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Microsoft word - 20140120extract from miuclinical protocols.doc

Extract from Minor Injury Unit Handbook of Clinical Protocols
Cumberland Centre, Plymouth
Tel: 01752 434390
Please note that this document is continually being updated, so the information
contained within is subject to change according to recognised best practice and
national guidelines.

• Patients who are under 20 or over 50 years • Patients who are pregnant • Patients with a history of osteoporosis • Patients who are immune-suppressed BOILS, CARBUNCLES, FOLLICULTIS, PARONYCHIA AND

• Patients with subungual abscesses and carbuncles with multiple heads, • Anthrax(haemorrhagic crusts and vesticular margins) • Orf (localised punched out, circular crusted lesions often found on the hands of patients who work with animal carcasses or uncured hides)
Refer any patient with the following:

• All burn/scalds with blistering over 2% of body mass for children and 3% if adult - rule • All circumferential burns • All burns with associated injuries such as smoke or gas inhalation/electrical shock or • explosions (may throw patient some distance) • Burns involving the airway • All burns that are full thickness or deep dermal burns • All burns that are not healed in two weeks • Burns to face affecting airway • Burns to perineum or genitalia • Any burn with suspicion of non-accidental injury • All neonatal burns of any size • Patient has signs/symptoms of toxic shock - High temperature, rapid pulse and/or • respiration rate, diarrhoea, vomiting, rash, general malaise CALF PROBLEMS and INJURIES

• Patients presenting with any evidence of an injury/trauma to the Achilles tendon i.e. positive Simmonds test, pain / tenderness below muscle-tendon junction (lower third of calf), palpable gap in tendon, or the inability to stand on tip-toes. • Patients presenting with any muscle wasting, varicose veins or ischaemia

• Patients complaining of musculoskeletal chest pain where there is little/no evidence • Patients complaining of crushing chest pain, pleuritic pain without injury, recent onset of pain or discomfort of suspected cardiac origin.

• Patients with chipped teeth and crowns that have become dislodged should be
redirected to their dentist.
• Patients with tooth fractures that involve the pulp present with a small area of
bleeding and the area is sensitive. These patients should be referred to their

• Patients with mobile teeth after trauma need to be stabilised as soon as possible.
Advise the patient to avoid manipulating the tooth, these patients should be referred
to their
dentist. If the patient is not registered with a dental practitioner and has
difficulty obtaining an emergency appointment, then contact the on call maxillofacial
surgeon at PHT for advice.
• Avulsed primary teeth are not suitable for re-implantation.
• A history of rheumatic fever; valvular heart disease, or immunosuppressive treatment
is relative contraindications to re-implantation. Refer to patient’s dentist or on call
Maxillofacial surgeon for advice
• Avulsed permanent teeth should be re-implanted immediately, to optimise the prognosis. Refer to patient’s dentist or on call maxillofacial surgeon for advice.

• Patients that attend the MIU with dental pain sustained from trauma. • Patients with: associated swelling; dysphagia; systemic evidence of infection (fever,

• Patient who is immunocompromised and has an increased risk of or suspected of • complications, • Severe Otitis Externa, mastoiditis, meningitis, facial paralysis: • Children with re-occurring ear infections (3 or more episodes in 6/12) must be

• Patients with trauma to the ear • Patients a history of previous ear surgery. • Patients with a foreign body • Patients who have a current or within the last 12 months a perforated tympanic • Any discharge or bleeding from the canal. EPISTAXIS

• Patients with newly diagnosed hypertension • Patients taking anticoagulants or have inherited coagulopathies • Patients with massive epistaxis These patients must be referred to a doctor once immediate treatment has been


• Children under 13 years of age • Women over 60 years of age • Children between 13 and 16 years of age that are not deemed Fraser competent • Fraser Guidelines by the Nurse Practitioner • More than 72 hours for Levonorgestrel or more than 120 hours for EllaOne, have elapsed since the first episode of unprotected sex within the current menstrual cycle • Women who have had Levonorgestrel EHC more than twice in the same cycle; women who have had EllaOne EHC more than once in the same cycle, or previous supply of Levonorgestrel EHC in the same cycle. Women excluded from Levonorgestrel or EllaOne must be referred to a medical practitioner or the Community Contraception & Sexual Health (CC&SH) Service

• Patients with uncharacteristic or excessive pain • Patients with bleeding from the ear • Patients with pus discharge from the ear • Patients with a history of trauma - head injury related FOREIGN BODIES IN THE NOSE (REMOVAL OF)

