Recognition and Early Management of Acutely Ill Patients Updated by Mrs Clare Cann, Senior Clinical Skills (Simulation) Tutor & Dr Katja Empson, Emergency Department Consultant, UHW July 2015 (First edition Dr Paul Frost, Intensive Care, UHW) Clinical Skills Simulation Team
Aims & Learning Outcomes Aims & Learning Outcomes The aim of this module is to describe and apply the airway, breathing, circulation, disability and exposure (ABCDE) approach to acutely ill patients The learning outcomes are to: Describe the clinical assessments of each element of the ABCDE approach. Describe the appropriate methods of oxygen and fluid delivery to acutely ill patients. Relate knowledge gained to case based scenarios. Understand the importance of SBAR when referring acutely ill patients. Evaluate own learning and recognise how improvements can be made.
AIRWAY BREATHING CIRCULATION DISABILITY EXPOSURE Recognition & Early Management of Acutely Ill Patients Introduction Introduction The General Medical Council expects that by qualification junior doctors will be able to provide immediate care in medical emergencies; specifically that the junior doctor will be able to: Assess and recognise the severity of a clinical presentation and a need for immediate emergency care. (Tomorrows Doctors 2009) Acutely ill patients are best approached using an ABCDE assessment in conjunction with a targeted history and examination in order to reach a diagnosis so that definitive treatment can be administered. A B C D E
Bedside Assessment of Acutely Ill Patients Bedside Assessments of Acutely Ill Patients The clinical management of acutely ill patients requires that life threatening problems are immediately addressed whilst a diagnosis is sought so that definitive treatment can be administered. The ABCDE approach and diagnostic synthesis are complementary and simultaneous processes (see next slide). Junior doctors can co-ordinate these activities by proceeding in a step wise fashion
Bedside Assessment of Acutely Ill Patients The ABCDE approach and diagnostic synthesis should be simultaneous and complementary processes. BMJ 2012; 345:e5667
Step 1 Step 1: Initial Assessment Much of the ABCDE assessment can be accomplished within moments of arrival at the bedside by observation of the patient and their charts. Offering a handshake is a good way to start the bedside assessment, not only will this provide clinical information about the level of consciousness, airway patency and peripheral perfusion but will also reassure a potentially frightened and distressed patient. Diagnosis requires a focussed history, examination and investigations history from the patient may be limited and may need to be supplemented by information obtained from the bedside nurse, medical notes and relatives. The ABCDE approach requires that concerns regarding each element of this bedside assessment have to be addressed before proceeding to the next element. For example, an obstructed airway must be opened before breathing is assessed.
AIRWAY Recognition & Early Management of Acutely Ill Patients Step 2 BREATHING CIRCULATION DISABILITY EXPOSURE Step 2: Airway Assessment Complete airway obstruction is very rare (patients usually dies within minutes) but partial airway obstruction is quite common and can be recognised by noisy breathing such as snoring or gurgling and evidence of increased work of breathing such as intercostal recession. The commonest cause of partially obstructed airway is a reduced level of consciousness (due to reduced airway muscular tone, loss of protective airway reflexes, principally the gag and cough reflexes, retention of oropharyngeal secretions and tongue mal-position). A A partially obstructed airway can be relieved with simple manoeuvres such as head tilt & chin lift or jaw thrust. Airway adjuncts such as oropharyngeal or nasopharyngeal devices can also be useful. B C D E
Simple Airway Manoeuvres Head tilt & Chin lift Tilt head backwards by placing one hand on patient`s forehead. Gently lift lower jaw by placing finger tips of other hand under patient`s lower jaw. Jaw thrust Tilt head back. With fingers placed behind lower jaw apply steady pressure to lift lower jaw forward. At same time open mouth slightly by displacing chin in downwards direction using thumbs. Pictures are from the ALERT Course Manual Third Edition January 2012 Portsmouth Hospitals NHS Trust 2012 www.alert-course.com
AIRWAY Recognition & Early Management of Acutely Ill Patients Step 3 BREATHING CIRCULATION DISABILITY EXPOSURE Step 3: Breathing Assessment Begin by counting the respiratory rate, breaths per minute (bpm). Increased respiratory work commonly accompanies acute illness as a result of an increased metabolic rate and oxygen consumption. This may lead to respiratory distress, signs of which include: inability to complete sentences, high respiratory rate, diaphoresis, accessory muscle use and cyanosis. Focussed clinical examination including tracheal palpation, percussion and auscultation may uncover the diagnosis. (Tracheal deviation-tension pneumothorax, hyper-resonance-tension pneumothorax, dull percussion note-pleural effusion/empyema, wheeze, silent chest-acute severe asthma, left ventricular failure, diminished or bronchial breath sounds-pneumonia) A B C D E
