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REVIEWING UNWELL PATIENTS PART A CARI O’ROURKE & JULIETTE SCRIVENObjectives ◦ To understand the structure of the on-call shift and the role of the on-call F1. ◦ To develop a structured approach to reviewing deteriorating patients using the ABCDE framework. ◦ To practise applying the ABCDE framework to common clinical scenarios, and to consider the appropriate assessment, investigations and management of these conditions.STRUCTURE OF ON-CALL SHIFTSOVERVIEW OF SHIFT F1 shifts include: 1) Day, 2) On-call, 3) Night, 4) Take/Post-take 0800 Day Team 1700 On-call Team 0000 Night Team 0800 On-call shifts are for completing clinically urgent tasks that cannot wait until the next day Answer bleeps and complete Collect bleep tasks Return bleep Receive Handover to handover from Night Team Day TeamROLES AND RESPONSIBILITIES Tasks for On-call Team Tasks for Day Team • Reviewing and managing acutely unwell patients • Reviewing stable patients • Inserting cannulas or catheters • Discharging patients • Requesting or reviewing urgent investigations • Requesting or reviewing non-urgent • Prescribing or changing urgent* medications investigations • Clerking new patients • Prescribing or changing non-urgent medications • Updating acutely unwell patients and their • Clerking new patients relatives • Updating stable patients and their relatives • Miscellaneous • MiscellaneousREVIEWIN G UNWELL PATIENTS GENERALAPPROACH 1. Receive handover 2. Review observations (and eyeball at patient) – if concerning, skip to Step 4 3. Review medical notes, drug chart, and available results 4. Assess patient – ABCDE framework 5. Formulate impression and management plan 6. Implement management plan 7. Escalate or handover 8. Document ABCDE APPROACH Examination Examination Examination Examination Examination • RR and • Patent SpO2 • HR and BP • GCS • Abdomen • Protected • Chest sounds • Pulse • Pupils • Calves Interventions • Heart sounds • Glucose • Signs of Interventions Interventions • Temperature bleeding • Airway • ABG adjuncts • COVID swab • ECG Interventions Interventions • Suction • Bloods • Medications • Medications • CXRCOMMON PRESENTATIONSSCENARIO 1 BLEEP FROM WARD 9 NURSING STAFF: “Doctor, Mr Chen in bed 7 has become really short of breath, please can you come review?” SCENARIO 1 What is their hospital number/full name/dob/ward and bed number? What are his observations/NEWS score? Do they look unwell/are you worried? Are they on oxygen? What have they come into hospital for? Do they have any other medical conditions? SCENARIO 1 What is their hospital number/full name/dob/ward and bed number? …. What are his observations/NEWS score? NEWS 10 RR 30, SpO2 81% on air, BP 98/55, HR 101, confused, Temp 38.4 Do they look unwell/are you worried? Yes, please come now Are they on oxygen? I’ve put them on 15L non-rebreathe mask What have they come into hospital for? admitted for SOB, cough and confusion for 3 days Do they have any other medical conditions? COPD, HTN, T2DM SCENARIO 1 What is their hospital number/full name/dob/ward and Follow up questions: bed number? ….71 yr old 1. What are his sats doing now? do we know if What are his observations/NEWS score? NEWS 10 he’s a retainer? RR 30, SpO2 81% on air, BP 98/55, HR 101, confused, 2. What are his meds? any antibiotics? Temp 38.4 3. Is he passing urine/does he have a catheter Do they look unwell/are you worried? Yes, please come in? now 4. What’s his TEP/RESPECT status? Are they on oxygen? I’ve put them on 15L non-rebreathe mask What have they come into hospital for? admitted for SOB, cough and confusion for 3 days Do they have any other medical conditions? COPD, HTN, T2DM SCENARIO 1 What is their hospital number/full