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EVERYTHING YOU NEED TO KNOW ABOUT: DR ABCDE:AN ACUTELY UNWELL PATIENT Harish Bavaand Anirudh Manivannan Reviewed by Dhivya Ilangovan Here’s whatwedo: ■ Weekly tutorialsopento all! ■ Focussed oncore presentationsand teaching diagnostictechnique If you’re new here… ■ By medical students, for medical students Welcome to ■ Reviewed by doctorsto ensure accuracy Teaching ■ We’ll keepyouupdatedabout our Things! upcoming events viaemail and groupchats!What will we be covering? ■ The DR ABCDE algorithm used for an acutely unwell patient ■ The structure of this assessment ■ Basic treatments and interventions during each step of the pathway ■ Important redflags to look out for throughout the assessment ■ Common emergencies you may come across and how tomanage them ■ The SBAR Handover NOTE: This presentation is primarily regarding adult patients. Though the structure is identicalfor paediatric patients,certain treatments andinterventions may be different which we will not be covering today.What is the DR ABCDE algorithm?What is the DR ABCDE algorithm? D- Danger R - Response A- Airway B - Breathing C- Circulation D- Disability E- Everything ElseWhat is the DR ABCDE algorithm? ■ As assessment used when seeingany acutely unwell patient D- Danger – This is the bread and butter of all junior doctors R - Response especially in the ED but also on all wards A- Airway ■ Gives a broad overview of what the acute problem is, in a manner that investigates in order of danger to the B - Breathing patient C- Circulation – I.e. what is going to kill my patient first? D- Disability E- Everything Else ■ Allows you to identify any major problems that require immediate treatment, intervention or investigationHow to practice this assessment? TheDRABCDEalgorithm is somethingyouwill beconstantlyperforming asa doctor. Some goodways to practiceare:How to practice this assessment? TheDRABCDEalgorithm is somethingyouwill beconstantlyperforming asa doctor. Some goodways to practiceare: ■ Withfriends,going through the structureand ensuring to ask andassessfor eachthingHow to practice this assessment? TheDRABCDEalgorithm is somethingyouwill beconstantlyperforming asa doctor. Some goodways to practiceare: ■ Withfriends,going through the structureand ensuring to ask andassessfor eachthing ■ Inhospital emergency departments.There will always beacutely unwell patientshereHow to practice this assessment? TheDRABCDEalgorithm is somethingyouwill beconstantlyperforming asa doctor. Some goodways to practiceare: ■ Withfriends,going through the structureand ensuring to ask andassessfor eachthing ■ Inhospital emergency departments.There will always beacutely unwell patientshere ■ On well patients - youcanpracticethisassessment onall patientsevenif they arenot acutelyunwell.Thisincludespatientsunder anaesthesiaCase Youarea junior doctor oncall intheEmergency Department.ANursehas called youovertoassessapatient who sheisworried about asthey areacutely unwell.Case Youarea junior doctor oncall intheEmergency Department.ANursehas called youovertoassessapatient who sheisworried about asthey areacutely unwell. What is thefirst thingyouwant to do?Initial steps? What is thefirst thingyouwant to do?Initial steps? What is thefirst thingyouwant to do? Thefirst stepisto always introduce yourself and ask fora briefhistory:Initial steps? What is thefirst thingyouwant to do? Thefirst stepisto always introduce yourself and ask fora briefhistory: “Hi mynameis …,Iam a… doctor.Can youpleasetell memore about thepatient andwhat hashappened?”Initial steps What might youwant to findout?Initial steps What might youwant to findout? - Whois thepatient? Anyknown PMH? Anyknownallergies?Initial steps What might youwant to findout? - Whois thepatient? Anyknown PMH? Anyknownallergies? - What cantheNurseor whoever has called youtell youabout whathas happenedor whatis going on?Initial steps What might youwant to findout? - Whois thepatient? Anyknown PMH? Anyknownallergies? - What cantheNurseor whoever has called youtell youabout whathas happenedor whatis going on? - Whereareyouinthehospital?Initial steps What might youwant to findout? - Whois thepatient? Anyknown PMH? Anyknownallergies? - What cantheNurseor whoever has called youtell youabout whathas happenedor whatis going on? - Where areyouinthehospital? All of thiscanprovidevaluableinformationand directionof what specificthings youmay beworriedabout andlookout for.Thecontext of thepatient will also help in your diagnosisand treatments/interventionsyouwill consider giving.Initial steps What might you want to find out? - What can the Nurse or whoever has called you tell you about what has happened or what is going on? - Where are you in the hospital? All of this can provide valuable information and direction of what specific things you your diagnosis and treatments/interventions you will consider giving.also help in This is also a goodopportunity toask the Nurse to assist you in your examination. Do not assume they will automatically help you. “I am goingto examine the patient now. Can you please assist me?”Danger and ResponseDanger and Response “Checkingfor anydanger” - Important tomake sure there isnothingin the surrounding area that could put you at risk of injuryorharm - This is a good opportunityto washyour hands and donPPEDanger and Response “Checkingfor anydanger” - Important tomake sure there isnothingin the surrounding area that could put you at risk of injuryorharm - This is a good opportunityto washyour hands and donPPE “Hi, my nameis…,I’mthedoctor heretoassess you,canyou hear me?” - ALWAYScheck for a response. Isthe patient able to respond toyou in some manner? Mostimportantly, doyouneedtoconsiderBLS?Danger and Response “Checkingfor anydanger” - Important tomake sure there isnothingin the surrounding area that could put you at risk of injuryorharm - This is a good opportunityto washyour hands and donPPE “Hi, my nameis…,I’mthedoctor heretoassess you,canyou hear me?” - ALWAYScheck for a response. Isthe patient able to respond toyou in some manner? Mostimportantly, doyouneedtoconsiderBLS? “Canyou tell mewhat’s going on?” - If they are able to, take a very brief history from the patientand ask their presenting complaintHow do you check for response? A. Talk loudly, shake the patient, trapezius squeeze B. Poke the patient, shake the patient C. Feelforthe patient’s pulse D. Defibrillation E. Whisperat the patient from the end of the bedHow do you check for response? A. Talk loudly, shake the patient, trapezius squeeze B. Poke the patient, shake the patient C. Feelforthe patient’s pulse D. Defibrillation E. Whisperat the patient from the end of the bedDanger and ResponseDanger and Response Typesof responseyoumay get:Danger and Response Typesof responseyoumay get: ■ Patient isalert and talking freelyDanger and Response Typesof responseyoumay get: ■ Patient isalert and talking freely ■ Patient isable to respond whenspokento but otherwiseis not alertDanger and Response Typesof responseyoumay get: ■ Patient isalert and talking freely ■ Patient isable to respond whenspokento but otherwiseis not alert ■ Patient isconfused and mumblingDanger and Response Typesof responseyoumay get: ■ Patient isalert and talking freely ■ Patient isable to respond whenspokento but otherwiseis not alert ■ Patient isconfused and mumbling ■ Patient isresponsiveto painDanger and Response Typesof responseyoumay get: ■ Patient isalert and talking freely ■ Patient isable to respond whenspokento but otherwiseis not alert ■ Patient isconfused and mumbling ■ Patient isresponsiveto pain ■ Patient isnot responding/unconsciousGeneral pointsGeneral points - Ineachsectionapply this approach: - Look - Feel - Listen - Measure - Treat - REASSESS!General points - Ineachsectionapply this approach: - Look - Feel - Listen - Measure - Treat - REASSESS! - Thisorder allows youto comprehensively assess and identify the immediateissues that requiretreatment or interventionGeneral points - In each section apply this approach: - Look - Feel - Listen - Measure - Treat - REASSESS! - This order allows you to comprehensively assess and identify the immediate issues that require treatment or intervention - The most important thing to remember: ALWAYS CALL FORHELP - You should do this at the earliest,most appropriate timeGeneral points - Ineachsectionapplythisapproach: - Look - Feel - Listen - Measure - Treat - REASSESS! - This orderallows you tocomprehensively assess and identify theimmediateissues thatrequiretreatmentorintervention - Themostimportant thingtoremember: ALWAYSCALLFORHELP - You shoulddothisattheearliest, mostappropriatetime - Agoodruleof thumb is wheneveryou measureanabnormal observation or havetogivesomeintervention, you should be callingfor helpAirwayAirway ■ If the patient is speaking to you or making noises, you can say that: – “The airway is patent” – This means that if there is an issue in the breathing,the cause is not likely an airway issue.Airway ■ If the patient is speaking to you or making noises, you can say that: – “The airway is patent” – This means that if there is an issue in the breathing,the cause is not likely an airway issue. ■ Though the airway may be patent, it is still important to go through the steps. The main thing you are looking for is anysign ofobstruction/anaphylaxis.Airway ■ If the patient is speaking to you or making noises, you can say that: – “The airway is patent” – This means that if there is an issue in the breathing,the cause is not likely an airway issue. ■ Though the airway may be patent, it is still important to go through the steps. The main thing you are looking for is anysign ofobstruction/anaphylaxis. ■ Look: swollen lips/tongue,obvious obstruction (foreign bodies,phlegm, saliva)Airway ■ If the patient is speaking to you or making noises, you can say that: – “The airway is patent” – This means that if there is an issue in the breathing,the cause is not likely an airway issue. ■ Though the airway may be patent, it is still important to go through the steps. The main thing you are looking for is anysign ofobstruction/anaphylaxis. ■ Look: swollen lips/tongue,obvious obstruction (foreign bodies,phlegm, saliva) ■ Feel: on cheek for presence of air, trachea centralAirway ■ If the patient is speaking to you or making noises, you can say that: – “The airway is patent” – This means that if there is an issue in the breathing,the cause is not likely an airway issue. ■ Though the airway may be patent, it is still important to go through the steps. The main thing you are looking for is anysign ofobstruction/anaphylaxis. ■ Look: swollen lips/tongue,obvious obstruction (foreign bodies,phlegm, saliva) ■ Feel: on cheek for presence of air, trachea central ■ Listen: stridor, wheeze, gurgling, snoring, talkingAirway What treatments/interventions might you give?Airway What treatments/interventions might you give? ■ H–adtA very simple,yet effective manoeuvre andcan open up an airwayAirway What treatments/interventions might you give? ■ Headtilt/chin lift/jawthrust – A very simple,yet effective manoeuvre andcan open up an airway ■ Suction – To remove any saliva, phlegmor bloodAirway What treatments/interventions might you give? ■ Headtilt/chin lift/jawthrust – A very simple,yet effective manoeuvre andcan open up an airway ■ Suction – To remove any saliva, phlegmor blood ■ Magill’s forceps – For both of these, do not gofurther than you can see. If you cannot see it,donot attempt toremove