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Action and evaluation Assessment

Assessment is the first step in caring for a patient, and assessing the critically ill patient is an essential part of their care.

Learning outcomes:


Careful assessment is fundamental in order to recognise when a patient is becoming compromised.

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Identify the correct sequence of priorities in assessing the critically ill patient.

State why it is important to have a systematic approach to assessment and care, with rational for each step.

Identify clinical situations in which a patient’s condition may become compromised.

Demonstrate safe and effective assessment and care of the critically ill patient using a systematic approach. Introduction Facts

Patients admitted from the wards to ICU when compared to those admitted from A&E have a higher percentage mortality (Goldhill, 2001).

Nearly 80% of hospital inpatients who experience a cardiorespiratory arrest have documented observations of deterioration in the 8hours before the arrest (Bristow et al 2000)

The 3 key stages of recognition and treatment of a critically ill patient:

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Understanding that an emergency exists

Identifying and prioritising problems.


The nurse acts as patient advocate, monitoring, anticipating potential problems, planning, implementing and constantly evaluating care, and communicating with other MDT staff involved in the patient care.

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? Current practice in critical care services

Development of outreach services from critical care specialists to support ward staff in managing patients at risk.

Patient Assessment Systems

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Improved patient monitoring through the use of early warning scores (EWS) or modified early warning scores (MEWS) Definition

Basic Life support (BLS)

Advanced Life Support (ALS)

Acute Life-threatening Events, Recognition and Treatment (ALERT)

The Advanced Trauma Life Support (ATLS)

All of these assessment systems use a systematic approach in a strict order:

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A: airway (with C-spine protection in trauma)

B: breathing

C: circulation

D: deficits in neurological status

E: environment (exposure)

* 5. 4. . Critical care nursing deals with human responses to life-threatening problems and includes the critically ill patient. and achieve and maintain optimal responses 1. the more likely he or she is to be highly vulnerable. * 3. prevent complications. multidisciplinary assessment and intervention to restore stability. such as emergency departments and the intensive care units. The critical care nurse coordinates interventions aimed at resolving life-threatening problems. unstable and complex. intensive. Critically ill patients are defined as those patients who are at high risk for actual or potential lifethreatening health problems. Critically Ill Patient * 1. General information 2. The critically ill patient is at high risk for developing life-threatening problems and requires constant. thereby requiring intense and vigilant nursing care. B. * 3. A. the critical care nurse. Critical care nurses can be found working in a wide variety of environments and specialties. The more critically ill the patient is. Care is provided to patients of all ages with alterations in physical or emotional health.CRITICALLY ILL * * * Defined as those patients who are high risk for actual or life threatening health problems. 2. and the critical care environment. It is the field of nursing with a focus on the care of the critically ill or unstable patients.

prevent complications. Advocate: protects the patient’s rights E. these may create safety hazards for patients. dependent. Legal. Care provider: provides comprehensive—and at times highly technical—direct care to the patient and family in response to life-threatening health problems * 2. Uses independent.* 3. Manager: coordinates the care provided by various health care workers to achieve the specific goal of providing optimal nursing care to critically ill patients 4. and interdependent interventions to restore stability. from emergency department to discharge * 2. if necessary 3. social. Provides direct measures to resuscitate. A management and administrative structure is required to ensure effective care through all phases of the patient’s hospital stay. such as possible exposure to electric shock D. Functions of the critical care nurse * * * 5. and achieve and maintain optimal patient responses . Assesses and implements treatment for patient responses to life-threatening health problems 1. Educator: provides patient and family with education based on their learning needs and the severity of the situation and allows the patient to assume more responsibility for meeting health care needs as health condition stabilizes or improves * 4. Roles of the critical care nurse 1. economic. Specialized electronic technology and techniques are used to monitor patient status continuously. regulatory. and political trends must be monitored to promote the early recognition of problems and a timely response * 3.

Shock . and preserves the patient’s rights. MALPRACTICE 3. Supervises patient care and ancillary personnel * * * Chest trauma. Provides health education to the patient and family 5. Post successful CPR Post major surgery Acute renal failure Special considerations in assessing a critically ill patient * * 6. Supports patient adaptation. restores health.* 4. Implied consent 5. including the right to refuse treatment Assess patients fluid and electrolytes * * * * * Assess hemodynamic stability (V/S) Assess patient clinically and laboratory F. Negligence 2. INFORMED CONSENT 4. including DURABLE POWER OF ATTORNEY and living wills Assess patients capability to do activities Admission Protocol * * Patients with respiratory failure such as pneumothorax and hemothorax. Legal issues affecting the provision of critical care nursing Assess the patients nutritional status * Assess the neurological function 1. Advanced directives.

Observe for condition changes in critically ill patients Listen and offer emotional support for the patient dealing with chronic issues. Cerebral function Sensory function Deficits in neurological status & environment (exposure) . Components of a neurological assessment Interview LOC Pupillary assessment Cranial Nerve testing V/S Motor function.* Assess patients pain scale * How will you assess neurological status and environment? Important factors to consider in assessing a critically ill * * * * * * * * * * * Educate yourself on the patients illness.

Confused (obtunded)–This is transitional state between lethargy and stupor Sleeps most of the time.Alert – awake.Stuporous (semi-coma)– generally unresponsive except to vigorous stimulation. coherent. cognitive) * Exhibits alteration in perception of stimuli.opens eyes to deep pain Spontaneously unconscious.Level of Consciousness 1. oriented. drifts off to sleep when not stimulated Can be aroused to name when called in normal voice but looks drowsy Responds appropriately to questions or commands but thinking seems slow.Drowsy (lethargic. difficult to aroused-needs loud shout or vigorous shake.responds in a meaningful manner to verbal instructions and gestures. conducts meaningful interpersonal interaction (3 C’s-conscious. spontaneous movements are decreased 3. loses train of thought. may be agitated 4. inattentive. . Readily aroused. has appropriate motor response * * * * 2. acts confused when is incoherent. responds only to persistent and vigorous shake or pain. place or person memory difficulty is common * has difficulty with commands . fully aware of external and internal stimuli Responds appropriately. looks about . somnolent) – oriented when awake but if left alone will sleep. requires constant stimulation for even marginal cooperation disoriented to time. Not fully alert.

Special States of altered level of consciousness .* 5. incoherent conversation.Locked in Syndrome – a state of muscle paralysis. while there is preservation of full consciousness and cognition. involving voluntary response to pain or to any external or internal stimuli Light coma has some reflex activity but no purposeful movement Deep coma has no motor response 3. Comatose – unarousable and unresponsive .Brain Death – an irreversible loss of cortical and brain stem activity. impaired recent memory. disoriented . inattentive.Persistent vegetative state – a condition that follows severe cerebral injury in which the altered state becomes chronic or persistent. often agitated and having visual hallucinations. with confusion worse at night when environmental stimuli are decreased The difference between coma and sleep * * * * Sleeping persons respond to unaccustomed stimuli Sleeping persons are capable of mental activity(dreams) Sleeping persons can be roused to normal consciousness Cerebral oxygen uptake does not decrease during sleep as it often does in coma Special States of altered level of consciousness 1. GLASGOW COMA SCALE * