Assessment of the Acutely Ill Patient

( A Dummies Guide )

(There is also an MS Word version of this here. which will print on fewer pages.)

Contents:


  • Don't panic! There are very few emergencies to which you have to run
  • Taking the time to do a systematic (ABCDE) assessment is the only way to get anywhere
  • If in doubt, a CXR, ECG and ABG are useful in most sick patients
  • Don't assume in confused/drowsy/unresponsive patients that this is their normal status
  • Think in terms of physiology and pathophysiology

PRIMARY SURVEY

Eyeball the patient - do they look sick?

Airway assessment + C-spine

Airway problems:

If evidence of actual or potential airway obstruction - get anaesthetics help early.

Don't wait for O2 saturations to drop - by that stage your patient may be in big trouble.

Remember airway adjuncts if inability to maintain an airway due to decreased conscious level.

Consider suctioning (call chest physio) if evidence of retained secretions i.e. gurgling noises.

Breathing assessment - look/feel/listen

Breathing problems:

There are only a few things that commonly cause life-threatening breathing problems: These can co-exist.

O2 Saturations of 92% in a young, previously healthy patient are *not* ok.

Not everyone with tachypnoea has a primary respiratory problem, it can be secondary to a metabolic acidosis or a CNS problem.

O2 Sats of 97% might be ok on room air, but if it takes high-flow oxygen to achieve this, something is badly wrong with gas exchange in the lungs.

Circulation assessment (Hands-face-chest-abdomen-legs)

Circulatory problems:

Shock is a failure to adequately perfuse organs, not just hypotension. Hypotension means advanced shock.

Think of the cardiovascular system as plumbing. Things that can go wrong:

In most cases, fluid resuscitation is the first-line treatment for shock, but not always.

In cardiogenic shock, fluids will tend to make a bad situation worse, and the management is to treat any immediate cause eg arrhythmia or MI, and/or use inotropes.

Unless there is obvious pulmonary oedema, a fluid challenge is worthwhile (250-500mls of colloid e.g. Voluven or Gelofusin over 15-30mins, and assess response - HR, BP, urine output and CVP if available).

Never use hypotonic fluids e.g. 5% dextrose for resuscitation purposes.

If bleeding + hypotensive, use blood, ideally cross-matched.

Disability assessment

Quick neurological screen - time to do a full assessment later:

Disability problems:

New focal neurology? Is it haemorrhage? - this is the most treatable cause.

Generalised deterioration in conscious level - 1° CNS cause, or a response to other pathology?

Confusion/agitation can be a manifestation of hypoxia/shock/hypoglycaemia/lots of other things for which sedation is not the treatment.

Check capillary blood glucose.

E-exposure (SECONDARY ASSESSMENT + INVESTIGATIONS)

 

Specific Management of Some Common Emergencies

1. Cardiac Arrest

(http://www.resus.org.uk/pages/guide.htm - Resuscitation Council (UK) Guidelines 2000.)

Basic Life Support (BLS):

Advanced Life Support (ALS):

Reversible causes:

 

2. Myocardial Infarction

Management: (BOOMASS)

Bed rest
Oxygen
Opiates
Monitor rhythm (ECG)
Aspirin (300mg) (GTN and Beta-blockers can help)
Steptokinase or tPA (if within 12hr and elevated ST, but no contraindications)
Stop smoking (exercise, diet, physio)

In more detail:

Contraindications to Thrombolytics (Variation between clinicians - these are typical):

 

3. Acute severe Asthma

(http://www.enterpriseportal2.co.uk/filestore/bts/asthmafull.pdf - British Thoracic Society - A Guideline on the Management of Asthma)

Signs of Severe attack:

Signs of Life-threatening attack:

Treatment:

 

4. Anaphylactic Shock

Symptoms & signs:

Management:

 

5. Diabetic Ketoacidosis

Dehydration is more life threatening than any hyperglycaemia.

Signs & symptoms:

Management:

 

6. Acute upper GI bleed

Assess for shock:

If shocked:

 

7. Respiratory Arrest

 

8. Ischaemic Chest Pain

 

9. Pulmonary Embolus

 

Scenarios

See how you would handle some real life situations. How much have you learnt from your experiences and reading the summary above?

For each case, discuss your assessment and management - you may have enough information already to tell you what action to take. It's not about the diagnosis, it's about assessing and managing ABCs. For exams, a good way to phrase your answer is:

"I would go immediately to see the patient and assess airway, breathing, circulation and disability before taking a full history, performing a full examination and appropriate investigations. In this case, the patient's airway..."

(Answers are given further below.)