it, asyou risk pushingit further down the airway causingmore obstructionAirway What treatments/interventions might you give? ■ Headtilt/chin lift/jawthrust – A very simple,yet effective manoeuvre andcan open up an airway ■ Suction – To remove any saliva, phlegmor blood ■ Magill’s forceps – For both of these, do not gofurther than you can see. If you cannot see it,donot attempt toremove it, asyou risk pushingit further down the airway causingmore obstruction ■ Airway adjuncts – Nasopharyngeal - alwayscheck for any signsof basal skull fracture – Oropharyngeal - only tolerated if the patient isunconscious asit triggersthe gag reflexAirway What treatments/interventions might you give? ■ Headtilt/chin lift/jawthrust – A very simple,yet effective manoeuvre andcan open up an airway ■ Suction – To remove any saliva, phlegmor blood ■ Magill’s forceps – For both of these, do not gofurther than you can see. If you cannot see it,donot attempt toremove it, asyou risk pushingit further down the airway causingmore obstruction ■ Airway adjuncts – Nasopharyngeal - alwayscheck for any signsof basal skull fracture – Oropharyngeal - only tolerated if the patient isunconscious asit triggersthe gag reflex ■ Anaphylaxis – Swollen lips/tongue, urticaria,pt is tired,tachypnoea – Immediate IM adrenaline 0.5ml 1:1000 – 2222andimmediate anaestheticssupportAirway Whatis adefinitiveairway?Airway Whatis adefinitiveairway? - Youcan get adefinitiveairway throughintubation - An endotracheal tubehasaninflated ballooncuff that sitsbelow thelarynx, preventingany aspiratethroughAirway Whatis adefinitiveairway? - Youcan get adefinitiveairway throughintubation - An endotracheal tubehasaninflated ballooncuff that sitsbelow thelarynx, preventingany aspiratethrough Whenis this necessary? - Inanemergent setting,adefinitiveairway wouldberequiredifthepatient has aGCS <=8 - Inthisscenario,it isimperativeto fastbleep theanaesthetistandITUfor emergency intubationand ventilationsupportAirway REASSESSAirway REASSESS “Is theairway now patent?”BreathingBreathing What aresomeof themain presentationsyoumay encounter?Breathing What aresomeof themain presentationsyoumay encounter? ■ Shortnessof breathand/or difficulty breathing ■ Tachypnoea ■ Low O2 saturations ■ Slowbreathing ■ Cough ■ Coughingup phlegm/blood NOTE: Thisis not an exhaustive listBreathing What aresomeof themain What aresomeof themain presentationsyoumay encounter? diagnosesyoumay encounter? ■ Shortnessof breathand/or difficulty breathing ■ Tachypnoea ■ Low O2 saturations ■ Slowbreathing ■ Cough ■ Coughingup phlegm/blood NOTE: Thisis not an exhaustive listBreathing What aresomeof themain What aresomeof themain presentationsyoumay encounter? diagnosesyoumay encounter? ■ Shortnessof breathand/or ■ TensionPneumothorax difficulty breathing ■ Pneumonia - VERY ■ Tachypnoea IMPORTANT TOIDENTIFY ■ Low O2 saturations SEPSIS ■ Slowbreathing ■ Pulmonary Embolism ■ Cough ■ Opiateoverdose ■ Coughingup phlegm/blood ■ Asthmaexacerbation ■ COPD exacerbation ■ Anxietyattack NOTE: Thisis not an exhaustive listBreathing ■ Look:sweating, cyanosis, pursed lips, nasal flaring, useof accessory muscles, tripodposition, clear SOBBreathing ■ Look:sweating, cyanosis, pursed lips, nasal flaring, useof accessory muscles, tripodposition, clear SOB ■ Feel:tracheal deviation,chest expansionBreathing ■ Look:sweating, cyanosis, pursed lips, nasal flaring, useof accessory muscles, tripodposition, clear SOB ■ Feel:tracheal deviation,chest expansion ■ Listen:percuss, breathsoundsBreathing ■ Look:sweating, cyanosis, pursed lips, nasal flaring, useof accessory muscles, tripodposition, clear SOB ■ Feel:tracheal deviation,chest expansion ■ Listen:percuss, breathsounds ■ Measure:Breathing ■ Look:sweating, cyanosis, pursed lips, nasal flaring, useof accessory muscles, tripodposition, clear SOB ■ Feel:tracheal deviation,chest expansion ■ Listen:percuss, breathsounds ■ Measure: – SOCRAPBreathing ■ Look:sweating, cyanosis, pursed lips, nasal flaring, useof accessory muscles, tripodposition, clear SOB ■ Feel:tracheal deviation,chest expansion ■ Listen:percuss, breathsounds ■ Measure: – SOCRAP ■ Sputum sample (if required)Breathing ■ Look:sweating, cyanosis, pursed lips, nasal flaring, useof accessory muscles, tripodposition, clear SOB ■ Feel:tracheal deviation,chest expansion ■ Listen:percuss, breathsounds ■ Measure: – SOCRAP ■ Sputum sample (if required) ■ O2saturationsBreathing ■ Look:sweating, cyanosis, pursed lips, nasal flaring, useof accessory muscles, tripodposition, clear SOB ■ Feel:tracheal deviation,chest expansion ■ Listen:percuss, breathsounds ■ Measure: – SOCRAP ■ Sputum sample (if required) ■ O2saturations ■ Chest X-RayBreathing ■ Look: sweating,cyanosis, pursed lips, nasal flaring, use of accessory muscles, tripod position, clear SOB ■ Feel: tracheal deviation, chest expansion ■ Listen: percuss, breath sounds ■ Measure: – SO CRAP ■ Sputumsample (ifrequired) ■ O2saturations ■ Chest X-Ray ■ Respiratory RateBreathing ■ Look: sweating,cyanosis, pursed lips, nasal flaring, use of accessory muscles, tripod position, clear SOB ■ Feel: tracheal deviation, chest expansion ■ Listen: percuss, breath sounds ■ Measure: – SO CRAP ■ Sputumsample (ifrequired) ■ O2saturations ■ Chest X-Ray ■ Respiratory Rate ■ ABG- includes lactate andketonesBreathing ■ Lposition, clear SOBosis, pursedlips, nasalflaring, use ofaccessory muscles, tripod ■ Feel: trachealdeviation, chest expansion ■ Listen: percuss,breathsounds ■ Measure: – SO CRAP ■ Sputumsample (if required) ■ O2saturations ■ Chest X-Ray ■ Respiratory Rate ■ ABG - includes lactate andketones ■ Peakflow (ifrequired)Breathing SBA Youare assessinga 24-year-old patientwhois acutely unwell.The patientis saturating at91%. Howdo youwantto