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CSI:Bill Emergency Meded CSI Crashcourse Phase 1b Lead bs1021@ic.ac.ukLearning Objectives I. Surgical sieve II. A-E Assessment III. NEWS2 IV. Shock V. Sepsis VI. Abdominal Pain VII. Diverticular DiseaseSurgical Sieve Surgical Sieve is an acronym that helps you remember the different causes for the patient’s symptoms. Vascular Neoplasia/Cancer Infective/Inflammatory Congenital Trauma Degeneterative Autoimmune Environment Metabolic Functional Idiopathic VITAMIN CDEF Bill’s Surgical Sieve DO NOT NEED TO KNOW ANY OF THESE, JUST A PRATICAL EXAMPLE OF BILL’S SURGICAL SIEVE V: Stroke, TIA N: Cancer Brain Cancer, Colorectal Cancer I: Meningitis, Diverticulitis C: Sturge Weber Syndrome T: Head injury, abdominal injury D: Motor Neurone Disease A: Autoimmune encephalitis E: Alcohol abuse, drug overdose M: Diabetic Ketoacidosis, HHS F: Epilepsy I: Shock VITAMIN CDEFAbdominal Surgical Sieve Question 1: A-E Assessment You are a medical student on placement in your local A+E department. The busy F1 has asked for your help. They have asked you to find out the GCS score on Willow. Willow was sleeping and only open her eyes when you said hello to her . When you started talking to her, she responds with muffled noises that are not coherent words. You asked her to raise her hands, and she does not respond. You apply a slightly painful pressure on both her shoulders. On the right side she can localize the pain however on the left side, she does not move. Can you calculate her GCS score? 1.GCS 10 (E4 V4 M2) 2.GCS 10 (E3 V1 M6) 3.GCS 11 (E4 V2 M5) 4.GCS 10 (E3 V2 M5) 5.GCS 10 (E2 V2 M6)A-E Assessment: Airway Assessment IF GCS UNDER 8 PLEASE INTUBATE Check if the airway is cle.r Hear for noisy breathing (snoring or stridor or wheeze or no breath) Check for pallor and cyanosis Action Airway opening manoeuvres (head tilt or chin lift or jaw thrust) Suction to clear debris DO NOT USE YOUR FINGERS Intubate 15L/Min High flow oxygenA-E Assessment: Breathing Assessment Oxygen saturation and Respiratory rate Can they talk or not Look for cyanosis or sweating Feel for chest symmetry in movement Feel for the trachea see if it is deviated Percuss and Listen to the chest Action Anaphylaxis IM adrenaline and Chest drain for pneumothorax ABG to look at blood and Oxygen level Oxygen saturation must be over 94% Intubate and ventilate A-E Assessment: Circulation Assessment Look at the color of hand. Measure capillary refill time and normal is under 2 seconds Measure HR and take a 3 lead ECG Palpate peripheral and central pulses Measure BP Auscultate the Heart Action Insert IV cannula Take bloods If BP low give fluid challenge A-E Assessment: Disability Assessment Check blood glucose Take temperature Do a GCS Check pupil size Check for pain Check for drug/reversible causes (low oxygen or glucose) for reduced consciousness Action Oral/IV glucose Painkillers Treat any issues like opioid overdose or seizures or raised ICPA-E Assessment: GCS GCS 3-8 is severe brain Injury GCS 9-12 is moderate brain injury GCS 12-15 is mild brain injuryA-E Assessment: GCSA-E Assessment: Exposure Answer 1: A-E Assessment You are a medical student on placement in your local A+E department. The busy F1 has asked for your help. They have asked you to find out the GCS score on Willow. Willow was sleeping and only open her eyes when you said hello to her . When you started talking to her, she responds with muffled noises that are not coherent words. You ask her to raise her hands, and she does not respond. You apply a slightly painful pressure on both her shoulders. On the right side she can localize the pain however on the left side, she does not move. Can you calculate her GCS score? 1.GCS 10 (E4 V4 M2) 2.GCS 10 (E3 V1 M6) 3.GCS 11 (E4 V2 M5) 4.GCS 10 (E3 V2 M5) 5.GCS 10 (E2 V2 M6) Question 2: NEWS2 You are a medical student on placement in your local A+E department. The busy F1 has asked for your help. They have asked you to performan NEWS2 assessment on Will. Here are your findings: Respiratory Rate: 15 per minutes Sp02 is 97% on Air Blood Pressure is 89/60 mmHg Patient is confused Heart rate is 80 bpm Temperatureis 37.9 degrees Can you please calculate the NEWS2 score and the frequency of patient monitoring? 