• Patients with uncharacteristic or excessive pain • Patients with respiratory difficulty • Patients with excessive bleeding from the nose SIMPLE FRACTURE & SOFT TISSUE INJURY MANAGEMENT
Nurse Requested x-rays
The nurse practitioner may request x-rays, when clinical assessment indicates
either a suspected fracture or a suspected embedded foreign body
Nurse practitioners requesting x-rays should have undertaken training which satisfies
IR(ME)R requirements. The referrer must understand their responsibilities under IR(ME)R
and have attended a Radiation Protection and IR(ME)R training session, and work to a
protocol approved by the Medical Imaging Directorate.
• X-rays of the upper limb from fingers to clavicle including the humerus. This includes shoulder views for patients aged 16 years and over. • X-rays of the lower limb from the toes up to the knees. This includes views of the knee for patients aged 16 years and over. Exclusions:
• Rose thorns, wooden splinters or other organic FB, these do not show up on x-ray. • Patients who may have sustained serious/multiple injuries that are best managed in ED should not have their transfer to ED delayed due to nurse requested x-rays. • Patients who are in shock
All children under 2 years are excluded from the MIU X-ray protocol**
• If no fracture is suspected but a soft tissue injury:- NP to follow soft tissue injury
management of the affected area as per protocol • If a fracture is suspected clinically but x-ray is not required e.g. undisplaced fracture of toe or minor fractured rib then discuss rationale for not x-raying with patient General Management
Patients with a fracture or soft tissue injury should be generally managed according to MIU
specific fracture management protocols. In certain circumstances the management
described in the protocols may not be appropriate. These include:
• patient not presented within a reasonable time since injury accruing, • has been treated elsewhere, • has a pre-existing injury, • has a pre-existing medical condition preventing specific management
The Minor Injuries Nurse may assess patients with suspected fractured nose or soft
tissue injury and complete initial treatments as defined within this protocol.

• Patients with associated Head Injury that are excluded under that protocol • Patients with evidence of bony injury extending further onto the face (especially • Patients with obvious airway problems associated with nose injury. • Patients with a septal haematoma FUNGAL INFECTIONS PROTOCOL

• Age < 2 months • The immunocompromised patient with signs and symptoms of fungal infection • Patients with a known allergy to chrysanthemums • Patients excluded from Topical antifungal treatment PGD GASTROENTERITIS PROTOCOL

• Patients under 1 year and over 75 years due to risk of complications • Patients who are immunocompromised, including patients taking immunosuppressants or systemic corticosteroids • Patients with a history of carditis, pancreatitis or renal failure. MINOR HEAD INJURIES

• Infants < 1 year • Adults > 65 years or over • Patients on warfarin

• Secondary headache disorders (attributed to another condition): • Head and neck trauma e.g. whiplash or head injury • Cranial or cervical vascular disorders e.g. stroke • Non vascular intracranial disorders • Substance use or withdrawal or medicine overuse • Infections e.g. intracranial abscess, meningitis or encephalitis • Disorders of homoeostasis e.g. fasting, sleep apnoea • Disorders of structures of the head and neck e.g. sinusitis, acute glaucoma • Psychiatric disorders • Any other headache of unknown cause HEAD LICE PROTOCOL

• Children under 2 years and women who are pregnant or are breastfeeding for • treatment – wet combing only • Patients with asthma or severe eczema should not use alcohol based preparations

• Age < 6 months • Patients with cardiac disease, chronic skin disorders, glaucoma, bipolar disorder or • The immunocompromised patient with signs and symptoms of herpes virus • Pregnant women • Patients with a recent history of shingles • Patients with a rash near the eye, tip of nose or ear • Children with an extensive rash have eczema, ophthalmic involvement, Ramsay Hunt • Syndrome or are systemically unwell. • Patients presenting with Herpes Varicella Zoster type rash more than 24 hours since the onset of that rash if already treated with acyclovir. • Patients presenting with Herpes Zoster type rash more than 72 hours since the onset of that rash if already treated with acyclovir. INGESTED FOREIGN BODIES

• Patients with current choking, dyspnoea or any respiratory distress • Patients with dysphagia (difficulty in swallowing) • Patients who have swallowed batteries (larger batteries may become stuck in the oesophagus causing perforation or later stenosis).

