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Acute Illness on the Wards

Introduction

The prospect of being bleeped about an acutely unwell patient is an unnerving thought for all new and soon to be new doctors.  As a medical student, it can be difficult to acquire the experience to confidently approach these situations before suddenly finding yourself in the hot seat.

Evidence has underlined the benefit of recognising the decline of patients before they reach a state of extremis and imminent arrest. This has driven the national introduction of novel systems including early warning scores and critical care outreach services.  The key message being that simple things done early saves lives.

As easy as ABC?

The well-established ABCDE approach to medical emergencies and acute illness is grounded in the knowledge that problems with a patient's airway (A) will cause death more quickly than problems with their breathing (B) which in turn is essential for the circulation (C) to function. In short it is necessary to fix A before worrying about B and so on.

However, issues with one stage can impact all the others; sometimes an apparent problem with B (shortness of breath) may be actually be the result of a C problem (shock).

Whilst it is easy to state 'I would first carry out an ABCDE assessment' when asked 'how would you manage this patient', actually performing and responding to that asessment can be confusing.

The following is a suggested, generic approach to an acutely unwell patient that hopefully provides a useful framework for thinking about these situations. Fastbleep.com contains many other articles that go into individual aspects in more detail.

For each stage it is helpful to consider the following general points:

 

  • The approach is dynamic, requiring continuous review of each stage to decide if your interventions are helping, and crucially to pick up if the patient is clinically deteriorating despite your efforts.

 

  • Progressing via the ABCDE helps narrow down possible causes at each subsequent level, so an apparent 'D' issue (altered level of consciousness) may be corrected by successfully correcting issues discovered at A,B and C first. Similarly, the issue at one level may be the result of a problem further down (shortness of breath in a shocked patient).

     

      • The time spent at each stage will vary widely depending on the situation, securing A in a very drowsy hypoglycaemic patient may take more time and intervention than in an alert patient suddenly short of breath with a post-operative pulmonary embolism.

       

        • Constantly ask yourself 'is this progressing out of my depth?' It is dangerous to try and manage a sick patient single handed, there is always someone who can come and help. The possible consequences of calling for help unecessarily are nowhere near as severe as not doing so when needed. If you think you need a senior, you probably do!

        Using your acute management toolkit

        For each stage, there are four questions to address:

        1. Is there a problem at this level? (assessment)
        2. What is there in my knowledge (toolkit of skills) and investigations that could help with this stage? (intervention)
        3. Has it worked? (re-assessment)
        4. Do I need help yet? (staying safe)

        Assessment may involve a clinical examination and review of obervations.

        Your toolkit can be mentally divided into sections for ABCD and E and contains everything from positioning the patient differently to IV fluids. Whats in each part may vary from person to person and your collection of 'A' tools as an FY1 won't be as wide as that of the on-call anaesthetist. if you've tried everything in your box and the problem isn't on the mend its time to call someone with more tools urgently!

        Some tools are best and easily deployed immediately after you decide they could help (e.g. oxygen) others might be better briefly kept in waiting until you have finished running through ABCDE once and are trying to reach a a definitive diagnosis and make a specific management plan (e.g. ordering a chest x-ray)

          Before you get to the patient...

          Before you arrive to see the patient it is worth asking the person who has bleeped you a few important questions, helping your assessment on arrival. Some of these may seem like common sense but are easily forgotten!

          • Patient's name and location
          • The patient's observations (including heart and respiratory rate, temperature, blood pressure, oxygen saturations (and if on any oxygen therapy), urine output)?
          • If they have 'triggered' i.e. are scoring highly on one particular observation, e.g. blood pressure. If so, what have their previous results been like?
          • How does the patient look clinically (are they alert or confused for example)?
          • If the patient has symptoms, such as new onset chest pain or vomiting, how long have these been going on for?

           

            It is worth asking the referring staff member to prepare for you before you arrive at the patient. Some examples are:

            • Repeat observations
            • Prepare the medical notes and medication chart in anticipation of your arrival
            • Sit the patient up (if they have low oxygen saturations)
            • Perform an ECG (if they have chest pain)
            • Test the patient's blood glucose and/or dip their urine (if altered state of consciousness)

             

              Ultimately it depends on the scenario and your clinical judgement as to what your initial management before you arrive is.