managethis? A– Ask thepatient to sit upand takedeep breaths B – Start thepatient on4L of Oxygenvia anasal cannula C– Do nothing asthesaturationsarenormal D – Start thepatient on15Lof oxygen viaaNon-Rebreather Mask E– Call ananaesthetist tointubatethepatient F – Start CPAPfor thepatientBreathing SBA Youare assessinga 24-year-old patientwhois acutely unwell.The patientis saturating at91%. Howdo youwantto managethis? A– Ask thepatient to sit upand takedeep breaths – though thiscanbe useful and canimprovesaturations,thispatient definitely needssomeoxygen youwant highflow immediately toensurethereisnohypoxia – this could work but C– Do nothing asthesaturationsarenormal – Sats <94%require supplemental oxygen D–Startthe patienton15Lofoxygen via aNon-Rebreather Mask E– Call ananaesthetist tointubatethepatient - this may beneeded further downthelinebut not immediately F – Start CPAPfor thepatient - this may beneeded further downthelinebut not immediatelyBreathing Treat:Breathing Treat: “I’d liketo start the patienton15Lof high-flowoxygenviaaNon-Rebreathermask”Breathing Treat: “I’dliketo start the patienton15Lof high-flowoxygenviaaNon-Rebreathermask” This isthemost common treatment youwill give. You may also consider giving:Breathing Treat: “I’dliketo start the patienton15Lof high-flowoxygenviaaNon-Rebreathermask” This isthemost common treatment youwill give. You may also consider giving: - Bronchodilators (e.g. salbutamol,ipratropium bromide) via a nebuliserBreathing Treat: “I’dliketo start the patienton15Lof high-flowoxygenviaaNon-Rebreathermask” This isthemost common treatment youwill give. You may also consider giving: - Bronchodilators (e.g. salbutamol,ipratropium bromide) via a nebuliser - Antibioticsif you are suspectinginfective exacerbation of COPD or pneumoniaBreathing Treat: “I’dliketo start the patienton15Lof high-flowoxygenviaaNon-Rebreathermask” This isthemost common treatment youwill give. You may also consider giving: - Bronchodilators (e.g. salbutamol,ipratropium bromide) via a nebuliser - Antibioticsif you are suspectinginfective exacerbation of COPD or pneumonia - Lower% ofoxygen via venturi mask or nasal cannulaeBreathing Treat: “I’dliketo start the patienton15Lof high-flowoxygenviaaNon-Rebreathermask” This isthemost common treatment youwill give. You may also consider giving: - Bronchodilators (e.g. salbutamol,ipratropium bromide) via a nebuliser - Antibioticsif you are suspectinginfective exacerbation of COPD or pneumonia - Lower% ofoxygen via venturi mask or nasal cannulae - Ruleof thumb- hypoxia kills first - always start highand titrate down - Onlystartlow ifyou canconfirm thepatient is a CO2 retainer - Todothis, look at theABG - if the bicarbis high, it suggests the patient is a retainerBreathing REASSESSBreathing REASSESS “Havetheoxygensaturations or respiratoryrateimproved?Istheairway still patent?” This is alwayssuper importanttoensure the intervention you have given isactually working. If the O2sats don’timprove, there could be some other issue such asthe lungs have collapsed orthe patient mayhave stoppedbreathing.Breathing REASSESS “Havetheoxygensaturations or respiratoryrateimproved?Istheairway still patent?”Breathing REASSESS “Havetheoxygensaturations or respiratoryrateimproved?Istheairway still patent?” This is alwayssuper importanttoensure the intervention you have given isactually working. If the O2sats don’timprove, there could be some other issue such asthe lungs have collapsed orthe patient mayhave stoppedbreathing.Breathing - CASE 19 y/o patientBreathing - CASE 19 y/o patient Assessment: ■ Bilateraldecreasedchestexpansion ■ Increased workofbreathingwithaccessorymuscle use ■ No trachealdeviation https://www.youtube.com/watch?v=T4qNgi4Vrvo ■ Normal resonanceonpercussion ■ Auscultationof thelungs:bilateral wheeze Listen to breath sounds ■ Respiratory rate:33breaths per minute ■ Oxygensaturation:91%breathingroomairBreathing - CASE 19 y/o patient Assessment: ■ Bilateraldecreasedchestexpansion ■ Increased workofbreathingwithaccessorymuscle use ■ No trachealdeviation https://www.youtube.com/watch?v=T4qNgi4Vrvo ■ Normal resonanceonpercussion ■ Auscultationof thelungs:bilateral wheeze Listen to breath sounds ■ Respiratory rate:33breaths per minute ■ Oxygensaturation:91%breathingroomair Investigations: ■ ABG: lowPaO2andlow PaCO2 ■ Peak expiratory flow rate(PEFR): 35% of predicted ■ PortablechestX-ray: unremarkable Whatmight begoingon?Breathing - CASE 19 y/o patient Assessment: ■ Bilateraldecreasedchestexpansion ■ Increased workofbreathingwithaccessorymuscle use ■ No trachealdeviation https://www.youtube.com/watch?v=T4qNgi4Vrvo ■ Normal resonanceonpercussion ■ Auscultationof thelungs:bilateral wheeze Listen to breath sounds ■ Respiratory rate:33breaths per minute ■ Oxygensaturation:91%breathingroomair Investigations: ■ ABG: lowPaO2andlow PaCO2 ■ Peak expiratory flow rate(PEFR): 35% of predicted ■ PortablechestX-ray: unremarkable Whatmight begoingon? Acuteexacerbationof AsthmaBreathing - CASE 19 y/o patient Assessment: ■ Bilateraldecreasedchestexpansion ■ Increased workofbreathingwithaccessorymuscle use ■ No trachealdeviation https://www.youtube.com/watch?v=T4qNgi4Vrvo ■ Normal resonanceonpercussion ■ Auscultationof thelungs:bilateral wheeze Listen to breath sounds ■ Respiratory rate:33breaths per minute ■ Oxygensaturation:91%breathingroomair Investigations: ■ ABG: lowPaO2andlow PaCO2 ■ Peak expiratory flow rate(PEFR): 35% of predicted ■ PortablechestX-ray: unremarkable Whatmight begoingon? How do you want to manage this? Acuteexacerbationof AsthmaBreathing - CASE 19 y/o patient Whatinterventions would youlike to do?Breathing - CASE 19 y/o patient Whatinterventions would youlike to do? ■ 15L high flow oxygenvia anon-rebreathermask: improves oxygen saturation to 94%Breathing - CASE 19 y/o patient Whatinterventions would youlike to do? ■ 15L high flow oxygenvia anon-rebreathermask: improves oxygen saturation to 94% ■ Nebulised salbutamol(5mg)and ipratropium (500mcg) - BURST therapy - oxygen driven: improves oxygen saturation to 98% and RR to 25/minBreathing - CASE 19 y/o patient Whatinterventions would youlike to do? ■ 15L high flow oxygenvia anon-rebreathermask: improves oxygen saturation to 94% ■ Nebulised salbutamol(5mg)and ipratropium (500mcg) - BURST therapy - oxygen driven: improves oxygen saturation to 98% and RR to 25/min ■ Call formedical registrar forsenior review and consider starting steroidtreatmentDo I haveto follow thisexact order?Do I haveto follow thisexact order? For majority of situations,yesDo I haveto follow thisexact order? For majority of situations,yes Insomesituations, youmay want to ask for certain observations/check for certainthings earlier. Forexample:Do I haveto follow thisexact order? For majority of situations,yes Insomesituations, youmay want to ask for certain observations/check for certainthings earlier For example: ■ SEPSIS- if you noticethepatient istachypnoeic, hypoxicandlooksvery unwell, youmay want to ask for abloodpressure,heart rateand temperature to quickly find out ifyour patient may beseptic – If so, youcanstart theSepsis6imminentlyDo I haveto follow thisexact order? For majority of situations,yes Insomesituations, youmay want to ask for certain observations/check for certainthings earlier For example: ■ SEPSIS- if you noticethepatient istachypnoeic, hypoxicandlooksvery unwell, youmay want to ask for abloodpressure,heart rateand temperature to quickly find out ifyour patient may beseptic – If so, youcanstart theSepsis6imminently ■ PulmonaryEmbolism/HeartFailure – If youaresuspecting either oneof thesebecauseof tachycardiaor dullness,youmay want tocheck thelegsfor signsof DVT or oedemaDo I haveto follow thisexact order? For majority of situations,yes In some situations, you may want to ask for certain observations/check for certain things earlier For example: ■ SEPSIS - if you notice the patient is tachypnoeic, hypoxic and looks very unwell, you may want to ask for a blood pressure, heart rate and temperature to quickly find out if your patient may be septic – If so, you can start the Sepsis 6 imminently ■ PulmonaryEmbolism/Heart Failure – If you are suspecting either one of these because of tachycardia or dullness, you may want to check the legs for signs of DVT or oedema thatyoudon’t miss any otherimportantthings. Somesigns canbeadistractiontothe moreimportant problem!CirculationCirculation Commonpresentationsyou may encounter:Circulation Commonpresentationsyou may encounter: ■ Chest pain ■ Tachycardia/Bradycardia ■ Hypertension/hypotension ■ Weak,absent pulses, delayed cap refill - shock ■ Irregular pulse ■ Cyanosis ■ Oliguria NOTE: Thisis not an exhaustive listCirculation Commonpresentationsyou may Commondiagnosesyoumay encounter: encounter: ■ Chest pain ■ Tachycardia/Bradycardia ■ Hypertension/hypotension ■ Weak,absent pulses, delayed cap refill - shock ■ Irregular pulse ■ Cyanosis ■ Oliguria NOTE: Thisis not an exhaustive listCirculation Commonpresentationsyou may Commondiagnosesyoumay encounter: encounter: ■ Chest pain ■ Aorticdissection ■ Tachycardia/Bradycardia ■ ACS ■ Hypertension/hypotension ■ Decompensatedheart failure ■ Weak,absent pulses, delayed ■ Brady/Tachyarrhythmias cap refill - shock ■ Atrial fibrillation ■ Irregular pulse ■ Sepsis ■ Cyanosis ■ Oliguria NOTE: Thisis not an exhaustive listCirculation ■ Look: Pallor, grey, raised JVP, sweating, flushing, mucous membranesCirculation ■ Look: Pallor, grey, raised JVP, sweating, flushing, mucous membranes ■ Feel: Temperature, pulses, clamminess, CRTCirculation ■ Look: Pallor, grey, raised JVP, sweating, flushing, mucous membranes ■ Feel: Temperature, pulses, clamminess, CRT ■ Listen: Heartsounds - murmurs, thirdheartsounds, lung bases, pericardial rubCirculation ■ Look: Pallor, grey, raised JVP, sweating, flushing, mucous membranes ■ Feel: Temperature, pulses, clamminess, CRT ■ Listen: Heartsounds - murmurs, thirdheartsounds, lung bases, pericardial rub ■ Measure: BUTCHECirculation ■ Look: Pallor, grey, raised JVP, sweating, flushing, mucous membranes ■ Feel: Temperature, pulses, clamminess, CRT ■ Listen: Heartsounds - murmurs, thirdheartsounds, lung bases, pericardial rub ■ Measure: BUTCHE BPCirculation ■ Look: Pallor, grey, raised JVP, sweating, flushing, mucous membranes ■ Feel: Temperature, pulses, clamminess, CRT ■ Listen: Heartsounds - murmurs, thirdheartsounds, lung bases, pericardial rub ■ Measure: BUTCHE BP, Urine Output,Circulation ■ Look: Pallor, grey, raised JVP, sweating, flushing, mucous membranes ■ Feel: Temperature, pulses, clamminess, CRT ■ Listen: Heartsounds - murmurs, thirdheartsounds, lung bases, pericardial rub ■ Measure: BUTCHE BP, Urine Output, Temperature,Circulation ■ Look: Pallor, grey, raised JVP, sweating, flushing, mucous membranes ■ Feel: Temperature, pulses, clamminess, CRT ■ Listen: Heartsounds - murmurs, thirdheartsounds, lung bases, pericardial rub ■ Measure: BUTCHE BP, Urine Output, Temperature, Cap Refill (<2s),Circulation ■ Look: Pallor, grey, raised JVP, sweating, flushing, mucous membranes ■ Feel: Temperature, pulses, clamminess, CRT ■ Listen: Heartsounds - murmurs, thirdheartsounds, lung bases, pericardial rub ■ Measure: BUTCHE BP, Urine Output, Temperature, Cap Refill (<2s), HR,Circulation ■ Look: Pallor, grey, raised JVP, sweating, flushing, mucous membranes ■ Feel: Temperature, pulses, clamminess, CRT ■ Listen: Heartsounds - murmurs, thirdheartsounds, lung bases, pericardial rub ■ Measure: BUTCHE BP, Urine Output, Temperature, Cap