Emergency Nursing Means Blood!

Author: Cristiana Theodoli
Date: 1/8/2018

Emergency nursing means blood.
Lots of blood.
Blood from minor wounds, self-harm wounds, and major trauma wounds.
Blood in urine, vomit, and sputum.
Nose bleeds, PR bleeds and PV bleeds.
We see fresh blood, brown blood, dried blood and coffee grounds blood.
Blood that has crusted all over someone’s clothes,
And blood that has spurted all over our floors.
At times the bleeding is hard to find or hard to stop,
Internal,
Of unknown source,
Whether someone is anticoagulated or not.
At times it’s ‘kicking a football full of bricks and breaking a toenail’ blood.
Often, during the winter months, it’s ‘I slipped on ice’ blood.
And several times a day and several times a night,
It’s ‘I’d like to take some blood tests, is that’s ok?’ blood.

One thing I’m trying to get to grips as a new nurse with the recent “level-up” skills of venepuncture and cannulation is what bloods are needed for each presentation and why.

In emergency departments we often take bloods before a doctor even gets a chance to review a patient, so knowing which ones to take and why we are taking them is key. Here is a (non-exhaustive!) A-Z of common blood tests requested in ED, why we take them and for what conditions.

Please note, this is *not* a blood tests interpretation post!

Amylase

A protein primarily produced by the pancreas, amylase levels – too high or too low - can indicate if pancreas is inflamed or damaged. Usually taken for patients with abdominal pain or known pancreatitis. Serum Separator Tube.

Bone profile

A bone profile covers a number of tests that include enzymes, proteins and minerals involved in bones health, dispersion and reabsorption:
Alkaline phosphatase (a protein which has an impact on bone calcification and the transport of lipids and metabolite, also increases when bile ducts are blocked);
Albumin (a liver-made protein which ensures fluids doesn’t leak from blood vessels and helps with the transport of hormones, drugs, vitamins and ions);
Globulins (a protein involved in liver functions, blood clotting and the fighting of infections);
Adjusted calcium (though primarily found in bones, calcium in blood can indicate dysfunction of the heart, kidneys or endocrine system);
Phosphate (used for the production of energy along with maintaining muscle and nerve function and helps maintain the acid-base balance of the body, high levels of phosphate can cause itching).
Bone profile tends to be requested more specifically for patients with known or suspected bone diseases or if they are on thyroid meds. Serum Separator Tube.

CK

Creatine Kinase: An enzyme found primarily in skeletal muscles, heart and brain. It is found in greater quantity in the blood stream after cell damage, especially muscle damage. Taken primarily for patients after falls or who have been found after lying for any length of time to assess muscle waste. Serum Separator Tube.

Coag

Coagulation factors are proteins used for blood clot formation to see if blood is clotting in a normal way. Usually taken for Abdo pain, Sepsis, stroke, head injuries, acute bleeding, confusion, PV bleed, overdoses, chronic alcohol abuse, patients on anticoagulants. Coag (like D-dimers) can be very expensive to run, if in doubt double check with a doctor before you take it to see if it’s necessary. Sodium Citrate Tube.

CRP

C-Reactive Protein is an inflammatory marker made by the liver and released into the blood soon after tissue injury, at the start of an infection or other sources of inflammation. It can give an indication of whether there is inflammation in the body and its severity though it will not give an indication as to what is causing the inflammation. Usually requested as part of a basic set. Serum Separator Tube.

D-Dimer

After a clot is formed and the area is healed, the body uses a protein to break the clot apart so it can be removed. One of the products of the fragments being removed is D-dimer which is only detectable in the blood after a clot has started breaking down. Mainly taken if querying deep-vein thrombosis or pulmonary embolism, with symptoms such as shortness of breath, chest pain at the lungs (worsening on inspiration/coughing), swelling, tenderness or pain to one leg. Like a Coag a D-Dimer test can be very expensive, so if in doubt double check if it is necessary. Sodium Citrate Tube.

ESR

Erythrocyte Sedimentation Rate. This tests how fast red blood cells fall and settle at the bottom of a test tube as certain proteins associated with inflammation cause them to fall faster. ESR is a non-specific test as it can’t indicate the cause of an inflammation but rather is a general indication of inflammation in the body. Used in ED primarily for headaches, it can also be requested for confusion, reduced GCS, unexplained weight-loss and ‘all over’ pain. EDTA Tube.

Ethanol

Ethanol levels will show the level of alcohol in the body. While we won’t be requesting an ethanol level for every intoxicated patient visiting an ED, certain patients with reduced GCS and no obvious other cause might benefit for an ethanol level. Fluoride/Oxalate top.

FBC

A Full Blood Count tests, among others:
White Blood Cells (help fight infections);
Red Blood Cells (help assess body’s oxygen capacity);
Haemoglobin (a protein within red blood cells which helps in the transportation of O2 around the body – used to diagnose anaemia and assess whether someone might require a blood transfusion);
Haematocrit (the density of red blood cells within the blood – can show dehydration among other disorders);
Platelets (which help clotting).
Usually requested as part of a basic set. EDTA Tube.

