Treat and Refer

Question 1

1. Who do the TnR guidelines apply to?

Answer 1

Adult patients

• elderly/frail have higher risk of deterioration so are not covered
• Paed pts not covered

Question 2

2. When should a pt with epistaxis not be left at home?

Answer 2

• Unable to control bleeding after 15mins
• Recent hx of facial or head trauma
• Hx of bleeding disorder or anticoagulant therapy

Question 3

3. What is the basic Mx of epistaxis?

Answer 3

• Position upright, neck flexion, pinch soft part of nose firmly for 15mins
• Cold compress to forehead/neck
• Encourage pt to breathe through mouth and spit out blood
• Avoid picking/blowing nose for 12hours

Question 4

4. When should a pt with gastro not be left at home?

Answer 4

Pt requires timely hospital Ax/Mx:
- Significant dehydration
- Potential GIT bleeding - haematemesis, melaena, PR bleeding
- Severe/constant abdo pain
- BGL >17
Sx may be due to Ddx
- Absence of diarrhoea
- PHx of IBD
Higher risk of complications
- Pregnant
- Co-morbidities

Question 5

5. What actions should be taken when leaving gastro pt at home?

Answer 5

• Provide oral rehydration + refer to pharmacy
• Refer to GP: Sx not improved after 48hrs, pt recently returned from overseas, Temp>40
• N/V severe, consider single dose of Ondans - inform pt of potential for extrapyramidal adverse effects

Question 6

6. When should a heroin OD not be left?

Answer 6

• Incomplete recover - GCS<15, RR<10
• Pt required second dose of naloxone
• Other opioid confirmed
• Polypharmacy OD
• Other factos - hypoglycaemia, infection, trauma
• Any seizure activity
• Suspected aspiration/APO
• Pregnancy
• Pt a risk to self or others

Question 7

7. What needs to be assessed and done before leaving heroin OD at home?

Answer 7

• Pt chest clear?
• Sats>94%?
• Fully recovered, low risk and able to be supervised for 4hrs?
  Advise risk of relapse if further opioids taken in 6hrs, avoid all sedating drugs, advise local support

Question 8

8. When should a hypo not be left at home?

Answer 8

1. Incomplete recovery to conscious state
2. Risk of prolonged hypoglycaemia:
   - Unwitnessed
   - Pt on oral hypoglycaemic meds
   - OD on meds
   - Unable to consume further carbs
   - Unable to be monitored for 4hrs
3. No Dx of diabetes
4. Suspected cause requires investigation e.g. infection
5. Injury or seizure
6. Pregnancy

Question 9

9. When should a pt with burns not be left at home?

Answer 9

1. Involves sensitive area: face, hands, feet, major joint, genitalia, circumferential
2. Partial/full thickness
3. Smoke inhalation
4. Chemical, electrical or radiation
5. Suspected non-accidental
6. Assoc traumatic injury
7. Pain unlikely to be controlled by oral analgesia
8. Co-morbidities that may impair wound healing

Question 10

10. When should a pt with a wound not be left at home?

Answer 10

1. Requires acute hospital Mx: uncontrolled bleeding, neurovascular impairment, penetrating/degloving/crush, compound #, pain unlikely to be controlled with oral analgesia, suspected non-accidental or self-harm attempt
2. Wound potentially requires plastic surgery: to special areas, suspected muscle/tendon damage
3. At risk of infection or impaired healing: unable to clean, bite wound, >6hrs old, signs of infection, Co-morbidities

Question 11

11. When should a pt suffering a seizure not be left at home?

Answer 11

1. Pt requiring further Ax/Mx in hospital:
   - incomplete recovery
   - susp non-epileptic cause
   - First presentation seizure
   - Different to usual presentation
   - Concurrent illness
   - Injury, aspiration or submersion
   - Pt administered Midazolam
2. Seizure unwitnessed
3. Risk of recurrent seizure:
   - Hx of multiple seizures
   - Pt has feeling of impending seizure
   - Unable to be monitored
4. Pregnant
5. Pt requests Tx

Question 12

12. When should a pt with soft-tissue injury not be left at home?

Answer 12

1. Evidence of # or dislocation
2. Neurovascular impairment
3. Pain unlikely to be controlled with oral analgesia
4. Suspected NAI
5. Isolated ankle/foot - Ottawa +ve

Question 13

13. When should a pt with lower back pain not be left at home?

Answer 13

1. Pain not isolated to lower back
2. Susp cauda equina syndrome: loss of bladder/bowel control, saddle anaesthesia, lower limb weakness or numbness
3. Susp vertebral #: Hx of fall/significant trauma, Hx of osteoporosis/chronic steroid use
4. Suspected dissecting aortic aneurysm
5. Pain unlikely to be controlled with oral analgesia
6. Susp to be 2nd to cancer
7. Susp vertebral infection: fever/recent Hx of infection, Hx IVDU, immunocompromised