Displaced distal radius fractures


A 65yo woman comes into your Emergency Department (ED) presenting with right wrist pain, swelling and deformity following a fall onto an outstretched hand (FOOSH). An x-ray reveals a dorsally angulated and displaced distal radius fracture. It is suggested this type of fracture requires reduction and cast immobilisation, so how do you make the decision on when to perform closed reduction and which anaesthetic technique is most appropriate…… (more…)

Coming soon – ED Pearls

The team at HEFT EMCAST are extremely excited to announce a new stream of work that will be hitting our website (alongside the usual content) within the next couple of weeks.

Dr Catrin Dyer and Dr Caroline Park are ED consultants working at HEFT. As many of you who have worked within the trust will know, they are both fantastic clinicians and educators. They have spent a lot of time putting together their “ED Pearls” which are just too useful not to share on a wider scale.

These were initially used within our department during morning handover to spark discussion and allow the sharing of both experience and best practice. As a way of disseminating these further they will be shared on the HEFT EMCAST website and via the twitter and Facebook feeds.

They represent a mixture of evidence, experience and opinion and really are a superb snapshot of what you need to know about some core ED problems and presentations.

We really hope you enjoy them and would value your feedback.

Rob Fenwick


Traumatic Cardiac Arrest


Its 01:00 and the resus emergency bell rings out across the department. On your arrival you find a young male in cardiac arrest and nursing staff have initiated Basic Life Support (BLS). His friends have brought him to the Emergency Department (ED) after he was stabbed twice in the chest 5 minutes ago, following an altercation in a nearby street.

You are the ED clinician allocated to resus and now the clinician who will to lead this Traumatic Cardiac Arrest (TCA). (more…)

Tranexamic Acid


A 32-year-old male presented to the Emergency Department (ED) with two self-inflicted stab wounds to the abdomen. He had used a knife with a 6-inch blade which had been recovered by the ambulance crew. Prior to arrival in the ED he had been cold, clammy and sweating profusely with a blood pressure initially of 85/40 mmHg. On examination he looked unwell and had two wounds in the right upper quadrant of his abdomen. There is minimal external haemorrhage and a dressing has been applied. He has considerable pain on palpation of his abdomen.

A Computed Tomography (CT) scan of the abdomen is arranged and whilst waiting it was suggested that the should patient receive 1g Intra Venous (IV) tranexamic acid (TXA). (more…)



A 56-year-old female presented to the Emergency Department (ED) following an overdose of her modified-release morphine tablets, prescribed for her chronic lower back pain. She was last seen by her partner when he left for work that morning and on returning home she was found collapsed at home with slow, shallow respirations and central cyanosis. 999 had been called immediately and on arrival of the ambulance crew her ventilations were supported until Intra Venous (IV) access had been gained. Once achieved, 400mcgs of IV naloxone was given with the immediate effect of the patient waking and spontaneously breathing. She was brought to the resuscitation room of the ED. (more…)

Aspirin for ACS


A 64-year-old male attends the Emergency Department (ED) following an episode of central crushing chest pain lasting 30 minutes. He was known to suffer from Ischaemic Heart Disease (IHD) and had taken his own glycerine trinitrate (GTN) with no effect.

An ambulance had been called and the paramedic crew administered intravenous (IV) morphine until he was pain free. The patients electrocardiogram (ECG) was suggestive of a non-ST elevation myocardial infarction (NSEMI) and he was therefore alerted into the resuscitation room of the ED.

On arrival the patient looked well, was haemodynamically stable and was now completely pain free. His ECG changes persisted, therefore blood samples were taken and the cardiology team was contacted.

Prior to leaving the paramedic crew explained they had not administered aspirin, as the patient was currently taking warfarin (lifelong following a pulmonary embolism 10 years earlier). (more…)

Apparent Life Threatening Events


A 6-month old infant is presented to the Emergency Department by his parents with a history of a ‘floppy’ episode approximately 30 seconds in duration. It was noted that he did not respond to his mother’s voice and she was concerned enough to call an ambulance. (more…)

Acute Throat Infections


14 year old girl presents to the Emergency Department (ED) with a 4 day history of fever (38.7C), sore throat and odynophagia.

On examination, she appeared comfortable but was pale, had lymphadenopathy to her anterior cervical chain and was pyrexial at 38.7°C. Whilst she had no drooling, she had been unable to take oral fluids or analgesia due to the pain when swallowing. She was unable to fully open her mouth due to pain, so an initial examination of her throat was unsuccessful. Remainder of examination was normal. (more…)

Neonatal Jaundice


A 2-week old baby girl is presented to the emergency department (ED) by her parents on the advice of her Health Visitor (HV) who has noted that she still appears to be jaundiced. Her parents tell you that she has been breastfeeding less over the past 24-hours, but continues to have wet nappies as normal and last had her bowels open only few hours ago with a soft, yellow stool. Parents report she was born at 39 weeks gestation by normal vaginal delivery and began looking jaundiced at about 4 days old.