AIRWAY Recognition & Early Management of Acutely Ill Patients Step 3 BREATHING CIRCULATION DISABILITY EXPOSURE Step 3: Breathing Assessment High flow oxygen should be administered to all acutely ill patients the effects of therapy should be assessed using pulse oximetery and the target oxygen saturations should be between 94% and above. The appropriate oxygen delivery device to use is a oxygen mask with a reservoir bag. The reservoir bag should be inflated by placing a finger over the valve before applying on the patient. It is vital that the reservoir is kept inflated at all times this is usually achieved by setting the flow rate of oxygen to 15 L/min. This mask will usually deliver an inspired oxygen concentration (FiO 2 ) of 60-85% A B C D E
AIRWAY Recognition & Early Management of Acutely Ill Patients Step 4 BREATHING CIRCULATION DISABILITY EXPOSURE Step 4: Circulatory Assessment Begin by assessing the radial pulse, beats per minute (bpm), rhythm and character. Attach cardiac monitoring if available. Note the blood pressure. Clinical signs that are common to hypovolaemic, obstructive and cardiogenic shock include: Confusion or agitation Cold extremities Reduced capillary refill Tachycardia Absent or small volume peripheral pulses Hypotension Oliguria A B C D E
AIRWAY Recognition & Early Management of Acutely Ill Patients Step 4 BREATHING CIRCULATION DISABILITY EXPOSURE Step 4: Circulatory Assessment The jugular venous pulse may be useful in distinguishing between hypovolaemic states (low) and cardiogenic or obstructive shock (elevated). Circulatory features of septic shock include warm peripheries (vasodilatation) and bounding pulse. With the exception of cardiogenic shock, complicated by pulmonary oedema, the management of shocked patients invariably requires the administration of intravenous fluid. Peripheral cannulae can usually be inserted into antecubital fossa or external jugular veins whilst central lines can be into internal jugular, subclavian and femoral veins. Very rarely venous access may require a senior to perform a cut-down approach or an intraosseous approach may be needed if venous access cannot be obtained at all. A B C D E
Poiseuille s Law Recognition & Early Management of Acutely Ill Patients Step 4 Step 4: Circulatory Assessment Sizes of peripheral cannula are determined by gauge (12 largest, 14, 16, 18, 20, 22, 24 smallest). Poiseuille s law states that flow is inversely related to the length of the IV catheter and directly related to its radius to the fourth power. Therefore fluids flow fastest down short cannula with large diameter. Two 16-gauge lines are recommended for resuscitation. Flow Rate Pressure Radius Fluid Viscosity Length of Tubing Administer intravenous fluids if hypotensive. Bolus of 500 ml of crystalloid (containing sodium in the range of 130-154 mmol/l) over 15 minutes. (NICE IV Fluid Therapy Guidelines 2013).
AIRWAY Recognition & Early Management of Acutely Ill Patients Step 5 BREATHING CIRCULATION DISABILITY EEXPOSURE Step 5: Disability Assessment Disability refers to neurological status, relevant clinical examination would include assessment of the level of consciousness, focal and localising neurological signs, pupillary reflexes and signs of meningism. A B C D
Alert Recognition & Early Management of Acutely Ill Patients Step 5 Voice Pain Unresponsive Step 5: Disability Assessment Level of consciousness can be rapidly assessed using the AVPU method Further evaluation of level of consciousness can be made with Glasgow Coma Score http://patient.info/doctor/glasgow-coma-scale-gcs A V P U Include an assessment of blood glucose level.
AIRWAY Recognition & Early Management of Acutely Ill Patients Step 6 BREATHING CIRCULATION DISABILITY EXPOSURE Step 6: Exposure Assessment Exposure is a prompt to ensure the body is examined as a whole. Paying particular attention to wound sites or other injuries on the body. During examination, being mindful of environmental temperature and potential adverse effects of cooling (shivering causes increased metabolic work and contributing to further cardiovascular decompensation). Body temperature should be assessed. A B C D E
Step 7 Step 7: Diagnostic synthesis, investigation and definitive management Once diagnosis is obtained and/or the causes of deterioration understood, definitive treatment can be started. This may require transfer of the patient to the operating theatre, interventional cardiology laboratory, endoscopy suite, intensive care unit or high dependency unit. Regardless, transfer will need to be conducted by trained personnel and the proposed management carefully communicated to the patient and those close to the patient.
