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REVIEWING UNWELL PATIENTS PART B Bassant Abdelfadeel AND Amitoj HeerObjectives ◦ 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 • MiscellaneousON-CALL SKILLS ◦ Use the SBAR framework to help you to give ISBAR and receive effective handovers ◦ Familiarise yourself with how to actually send I Introduction and answer bleeps at your Trust S Situation ◦ Make an organised jobs list to help you to prioritise your tasks in order of clinical urgency Background A Assessment ◦ If in doubt, ASK FOR HELP! R RecommendationREVIEWIN G UNWELL PATIENTS GENERALAPPROACH 1. Receive handover 2. Review observations (and look 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 • Patent • Protected Interventions • ABCDE APPROACH Examination • Patent • Protected Interventions • Oxygen • Aadjuncts ABCDE APPROACH Examination • Patent Examination • RR and • Protected SpO2 Interventions • Chest sounds • Oxygen Interventions • Airway adjuncts • ABCDE APPROACH Examination Examination • RR and • Patent SpO2 • Protected • Chest sounds Interventions Interventions • Oxygen • ABG • Airway adjuncts • COVID swab • CXR ABCDE APPROACH Examination Examination • RR and Examination • Patent SpO2 • HR and BP • Protected • Chest sounds • Pulse Interventions Interventions • Heart sounds • Oxygen • ABG Interventions • Airway • COVID swab • adjuncts • CXR ABCDE APPROACH Examination Examination Examination • RR and • Patent SpO2 • HR and BP • Protected • Chest sounds • Pulse Interventions • Heart sounds Interventions Interventions • Oxygen • ABG • Airway • COVID swab • ECG adjuncts • Bloods • CXR ABCDE APPROACH Examination Examination Examination Examination • RR and • Patent SpO2 • HR and BP • GCS • Protected • Chest sounds • Pulse • Pupils Interventions • Heart sounds • Glucose Interventions Interventions • Temperature • Oxygen • ABG • Airway • COVID swab • ECG Interventions adjuncts • Bloods • • CXR ABCDE APPROACH Examination Examination Examination Examination • RR and • Patent SpO2 • HR and BP • GCS • Protected • Chest sounds • Pulse • Pupils Interventions • Heart sounds • Glucose Interventions Interventions • Temperature • Oxygen • ABG • Airway • COVID swab • ECG Interventions adjuncts • Bloods • Medications • CXR 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 • Oxygen • ABG • Airway • COVID swab • ECG Interventions Interventions adjuncts • Bloods • Medications • Medications • CXRCOMMON PRESENTAT IONS SCENARIO 1 *Dialing 37483* … … … Nurse: Hello, this is SAU. You: Hello, this is Fran, the F1 cover doctor. How can I help? 37 483 Nurse: Hi doctor, I have a patient here who is NEWSing a 12, please can you come and review him?SCENARIO 1 Mr Singh is a 67 year old man who is D2 post-cholecystectomy. Observations: ◦ NEWS 12: RR 25, SpO2 98% on 10L via mask, HR 120, BP 90/50, Temp 38.3, Confused History: ◦ HPC – Unable to give detailed history. New cough and SOB. No chest pain/dysuria/bowel changes. ◦ PMH – HTN, MI, T2DM, Heart failure, OA. ◦ DHx – Multiple medications ◦ SHx – Lives alone. Non-smoker. No alcohol. Investigations: ◦ Bloods – eGFR 86, CRP 112, Na 134, K 4.1, Creatinine 76, INR 1.0, WCC 12.4, Hb 125.SCENARIO 1 EXAMINATION INTERVENTIONS Observations None required • RR 25 • SpO2 98% on 10L O2 via mask Inspection • Able to talk in full sentences • No audible wheeze or stridorSCENARIO 1 EXAMINATION INTERVENTIONS Observations Bedside • RR 25 • Titrate O2 • SpO2 98% on 10L O2 via mask • ?ABG Inspection • COVID swab • No audible wheeze or stridor Imaging Palpation • CXR • No tracheal deviation Percussion • Dullness in right lower zone Auscultation • Crackles in right lower zoneSCENARIO 1 EXAMINATION INTERVENTIONS Observations Bedside • HR 120 • 12 lead ECG • BP 90/50 Bloods Inspection • Cannula • Dry mucous membranes • FBC, U+Es, CRP Palpation • Blood cultures • Peripherally cold • ?VBG • Pulse: tachycardic, normal rhythm Medications or Fluids and character • NaCl 0.9% 250ml IV STAT (over Auscultation 15-30 mins) • HS I+II+0SCENARIO 1 EXAMINATION INTERVENTIONS Observations Medications or Fluids • C of ACVPU • Antibiotics • Temperature 38.3C GCS • GCS 14 • PEARL Glucose • Glucose 7.6SCENARIO 1 EXAMINATION INTERVENTIONS Observations Bedside • UO 20ml/hr in last 2 hours • Catheterise Inspection • Urine dip and MSU • No NGT or catheter in situ • Monitor UO closely • No abdominal distention • No rashes/bleeding Palpation • Abdomen soft, mildly tender • Calves soft, non-tender Auscultation • Bowel sounds presentImages: https://commons.wikimedia.org/wiki/File:X-ray_of_lobar_pneumonia.jpgSCENARIO 1 Impression: ◦ Sepsis – likely HAP Management: ◦ Reassess the patient using the ABCDE framework ◦ If improving, continue your management ◦ If deteriorating, escalate to your senior or send a MET call ◦ Handover ◦ DocumentSEPSIS OVERVIEW Investigations: ◦ Bedside: ABG, COVID swab, ECG, Urine dip and MSU SEPSIS SIX ◦ Bloods: FBC, U+Es, CRP, VBG, Blood cultures Give 3: 1. Oxygen ◦ Imaging: CXR 2. Fluids Management: 3. Antibiotics ◦ Oxygen Take 3: ◦ Fluids ◦ Antibiotics 1. Lactate 2. Blood cultures ◦ Catheterise 3. Urine output SCENARIO 2 *Dialing 37482* … … … Nurse: Hello, this is SAU. You: Hello, this is Fran, the F1 cover doctor. How can I help? 37 482 Nurse: Hi doctor, I have a patient here who is has just had a fall and now seems very drowsy, please can you come and review her?SCENARIO 2 Mrs Jones is a 72 year old woman who was admitted 2 days ago with adhesional bowel obstruction. Observations: ◦ NEWS 4: RR 16, SpO2 96% on air, HR 92, BP 114/67, Temp 37.2, Voice History: ◦ HPC – Unable to give history. Nurses report that she was found on the bathroom floor following an unwitnessed fall around 30mins ago and helped back into bed. No new symptoms noted. ◦ PMH – HTN, T2DM. ◦ DHx – Multiple medications ◦ SHx – Lives alone. Non-smoker. No alcohol. Investigations: ◦ Bloods – eGFR 67, CRP 42, Na 136, K 3.1, Creatinine 92, INR 1.0, WCC 10.2, Hb 109.SCENARIO 2 EXAMINATION INTERVENTIONS Observations • RR 16 • SpO2 96% on air Inspection • Able to talk but only incomprehensible words • No audible wheeze or stridorSCENARIO 2 EXAMINATION INTERVENTIONS Observations None required • RR 16 • SpO2 96% on air Inspection • Able to talk but only incomprehensible words • No audible wheeze or stridorSCENARIO 2 EXAMINATION INTERVENTIONS Observations • RR 16 • SpO2 96% on air Inspection • No audible wheeze or stridor Palpation • No tracheal deviation Percussion • Normal Auscultation • NormalSCENARIO 2 EXAMINATION INTERVENTIONS Observations None required • RR 16 • SpO2 96% on air Inspection • No audible wheeze or stridor Palpation • No tracheal deviation Percussion • Normal Auscultation • NormalSCENARIO 2 EXAMINATION INTERVENTIONS Observations • • HR 92 • BP 114/67 Inspection • Dry mucous membranes Palpation • Warm and well-perfused • Pulse: mildly tachycardic, normal rhythm and character Auscultation • HS I+II+0SCENARIO 2 EXAMINATION INTERVENTIONS Observations Bedside • HR 92 • ?12 lead ECG • BP 114/67 Bloods Inspection • Cannula • Dry mucous membranes • FBC, U+Es, CRP Palpation • ?Blood cultures • Warm and well-perfused • ?VBG • Pulse: mildly tachycardic, normal rhythm and character Auscultation • HS I+II+0SCENARIO 2 EXAMINATION INTERVENTIONS Observations • V of