Refill (<2s), HR, ECGCirculation Feeling for pulses ■ Thiscangiveyoua lot of informationCirculation Feeling for pulses ■ Thiscangiveyoua lot of information ■ Check if it isregular/irregular ■ Check for radio-radial delay - could suggest aorticdissectionCirculation Feeling for pulses ■ Thiscangiveyoua lot of information ■ Check if it isregular/irregular ■ Check for radio-radial delay - could suggest aorticdissection ■ Check for brady/tachycardia – Along withECG – If youidentify anarrhythmia, refer to the UK Resuscitation Council AdultALSAlgorithmand get immediatesenior supportCirculation Treat:Circulation Treat: ■ 2 wide bore cannulas, 1 in each antecubital fossaCirculation Treat: ■ 2 wide bore cannulas, 1 in each antecubital fossa ■ From one take bloods - what?Circulation Treat: ■ 2 wide bore cannulas, 1 in each antecubital fossa ■ From one take bloods - what? ■ From other, give fluids: what and how much?Circulation Treat: ■ 2 wide bore cannulas, 1 in each antecubital fossa ■ From one take bloods - what? ■ From other, give fluids: what and how much? ■ Insert urinary catheter if required and not already in situ (good opportunity to also geta urinary dipstick)Circulation Treat: ■ 2 wide bore cannulas, 1 in each antecubital fossa ■ From one take bloods - what? ■ From other, give fluids: what and how much? ■ Insert urinary catheter if required and not already in situ (good opportunity to also geta urinary dipstick) WHAT COLOUR & WHAT SIZE?Circulation Treat: ■ 2 wide bore cannulas, 1 in each antecubital fossa ■ From one take bloods - what? ■ From other, give fluids: what and how much? ■ Insert urinary catheter if required and not already in situ (good opportunity to also geta urinary dipstick) WHAT COLOUR & WHAT SIZE? Coloursmay bediffer betweentrustsCirculation Bloods:Circulation Bloods: ■ FBC ■ U&Es ■ LFTs ■ Clotting ■ Blood Cultures ■ Group & Save and Crossmatch ■ LABG not requesteds if ■ Bone profile ■ TFTs ■ MagnesiumCirculation Bloods: Fluids: ■ FBC ■ U&Es ■ LFTs ■ Clotting ■ Blood Cultures ■ Group & Save and Crossmatch ■ LABG not requesteds if ■ Bone profile ■ TFTs ■ MagnesiumCirculation Bloods: Fluids: ■ FBC ■ “500mlof0.9% ■ U&Es saline/Hartmann’s innoless ■ LFTs than15 mins/STAT” ■ Clotting ■ Blood Cultures ■ Group & Save and Crossmatch ■ LABG not requesteds if ■ Bone profile ■ TFTs ■ MagnesiumCirculation Bloods: Fluids: ■ FBC ■ “500mlof0.9% ■ U&Es saline/Hartmann’s innoless ■ LFTs than15 mins/STAT” ■ Clotting ■ ONEBOLUS ■ Blood Cultures ■ Group & Save and Crossmatch ■ ABG not requestedes if ■ Bone profile ■ TFTs ■ MagnesiumCirculation Bloods: Fluids: ■ “500mlof0.9% ■ U&Es saline/Hartmann’s innoless ■ LFTs ■ CRP than15 mins/STAT” ■ Clotting ■ ONEBOLUS ■ Blood Cultures ■ You may consider giving a 250ml ■ GCrossmatche and bolus in an elderly patient ora ■ Lactate and Ketones if patientin heart failure astheyare ABG not requested at greater risk of pulmonary ■ Bone profile oedema ■ MagnesiumCirculation REASSESSCirculation REASSESS “Hasthebloodpressureor heart rateimproved?”Circulation SBA Youareassessing anacutely unwell patient inED with ablood pressureof 84/50.You have givenfour bolusesof acrystalloidfluid.Out of the following options,whichoneswould beappropriate to do? A- Giveanother bolusof fluid B - ImmediateITUreferral C- Start thepatient onvasopressors D - Consider major haemorrhageprotocol becauseyou suspect bleeding E- Wait 20 minutes to seeif theblood pressureimprovesCirculation SBA Youareassessing anacutely unwell patient inED with ablood pressureof 84/50.You have givenfour bolusesof acrystalloidfluid.Out of the following options,whichoneswould beappropriate to do? A- Giveanother bolusof fluid- youcangiveamaxof 2L of bolus B - ImmediateITUreferral- thepatient isdecompensatingandyou definitely want immediatesupport from ITU C- Start thepatient onvasopressors- though thisis definitely required,you would want to ensure youget senior input first D - Consider major haemorrhageprotocol becauseyou suspect bleeding- bleeding is amajor causeof hypotensionandit hasto beruledout or treated E- Wait 20 minutes to seeif theblood pressureimproves- this isvery dangerous and could causethepatient todeteriorate furtherCirculation REASSESS “Hasthebloodpressureor heart rateimproved?” If the patient is still hypotensive: ■ Youcan giveup to 4 boluses - amaximum of2L ■ Consider themajor haemorrhageprotocol ifyoususpect bleeding ■ Consider ITUsupport Circulation - CASE 59 y/o patient Onassessment ■ Clammy peripheries ■ Radial pulserate:100bpm and regular ■ Blood pressure:155/117mmHg ■ Capillary refill time:3 seconds ■ Patient complains ofpain andappears pale ■ No peripheral oedema ■ Fluid balance:not being monitoredas thepatient isnot aninpatient; no catheter in-situ orIV fluids Circulation - CASE 59 y/o patient Onassessment Investigations/Interventions ■ Clammy peripheries ■ ECG ~ showswidespreadT waveflattening/inversion. ■ Radial pulserate:100bpm and regular Thereis also 1mmSTdepressioninleadsI,II, III, V4, V5, and V6 ■ Blood pressure:155/117mmHg ■ Capillary refill time:3 seconds ■ Patient complains ofpain andappears pale ■ No peripheral oedema ■ Fluid balance:not being monitoredas thepatient isnot aninpatient; no catheter in-situ orIV fluids Circulation - CASE 59 y/o patient Onassessment Investigations/Interventions ■ ECG ~ showswidespreadT waveflattening/inversion. ■ Clammy peripheries ■ Radial pulserate:100bpm and regular Thereis also 1mmSTdepressioninleadsI,II, III, V4, ■ Blood pressure:155/117mmHg V5, and V6 ■ Capillary refill time:3 seconds ■ Intravenous cannulation(twowide-borecannulae- 14G/16G) ■ Patient complains ofpain andappears ■ Blood tests:Serialhighsensitivitytroponin, FBC, pale U&Es,LFTs, CRP, serum glucose,coagulationscreen ~ troponinT