Referral Referral of Acutely Ill Patient using the SBAR Approach Following the bedside assessment it is likely that the junior doctor will need to discuss further management with a senior colleague. The NHS Institute for Innovation and Improvement has recommended the Situation, Background, Assessment and Recommendation (SBAR) approach for such communications. Identify yourself (name, role, location) Confirm the identity of the person you are speaking to Identify the patient (name, age, sex, and location) State the problem S B BACKGROUND Relate the history Date of admission Diagnosis Management Describe current interventions State NEWS score A,B,C,D,E assessment Any other relevant factors eg relevant physical examination, blood results, sepsis screening, pain A R RECOMMENDATION State the request e.g. I need you to see this patient urgently; please come to the ward immediately SITUATION ASSESSMENT
Referral Referral of Acutely Ill Patient using the SBAR Approach Once SBAR handover has been conveyed ensure that the receiver of this information understands the information and the urgency of the call. It is useful to hear the receiver Recall:- Summarise what you have said Ask for further information if necessary Confirm when they should come and see you and / or an alternative plan
Demonstration Case Acutely Ill Patient 1: Acute ST elevation myocardial infarction Mr Lee Clarke
Demonstration Case PATIENT INFORMATION Background History of present complaint Setting Patient Information History Medication Allergies Name Age Weight Height Gender Mr Lee Clarke 49 Years 90 kg 160 cm Male Mr Clarke was found collapsed with severe central chest pain 30 mins ago. He was brought to hospital by ambulance. GTN spray and aspirin given by paramedic. Patient responds to voice, respirations 20 bpm, sats 94% using face mask, pulse 70 bpm with ST elevation, BP 120/60 mmhg, temperature 37 C. The nurse wants you to review this patient, National Early Warning Score is 6. Emergency Department, UHW Mr Clarke has a history of angina and has had a previous myocardial infarction 2 yrs ago. He is obese and smokes 20 cigarettes per day. He takes clopidogrel, Ramipril, atorvastatin, fluoxetine and GTN spray. He is allergic to penicillin.
Demonstration Case A How would you manage this acutely ill patient? B C D Mr Lee Clarke E
Demonstration Case A B C Introduce yourself with a handshake Spend a short time at foot of bed inspect observation charts. Note breathing Assess radial pulse; rate, rhythm, character and blood pressure, fluid balance, capillary refill time, JVP Provides clinical information about level of consciousness, airway patency and perfusion Assess respiratory rate, accessory muscle use, cyanosis. Attach oximeter. Auscultate / percuss Attach ECG monitoring Ensure IV access Observe overall presentation of patient note colour and clamminess Administer high flow oxygen mask with reservoir bag. Assess pain consider analgesia / Anti emetic Perform ECG. Perform bloods. Check aspirin & clopidogrel given D E Assess level of consciousness and blood glucose level Examine the body as a whole Use AVPU. Note facial neurological signs. Perform bedside blood glucose test Check body temperature and body integrity. Call for help Doctor...Please give me something for this pain. It`s like an elephant sitting on my chest!! Doctor...Am I having another heart attack?
Demonstration Case Notes on the Management of acute ST elevation myocardial infarction 1 2 3 4 5 6 Attach cardiac monitoring Administer high flow oxygen via mask with reservoir bag Ensure intravenous access Administer analgesia & an anti emetic Perform & interpret ECG and bloods (FBC, U&Es, clotting, glucose, Troponin T) Antiplatelet therapy 300 mg aspirin, 300 mg clopidogrel Call for senior help regarding treatment plan Call senior help!
Case Example 1 Acutely Ill Patient 2: Sepsis Mr John Jones
Case Example 1 PATIENT INFORMATION Background History of present complaint Setting Patient Information History Medication Allergies Name Age Weight Height Gender Mr John Jones 62 Years 75 kg 175 cm Male Mr Jones underwent a total knee operation two days ago. He now complains of a cough and being off his food. He responds to voice, respirations 20 bpm, sats 92% using nasal specs, pulse 110 bpm, BP 103/60 mmhg, temperature 38.5 C. The nurse wants you to review this patient as his National Early Warning Score is 7. Orthopaedic ward, Llandough Hospital Mr Jones is a type 2 diabetic and smokes 20 cigarettes per day. He takes bendroflumethiazide, simvastatin, and since the operation is receiving low molecular weight heparin and the usual post operative analgesia. He is allergic to penicillin.
Case Example 1 A How would you manage this acutely ill patient? B C D Mr John Jones E
Case Example 1 A Introduce yourself with a handshake Provides clinical information about level of consciousness, airway patency and perfusion Observe overall presentation of patient B Spend a short time at foot of bed inspect observation charts. Note breathing & sputum Assess respiratory rate, accessory muscle use, cyanosis. Attach oximeter. Auscultate / percuss Administer high flow oxygen using a mask with a reservoir bag C Assess radial pulse; rate, rhythm, character and blood pressure, fluid balance, capillary refill time, JVP Attach ECG monitoring Ensure IV access Perform bloods & blood cultures. Administer IV fluids & IV anti biotics. Assess output D E Assess level of consciousness and blood glucose level Examine the body as a whole Use AVPU. Note facial neurological signs. Perform bedside blood glucose test Check wound site and potential secondary sites of infection and body temperature. Call for help Doctor...I feel awful, I have been coughing and am off my food and feel sweaty Doctor...is it normal to feel like this after an operation?