name/dob/ward and Follow up questions: bed number? ….71yr old 1. What are his sats doing now? know if he’s a What are his observations/NEWS score? NEWS 10 retainer? RR 30, SpO2 81% on air, BP 98/55, HR 101, Sats are now 96% on 15L, don’t know if he’s a confused, Temp 38.4 retainer 2. What are his meds? any antibiotics? Do they look unwell/are you worried? Yes, please come now Ramipril 2.5mg OD, Inhalers. Are they on oxygen? I’ve put them on 15L He’s had 1 dose of oral doxycycline for ?pneumonia non-rebreathe mask 3. Is he passing urine/have a catheter? He does have a catheter. Haven’t been What have they come into hospital for? admitted for measuring it accurately but not passed much SOB, cough and confusion for 3 days 4. What’s his TEP/RESPECT status? not for Do they have any other medical conditions? COPD, HTN, T2DM CPR but for all other treatment escalationSCENARIO 1 What can the nurses do whilst you’re on your way?SCENARIO 1 What can the nurses do whilst you’re on your way? 1. Please could you put a wide bore cannula in and take some bloods, blood cultures, VBG and an ECG off him please whilst I make my way up 2. Could you prepare a 500ml bag of 0.9% saline and give some IV paracetamol 3. +/- could you also bleep to ask the med reg to come review? SCENARIO 1 What are you thinking whilst you’re on your way there? 1. Possible differentials? 2. Other investigations that might be helpful? SCENARIO 1 What are you thinking whilst you’re on your way there? 1. Possible differentials? i. worsening pneumonia? escalate antibiotics/sepsis 6 ii. PE? need to check calves/if on VTE prophylaxis/other RF iii. pulmonary oedema? any heart failure history, other signs? 2. Other investigations that might be helpful? i. ABG, CXR, MSU, CBG SCENARIO 1 History from nurse/notes: Examination: ○ 3 days of SOB, cough, fever and ○ NEWS 8: RR 25, SpO2 97% on 15L, BP 89/54, HR 99, confused, Temp 37.9 confusion before coming to hospital ○ Gradually become more breathless over ○ A – Patent today, last did his obs 4hrs ago and his sats were borderline but now he’s a lot ○ B – Increased WOB. Focal crackles on L side of more breathless chest ○ C – Pulse irregular, weak volume. HR 99. HS History from patient: ○ Confused- 0/4 for AMT4 normal. Hot to touch, sweaty but cold peripherally ○ unable to give any history ○ D – Confused but alert, CBG 9.1 ○ E - Abdo soft, non-tender. BS present. Calves SNT. SCENARIO 1 Investigations: ◦ ECG – ◦ VBG – Na 135 (N) K 3.5 (N) Hb 112 (L) bicarb 24 (N) CO2 7.2 (H) PaO2 5.4 (L) pH 7.31 (L) lactate 4.5 (H) https://litfl.com/atrial-fibrillation-ecg-library/ SCENARIO 1 Investigations: ◦ ECG – atrial fibrillation ◦ VBG – Na 135 (N) K 3.5 (N) Hb 112 (L) bicarb 24 (N) CO2 7.2 (H) PaO2 5.4 (L) pH 7.31 (L) lactate 4.5 (H) https://litfl.com/atrial-fibrillation-ecg-library/ SCENARIO 1 What do you do next whilst awaiting senior review? Impression: Plan: SCENARIO 1 What do you do next whilst awaiting senior review? Impression: 1. Respiratory sepsis- worsening of left sided pneumonia 2. New AF likely secondary to sepsis Plan: 1. IV fluid bolus 500ml 0.9% saline over 15mins 2. Escalate antibiotics as per local micro guidelines 3. Accurate hourly fluid input/output 4. ABG + CXR 5. Chase bloods, blood cultures- already sent by nurse 6. Hold ramipril due to AKI risk 7. Senior review 8. Escalate if any concerns of deterioration prior to re-review - bleep 2385 SCENARIO 1 Re-review following fluid bolus: - NEWS 3- RR 19, sats 97% on 10L, BP 110/80, HR 79, temp 37.6 - O/E: - A: patent - B: ongoing L sided crackles but improved WoB - C: warmer peripherally, ongoing dry mucous membranes, HS normal, pulse regular, urine output- around 10mls since last review 30mins ago - D: ongoing confusion but alert - E: Abdo SNT -ABG: pH 7.33, lactate 2.8, pCO2 4.5 (4.5-6), pO2 10 (10-14), HCO3 22 (22-26), anion gap- high On admission Today https://radiopaedia.org/cases/left-lower-lobe-pneumonia-10 https://www.sciencephoto.com/media/447332/view/pneumonia-x-ray SCENARIO 1- summary Impression: 1. Improving respiratory sepsis with resolution of AF 2. Ongoing hypovolaemia Plan: 1. Further IV fluids: 1L over 4hrs then review 2. Continue IV antibiotics + IV paracetamol 3. Accurate fluid balance 4. Wean O2 to aim for sats >94% 5. Re-review and repeat VBG in 2hrs 6. Escalate if any concerns in interim - bleep 2385 7. Update NOKSCENARIO 2 Job handed over by day team on Ward 7 - “please chase bloods” “Please chase bloods for Miss Williams, she was accidentally missed off the phlebotomy round this morning so I’ve just sent the bloods. I’m going home now.”SCENARIO 2 What is her hospital number/full name/dob/ward and bed number? When and why was she admitted? What are is her current management? Does she have any other medical conditions? What would you like me to look out for on her bloods? Are you worried about her? When were the bloods sent (so you know roughly when to look out for them?)SCENARIO 2 What is her hospital number/full name/dob/ward and bed number? 53F When and why was she admitted? Admitted yesterday with 3 day history of severe N&V. What are is her current management? WCC was normal so we’re treating this as viral gastroenteritis and she’s not on antibiotics. Bloods showed she she was a bit dehydrated with a mild AKI so we’re giving her some IV fluids. Does she have any other medical conditions? HTN, GORD What would you like me to look out for on her bloods? Are you worried about her? Please can you review her U&Es and check her renal function is improving with the fluids. Not very worried. When were the bloods sent (so you know roughly when to look out for them?) - 5pmSCENARIO 2 What is her hospital number/full name/dob/ward and bed number? 53F Follow up questions: When and why was she admitted? Admitted yesterday with 3 day 1. Regular medications - if she history of severe N&V. has an AKI, D.A.M.N. drugs should be held (diuretics, What are is her current management? WCC was normal so we’re treating this as viral gastroenteritis and she’s not on antibiotics. ACEi/ARA, metformin, NSAIDs) Bloods showed she she was a bit dehydrated with a mild AKI so 2. What fluids is she on? Does we’re giving her some IV fluids. she need a fluid review with Does she have any other medical conditions? HTN, GORD further fluid prescription as What would you like me to look out for on her bloods? Are you well? worried about her? Please can you review her U&Es and check 3. Is she passing urine? her renal function is improving with the fluids. Not very worried. When were the bloods sent (so you know roughly when to look out for them?) - 5pmSCENARIO 2 6.30pm: bloods are reported WCC 9.8 Na 134 Hb 125 K 6.9 INR 1.0 Urea 16.7 LFT - NAD Creatinine 384 CRP 7 eGFR 14SCENARIO 2 6.30pm: bloods are reported What do you do next? WCC 9.8 Na 134 Hb 125 K 6.9 INR 1.0 Urea 16.7 LFT - NAD Creatinine 384 CRP 7 (155 yesterday, baseline 90) eGFR 14SCENARIO 2 6.30pm: bloods are reported What do you do next? 1. ABCDE WCC 9.8 Na 134 2. ECG & VBG Hb 125 K 6.9 3. Look up trust protocol for INR 1.0 hyperkalaemia Urea 16.7 4. Escalate to medical reg on call - Creatinine 384 LFT - NAD SBAR, are you happy for me to CRP 7 (155 yesterday, baseline 90) start xyz for ?K eGFR 14SCENARIO 2 You go straight to ward 7 & ask for an ECG & VBG. Perform ABCDE while nurse looks for ECG machine. NEWS = 4: RR 22, SpO2 98% on air, BP 98/63, HR 111, Alert, Temp 36.3. A – Patent and maintained B – Chest clear C – Dry mucous membranes. Cool peripherally. CRT 5 secs. Pulse regular. HS normal. 