Common ER Encounters
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Use YKHC published guidelines for all types of encounters, if a guideline is available. If you deviate from the guidelines, document in the chart why you didn't follow the guidelines.
- 1 Acute Coronary Syndrome (ACS)
- 2 Acute Ischemic Stroke
- 3 Sepsis (Adult) and (Pediatric)
- 4 Fever in Infant(0-90 days)
- 5 Respiratory illnesses
- 6 Skin and Soft Tissue Infection
- 7 Head injuries (Pediatric)
- 8 First Trimester Vaginal Bleeding
- 9 Alcohol Related Encounters
- 10 Title 47 Hold
- 11 Abdominal pain
- 12 Injuries/Fractures
- 13 Neonatal Jaundice
- 14 Dog Bites
- 15 Botulism
- 16 Acetaminophen overdose
- 17 Sexual assault/sexual abuse of a minor
- ACS has become increasingly common in our population and, as a result, our use of lytics has increased. If ACS is suspected, the order set for chest pain will be initiated. Cardiology is usually available at ANMC to review your EKG if you wish before initiating lytics. Most acute MI patients will be medevac’d to ANMC – possible exceptions include the elderly with multiple co-morbid conditions who aren’t eligible for operative intervention.
- If you give lytics, the patient goes via medevac to ANMC.
- ACS (Acute Coronary Syndome) in the Emergency Department
- ED ACS Adult Guideline revision 2020 by Dr. Andrew Swartz
- High-sensitivity Troponin-T by Dr. Andrew Swartz
- We do give lytics for acute stroke if appropriate and no contraindications. Neurology at ANMC must be consulted if you are considering lytics.
- All acute strokes and TIAs are medevac’d to ANMC for further workup. This is true even if they have recovered from a neuro standpoint.
Sepsis (Adult) and (Pediatric)
- Sepsis is very common in our population, both adult and pediatric patients. As a consequence we have St. Johns Sepsis alerts in RAVEN (our EMR) and order sets for you to use when sepsis is suspected. Don’t hesitate to start antibiotics on a village-based patient who appears septic and is awaiting medevac.
- We also have a very high rate of neonatal sepsis. Follow the guidelines on neonatal sepsis . ANY neonate <30 days requires an LP as part of the workup and MOST neonates <90 days also require an LP. In general, err on the side of a more conservative approach due to the high incidence of sepsis and the distance folks have to travel.
- Sepsis (Adult) YKHC Clinical Guideline
- Sepsis (Pediatric) YKHC Clinical Guideline
- This is another common reason for a visit to the ED in our region. We have an unusually high rate of serious bacterial infections in our Alaska Native children. Please follow our guidelines very carefully, if you deviate from the guidelines, please document in your note. Consult peds if needed.
- Fever – Infants 0-90 days
- UTI – Children 3 Months–5 Years
- This is one of the most common reasons for visits to the ED. Because our patients come in from villages and we have a very high burden of bacterial pneumonia, err on the side of obtaining chest radiographs and blood work.
- Pneumonia (Adult) (YKHC Clinical Guideline)
- Pneumonia (Pediatric) (YKHC Clinical Guideline)
- Bronchiolitis/Wheezing (YKHC Clinical Guideline)
- Croup/Stridor (YKHC Clinical Guideline)
- Influenza (YKHC Clinical Guideline)
- Community acquired MRSA is very common here and boils and cellulitis is a common reason for visits to the ED. Please follow our guideline on boils. Most of the MRSA is sensitive to Septra. We prefer the use of penrose drains if at all possible in our patients, especially in children
- Skin and Soft Tissue Infection YKHC Clinical Guideline
Head injuries (Pediatric)
- Head injuries in our region are common and often related to motor vehicle crashes and alcohol. We have developed guidelines to use locally and ANMC has state-wide guidelines as well. Generally speaking, these patients need to come to Bethel for evaluation. Our pediatricians can be consulted on the use of CT scans in children with head injuries.
- YKHC Guidelines for Head Injury/Concussion 5-18 Years
- We have a very high rate of pregnancies in our region. Please carefully follow our guidelines.
- First Trimester Vaginal Bleeding: Ectopic Pregnancy Diagnosis & Treatment of Non-Viable Early Pregnancy
- These are quite common here as in many EDs. We have a “sobering center” where patients can be sent to sober up, but the patients have to be able to ambulate with minimal assistance and have a BRAC of <400 (they have to check breath alcohol levels because of the grant funding of the sobering center.) If the patient is being cleared for jail or is under arrest, they need to have a BRAC <300. You need to complete the paper form for the patient to be released to the jail or sobering center.