1. You are called to see a 38-year old patient who has been admitted following an overdose of benzodiazepines and alcohol. His GCS was 11 on admission, and is now 8. The nurses are concerned that he is making loud snoring noises and his oxygen saturations are 88% on room air.   Answer...

2. You are asked to admit Una Johnston, a 45-year old known brittle asthmatic, who is complaining of chest tightness and breathlessness. She has been given a 5mg salbutamol neb in casualty, which helped a little.   Answer...

3. You are called to see Mrs Jones (68) in the fractures ward where she is day 1 post-DHS. She is short of breath. Her current medications include furosemide, rampiril, and spironolactone tablets, and salbutamol, ipratropium bromide and budesonide nebs.   Answer...

4. Mr Gumble (52), a long-term alcoholic, was admitted with haematemesis. He was haemodynamically stable on admission, but has just filled his 4th kidney dish with bright red blood.   Answer...

5. James Brown is a 24-year old with Down's syndrome, who was admitted with a chest infection and commenced on amoxicillin. You are called because his temp is now 39.1, and the nurses think you should take blood cultures. He's a bit drowsy and you think he doesn't seem too well.   Answer...

6. Mary Ryan is a 78-year old who is day 2 post-op and gives an 8-hour hx of shortness of breath and mild central chest pain. Her ECG was normal this morning. She has no past medical history, but appears very short of breath, and is sweating profusely.   Answer...

7. Karl Barth is an 84-year old with mild dementia who was admitted 10 days ago with acute exacerbation of his COPD. He responded well to treatment with 28% oxygen, regular salbutamol and ipratropium bromide nebs, co-amoxoiclav and prednisolone and is waiting for a bed in a private nursing home. You are asked to prescribe something to settle him down, as he appears very agitated tonight.   Answer...

Scenarios (Answers)

1. You are called to see a 38-year old patient who has been admitted following an overdose of benzodiazepines and alcohol. His GCS was 11 on admission, and is now 8 (E2M5V1). The nurses are concerned that he is making loud snoring noises and his oxygen saturations are 88% on room air.

 

2. You are asked to admit Una Johnston, a 45-year old known brittle asthmatic, who is complaining of chest tightness and breathlessness. She has been given a 5mg salbutamol neb in casualty, which helped a little.

 

3. Mrs Jones (68) day 1 post-DHS. She presents with dyspnoea. Her current medications include aspirin /simvastatin/ frusemide/ rampiril tablets, and salbutamol/ atrovent/ pulmicort nebs.

Management of ACUTE PULMONARY OEDEMA (But don't usually just do 1 step at a time):

 

4. Mr Barnet (52), a long-term alcoholic was admitted with haematemesis. He was haemodynamically stable on admission, but has just filled his 4th kidney dish with bright red blood.

 

5. James Brown is a 24-year old with Down's syndrome, who was admitted with a chest infection and commenced on oral amoxicillin. You are called because his temp is now 39.1, and the nurses think you should take blood cultures. He's drowsy and you think he doesn't seem too well.

Classical picture of SEPTIC SHOCK - but not all are warm and hyperdynamic circulation - later on these patients become cold and shut down.

 

6. Mary Ryan is a 78-year old who is day 2 post-op and gives an 8-hour hx of shortness of breath and mild central chest pain. Her ECG was normal this morning. She has no past medical history, but appears very short of breath, and is sweating profusely.

After 1 hour - HR 170 irreg, BP 70/40, cold, clammy, shut down. Urine output 10mls. Mild chest pain, drowsy. Now in cardiogenic shock. Unstable. Synchronised DC cardioversion the definitive treatment +/- inotropic support with dobutamine. Will need sedation e.g. with Midazolam.

 

7. Karl Barth is an 84-year old with mild dementia who was admitted 10 days ago with acute exacerbation of his COPD. He responded well to treatment with 28% oxygen, regular salbutamol and atrovent nebs, augmentin and prednisolone and is waiting for a bed in a private nursing home. You are asked to prescribe something to settle him down, as he appears very agitated tonight.

http://www.studentbmj.com/issues/04/02/education/56.php - useful Student BMJ article on oxygen therapy.

 

Recommended reading:

"Essential Guide to Acute Care",   By: Cooper N and Cramp P,   Pub: BMJ books 2003.

Everyone should read this book before starting as a JHO - it contains lots of information about managing sick patients that everyone should know but most people don't.

(Note: if you purchase this book on Amazon.co.uk via the above link, medicalfinals.co.uk does get a referral fee, which will help with further developing this site. The book is still the same price to purchaser.)

 

BY: Jon Silversides, May 2005
www.MedicalFinals.co.uk