• Patients with diabetes • Patients with ischaemic lower limb NAIL INJURIES

• Patients with Diabetes • Obvious damage to the nail bed

• Patients whose mechanism of injury includes blunt trauma above the clavicle or high • Patients whose injuries involve suspected fractures, dislocations or spinal cord • Patients, who have any neurological signs and symptoms • Patients with a history of neck surgery • Patients with osteoporosis, premature menopause or use steroids • Patients over 65 years NECK PAIN

• Patients who have been involved in trauma - see neck 'whiplash' protocol • Patients whose injuries involve suspected fractures, dislocations or spinal cord • Patients, who have any neurological signs and symptoms. • Patients with osteoporosis, premature menopause or use steroids OPHTHALMIC INJURIES AND PROBLEMS
The Minor Injuries Nurse may assess and treat patients with corneal, sub tarsal

and loose conjunctival foreign bodies and abrasions, and provide emergency
treatment for patients who have sustained chemical burns to the eyes.
All other ophthalmic injuries must be referred to the Royal Eye Infirmary (REI). This
ophthalmic protocol has been agreed by PHT Royal Eye Infirmary


• If the patient has Loss of visual acuity, • Pupil abnormality, • If the foreign body is embedded, • If there is a history of high velocity injury (e.g. hammering). • If the patient has any severe pain, marked redness, photophobia, eye inflammation associated with a rash to the scalp or face, cloudiness, glaucoma, dry eye syndrome or any recent eye or laser surgery PATIENTS EXCLUDED MUST BE REFERRED TO THE ROYAL EYE INFIRMARY POISONING

• Patients that have taken a treatable overdose as a deliberate self-harm. • When advised by the National Poisons Unit - Toxbase that the patient requires SCABIES PROTOCOL

• Age < 2 and age > 60 years • The immunocompromised patient with signs and symptoms of scabies • Pregnant women and women who are breastfeeding • Patients on steroids • Patients with crusted scabies (Norwegian Scabies) or secondary infection • Patients with a known allergy to Chrysanthemums

• Patient presenting with; Vacuum sinus pain; Temporo-mandibular joint dysfunction; atypical migraine; trigeminal neuralgia; temporal arteritis; acute glaucoma, and facial trauma. These patients must be referred to their GP.

• Children under 6 years, • Patients with Epiglottitis or Quinsy, • Patient is immunocompromised, • Patients suspected of Kawasaki disease or those with severe peri-tonsillar • If evidence of drooling, having breathing difficulties, stridor or unable to swallow
The Minor Injuries Nurse may remove lost tampons that are caused by either:
Faulty tampon, lost tampon strings, inserting a second tampon, sexual
intercourse during menstruation with tampon in place
If patient shows any of the following symptoms: sudden high fever, vomiting, rash, diarrhoea,
faintness, aches, dizziness. Consider Toxic Shock Syndrome and refer patient to Derriford

• Patients with urinary retention • Patient with renal or ureteric colic • The immunocompromised patient with urinary symptoms • Pregnant and breastfeeding women • Adult male patients and male children over 12 years (symptoms may be due to other • underlying conditions) • Females over 65 years and Children under 6 years WOUND MANAGEMENT PROTOCOL
Refer to a doctor, wounds that:
• May have damage to underlying structures e.g. tendon or nerve damage (particularly • hand/wrist wounds) • Require debridement or decompression of devitalised tissue • Are deep facial wounds, especially those involving eye, lip and ear margins. • Contain foreign bodies that are not easily removed • Deep wounds that are present over joints • Show signs of ascending lymphangitis/systemic infection and patient unwell Nurse practitioners also adhere to the following general guidance:

Patients (adult or children) should be referred to a GP/OOH GP either the same
day if urgent, or the next available opportunity when they have:
• Any Illness or ailment that falls outside of these protocols and/or is of a chronic nature, i.e. unwell, symptoms not settling/worsening or non-specific pain etc. • Localised and/or uncomplicated infections i.e. of the eye sustained more than 48
Patients (adult or children) should be referred to Plymouth Hospital Trust when they
Present with:
• Any injury, acute Illness or ailment that falls outside of these protocols • Serious multiple injuries, • Pain that may be of cardiac origin/respiratory distress and/or cardiac arrest, • Fractures that are outside of the protocol management (either displaced or angulated, involving potential nerve or blood vessel damage) • All head injuries that fall outside the clinical protocols, • Significant overdose and/or self-harm that requires medical management • Acute medical emergencies i.e. acute abdominal pain, uncontrolled asthma, suspected stroke, diabetic coma, status epilepticus, • Suspected and/or potential bony injuries in the absence of x-ray facilities, • Patients with a suspected non-accidental injury. • Severe acute pain of an unknown cause • Potential penetrating eye injuries and corneal injuries (refer to REI)
This list is not exhaustive and other patients presenting to the unit may be
referred to ED or other HCP at Derriford.



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