1x cannula in situ. D – GCS 15. PEARL. BM 4.7. E – Abdomen soft and mildly tender. Calves SNT. No oedema/erythema. VBG: pH 7.31, pO2 13, pCO2 3.8, K 6.9, bicarb 13, BE -8, normal anion gapImages:Images:Call senior Call senior SCENARIO 2 - summary Impression: 1. Hyperkalaemia secondary to acute renal failure, with associated metabolic acidosis 2. AKI-3 3. Dehydration Plan: 1. After discussion with senior: calcium gluconate, insulin-dex 2. Recheck VBG K post-treatment and repeat if needed 3. IV bicarbonate as per guideline (acidosis further drives ↑ K) 4. IV fluids - normal saline or dextrose, not Hartmann’s as this contains K 5. Consider lokelma - local policies 6. HO to night team to repeat VBG at 9pm to check for recurrence of hyperkalaemia SCENARIO 3 BLEEP FROM NURSE ON WARD 4: “Doctor, this patient’s just coughed up loads of brown grainy stuff, please come review?” SCENARIO 3 What is their hospital number/full name/dob/ward and bed number? What are his observations/NEWS score? Do they look unwell/are you worried? Has it only happened once? when did it happen? have they opened their bowels today? What have they come into hospital for? Do they have any other medical conditions? SCENARIO 3 What is their hospital number/full name/dob/ward and bed number? 67 yr old What are his observations/NEWS score? NEWS 10 RR 30, SpO2 95% on air, BP 67/43, HR 125, Confused, Temp 37.7 Do they look unwell/are you worried? Yes, please come quickly Has it only happened once? when did it happen? have they opened their bowels today? some really smelly dark tarry stoolsnutes. He’s also just opened his bowels and had What have they come into hospital for? Came into hospital due to a fall Do they have any other medical conditions? HTN, MI, T2DM, Heart failure, OA. SCENARIO 3 What is their hospital number/full name/dob/ward and bed number? 67 yr old Follow up questions? What are his observations/NEWS score? NEWS 10 1. Has he got a cannula in situ? 2. Do we know his alcohol history? Temp 37.6O2 95% on air, BP 67/43, HR 125, Confused, 3. What medication is he on? Do they look unwell/are you worried? Yes, please come 4. What’s his CPR/RESPECT status? quickly Has it only happened once? when did it happen? have the last 5minutes. He’s also just opened his bowels and had some really smelly dark tarry stools What have they come into hospital for? Came into hospital due to a fall Do they have any other medical conditions? HTN, MI, T2DM, Heart failure, OA. SCENARIO 3 What is their hospital number/full name/dob/ward and bed Follow up questions? number? 67yr old What are his observations/NEWS score? NEWS 10 1. Has he got a cannula in situ? yes 1 blue cannula Temp 37.6O2 95% on air, BP 67/43, HR 125, Confused, 2. Do we know his alcohol history? Do they look unwell/are you worrieYes, please come says drinks 10 units a week on his quickly Has it only happened once? when did it happen? have clerk in they opened their bowels today? No it happened twice in 3. What medication is he on? the last 5minutes. He’s also just opened his bowels and Metformin, Lisinopril, Atenolol, had some really smelly dark tarry stools What have they come into hospital for? Came into hospital Furosemide, Dapagliflozin, and OTC due to a fall naproxen Do they have any other medical conditionHTN, MI, 4. What’s his CPR/RESPECT status? T2DM, Heart failure, OA. for CPRSCENARIO 3 What can the nurses do whilst you’re on your way?SCENARIO 3 What can the nurses do whilst you’re on your way? 1. Please could you put in another two wide bore cannulas if you can and start a 500ml bolus of 0.9% saline 2. Please could we get an ECG, bloods including a G+S/clotting and VBG 3. Please could you fast-bleep the med reg/if any concern that he’s worsening before I get there please put out a peri-arrestSCENARIO 3 1. Possible differentials?st you’re on your way there? 