Documenting an emergency presentation
ED notes with treatment times and doses, handover notes, referrals to the admitting team and discharge letters.
Handover out of resus
Resus two. Seventy-four-year-old man, acute pulmonary oedema, in by ambulance at 0340.
Sats 82% on air on arrival. On BiPAP 12 over 6, FiO2 40%, sats 96, resp rate 22, down from 34.
BP 188/104 on arrival, GTN infusion at 50 mics a minute, BP now 142/80.
Frusemide 80 IV, 900 mL out through the IDC.
ECG sinus tach 108, known left bundle, no change from his last one. Trop 42 then 58.
Cardiology have accepted him, waiting on a CCU bed. Wean the BiPAP over the next two hours.
Presentation
Acute pulmonary oedema. Arrived 03:40 by ambulance. SpO2 82% RA, RR 34, BP 188/104.
Treatment
- BiPAP 12/6, FiO2 40%
- GTN infusion 50 mcg/min
- Furosemide 80 mg IV, 900 mL via IDC
Current
SpO2 96%, RR 22, BP 142/80.
Investigations
ECG: sinus tachycardia 108, known LBBB, unchanged from previous. Troponin 42, then 58.
Disposition
Accepted by cardiology, awaiting CCU bed. Wean BiPAP over 2 h.
Out of the department
- ED note
- Presentation, treatment with times and doses, response and disposition.
- Referral to the admitting team
- The question for the inpatient team and what has been done.
- Discharge letter from ED
- For a patient going home: the diagnosis, what was given, follow-up and when to come back.