Glucose

As the main source of energy for the body, especially relied on by the brain and central nervous system, a full glucose check is far more accurate than a simple pin prick test. Requested as part of a basic set for all patients. Fluoride/Oxalate tube.

Group & Save

In preparation for a blood transfusion a group and save is used to cross match a patient by checking their blood group and rhesus factor. To be taken for patients with known anaemia who might require transfusion, pre-op patients and trauma patients. It is now policy in Greater Glasgow & Clyde to take two separate group & save samples at two separate times by two different practitioners. EDTA Blood Transfusion tube.

LFT

Like a Bone Profile test, a Liver Function Test assesses a number of enzymes, protein and waste products made by the liver to assess its health. These include:
Bilirubin (a waste product of haemoglobin which is processed by the liver and becomes the main pigment in bile, also what causes patients to look jaundiced, can increase with liver problems or sickle cell disease);
AST (Aspartate Aminotransferase, an enzyme found in the liver, heart and muscles and helps assessing the extent of any damage in the liver);
ALT (Alanine Aminotransferase, an enzyme found primarily in the liver which, if found in the blood in high concentrations can indicate liver damage);
GGT or Gamma GT (Gamma Glutamyne Transferase rises in the blood when the liver is injured or when there is an obstruction in the flow of bile and can help diagnose bile duct issues);
Alkaline phosphatase (a protein which has an impact on bone calcification and the transport of lipids and metabolite, also increases when bile ducts are blocked);
Albumin (a liver-made protein which ensures fluids doesn’t leak from blood vessels and helps with the transport of hormones, drugs, vitamins and ions);
Globulins (a protein involved in liver functions, blood clotting and the fighting of infections).
Usually requested as part of a basic set for all patients. Serum Separator Tube.

Magnesium

A mineral part of the production of energy, muscle contractions, bone maintenance and nerve function, deranged magnesium levels can indicate poor kidney function, uncontrolled diabetes, or malnutrition. Particularly important for Chronic Kidney Disease and dialysis patients, head injuries and intoxicated patients. Serum Separator Tube.

Paracetamol

Self-explanatory, this test checks paracetamol levels in the blood to establish its degree of toxicity. For staggered overdoses it should be taken straight away, for overdoses taken in one go it must be at least 4 hours after the paracetamol was taken or it won’t give an accurate reading. Should be requested in all overdoses. Serum Separator Tube.

Salicylate

Similar to paracetamol, this checks the levels of salicylate, a group of drugs including aspirin primarily used as analgesic, anticoagulants and antipyrexials. Should be requested in all overdoses. Serum Separator Tube.

TFT

Thyroid Function Tests are, similarly to LFTs, requested as an overall umbrella of tests used to assess the function of the thyroid gland. These are usually requested in patients with known thyroid dysfunction or presenting with confusion or off their feet. Serum Separator Tube.

Troponin

Troponins are several proteins whose function is to help regulate muscle contraction in skeletal muscle (troponin C) and in cardiac muscle (troponin T and troponin I). Troponin I is requested to help diagnose a myocardial infarction as in the case of cardiac ischaemia troponin is released in the bloodstream. Requested for patients with cardiac chest pain. Lithium Heparin tube.

Venous Blood gas

Used as a quick way to establish an oxygen/carbon dioxide or pH imbalance, a venous blood gas is especially important in patients with respiratory, kidney or metabolic diseases and is a quick way to establish whether patients are retaining CO2, have deranged minerals or deranged glucose levels. Heparinised syringe.

U&E

Urea and Electrolytes are checked to assess kidney function and electrolyte balance. These include (among others):
Sodium: (helps control blood pressure as affects water distribution and neuromuscular function. Is also linked to potassium and chloride levels. Helps assessing levels of dehydration and oedema);
Potassium: (low potassium can cause twitching; deranged potassium levels - either high or low - are one of the reversible causes of cardiac arrest and should be addressed urgently. Kidney disease is the most common cause of hyperkalaemia while vomiting and diarrhoea-led dehydration the most common cause of hypokalaemia);
Chloride: (Along sodium, helps to maintain normal levels of water in the body and keeping a normal acid-base balance. Along the other U&Es levels it helps evaluate kidney function);
Bicarbonate: (Bicarbonate is one of three forms of carbon dioxide present in the blood. As it is processed by the kidneys it is another indication of kidney function);
Urea (As the liver produces nitrogen in the form of ammonia when breaking down protein it combines with other chemicals to form urea as a waste product. This is then released back into the blood stream and transported to the kidneys where it is then excreted through urine. Urea levels can be linked to issues with either kidney or liver);
Creatinine: (Creatinine is the breakdown product from muscles contraction, as it is primarily excreted by the kidneys it is another good indication of kidney function);
eGFR: (The estimated Glomerular Filtration Rate is an estimated level of kidney function. As glomeruli filter waste out of the blood yet keep blood cells and protein within the blood stream, an estimated rate of their function is a good estimate of how well the kidneys are working).
Usually requested as part of a basic set for all patients. Serum Separator Tube.