if not the largest ER provider subcontractor, keeps very close tallies of their "top ten" malpractice misdiagnoses. One of the three fastest-rising diagnoses- for reasons they can't figure out- is a missed spinal hematoma with permanent neurologic dysfunction. It certainly scares me with the vague complaints we sift through daily of "my back hurts and my leg feels numb" that has a normal exam that you can so easily write off as sciatica or a herniated disc. So you can add that in as a sort of "triple threat" of cauda equina/epidural abscess/spinal hematoma as back pain etiologies associated with neurologic symptoms that need emergent evaluation Can't disagree that these need to go to the ER - but would say that it is after being valuated, not before over the phone from a nurse. Link to comment Share on other sites More sharing options...
2234leej Posted December 21, 2014 Share Posted December 21, 2014 Sorry, I disagree - the worst place for him to go is the ER - these are the ones that you tell your office staff to work on, getting urgent labs, CT chest, abd plevis (single dye load) in the same day, then ONC refferral. He has been growing his CA for a number of months - agreed with the comment to tell him to go enjoy life while the work up gets done. Confirmed syncope - yes CP - have a younger population (mostly 20's 30's into early 40's so not sure if this would be a mandatory send out - more of a triage nurse talking to them on the phone to figure out Trauma with LOC - yes - sending out humm low back pain - >50% of my clients claim this - not sure I would want this population going to the ER urgently with out me seeing them. Nursing exam skills are not that great and waiting to the next day (as long as they are not toxic appearing would seem prudent with the population I am dealing with) Hum compartment syndrom - yes that would be ER send out - have to capture that in the protocol for pain out of proportion Eyes- yes that is a good one - might be tough to distinguish from the complaints of occipatial neuritis head ache for a non-provider, but get me thinking of the displaced eye, double vision, acute glaucoma complaints.... good one As a PT, I had the opportunity to see mostly musculoskeletal conditions in the ER. It gave the physicians and PA's an opportunity to focus on more serious matters that they needed to attend to. From my understanding of current research, urinary retention is the most sensitive and specific to rule in/out for cauda equina syndrome. You're right...I hear plenty of people who say that they are urinating uncontrollably or their bowel movements have changed. If they have to take a piss and they are unable to that's a big red flag (this accompanied with the back pain, weakness, saddle anesthesia, etc.) Just my 2 cents. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted December 21, 2014 Share Posted December 21, 2014 Seems to me the biggest reason for primary care to send to the ED is the little hand on the clock is approaching the four. :-) (ducking for cover now) Link to comment Share on other sites More sharing options...
Joelseff Posted December 21, 2014 Share Posted December 21, 2014 Seems to me the biggest reason for primary care to send to the ED is the little hand on the clock is approaching the four. :-) (ducking for cover now)That's ridiculous..... Knockoffs at 5 :P Link to comment Share on other sites More sharing options...
winterallsummer Posted December 21, 2014 Share Posted December 21, 2014 Another thing I see sent often is cp or ha with sbp > 200. Link to comment Share on other sites More sharing options...
Guest Paula Posted December 21, 2014 Share Posted December 21, 2014 A one week old infant with a fever and a cough. Yes, they tried to tell the walk-in clinic registration clerk that we could see the baby. They being the OB department. WHAT?????? (This was several years ago when I worked Urgent care.) That one quickly went to ER, flown out within a few hours. Sepsis workup for sure. Link to comment Share on other sites More sharing options...
primadonna22274 Posted December 21, 2014 Share Posted December 21, 2014 There's a great thread going on SDN about neonatal fever workup. Dogma has really changed in the past decade (thanks to improved herd immunity from strep pneumo and H. Flu), but anybody reasonable is still going to do full sepsis workup, empiric antibiotics and hospitalize a <30 day old. If they're an ex-preemie, use the corrected age. The grayer zone is that 31-day to 90-day range. Most of the peds attendings I've worked with lately are still erring on the side of caution with anyone under 10 wk and if they haven't had immunizations, all bets are off. I ran into this a month ago with a 28-day-old term infant with fever and proven influenza A (sister had it too). Baby looked great but we still had to do the sepsis workup, empiric abx and pan culture until we proved the baby wasn't septic. All cultures negative and baby went home 2 days later with relieved parents. Link to comment Share on other sites More sharing options...
Guest Paula Posted December 21, 2014 Share Posted December 21, 2014 ^^^Good to know. If I remember the case correctly this infant had ARDS and I was able to see the xray. Didn't look good but baby was ok in the end. There is a group of people in our area who do not immunize. I don't recall much else about the case, but clearly not appropriate for a walk-in clinic to work up, especially when the ER is 1/2 block away and connected by a hallway between clinic and ER. I think parents didn't know where to go, called the OB department and someone told them to go to the Walk-in first. That someone needed more training, especially since our standard of care was no infants under 3 months could be seen unless it was for something simple like conjunctivitis or diaper rash. I remember getting the call from the front desk clerk and I came out to talk to parents and escorted them directly over to the ER as the infant was definitely in trouble. Diaper rash is another story as we had an infant present with that and it really was staph or strep infection with toxic necrotizing epidermalysis syndrome. The NP on at the time diagnoses it correctly, sent to ER, they blew it off, sent baby home, only to have parents return within 12 hours, and baby flown out to larger pediatric unit. The challenges of rural care! Link to comment Share on other sites More sharing options...
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