1.NEWS2 score of 6 and continuous monitoring 2.NEWS2 score of 6 and hourly monitoring 3.NEWS2 score of 5 and continuous monitoring 4.NEWS2 score of 5 and hourly monitoring 5.NEWS2 score of 6 and 4-6 hourly monitoringNEWS2NEWS2 TOP TIPS/CPA TIPS: IF PATIENT IS ON OXYGEN ADD 2 TO THEIR SCORE IF PATIENT IS NOT ALERT THEN ADD 3 TO THEIR SCORE IF PATIENT HAS OVER 5 SCORE OR 3 IN ONE SECTION RULE OUT SEPSIS FIRST. ALWAYS FILL OUT PATIENT DETAILS FIRST AND DATES AND SIGN WITH YOUR INITALSNEWS2NEWS2 Answer 2: NEWS2 You are a medical student on placement in your local A+E department. The busy F1 has asked for your help. They have asked you to performan NEWS2 assessment on Will. Here are your findings: Respiratory Rate: 15 per minutes Sp02 is 97% on Air Blood Pressure is 89/60 mmHg Patient is confused Heart rate is 80bpm Temperatureis 37.9 degrees Can you please calculate the NEWS2 score and the frequency of patient monitoring? 1.NEWS2 score of 6 and continuous monitoring He scores 3 from the systolic blood pressure being under 90 and 3 2.NEWS2 score of 6 and hourly monitoring because he is confused. So, he scores 6 and 6 means continuous 3.NEWS2 score of 5 and continuous monitoring monitoring. 4.NEWS2 score of 5 and hourly monitoring 5.NEWS2 score of 6 and 4-6 hourly monitoring Question 3: Shock You are a medical student on placement in your local internal medicine ward. During your ward round, you met Gill. Gill is a 55-year-old man, and he presented with cardiac tamponade due to a stab wound and has been on your ward for a week. After treating the cardiac tamponade, Gill contracted a hospital acquired infection and went into sepsis. He was managed for his sepsis with the sepsis 6 and is now okay. The consultant unexpectedly talks to you and asks you a ”simple question”. They want to know what two types of shocks this patient has gone through and the order. Can you please identify the best answer to the consultant“simple question”?What are the two types of shocks and the order? 1.Distributive shock and Hypovolemic shock 2.Hypovolemic shock and Obstructive shock 3.Cardiogenic shock and Hypovolemic shock 4.Obstructive shock and Distributive shock 5.Distributive shock and Obstructive shockObstructive ShockDistributive ShockHypovolemic ShockCardiogenic ShockSummary of Shock Cardiogenic Shock e.g., heart failure, heart attack Low cardiac output due to the heart failing/unable to pump Increased central venous pressure as venous blood is being backed up. Hypovolemic Shock e.g., blood loss due to stabbing or bleeding peptic ulcer Low cardiac output and central venous pressure due to losing blood and the heart is just pumping less blood. Distributive Shock e.g., Sepsis and anaphylaxis Normal cardiac output as heart is working but tissues do not get enough blood as vessels are vasodilated. Obstructive Shock e.g., Massive PE, Cardiac tamponade, Low cardiac output as the heart is unable to dilate and contract properly so the stroke volume is decreased. Answer 3: Shock You are a medical student on placement in your local internal medicine ward. During your ward round, you met Gill. Gill is a 55-year-old man, and he presented with cardiac tamponade due to a stab wound and has been on your ward for a week. After treating the cardiac tamponade, Gill contracted a hospital acquired infection and went into sepsis. He was managed for his sepsis with the sepsis 6 and is now okay. The consultant unexpectedly talks to you and asks you a ”simple question”. They want to know what two types of shocks this patient has gone through and the order. Can you please identify the best answer to the consultant“simple question”?What are the two types of shocks and the order? 1.Distributive shock and Hypovolemic shock Obstructive due to cardiac tamponadepreventinghis heart to contract. 2.Hypovolemic shock and Obstructive shock Distributive shock due to widespread vasodilation due to 3.Cardiogenic shock and Hypovolemic shock sepsis. 4.Obstructive shock and Distributive shock Can say cardiogenic as the heart is unable to pump but 5.Distributive shock and Obstructive shock more Obstructive then cardiogenicQuestion 4: Sepsis You are a F1 doctor on call. You suddenly get a bleep from one of the nurses. They starting talking to you about a patient they want you to see as soon as you can. The key observations and bloods of the patient are below. Patient Details: Temperature of 39 degrees Celsius Heart Rate of 82 bpm Respiratory rate of 17 breaths per minute WBC of 15 Blood pressure of 97/55 mmHG after giving IV fluids Blood culture positive for C difficle EGFR of 55 (Normal is above 90) Can you identify what classification of sepsis this patient has? 1.SIRS 2.SEPSIS 3.SEVERE SEPSIS 4.SEPTIC SHOCKSepsisSepsis FEEDBACK QR CODE Please Scan the QR code Please Please Scan the Scan the QR code QR codeSepsis Bloods Raised/Lowered in Sepsis CRP (C-Reactive Raised Protein) Creatinine Raised Urea Raised Lactate Raised (Lactic Acidosis) WBC Raised ESR