- YKHC Clinical Guideline for Intoxicated ER Patient
- Alcohol Withdrawal in the YK-Delta
- These are patients who are placed on an involuntary hold who are sent to the ED for evaluation by our emergency behavioral health clinician. They need medical clearance and appropriate disposition. They must be sober (blood alcohol level <80) before the clinician will evaluate them. They are held in the ED until they are sober enough for evaluation and sometimes after evaluation until definitive disposition can be arranged.
- Title 47 Hold
- This is another very common reason for a visit to the ED. Most of our patients do not have access to fresh fruits and vegetables and reliable safe drinking water and therefore constipation is very common. The nursing staff has standard orders for triage for this problem. We do not have surgeons in Bethel (except for OB related issues) and so all appys need to travel to Anchorage if the surgeon wants to take out the appendix. They can often travel in on a commercial flight if they are stable. If unstable, or if pain can’t be controlled, they will need a medevac.
- Please send all x-rays with fractures diagnosed to ANMC orthopedic telerad. This is a paper form you must complete. That allows for non-urgent consultation to take place via the ambulatory clinic. If there is an urgent need, please call ANMC and speak to the on-call ortho doc. They can give you some advice over the phone and, during the day, look at your x-rays.
- If the patient is a trauma victim, call ANMC surgeon on call. They handle all calls related to trauma, even if the primary injury is orthopedic.
- Occasionally infants with jaundice will come to the Emergency Department from villages for the express purposes of checking a serum total and direct bilirubin. Since this lab test takes considerable time to return, a general recommendation is to sequester this child and mother in either the quiet room or in another area away from the general ED population while awaiting test results. If the child is ill appearing, or has other complaints such as fever, of course have them evaluated in the main ED per guideline.
- YKHC Guidelines for Neonatal Jaundice
- Dog bites are relatively common in this region. A “rabies investigation report” from our Office of Environmental Health (OEH) department must be completed on every patient with a dog bite.
- Rabies prophylaxis: if the dog can’t be found, the bite wasn’t provoked or if the dog was behaving strangely, rabies prophylaxis should be administered and the State of Alaska, section of epidemiology notified: 907-269-8000 or 800-478-0084.
- The order for the rabies immune globulin and vaccination are in RAVEN and have attached references in the reference tab of the order.
- Link to the web site from the State of Alaska: Rabies
- Link to the post-exposure prophylaxis recommendations from the State of Alaska
- YKHC Clinical Guideline for Rabies
- Food borne botulism is very common in our region as the consumption of fermented traditional foods is very common. Bethel is one of the repositories of botulism anti-toxin from the CDC and we have several kits here that we can use to treat patients. Botulism should be suspected in any patient with a history of consuming traditional fermented foods and symptoms such as weakness, dry mouth, blurred vision, urinary retention, ileus, diarrhea or dyspnea (especially without gasping or rapid respiratory rate.)
- All suspected cases of botulism MUST be reported immediately to State of Alaska section of epidemiology 907-269-8000 or 800-478-0084. The state of Alaska has a very nice booklet on botulism that outlines symptoms and case recognition and appropriate treatment that can be found on the following web site. There are also *hard copies in the ED and on NW.
- Link to: State of Alaska website on botulism
- Patients with suspected exposure to botulism should be treated with the anti-toxin and hospitalized. Measured Forced Vital Capacity needs to be measured and repeated hourly and if less than ____% predicted or a decreased in ____%, intubation should be considered. There is a special kit with the anti-toxin in the ED that you need to look over with information on administration and dosage. This paperwork MUST be completed and returned to the State of Alaska.
- This is a common occurrence in our region. Many times the patient overdoses in a village. This doesn’t always mean they are medevac’d in, so most patients are started on oral Mucomyst in the village clinic. The Health Aides can draw a 4-hour post-ingestion level of acetaminophen to send in with the patient, while continuing the oral protocol. Once they arrive in Bethel, the level can be run and the Mucomyst can be continued or not depending on the level. This can be switched to an IV protocol once they arrive as well.
- Poison control number is 800-222-1222
- YKHC Clinical Guideline for Acetaminophen Overdose
Sexual assault/sexual abuse of a minor
see SART page for detailed information