Case Example 1 Notes on the Management of Septic shock On reverse of the NEWS chart is the sepsis screening / awareness tool If a patient has a confirmed or suspected infection and has 2 or more of the below:- Signs and symptoms of infection from their NEWS chart 1. Temperature > 38.3 C or < 36 2. Heart rate > 90bpm 3. Respiratory rate > 20 / min 4. Acutely altered mental state or signs from their blood tests: 5. White cell count >12 or <4 x 10^9 6. High glucose > 12 g/dl Begin the SEPSIS 6 proforma! First line anti biotic therapy guidance advised by relevant Trust
Case Example 1 Notes on the Management of Septic shock - Perform the sepsis 6 1 2 3 4 5 6 (Red to administer, Green to measure) Administer high flow oxygen via mask with reservoir bag Take blood cultures (and other relevant cultures e.g. sputum sample) Administer broad spectrum intravenous antibiotics as per hospital policy Administer 500 ml of crystalloid (containing sodium 130-154 mmol/l) over 15 minutes if hypotensive Take serum lactate (may be raised if septic) and haemoglobin Take hourly urine output (consider catherisation) Call senior help!
Case Example 2 Acutely Ill Patient 3: Acute Gastrointestinal Haemorrhage Mrs Bronwen Thomas
Case Example 2 Background History of present complaint Setting Patient Information HistoryMedication Allergies PCP PATIENT INFORMATION Name Age Weight Height Gender Mrs Bronwen Thomas 72 Years 57 kg 140 cm Female Mrs Thomas has been admitted to hospital with a three week history of epigastric pain. An ECG, full blood count and urea and electrolytes have been performed. She responds to voice, respirations 20 bpm, sats 94%, pulse 115 bpm, BP 90/60 mmhg, temperature 37 C. The nurse wants you to review this patient as she now has a National Early Warning Score of 8. Medical Emergency Admissions Unit, University Hospital Wales Mrs Thomas has arthritis and takes ibuprofen PRN
Case Example 2 A How would you manage this acutely ill patient? B C D Mrs Bronwen Thomas E
Case Example 2 A Introduce yourself with a handshake Provides clinical information about level of consciousness, airway patency and peripheral perfusion B Spend a few moments at foot of bed inspect observation charts. Note breathing Assess respiratory rate, accessory muscles & cyanosis. Attach pulse oximeter. Auscultate / percusss Administer high flow oxygen using a mask with a reservoir bag C Assess radial pulse; rate, rhythm, character and blood pressure. fluid balance, capillary refill, JVP Attach ECG monitoring. Check IV access Administer IV fluids. Check cross match, perform bloods D Assess consciousness Use AVPU. Note facial neurological signs. Perform bedside blood glucose E Examine body as a whole Perform gastrointestinal examination and per rectal examination. Call for help. Order urgent blood
Case Example 2 Notes on the Management of acute gastro intestinal haemorrhage 1 2 3 4 5 High flow oxygen via mask with reservoir bag Gain intravenous access Administer IV fluids per NICE IV Fluid Guidelines 2013 Order urgent blood, Ensure patient has up to date cross match, U&Es, FBC, Coag. CALL for help Correct coagulopathy and haemostasis (endoscopic, surgical or angiography and selective arterial embolisation)
Useful Resources Useful Resources Frost P, Wise M. Recognition and management of patient with shock. Acute Medicine 2006;5(2):43-47 Frost P, Wise M. Recognition and early management of the critically ill ward patient. Br J Hospital Med_2007;68(10):M180-3 Frost PJ, Wise MP. Early management of acutely ill ward patients. BMJ 2012;345: 43-47 NICE Intravenous fluid therapy in adults in hospital (2013) Clinical guideline 174. December 2013 NICE Short Clinical Guidelines Technical Team (2006). Acutely ill patients in hospital: recognition of and responses to acute illness in adults. London: National Institute for Health and Clinical Excellence. Available from www.nice.org.uk SIGN 93 Acute coronary syndromes Guideline, updated Feb 2013
Useful Resources Useful Resources Sepsis e-learning package (created by C Jefferies and C Kostov) https://xerte.cardiff.ac.uk/play.php?template_id=428 O; Driscoll Br, Howard LS, Davison AG. On behalf of the British Thoracic Society Emergency Oxygen Guideline Development Group. Guideline for emergency oxygen use in adult patients. Thorax 2008; 63: Supplement VI Scottish Intercollegiate Guidelines Network. Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline September 2008: Available from http://www.sign.ac.uk SBAR tool: http://www.institute.nhs.uk/safer_care/safer_care/sbar_handover_films.html http://www.institute.nhs.uk/safer_care/safer_care/situation_background_assessment_recom mendation.html