Figures 6.1 and 6.2 are provided as references to ensure that you don’t miss a crucial step. They are taken from the NICE guidelines for STEMI and NSTEMI pathways. Your hospital will also have a local policy.

Stroke

Nationally, strokes are now dealt with at hospitals with hyper-acute stroke units (HASU) departments. Hospitals providing this service are able to administer thrombolysis as clinically indicated, and anyone who has had a suspected stroke should be taken there if any suggestive symptoms are present. These centres also run clinical trials, and so patients may have other treatments as part of a trial if they meet the selection criteria. Thrombolysis is currently indicated if onset of symptoms has occurred within four and a half hours of presentation.

It is unlikely that you will have to deal with a suspected acute stroke by yourself. However, there are always exceptions, in particular if a stroke has occurred but has not been recognized. It is therefore important to have a grasp of the initial emergency management and a knowledge of whom to contact when you suspect a stroke.

Start by making an initial assessment of the patient using an airway, breathing, circulation (ABC) approach. Provide any necessary urgent interventions such as oxygen and airway manoeuvres, IV fluids, controlling seizures and contacting intensive therapy unit (ITU) if the patient is likely to require intubation. Much of the medical management of a stroke is done after the patient reaches the ward, for example, organizing an echocardiogram and carotid Dopplers or starting anticoagulation. In A&E, assess the patient and then discuss with a senior colleague with a view to arranging imaging (CT head) and then considering transfer to a HASU. Once you have ruled out a bleed on CT, you can start 300 mg of aspirin, unless there are contraindications. Discuss with your senior or the stroke registrar on call if you are unsure.

If the patient’s symptoms have resolved, this may suggest a transient ischaemic attack (TIA). You should perform an ABCD² score which predicts risk of a completed stroke over the coming days. A score of 4 or more indicates high risk of an early stroke. In addition, a person is at higher risk (even with a low score) if they have had 2 or more TIAs within 1 week (crescendo attacks). Those at high risk should be seen and assessed by a specialist within 24 hours, for example, in an outpatient TIA clinic the next day. If the score is ≤3 with no other episodes in the past week, they can be seen within 1 week. If the patient is on anticoagulation but has had symptoms of a TIA, they must have brain imaging immediately.

DVT and PE

Once you have reviewed a patient and suspect a DVT or PE, it is important to estimate the likelihood of these conditions. This will guide further investigations and management.

The pretest probability of a DVT is calculated using the Well’s Score.

A score of ≥3 suggests high probability of DVT/PE, and so the patient should be treated. The same should be done with those patients with intermediate probability of DVT/PE. If they have a low likelihood, then a D-dimer test should be performed. Be wary of a raised D-dimer, as it is not specific for DVT and can be raised in a broad range of conditions including pregnancy, inflammation and malignancy. A negative D-dimer is a good way to exclude a DVT/PE, but if positive, you should treat and investigate.

Patients can generally be given LMWH injections at a treatment dose. This is calculated according to their weight. Consult the BNF or your local hospital protocol for advice.

The USS scan can then be performed either the same day as an inpatient or if it is out of hours then urgently as an outpatient. If they do have a DVT and oral anticoagulation needs to be started, they should continue LMWH injections outside of hospital until their international normalized ratio (prothrombin ratio) reaches a therapeutic level. They will need to be taught how to inject, or they will need referral to district nurses.

Most PEs arise as a consequence of existing DVTs. Other possible sources include septic emboli from right-sided endocarditis or air, fluid, amniotic or fat emboli. Assess for risk factors (pregnancy/oral contraceptive pill/recent flights/immobilization in hospital/active malignancy/thrombophilia/recent surgery).

Once you have assessed the patient and ensured they are stable, perform the usual baseline tests including an arterial blood gas (ABG) and chest X-ray (CXR). Only perform a D-dimer test if the patient has a low probability of PE. If it is negative, you can reliably exclude PE. Imaging is usually a computerized tomography pulmonary angiogram (CTPA) and is now the recommended first-line imaging modality.

Thrombolysis is the treatment of choice for massive PE (i.e. where the PE has caused circulatory collapse). If it seems likely the patient may have a cardiac arrest, this can be given on clinical grounds alone. Otherwise, imaging (CTPA) should be arranged within 1 hour.

Haematemesis

Haematemesis can be a frightening prospect. You can do the best for your patient by following a series of important steps before definitive management, and control of bleeding is performed at endoscopy.

There are a number of causes of haematemesis. The following list gives the most common causes:

• Peptic ulcer disease
  
• Mallory–Weiss tears
  
• Oesophagitis
  
• Oesophageal varices
  
• Gastritis
  
• Malignancy
  
• Drugs such as non-steroidal anti-inflammatory drugs, anticoagulants and steroids

The patient may vomit fresh blood or ‘coffee grounds’. There are a number of scoring systems for predicting mortality in upper GI bleeds, including the Rockall risk-scoring system and the Glasgow–Blatchford system for predicting those patients who are likely to need medical intervention.

When a patient presents in shock (tachycardic/hypotensive/oliguric), the following algorithm should be followed.