levelis96 ng/L(<14) ■ No peripheral oedema ■ Fluid balance:not being monitoredas thepatient isnot aninpatient; no catheter in-situ orIV fluids Circulation - CASE 59 y/o patient Onassessment Investigations ■ Clammyperipheries ■ ECG ~ showswidespread Twave flattening/inversion. Thereis also 1mm ST ■ Radial pulserate:110bpm and regular depressioninleads I, II, III, V4, V5, and V6 ■ Blood pressure: 155/117mmHg ■ Intravenous cannulation(twowide-borecannula- ■ Capillary refill time:3 seconds 14G/16G) ■ Patient complains of pain and appears ■ Blood tests:Serialhighsensitivitytroponin, FBC, pale U&Es,LFTs, CRP, serum glucose,coagulationscreen ■ No peripheral oedema ~ troponin Tlevel is96ng/L(<14) ■ Fluid balance:not being monitoredas thepatient isnot aninpatient; no Initialthoughts?ACS catheter in-situ orIV fluids Nextsteps?Circulation - CASE 59 y/o patient Interventions?Circulation - CASE 59 y/o patient Interventions? ■ Morphine 5mg IV ■ Nitrates such asGTN aspatientisnothypotensive ■ Aspirin 300mg ■ Oxygenif requiredCirculation - CASE 59 y/o patient Interventions? ■ Morphine 5mg IV ■ Nitrates such asGTN aspatientisnothypotensive ■ Aspirin 300mg ■ Oxygenif required ■ Immediate referraltocardiology forassessment of GRACE scoringand decision regarding PCI ■ Diuretics are not indicated asthere are no signs of pulmonary oedema ■ Fluidresuscitation notindicatedas the patientisnot hypovolaemicDisabilityDisability ■ Split into three partsDisability ■ Split into three parts ■ Pupils – Are they equal and reactive to light?Disability ■ Split into three parts ■ Pupils – Are they equal and reactive to light? ■ Pinpoint could suggest opiateoverdose ■ Dilated could suggest increased intracranialpressure – this isnot something that is easily prescribed asa junior doctor, and in themeantime you may consider giving hypertonic saline. If youarein this situation, you should always ensureto get senior supportand ITU/HDU involvement.Disability ■ Split into three parts ■ Pupils – Are they equal and reactive to light? ■ Pinpoint could suggest opiateoverdose ■ Dilated could suggest increased intracranialpressure – this isnot something that is easily prescribed asa junior doctor, and in themeantime you may consider giving hypertonic saline. If youarein this situation, you should always ensureto get senior supportand ITU/HDU involvement. ■ Glucose – What is the patient’s Capillary BloodGlucose (CBG)?Disability ■ Split into three parts ■ Pupils – Are they equal and reactive to light? ■ Pinpoint could suggest opiateoverdose ■ Dilated could suggest increased intracranialpressure – In thiscase you may want to consider giving mannitol. However, this isnot something that is easily prescribed asa junior doctor, and in themeantime you may consider giving hypertonic saline. supportand ITU/HDU involvement. should always ensureto get senior ■ Glucose – What is the patient’s Capillary BloodGlucose (CBG)? ■ Hyperglycaemia could suggest the patient is in DKA or HHS ■ Hypoglycaemia isa common cause of confusion and can mimic a strokeDisability ■ Split into three parts ■ Pupils – Are they equal and reactive to light? ■ Pinpoint could suggest opiateoverdose ■ Dilated could suggest increased intracranialpressure – this isnot something that is easily prescribed asa junior doctor, and in themeantime you may consider giving hypertonic saline. If youarein this situation, you should always ensureto get senior supportand ITU/HDU involvement. ■ Glucose – What is the patient’s Capillary BloodGlucose (CBG)? ■ Hyperglycaemia could suggest the patient is in DKA or HHS ■ Hypoglycaemia isa common cause of confusion and can mimic a stroke ■ AVPU/GCS – What is the patient’s AVPU/GCS?Disability ■ Split into three parts ■ Pupils – Are they equal and reactive to light? ■ Pinpoint could suggest opiateoverdose ■ Dilated could suggest increased intracranialpressure – In thiscase you may want to consider giving mannitol. However, this isnot something that is easily prescribed asa junior doctor, If youarein this situation, you should always ensureto get senior supportand ITU/HDU involvement. ■ Glucose – What is the patient’s Capillary BloodGlucose (CBG)? ■ Hyperglycaemia could suggest the patient is in DKA or HHS ■ Hypoglycaemia isa common cause of confusion and can mimic a stroke ■ AVPU/GCS – What is the patient’s AVPU/GCS? ■ P → GCSof8 - requires immediate anaestheticinterventionDisability REASSESSDisability REASSESS “Hastherebeenany changes?CanIget arepeat set of observations?” Disability - CASE Situation ■ 73-year-old found unresponsive on the medical ward by a nurse ■ Reason for admission: cellulitis- now resolved - delayed discharge due to housingissues ■ Past medical history: hypertension, hypercholesterolaemia, type 2 diabetes (on insulin) Disability - CASE Situation ■ 73-year-old found unresponsive on the medical ward by a nurse ■ Reason for admission: cellulitis- now resolved - delayed discharge due to housingissues ■ Past medical history: hypertension, hypercholesterolaemia, type 2 diabetes (on insulin) Assessment ■ AVPU:responds to painful stimulus (groaning) ■ Pupils: equal and reactive 3mmbilaterally ■ Capillary blood glucose:1.9mmol/L ■ Ketones:not present What do you thinkis happening? Disability - CASE Situation ■ 73-year-old found unresponsive on the medical ward by a nurse ■ Reason for admission: cellulitis- now resolved - delayed discharge due to housingissues ■ Past medical history: hypertension, hypercholesterolaemia, type 2 diabetes (on insulin) Assessment ■ AVPU:responds to painful stimulus (groaning) ■ Pupils: equal and reactive 3mmbilaterally ■ Capillary blood glucose:1.9mmol/L ■ Ketones:not present What do you thinkis happening? Hypoglycaemic attackDisability - CASE Whatinterventions would