The Acutely Unwell patient

IDENTIFYING AND THE IMMEDIATE ASSESSMENT/MANAGEMENT OF THE ACUTELY UNWELL PATIENT

Most scenarios start with are ‘you are asked to see…’ or ‘you go to assess patient x…’.

Immediate assessment of a patient

• Before starting, remember what you have been asked to do (are you concerned this may be an ABC problem?)
• Go and introduce yourself and ask how the patient is.
  • If they have impaired consciousness start ABCDE
  • if they are short of breath start ABCDE
  • if they look unwell (I.e. grey, sweaty, miserable, tired etc) start ABCDE
  • if they are unresponsive, call for help and start ABCDE
  • if you have any concerns, start ABCDE
    • has the patient been brought in acutely?
    • are they confused?
    • if they appear ok, but their SEWS score is high/rising or they have a concerning observation e.g. dropping BP; climbing RR/HR
• THINK- do you need help? 
  • Call for another body/ crash team etc
•  Also consider what you know about the patient that might alter your management
  • e.g. does the patient have heart failure

Airway

• If the patient can talk to you, the airway is patent.  However…
  • If the airway doesn’t sound clear (usually this will be because the patient has a reduced conscious level), perform an airway manoeuvre.
    • Head tilt- chin lift or Jaw thrust (the latter particularly in patients with potential neck injuries)
    • If you can hear gurgling or you are worried about something that could potentially block the airway in the mouth, you may want to use suction (for fluids via a yankauer catheter) or forceps (for debris with Magills forceps)
    • If the patient is not managing to maintain the airway (collapsing e.g. in airway disease, or blocked e.g. by the tongue or throat, malposition etc), you may want to use an adjunct
      • An oropharyngeal adjunct (or Guedel airway) should only be used in heavily sedated or semi-/unconscious patients (otherwise the patient will not tolerate them)
        • To size, the adjunct should be the same length as from the mouth to the angle of the mandible
        • To insert, see this youtube clip http://www.youtube.com/watch?v=SvoJfxRbpkg
      • A nasopharyngeal airway may be more tolerable so can be used in most acutely unwell patients.  Put in the left nostril and use lubrication.
        • To size, the adjunct should be the same length as from the tip of the nose to the angle of the mandible
        • To insert, see http://www.youtube.com/watch?v=En2sXsOLzCs
  • If this doesn’t work you should call for an anaesthetic consult to help.
• In patients with a problematic airway, or who have obvious SOB or look acutely unwell, start high flow oxygen via a Hudson, non-rebreather mask (bag-mask).
  • 15l/min
  • 

Breathing

• The patient should be sitting upright as this is often the easiest position to breathe
• Count resp rate and look for general signs of respiratory distress (sweating, cyanosis, use of accessory muscles, abdominal breathing, seesaw chest)
  • If very low (4-8 breaths/min) you may want to assist ventilation by adding a breath between breaths using a ventilation bag and mask with high flow oxygen
  • If very high (>28bpm) this would be an indication to start high flow O2 also
  • Check also for rhythm and symmetry
• Check Oxygen sats
  • Normally >97% (88-92% ok in COPD) for patients on air
    • If on oxygen therapy, sats should be >95%
• Do a full chest exam- remember to expose the patient
  • Check for central trachea

    

    Anatomical sites for lung auscultation

  • Inspection/Expansion
  • Percussion is usually not necessary in the acute situation unless you need to investigate signs at ausculatation
  • Ausculatate the front and back of the chest (lung zones)
  • Also have a listen to the heart while using the stethoscope

Consider what could be wrong with the patient: if there is wheeze, consider giving nebulised salbutamol (usually 5mg) +/- ipratropium 0.5mg; if there is stridor, consider foreign body or anaphylaxis (consider IM adrenaline 1:1000 500mcg) ; if there are crackles, consider infection/po oedema; are there signs of pneumothorax e.g. emphysema, loss of breath sounds, unilateral expansion etc etc

IMPORTANT: DO NOT MOVE ON TO C UNTIL YOU HAVE DONE EVERYTHING POSSIBLE TO STABILISE B

Circulation

• Take pulse
  • If radial pulse is weak, compare with carotid
• Cap refill and check hand temperature/colour
  • Hand should be at the same level as the heart
  • Can test central cap refill (pressing your thumb on the patient’s sternum) if the patient is very cold
• Measure BP
  • If this is low, consider giving a fluid challenge (usually 500ml normal saline stat)
    • Be wary in patients with heart failure, kidney failure and in smaller, elderly people who may not be able to tolerate
    • Note that hypotension can be a very late sign of shock (decompensation)
• Get venous access
  • wide-bore venflon (green<grey<brown/orange (largest)) in both arms and remember to take blood
  • FBC, U&E, Lab Glucose (& usually LFT)
  • Saline–
    • 500ml bolus (250ml if CHF) as quick as possible, more if the patient is hypotensive
    • If does not improve, try another bolus.  If again does not improve, seek help.
      • ? bleed- look for signs
      • NB If patient develops signs of heart failure e.g. crepitations, raised JVP, tachypnoea, dyspnoea- decrease rate of fluid administration
• ECG
  • 3-lead usually more accessible but 12-lead higher quality
  • Red-Right; YeLlow-Left; GrEEn-SplEEn.
  • Assess rhythm, rate, size, function etc of heart
• Auscultate for heart sounds if these have not already been assessed previously
• Urine output

NB Now is also the time to reassess A, B and C.  If improving, it is suitable to move onto D and E.  If something has changed that can be fixed or there is deterioration, you may want to take further action which may involve going to get help there and then.

Disability

• AVPU assessment or Glasgow Coma Scale
• Bedside blood glucose (if <3mmol/l, give 25-50ml of 50% glucose IV)
• Neurological assessment
  • Pupillary reflexes
• Assessment of muscle tone/posture (if relevant)
• Review the patient kardex (Drugs)
• You may

Exposure

• Fully expose the patient, looking for sources of bleeding, infection etc
• Check temperature and consider temperature control (air blanket or similar)