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Deteriorating Patient |BSSNxPreparingfortheNHSObjectives Attheendofthissessionyouwill: ● UnderstandwhatNEWSisandhowitisimportantintheevaluationofthe unwellpatient ● BeabletoperformathoroughA–Eassessmentoftheunwellpatient ● Beabletotreatabnormalitieswhenfoundandthenreassessas appropriate ● Beabletoidentifyneedforescalation toseniorwhensupportrequired ● BeabletogiveaneffectivehandoverusingtheSBARapproachThe “NEWS-ing” Patient ….NEWSscore?National Early Warning Scores (NEWS) Aclinicalscoringsystemusedby medicalservices toquickly determinethedegreeofillnessofapatient.Itisbasedon the asetofparametersmeasuredatthebedside,including respiratoryrate, oxygensaturation, temperature, blood pressure, pulse/heartrateand levelofconsciousness NEWS ● Normalobservationsareawardeda scoreof0andabnormalobservations attracthigherscores. ● Higherscoresindicategreaterseverity ofillness ● Thevaluesforeachphysiological parameterareaddedtogether.NEWS Ifthistotalscorereachesa‘threshold’value (≥5,oranyindividualparameterscoring3), I’m worried thenursingstaffwillincreasefrequencyof about this observationsandalertadoctortoreview patient Doc. Can you come see thepatient him please?NEWS WhenattendingtoapatientwithhighNEWSscore,“trends”inphysiological parametersareoftenmoreusefulthanone-offobservations. Somepatientsmayhaveabnormallyhighbaselinescoresbuttheyseemrelatively ‘well’becauseofcompensatorymechanisms. Forthesepatients,higherNEWSthresholdsmaybeagreedbyseniordoctorsA to E assessment A – E assessment ● Thisisusedtoassessacutelyunwellordeterioratingpatients ● Theaimistoquicklyidentifylifethreateningabnormalities andtreatpromptly ● Itisimportanttoreassessaftergivingtreatmenttoconfirmif patientisrespondingappropriately ● Itisessentialtoworkinateamwithavailablenursesandother doctorsandescalatetoseniorspromptlyonceyoufeeloutof yourdepth ● Immediatelycallforhelpfromtheresuscitationteamifyou feelthisisappropriateAirway Airway ● Ifapatientisabletotalkclearlythentheycanmaintain theirownairway ● Lookinsidethemouth,removeobviousobjects/dentures ● Ifsecretionspresent,thenwide-boresuctionunderdirect vision ● Listenforanyabnormalrespiratorysoundslikestridor, snoring,gruntingorgurgling ● ApplyJawthrust/headtilt/chinliftwith(cervicalspine controlintrauma)toopenuptheairway ● InsertOropharyngeal ornasopharyngealairwayastolerated ● IfairwayisirreversiblyobstructedCALLARRESTTEAMInserting an Oropharyngeal Airway 1. Ensure no foreign bodies in the mouth 2. Lubricate the oropharyngeal airway 3. Insert into the mouth upside down (reduces risk of pushing tongue back) 4. Once tip is around hard-soft palate junction, rotate 180˚ and advance the rest of the way 5. If the patient gags it is unlikely they will tolerate this airway. Stop insertion and try a nasopharyngeal airway instead. 6. Confirm airway patencyNasopharyngeal AirwayBreathing Breathing ● Lookforchestexpansion(R=L?),foggingofmask ● Listentochestforairentry(R=L?) ● Feelfortrachealposition,expansionandpercussion(R=L?) ● Start15L/minO2initiallyinallpatientswithNon-rebreathermask ● Bagandmaskifpoororabsentbreathingeffort ● MonitorO2SATSandrespiratoryrate ● Consideranarterialbloodgas,portablechestxray ● IfrespiratoryeffortremainspoororabsentCALLARRESTTEAMNon-Rebreather MaskCirculationCirculation ● Lookforpallor,cyanosis,distendedneckveins/JVP ● Feelforacentralpulse(carotid/femoral)–rateandrhythm, capillaryrefilltime ● Listentoheartsounds,?newmurmurs ● MonitordefibrillatorECGleadsandBloodPressure ● Insertvenousaccess,sendbloodsiftimeallows ● 12-leadECG ● Callforseniorhelpearlyifpatientdeteriorating. ● IfnopulsestartCPRandCALLARRESTTEAMDisabilityDisability ● AssessGCSandcheckglucose ● Lookforpupilreflexesandunusualposture ● Feelfortoneinallfourlimbsandplantarreflexes. ● IfGCS≤8orfallingimmediatelyCALLforhelp! REGISTRAR/INTENSIVIST/ANAESTHETISTExposureExposure ● Removeallclothing,checktemp ● Lookalloverbodyincludingperineumand backforrashorinjuries ● Abdominalexam ● ExaminelegsforDVT/Pittingedema ● Coverpatientwithablanket. Common Causes Pulmonary Arrhythmias Sepsis Oedema Myocardial Hypoglycemia Pulmonary Infarction Embolism Hypovolemia Hypoxia PneumothoraxCalling for HelpOneofthepitfallsofbeingajuniordoctoron-call,particularly atnight,isthetendencynotfullyappreciatehowunwella patientisandthencallforhelpearlyenough Asajuniordoctoron-call,itisimportanttoknowwhat resourcesyouhaveatyourdisposalwithregardstosenior colleaguesandhowtoreachthemduringworkhours ● SHO ● Criticalcareoutreachteam/Rapidresponseteam ● Medicalregistrar ● Resuscitationteam ● IntensivecareteamScenario 1 YouaretheFY1oncall,nursesonthewardcallyoutoinformyou ofapatientwhoissaturating82%on6Lofoxygenandblood pressure88/30mmHg.What important information about the patient will you request of the nurse while on the phone?❏ Name,age,location,hospitalnumber ❏ Presentingcomplaint,currentissues,past medicalhistory,medications ❏ Escalationplan ❏ Mostrecentvitalsignsandtrendin observations ❏ Bedsidetests ?call for senior input early in a patient like thisScenario 1 Nurseprovidesmoreinformation… Patientisan70yearoldman,admittedyesterdaynightwithacuteconfusion.Hehad becomeprogressivelyunwelloveraweekwithreducedmobility,feverandlower urinarytractsymptoms. HewastreatedasaurinarytractinfectionandstartedonIVantibioticsandIVfluids. Hehadrapidlydeterioratedoverthecourseoftheday RR32/min,SATS82%on6L/minoxygen,HR120/min,BP88/30mmHg,Temp37.3C HeisforCPRScenario 1 A –patientspeaking,butunabletocompletesentencesdueto breathlessness B–100%oxygenviaNRM,SATSmovesupto92%,useof accessorymuscles,chestisclearwithequalairentrybilaterally, vesicularbreathsounds C-CRT5seconds,HR115/minsandregular,IVnormalsaline 500mlsbolusgiven,BPnow98/50mmHg,ECGsinustachycardiaScenario 1 D-GCS14/15,PEARL,Temp37.3C,BM7mmol/l, E -mildsuprapubictenderness,urinarycatheter drainingdarkurine,rightlegmoreswollenthanleftand mildlytenderScenario 1 Arterialbloodgas:type1respiratoryfailure,metabolic acidosis,lactate6 Previousbloodsfrommorning:WBC12,CRP120,other bloodsunremarkable Additionalbloodssenttolab–includingD-dimer PortableCXRunremarkableScenario 1 ?Differentials LikelyPEScenario 1 Management ● Callforseniorhelpifyouhavenotcalledalready ● MaintainSATSabove92%with100%oxygenviaNRM,considerHumidifiedhigh flownasalcannulaoxygen(optiflow) ● ContinueIVfluidsandmaintainbloodpressureaboveMAPof65mmHg,watch outforsignsoffluidoverload ● ITUconsideration ● CommencetherapeuticLMWH ● Ifpatienthaemodynamicallystable,thenurgentCTPA ● Ifunstable,thenconsiderthrombolysisandconsidertransferringtoITU ● ContinueIVantibioticsSBAR Handover Situation Introduceself Patientname,age,hospitalnumber,location Mainconcern Background Presentingcomplaintanddateofadmission Currentissuesandtreatmentsofar Pastmedicalhistoryandescalationplan WhathaschangednowSBAR Handover Assessment Mostrecentobservations Examinationfindings Mostrecentbloodsandimagingresults Recommendation Yourideasonwhatmaybegoingon Asfortheiropinions Askiftheycouldreviewandwhatshouldbedoneinthemeantime Summary 1. Whenaskedtoreviewadeterioratingpatient,askthenursekeyquestionsandaskthemtocarryoutanyurgent tasksuntilyouarrive 2. Considercallingforseniorhelpearlyifpatientsoundsquiteunwellandyouneedsupport 3. AssessallsickpatientsusingtheA-Eapproach,correctingabnormalitiesasyougoalong 4. Putoutmedicalemergencycallsifyouthinkimmediatehelpisrequired 5. HandoverpatientstootherhealthprofessionalsusingSBARapproach