ACVPU • Temperature 37.2C GCS • GCS 12: E3, V3, M6 • PEARL Glucose • Glucose 1.2SCENARIO 2 EXAMINATION INTERVENTIONS Observations Bedside • V of ACVPU • Monitor BMs closely • Temperature 37.2C Medications or Fluids GCS • Dextrose 10% 150-200ml IV • GCS 12: E3, V3, M6 STAT (over 15-30 mins) • PEARL Glucose • Glucose 1.2SCENARIO 2 EXAMINATION INTERVENTIONS Observations • • UO 40ml/hr Inspection • NGT in situ on free drainage • No signs of injuries Palpation •head/spinal/chestwall/limb/pelvic tenderness. • Abdomen soft, mildly tender • Calves soft, non-tenderSCENARIO 2 EXAMINATION INTERVENTIONS Observations Bedside • UO 40ml/hr • Monitor UO Inspection • NGT in situ on free drainage • No signs of injuries Palpation •head/spinal/chestwall/limb/pelvic tenderness. • Abdomen soft, mildly tender • Calves soft, non-tenderSCENARIO 2 Impression: ◦ Fall secondary to hypoglycaemia Management: ◦ Reassess the patient using the ABCDE framework ◦ If improving, continue your management ◦ If deteriorating, escalate to your senior or send a MET call ◦ Handover ◦ DocumentHYPOGLYCAEMIA OVERVIEWFALLS OVERVIEW SCENARIO 3 *Dialing 37485* … … … Nurse: Hello, this is SAU. You: Hello, this is Fran, the F1 cover doctor. How can I help? 37 485 Nurse: Hi doctor, I have a patient here with chest pain, please can you come and review him?SCENARIO 3 Mr Matthews is an 81 year old man who is D3 post-THR. Observations: ◦ NEWS 9: RR 28, SpO2 95% on 4L via mask, HR 112, BP 96/54, Temp 37.8, Alert History: ◦ HPC – New onset of central chest pain and SOB today. No N+V/dysuria/bowel changes. ◦ PMH – HTN, MI, T2DM. ◦ DHx – Multiple medications ◦ SHx – Lives alone. Non-smoker. No alcohol. Investigations: ◦ Bloods – eGFR 77, CRP 98, Na 134, K 4.1, Creatinine 92, INR 1.0, WCC 11.2, Hb 123.SCENARIO 3 EXAMINATION INTERVENTIONS Observations None required • RR 28 • SpO2 95% on 4L O2 via mask Inspection • Able to talk in full sentences • No audible wheeze or stridorSCENARIO 3 EXAMINATION INTERVENTIONS Observations Bedside • RR 28 • Titrate O2 • SpO2 95% on 4L O2 via mask • ?ABG Inspection • COVID swab • No audible wheeze or stridor Imaging Palpation • CXR • No tracheal deviation Percussion • Normal Auscultation • Reduced AE in right baseSCENARIO 3 EXAMINATION INTERVENTIONS Observations Bedside • HR 112 • 12 lead ECG • BP 96/54 Bloods Inspection • Cannula • Dry mucous membranes • FBC, U+Es, CRP Palpation • ?Blood cultures • Warm and well-perfused • ?VBG • Pulse: tachycardic, normal rhythm Medications or Fluids and character • NaCl 0.9% 250ml IV STAT (over Auscultation 15-30 mins) • HS I+II+0Images: https://commons.wikimedia.org/wiki/File:ECG_Sinus_Tachycardia_132_bpm.jpgSCENARIO 3 EXAMINATION INTERVENTIONS Observations Medications or Fluids • A of ACVPU • ?Antibiotics • Temperature 37.8C GCS • GCS 15 • PEARL Glucose • Glucose 7.6SCENARIO 3 EXAMINATION INTERVENTIONS Observations Bedside • UO 35ml/hr • Urine dip and MSU Inspection • Monitor UO • No abdominal distention Medications or Fluids • Catheter in situ – draining rosé • Treatment dose clexane haematuria with no clots Palpation • Abdomen soft, non-tender • Right calf swollen, tender and erythematous Auscultation • Bowel sounds presentSCENARIO 3 Impression: ◦ PE Management: ◦ Reassess the patient using the ABCDE framework ◦ If improving, continue your management ◦ If deteriorating, escalate to your senior or send a MET call ◦ Handover ◦ DocumentPE OVERVIEW Investigations: ◦ Bedside: ABG, COVID swab, ECG, Urine dip and MSU ◦ Bloods: FBC, U+Es, CRP, VBG ◦ Imaging: CXR, CTPA Management: ◦ Oxygen ◦ Treatment dose heparinSummaryKey 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