youlike to give?Disability - CASE Whatinterventions would youlike to give? ■ IVdextrose 10%or20%: improvescapillary blood glucose to 4.2, improves the level of consciousness (responding to verbal stimulus)Disability - CASE Whatinterventions would youlike to give? ■ IVdextrose 10%or20%: improvescapillary blood glucose to 4.2, improves the level of consciousness (responding to verbal stimulus) ■ 2222callfor ITU/anaestheticsupport in case you require a definitive airwayEverything Else and SBAREverything Else ■ Fully expose the patient and perform a top to toe examination – Remember to always respect the patient’s dignityEverything Else ■ Fully expose the patient and perform a top to toe examination – Remember to always respect the patient’s dignity ■ Look: Jaundice, oedema, bleeding, bruising ■ Assess for DVTEverything Else ■ Fully expose the patient and perform a top to toe examination – Remember to always respect the patient’s dignity ■ Look: Jaundice, oedema, bleeding, bruising ■ Assess for DVT ■ Abdominal examination – Look for fullness and tenderness to see if there could be any abdominal bleeding – Consider PR examEverything Else ■ Fully expose the patient and perform a top to toe examination – Remember to always respect the patient’s dignity ■ Look: Jaundice, oedema, bleeding, bruising ■ Assess for DVT ■ Abdominal examination – Look for fullness and tenderness to see if there could be any abdominal bleeding – Consider PR exam ■ SBAR - handover ■ FULL REASSESSMENTSBAR HandoverSBAR Handover SBAR Handover Example SBAR Handover: ■ Situation: 64-year-oldwith chestpainonthe surgical wardand suspectedpulmonary embolism ■ Background: hemiarthroplasty three days ago followingfracturedneck of femur ■ Assessment: ○ Airway:patent ○ Breathing: RR22, SpO2 93%on arrival - improvedto97%with2Loxygen, respiratory examotherwise unremarkable ○ Circulation: chestpain, pulse 126regular, BP 141/92. ECG - sinustachycardia ○ Disability: alert, capillary glucose 5.4, PEARL ○ Exposure: leftcalf appearserythematous and swollen, andistenderonpalpation. Temperature 37.2oC ■ Recommendation: ○ Diagnosis: suspectedpulmonaryembolism ○ Anticoagulation +analgesia ■ Response &review: ○ Urgentseniormedical review (e.g. registrar) ○ Arrange urgentCTPAand monitorvital signsTips for SBAR ■ What is goingtobring theregistrar,surgeon,consultant etc.toyouthe quickest? – You shouldalways say immediately what the problem is. ■ “I have apatient with suspected…” – Whoever you are callingneedsto know why yourpatientshould be their immediate priorityTips for SBAR ■ What is goingtobring theregistrar,surgeon,consultant etc.toyouthe quickest? – You shouldalways say immediately what the problem is. ■ “I have apatient with suspected…” – Whoever you are callingneedsto know why yourpatientshould be their immediate priority ■ Give a quick summary of who the patientis, anyrelevantbackground ■ Give a quick summary of yourA-E assessment and any interventions you have givenTips for SBAR ■ What is goingtobring theregistrar,surgeon,consultant etc.toyouthe quickest? – You shouldalways say immediately what the problem is. ■ “I have apatient with suspected…” – Whoever you are callingneedsto know why yourpatientshould be their immediate priority ■ Give a quick summary of who the patientis, anyrelevantbackground ■ Give a quick summary of yourA-E assessment and any interventions you have given ■ Tell them whatyou have already done/requested ■ “Isthere anythingelse youwould like me todointhe meantime?”Completing your assessment How to complete your examination?Completing your assessment How to complete your examination? ■ Do afull reassessment from airway throughto exposureCompleting your assessment How to complete your examination? ■ Do afull reassessment from airway throughto exposure ■ Updateany relevant drug and fluid chartsCompleting your assessment How to complete your examination? ■ Do afull reassessment from airway throughto exposure ■ Updateany relevant drug and fluid charts ■ Document your examinationand any interventionsCompleting your assessment How to complete your examination? ■ Do afull reassessment from airway throughto exposure ■ Updateany relevant drug and fluid charts ■ Document your examinationand any interventions ■ Contact relevant wards,theatres orITU as appropriate ■ Contact family/next of kinCompleting your assessment How to complete your examination? ■ Do afull reassessment from airway throughto exposure ■ Updateany relevant drug and fluid charts ■ Document your examinationand any interventions ■ Contact relevant wards,theatres orITU as appropriate ■ Contact family/next of kin Inanexam setting,it isimportant tostate that youwould liketo do all ofthese thingsto show good practiceasa doctorCommon Acute Presentations Thisisnot anexhaustivelist: ■ Anaphylaxis ■ Stroke/intracranial bleed ■ Sepsis ■ Heart failure ■ Asthmaexacerbation ■ Atrial fibrillation ■ COPD exacerbation ■ Tachycardia ■ Pneumonia ■ GIbleeding ■ Pulmonary Embolism ■ DiabeticKetoacidosis ■ Opiateoverdose ■ Hyperglycaemic ■ Anxietyattack hyperosmolar state ■ Pneumothorax ■ Hypoglycaemia ■ ACS ■ SeizuresSummary ■ TheDRABCDEalgorithm is an important assessment inacutely unwell patients ■ Usethestructureof Look,Feel, Listen, Measure,Treat, Reassessto get a comprehensiveassessment of the patient ■ Look out for red flagsduringyour assessment to quickly identify thingslike sepsis etc. ■ AlwaysREASSESSafter eachstep to ensurenothing haschanged and your interventionsareactually working ■ Alwayscall forhelp andgetseniorsupportatanappropriatetime ■ UsetheSBARmethodtoefficiently handovertosenior teams THANKS FOR WATCHING! Tutor 2:AnirudhManivannan Reviewed by DhivyaIlangovan Pleasefill out thefeedback form on Medall and seeyounext week!