Common ER Orders


Major Trauma (ESI 1 OR 2)

  1. CBC, CMP, PT/PTT, Type & Screen, UA, POC Preg (on all females of child bearing age)
  2. If appropriate ETOH, USD
  3. Foley
  4. All pts should have 2 large bor IV's completely disrobed and VS should include BP in both arms.
  5. Imaging: If CT needed, do it WITH IV Contrast

[See Trauma ]
 

Radiology

Head

  1. Skull x-rays rarely indicated
    • Penetrating trauma is exception
  2. Non-contrast CT for
    • Altered level of consciousness
    • Significant LOC
    • Severe headache
    • Persistent vomiting
    • Focal findings on neurologic exam
    • New seizure

Cervical Spine

  1. Maintain high index of suspicion for injury
  2. Maintain inline immobilization
  3. May obtain after Primary survey
  4. 3 views
    • AP, lateral, odontoid
      • Standard for all pts w/suspected C-spine injury
      • MUST visualize top of T1
    • Other views
      • Oblique views
        • Not routinely necessary, but complement 3 view
        • Obtain when possible fx identified
      • Flexion-extension view
        • Ordered when adynamic view negative & high clinical suspicion
        • Pt must have normal mental status to perform
        • Physician must be present
        • Have pt flex & extend; stop at point of pain or neuro symptoms (generally performed at follow-up visit)
  5. CT of C-spine
    • Indicated when
      • Plain films unable to visualize entire C1-T1
      • Patients with negative x-rays but a high clinical suspicion of a fracture
    • Used to better identify fx
    • Does not reveal ligamentous damage

Chest X-Ray

  1. Portable AP view
    • Obtained in resuscitation room
  2. Assess for:
    • Mediastinal width
      • Evidence of great vessel injury
    • Fractures
    • Pneumo/hemothorax
  3. Upright film
    • Perform after spine cleared if question about mediastinal widening on supine film
  4. Do multiple views to localize foreign body (e.g. bullet)
  5. CT of chest with IV contrast
    • More sensitive for pneumothorax, mediastinal injury

Abdomen

  1. Plain films generally not useful
    • Exception is penetrating trauma
      • May show missiles or other foreign material
        • AP and lateral projections to try to localize
  2. FAST Exam:
    • Evaluate for hemoperitoneum, hemopericardium, and hemothorax
  3. CT of abdomen with PO and IV contrast:
    • For detecting intraabdominal and retroperitoneal injuries

Pelvis

  1. Obtain portable AP view
    • Blunt trauma to the torso
    • Pelvic instability
    • Gross blood and/or disrupted prostate on rectal exam
    • Gross blood on vaginal examination
    • Gross hematuria
    • Unexplained hypotension
  2. Used to identify fx

Spine

  1. Obtain thoracic, lumbosacral spine as needed
    • Patient C/O localized pain
    • Neurologic deficit
  2. CT scan of spine
    • Can help identify fractures
  3. MRI of spine
    • Indicated for patients with neuro deficit

Extremities

  1. Obtain x-rays as needed
    • Evaluate pain or deformity

 


 

Abdominal Pain (> 17 yr of age)

  1. CBC, CMP, Lipase, UA, POC Preg (if indicated).
  2.  PT/INR if pt is taking warfarin
  3. Saline lock
  4. EKG if epigastric pain.

[ Acute Abdominal Pain ]

 

Altered Mental Status

  1. FIRST:
    • O2
    • POC Glucose
    • Narcan 0.4mg IV x1
    • Thiamine 100mg IV x1
  2. CBC, CMP, PT/INR, UA, POC Preg (if indicated), Cardiac Enzymes, CXR & EKG.
  3. ETOH level (if necessary). No UDS unless ordered by MD
  4. Blood cultures & Lactic acid if febrile
  5. Ammonia level if pt has liver disease
  6. Saline lock

[Altered Mental Status/Encephalopathy ]

Chest Pain

  1. EKG, CXR, CBC, BMP, PT/INR, STAT TROPONIN I or T, CK, CK-MB.
  2. Digoxin level (If pt on digoxin)
  3. Administer Oxygen
  4. ASA 325 mg upon arrival (unless contraindicated)

[ Chest Pain* ]

Diabetes

  1. POC Glucose
  2. If symptomatic (dizziness, n/v, abdominal pain) = CBC, BMP, UA & serum ketones
  3. EKG, Cardiac enzymes (if needed)
  4. Saline lock

Extremity Injury

  1. XR of injured extremity
  2. Splint if applicable
  3. Assess sensory, motor & Circulation status
  4. Apply ice pack for comfort,
  5. Consider initiating Pain Protocol.