              Airway

              1. Assessing the airway

              • Can the patient talk to you (a really good test to identify an unobstructed airway)
              • Look - any obvious signs of an obstructed airway (DO NOT 'blind sweep' the airway!)? Condensation in the oxygen mask? Paradoxical breathing movements? Cyanosis?
              • Listen - Is their breathing noisy? (snoring, stridor, gurgling)

               

                2. Airway Toolkit contents

                • Basic manouveres (head tilt-chin lift and jaw thrust)
                • Removing obstruction if safe and ideally using suction
                • Simple adjuncts (oropharyngeal/nasopharyngeal (avoid nasopharyngeal in ?base of skull fracture))
                • Repositioning the patient (might they be better on their side?)
                • Administer oxygen (15L via a reservoir bag mask)

                 

                  3. Re-assessment

                  4. Do you need help?- For 'A' problems this means urgently calling the on-call anaesthetist and your direct senior.

                  Breathing

                  1. Assessing breathing

                  • Look - is the patient cyanotic? What is their respiratory rate and oxygen saturations? Are they on any oxygen therapy? Are they using their accessory muscles of respiration?
                  • Listen - are they speaking and if so, are they completing sentences? Any audible wheeze? On auscultation are there any added sounds to their breathing or any areas of reduced breathing (silent chest)?
                  • Feel - Tracheal deviation? Altered chest expansion? Abnormal percussion notes?

                   

                  2. Managing breathing

                  • 15L oxygen via a reservoir bag mask (yes, even if they have COPD! Remember the 'hypoxia will kill first' mantra, you can always titrate down later)
                  • Consider sitting the patient up if they're conscious
                  • If their breathing effort is poor, consider using a bag and valve mask to ventilate the patient
                  • Treat any identifiable cause as appropriate (eg salbutamol nebs for acute asthma)
                  • Consider an arterial blood gas measurement at an appropriate time in your management plan

                   

                    3. Re-assessment (start again at A)

                    4. Do you need help?

                    Circulation

                    1. Assessing circulation

                    • Look - From the observations (blood pressure, heart rate), at the fluid balance chart, are they catheterised?
                    • Feel - Carotid/radial pulse (rate, rhythm, strength), capillary refill time

                     

                    2. Managing circulation

                    • Gain intravenous access ideally with two large-bore cannulae and take bloods (coagulation screen, U&E, FBC, glucose, G&S/cross-match). If querying sepsis, take some blood cultures
                    • Fluid challenge (250ml of colloid or 0.9% saline over 3-5 minutes)
                    • Consider catheterising the patient for accurate urine output measurements
                    • An ECG may be useful but only perform one if and when indicated

                     

                    3. Reassessment - following each fluid challenge bolus, reassess starting at A. Pay careful attention to signs of fluid overload.

                    4. Do you need help?

                    Disability

                    1. Assessing disability 

                    • AVPU - Alert? Responsive to voice? Responsive to pain? Unresponsive? AVPU is an easy way to assess a patient's state of consciousness
                    • Pupils - Measure and document a patient's pupil reactions to light
                    • Glucose - easily missed out from an assessment 'ABC - DEFG - Don't Ever Forget Glucose'. 
                    • What medications does the patient take?

                     

                      2. Managing disability

                      • Secure the airway if the patient cannot maintain their own airway
                      • If hypoxic, correct this with oxygen therapy
                      • If hypotensive, perform a fluid challenge
                      • If hypoglycaemic, administer glucose (surgical patients who have been starved are not likely to have much glycogen stores and in these cases, glucagon has reduced efficacy)
                      • Correct any iatrogenic causes (e.g. naloxone for opiate toxicity)

                       

                        3. Re-assessment - as ever, start at A. Correcting problems associated with A, B or C will often improve a patient's state of consciouness

                        4. Do you need help?

                          Exposure

                          1. Assessing exposure

                          • Look for any identifiable causes for the patient's deterioration such as rashes, swellings, distended abdomen, head injury, blood on the sheets, melaena, haematuria, etc

                           

                            2. Managing exposure - If you find any identifiable causes, then manage these appropriately.

                            3. Re-assessment - always the same, start at A!

                            4. Do you need help? 

                            Further management

                            • Review the notes and medication chart
                            • Perform a clinical examination (respiratory, cardiovascular, abdominal, neurological)
                            • What's your impression?
                            • Initial investigations (blood tests, ECG, radiological investigations?)
                            • Management plan
                            • Document EVERYTHING you've done in the notes!
                            • Senior review

                            Further reading

                            NICE Clinical Guidelines - Acutely ill patients in hospital http://www.nice.org.uk/CG50

                             

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