Raised aPTT Raised INR Raised Platelets LoweredAnswer 4: Sepsis You are a F1 doctor on call. You suddenly get a bleep from one of the nurses. They starting talking to you about a patient they want you to see as soon as you can. The key observations and bloods of the patient are below. Temperature of 39 degrees Celsius Heart Rate of 82 bpm Respiratory rate of 17 breaths per minute WBC of 15 Blood pressure of 97/55 mmHG after giving IV fluids Blood culture positive for C difficle EGFR of 55 (Normal is above 90) Can you identify what classification of sepsis this patient has? 1.SIRS 2.SEPSIS 3.SEVERE SEPSIS 4.SEPTIC SHOCK Septic shock because the patient has a diastolic blood pressure under 60 mmHG which we normally associate with shock. Secondly there is sign of end organ damage due to the low EGFR. Thirdly we meet the SIRS criteria from the raised temperatureand WBC. Finally, the blood pressure is still low after IV fluids so they are still in shock.Abdominal PainAbdominal PainAbdominal PainQuestion 5: Diverticular Disease You are a medical student on your GI Placement. You are taking a history What is the single best option you from a 65-year-old man name John. can do to help John with his John has been admitted to the ward constipation? because of a recent diverticulitis attack. He is complaining of not being 1.Flexible sigmoidoscopy to able to pass stool since he has been untwist the bowel and relieve the in hospital. You decide to check his obstruction medication, he is currently on IV 2.Surgery to remove the section of fluids, IV antibiotics and IV analgesia bowel effected by diverticulitis (morphine) to help manage his symptoms. After check his 3.Stop his opioid medication and medication, you do an abdominal X- replace with non opioid alternative RAY. 4. Wait and Watch Here is the X-RAY:Diverticulosis Definition: Diverticulosis is basically lots of outpouchings of the bowel wall (mostly in the sigmoid colon) Symptoms: Diverticulosis has no symptoms and just the presence of the outpouching Risk Factors: Increasing Age and low fiber diet Management: Increase fiber intake, fluid intake, reduce opioid painkiller , increase exercise, bulk forming laxatives.Diverticular DiseaseDiverticular Disease Definition: Diverticular Disease is the presence of multiple out pooching in the bowel wall and it causes symptoms. Symptoms: Change in BO (Bowel Habits), abdominal cramps/pain, constipation, bloating Risk Factors: Increasing Age and low fiber diet Management: Increase fiber intake, fluid intake, reduce opioid painkiller , increase exercise, bulk forming laxativeDiverticulitis Definition: Diverticulitis is infection of the diverticula. Symptoms: Left sided iliac fossa pain and tenderness on examination N+V (Nausea and Vomiting), Diarrhoea (can be bloody diarrhoea), Fever Bloating and change in BO (Bowel Habits) Investigation: RAISED WBC AND CRP and no colonoscopy as can cause perforation Risk Factors: Increasing Age and low fiber diet and obesity Mild attack: oral ABX and liquid diet and pain killers Severe Attack: Make patient NBM (nil by mouth) and give IV fluids and IV abxComplication of Diverticulitis Chest X-RAY Pneumoperitoneum: Air under the diaphragm (white line) because of a perforation in the abdominal region. Abdo X-RAY Large bowel obstruction (can be caused by diverticulitis) FEEDBACK QR CODE Please Scan the QR code Please Please Scan the Scan the QR code QR codeQuestion 5: Diverticular Disease You are a medical student on your GI Placement. You are taking a history What is the single best option you can do to help John with his from a 65-year-old man name John. constipation? John has been admitted to the ward because of a recent diverticulitis attack. He is complaining of not being 1.Flexible sigmoidoscopy to able to pass stool since he has been untwist the bowel and relieve the in hospital. You decide to check his obstruction medication, he is currently on IV fluids, IV antibiotics and IV analgesia 2.Surgery to remove the section of (morphine) to help manage his bowel effected by diverticulitis 3.Stop his opioid medication and symptoms. After check his medication, you do an abdominal X- replace with non opioid RAY. alternative Here is the X-RAY: 4. Wait and Watch This is normal abdominal X-RAY so no need to do surgery or flexible sigmoidoscopy.We will not wait and watch as the patient is complainingabout his constipation,and we can do something about it. We should stop his opioid medication because opioid medication can causes constipation.Also we give him an alternative painkiller.THANK YOU Meded CSI Crashcourse Phase 1b Lead bs1021@ic.ac.uk