Eye Injury/Visual Complaint

  1. Visual acuity Exam
  2. Prepare for examination my MD by placing fluorescein strip, tetracaine, Woods lamp, Kleenex, & burr on bedside table.

Flank Pain

  1. UA, POC Preg (If indicated), CBC, BMP
  2. Saline Lock
  3. CT abd/pelv w/wo contrast(after Preg test neg. and Cr normal)

Flu-like Symptoms

  1. (Fever > 100.4, cough, congestion, body ache) during months of October-March
    • Flu-Swab, RSV

Nausea/Vomiting/Diarrhea > 12hr
(> 17 yr age)

  1. CBC, BMP, UA, POC Preg (female)
  2. Saline Lock
  3. Zofran 4mg ODT (unless contraindicated)
  4. Stool CDT, Ova, Parasite.

Overdose/Suicidal

  1. CBC, CMP, PT/INR, Cardiac Enzymes, EKG, ETOH, UA, UDS, POC Preg (female).
  2. CXR
  3. Aspirin (Salicylate level) & Acetaminophen level, Any other drug levels if applicable (digoxin, phenytoin, carbamazepine, valproic acid, lithium, TCA etc)
  4. Saline lock
  5. Charchoal at physician discretion.
  6. Call Poison control.

 

Palpitation/Dysrhythmia

  1. EKG
  2. CBC, BMP, TSH, Mg
  3. CXR
  4. Saline Lock, O2

 

Psychiatric Complaint
(likely to require placement)

  1. CBC, BMP, ETOH, UA, UDS, POC Preg (female)
  2. EKG (if cardiac Hx/age > 45)
  3. Drug level if appropriate (carbamazapine, valproic acid, lithium etc. )

    [ Psych Rx ]

 

Seizure

  1. HOW LONG HAS THE SEIZURE BEEN GOING ON ?
  2. Vitals (inluding Temp)
  3. Finger-Stick sugar : Treat if < 80 or unable to determine
  4. CMP, Ca, Mg, UA
  5. CXR if indiacted
  6. CT/MRI brain for NEW seizure
  7. Anti-epileptic drug level
  8. +/- UDS
  9. Consider CSF studies if CNS infection suspected

    [ Seizure & Status Epilepticus* ]

Sexual Assault

  1. All sexual assaults should be treated as ESI level 2 and taken to a room ASAP
  2. HIV, Hep panel, POC preg (on all females of child bearing age).

Shortness of Breath
(Cardiac pt/Pt w. COPD/CHF)

  1. Oxygen (Nasal Cannula -- may need a BiPAP)
    • Get Ready to INTUBATE if needed
  2. EKG
  3. CBC, CMP, ABG (if SPo2 < 90%), Cardiac Enzymes, D-Dimer (if suspeted)
    • If ↑  D-Dimer = CTA (r/o PE) + LE Duplex (r/o DVT)
  4. Saline Lock
  5. Consider Duoneb updraft & Lasix IV.

[ Respiratory Distress/Shortness of breath ]

[Respiratory Meds]

Suspected Pneumonia

  1. CXR
  2. CBC, BMP, Blood culture x2, Sputum cultures
  3. Saline Lock

[Pneumonia *]

 

Syncope/Dizziness/Near-Syncope

If Dizziness DOES NOT seem to be vertigo then initiate the following tests:

  1. CBC, BMP, Cardiac Enzymes, POC Glucose, POC Preg (females).
  2. UA, UDS
  3. PT/INR if on warfarin
  4. Consider CT-Brain, CXR, Orthostatic vitals.
  5. EKG
  6. Saline lock

[Syncope *]

Vaginal Bleeding

  1. CBC, BMP, UA,PT/INR (if indicated), POC Preg (female)
  2. R/O Rectal Source (Physical Exam, Speculum Exam)
  3. If it is known that the pt is pregnant or they have (+) Preg test upon arrival = Quant. HCG (Serum), RH Type.
    • Quant > 1500 = OB US to R/O Ectopic
  4. FHT if > 12 wk gestation
    if a pt is pregnant, bleeding, & has abdominal pain along with abnormal VS (pulse > 110 or sBP < 90) she is ESI level 2 and is a RUPTURED ECTOPIC until proven otherwise.
    • OB US

[Vaginal Bleed DDx]

[Vaginal bleeding in Pregnancy]

Pediatric Fever

If < 6 wk old with rectal tem > 100.4  ESI 2, transfer to room ASAP
< 65 kg =   Acetaminophen 15mg/kg or Ibuprofen 10mg/kg
  • Avoid Motrin (ibuprofen) if < 6 months of age
> 65 Kg = Acetaminophen 1000 mg or Ibuprofen 800 mg