Management of the Acutely Ill Patient

Original article by Tom Leach | Last updated on 27/5/2014
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Introduction

Ok, so here’s the scenario. You are an FY1. It’s your first on call shift. It’s the middle of the night. A nurse bleeps you and says… ‘My patient’s ‘going off’ get here quick!’. What do you do?!

This kind of situation results in loads of cardiac arrests, and deaths – but many of these are avoidable, with early detection of disordered physiology
When a patient goes off its often the case that for the past few hours there have been signs… e.g. their BP has dropped, respiratory rate has increased, and as a result their EWS has increased. The EWS is an attempt to address these patients as soon as possible, to avoid arrests and deaths.

 

ABC

DON’T PANIC! Just got back to your ABC’s….
When you first get to the patient (or even better, over the phone when the nurse calls) find out a bit about the patient: name, age, why are they in hospital, what has happened?

If the patient is conscious, ask them how they are feeling, if they have any pain, and where is the pain. If they respond, it’s fairly safe to assume they have a patent airway

A – Airway

  • Check it is patent – to head tilt + chin lift or if this is not possible, jaw thrust
    • In an obstructed airway, there is often a characteristic method breathing, whereby on attempted inspiration, the abdomen expands, and the chest is drawn inwards.

B – Breathing

  • Look
    • Check the O2 sats
    • Check the respiratory rate
    • Look for chest expansion
      • If you can’t see any, consider feeling for breaths- could do this simultaneously to listening
    • Look for any signs of cyanosis
  • Listen
    • Listen to the chest
      • You might want to listen to the heart as well, just to speed things up
  • Feel       
    • Chest Expansion
    • Percuss

C - Circulation

  • Look
    • Temperature / colour of extremities
    • Check capillary return
  • Listen
    • BP – likely this will e done by nurse / automated machine
    • Heart sounds – you probably listened when listening for breath sounds
  • Feel
    • Pulse
      • Rate and character – probably already know the rate from the sats monitor
      • Check that radial is present – if systolic BP <70, this will likely be absent
      • If absent, feel for brachial, then carotid

D – Disability

  • Basically, check their conscious level. There isn’t time for a GCS, so instead, use AVPU:
    • A – Alert
    • V – Voice
    • P – Pain
    • U – Unresponsive
      • If the patient scores a ‘U’, this is equivalent to <8 on GCS – and the patient requires intubation!
  • Check the pupils
    • Indicate level of consciousness and head injury
    • In cases of head injury, avoid morphine for pain relief – it is contraindicated as it can alter papillary response
      • Check the glucose in any patient with impaired consciousness – its really easy, and if hypoglycaemia is the cause, it is easily corrected

E – Exposure

  • Expose the whole patient to look for any obvious signs –e.g. melaena, wound, rashes etc
  • Everything else
    • Full examination plus as much Hx as you can get from the patient, nurse and notes
    • Get an ECG
    • Check BP (if not already)
    • Give O2
    • Give fluids
    • Get bloods – including blood group for possible future transfusion
    • Taking blood from the acutely unwell patient – you should not ever use a cannula that has had fluid going through it – as the fluid will dilute the blood and give useless results. Use the arm that has no cannula. If both arms have cannulas, stop the fluid in one arm, wait ten minutes, then take blood from a separate site on that arm. If it is not sensible to stop the fluids, then take a femoral vein sample.
      • Consider catheter to monitor output
      • Consider ABG - Most useful for getting the pH. Hypovolaemia commonly causes a metabolic acidosis resulting from peripheral anaerobic metabolism – producing lactic acid.

R – Reassess

  • This is really important. keep going through your ABC’s to see if your interventions are having any effect!

P – Plan

  • Consider further investigations, e.g. CXR
  • Call for assistance. First port of call will likely be the surgical / medical SHO on call, but you might want to call the reg
  • When sending off your bloods, you should call ahead and state that they are urgent, to get the results back sooner.
 
Making a diagnosis is not critically important – you are just trying to stabilise and keep the patient alive at the moment. Obviously having an idea of the diagnosis helps direct what blood / investigations you will order, and who to call for help.
 
Giving fluids to the acutely ill patient
  • Get two wide bore (grey, or as big as you can manage) cannulas in ASAP
  • The actual fluid given is not that important. There is controversy over whether colloid or crystalloid is best, but it probably doesn’t make much difference. Avoid Potassium until you have blood results back! e.g. 0.9% saline or gelofusine will be fine
  • Consider how much to give. If your patient is in shock, then you should give a fluid challenge
  • FLUID CHALLENGE
    • Give your patient 500ml of 0.9% saline, as quickly as possible (e.g. over 5-10 minutes)
    • If the fluid doesn’t go in quick enough, then you can use a pressure bag to squeeze the fluid bag!
  • Recheck the BP / pulse / AVPU
    • If these have improved – GREAT! – your patient is in a non-cardiogenic shock, and you should continue to give more fluids. You can use both cannulas at the same time if you think it is necessary, and give the fluids as fast as possible (just leave the valve open in the giving set, and possibly use a pressure bag).
    • You can give up to 2-3L like this. If your patient is still in shock (aim for systolic >90), then you might now have to consider blood transfusion (hopefully your HB and blood group results are back from the lab!).
    • Remember! – when checking the Hb before transfusion, Hb is a measure of concentration. So if you have not given any liquids, but your patient has lost blood, their Hb concentration will still be the same as if they had lost no blood! But if you have given fluids to replace lost blood, you have diluted their blood, and as a result, has lowered their Hb
  • If these have not improved – your patient is likely to be in cardiogenic shock – don’t give any more fluids – as this will likely only fluid overload the patient.               
    • If BP is high, then heart failure is likely, and give furosemide 20mg and wait for response – make sure you have catheterised to measure urine output first