Following a full history and careful clinical examination, the suspected diagnosis of neonatal jaundice is made. (more…)

Paediatric Gastroenteritis


A 4-year-old male presents to the Emergency Department (ED) with a 3-day history of diarrhoea. The illness began with 24-hours of vomiting, subsiding as the diarrhoea became apparent. He had been running a low-grade fever (temperature  37.8C) accompanied by episodes of lethargy.  His parents are concerned that his fluid intake is decreasing and although the number of episodes of diarrhoea appears to be reducing, they are not sure of the last time he passed urine.

A full history and careful clinical examination were undertaken following which the diagnosis of gastroenteritis with mild dehydration has been made. (more…)

Buckle and Greenstick Fractures


A 9-year-old male presents to the Emergency Department (ED) following a fall whilst playing rugby at school earlier that day. He presents with left wrist pain and mild swelling. There are no wounds or breaks to the skin. On examination he is noted to be both swollen and tender over the distal radius. An x-ray is requested which confirms a buckle (or “torus”) fracture. (more…)



An 8-month old female is presented to the emergency department (ED) with a 3-day history of reduced feeding and less wet nappies. Accompanied by her parents and 4-year old sister, they report no fever (Temperature is recorded as 37.8C) but are concerned regarding the lack of fluid and dietary intake. Over the last 12-hours they have become more worried about her breathing, which they describe as noisier than normal, and with feeding times becoming more distressing for all, have arrived at the ED for further assessment. (more…)

Fever – is it cool to be hot?


A 60-year-old female has presented to the ED with a cough and fever for 2 days. She has her observations recorded in triage and has a fever of 38.1C (tympanic). She otherwise feels well and does not trigger the sepsis screening tool. She has no pain and appears comfortable as she walked into the department. A member of the nursing team asks you to prescribe 1g paracetamol (PO) to reduce her fever….. (more…)

Urine – to dip or not?


An 84-year-old female was found on floor by carers. No obvious head injury and was alert on scene with some mild confusion. Paramedics had documented strong smell of urine and a collateral history from her family stated she had reduced oral intake recently and was not her normal self for the past few days. (more…)

Paediatric hypertension


A twelve-year-old girl presents to the Emergency Department (ED) having had a fall at school, she is diagnosed with a sprain to her left wrist and minor head injury (contusion to her forehead). During the episode of care her physiological parameters are measured on a number of occasions and an incidental finding of persistently raised blood pressure is discovered (observations shown in table 1). (more…)

Head injury and anticoagulation


A 79 year old gentleman attends the Emergency Department (ED) after having tripped over his dog whilst out walking. He sustained a laceration to the back of his head. He did not lose consciousness, he has not vomited, has no amnesia, GCS 15 throughout and there was no evidence of a depressed or basal skull fracture. (more…)

AXR in abdominal pain


A 52-year-old male presented to the emergency department (ED) with a 1 day history of severe central abdominal pain and nausea. An AXR was undertaken as part of his care in the ED that demonstrated distended bowel loops in the upper abdomen leading to a diagnosis of possible bowel obstruction and a referral to the surgical team. (more…)



A 71-year-old man with a history of Atrial Fibrillation (AF) presented to the Emergency Department (ED) with a 3-day history of increasing palpitations following the reduction of his daily digoxin dose (from 125mcgs to 62.5mcgs). (more…)

Caustic Soda


A 3-year-old male was admitted to the ED after his mother had witnessed him drinking caustic soda. Whilst cleaning the house she had accidentally left open a cupboard where he was able to access drain cleaner containing the substance. (more…)

Ectopic Pregnancy


A 36-year-old female presented to the emergency department (ED) with a 3-day history of diarrhoea (approximately 5 episodes per day). The diarrhoea initially had a small amount of blood but had subsequently become green and very offensive. She had been diagnosed with gastroenteritis by her GP, however the patient could identify no causative factor. The day before this attendance she had developed sharp and intermittent upper abdominal pain. The pain had no exacerbating factors and she had been apyrexial and systemically well throughout the entire episode.




A 72-year-old male presented to the Emergency Department (ED) in the morning having woken with shortness of breath and a slight change to the colour of his sputum. His temperature had been recorded as 38.1C by the ambulance crew who brought him to hospital.


Acute Alcohol Withdrawal


A 33-year-old male was admitted to the emergency department after having 2 alcohol withdrawal seizures. He had been drinking 30U alcohol per day for many years and over the previous week he had been trying to reduce his alcohol intake without any support.