2. What are the urgent things to do?SCENARIO 3 What are you thinking whilst you’re on your way there? 1. Possible differentials? i. Upper GI bleed→ major haemorrhage protocol ii. Other source of bleeding?- GI/injury from the fall? 2. What are the urgent things to do when you get there? i. Get IV access and start fluids, ii. Get senior input asap ?need major haemorrhage protocol SCENARIO 3 History from the nurse: ◦ HPC – 67yr old admitted due to a fall 2 days ago, had x3 coffee ground vomits in last 10minutes. No fever/cough/SOB/urinary or bowel changes. 10 units of alcohol a week. Has been taking lots of naproxen recently due to bad hip OA History from the patient: ◦ Confused, not orientated to place, time or person ◦ Reports some epigastric tenderness Examination ◦ NEWS 9: RR 29, SpO2 96% on air, BP 70/53 post bolus, HR 120, Confused, Temp 37.6. ◦ A – Patent ◦ B – Chest clear ◦ C – Pale. Cool peripheries. CRT 4 secs. Pulse regular, thready. HR 120. HS normal. ◦ D – GCS 14. PEARL CBG 5.5. ◦ E - Abdo soft, epigastric tenderness. Calves SNT. No erythema/oedema. Scenario 3 Investigations: ECG: VBG: pH 7.41 Hb 56 Lactate 2.1 Na 130 K 4.5 sinus-tachycardia-ecg-library Scenario 3 Investigations: ECG: sinus tachycardia VBG: pH 7.41 Hb 56 Lactate 2.1 Na 130 K 4.5 sinus-tachycardia-ecg-library SCENARIO 3 Your senior is on their way, what do you want to do whilst your waiting? Impression: Plan: SCENARIO 3 Your senior is on their way, what do you want to do whilst your waiting? Impression: 1. Upper GI bleed a. likely secondary to naproxen use: b. haemodynamically unstable Plan: 1. 2 wide bore cannulas in situ 2. Further IV fluid bolus 500ml over 15mins 3. Activate major haemorrhage protocol under senior guidance 4. NBM 5. IV omeprazole - based on local guidelines 6. PR exam to look for melena 7. Catheter for strict input/output 8. Chase formal bloods 9. Hold all medication: dapagliflozin, lisinopril, atenolol, naproxen, metformin, furosemide SCENARIO 3 Major haemorrhage protocol: ❖ Activated in patients who are hemodynamically unstable secondary to blood loss ❖ You need to know: hospital number, name, DOB, location ❖ MHP will have readily available bundles: eg initial pack might have 4 units RBC (would give group O blood if need immediately/unknown blood type) ❖ In some hospitals, MHP doesn’t necessarily mean seniors alerted, just means you get a porter with blood (check in your induction in your local hospital) Other things in major haemorrhage: ❖ Anticoagulation reversal required in some: PCC in warfarin- guided by haematology ❖ Terlipressin/ciprofloxacin if variceal bleed (consultant decision) ❖ OGD if not too frail- immediately once resuscitated unstable patients, within 24h for othersSummaryKey Learning Points ◦ On-call shifts are for completing clinically urgent tasks that cannot wait until the next day ◦ Before you start work, find out all the key information that will help you in your on-call shifts, including: ◦ Structure of the shift – hours, wards to cover, handover location ◦ How to send and answer bleeps ◦ Seniors – names and bleeps ◦ Trust guidelines for common conditions (eg. DKA, hyperkalaemia, VRII) ◦ Download useful apps - BNF, Pocket/Smart Doctor, Rx Guidelines, Induction, MDCalc, MyShiftPlanner ◦ Use the SBAR framework to help you to give and receive effective handovers ◦ Make an organised jobs list to help you to prioritise your tasks in order of clinical urgency ◦ Familiarise yourself with common prescriptions ◦ Always use the ABCDE approach to review acutely unwell patients ◦ Most importantly, ALWAYS look after yourself!!Questions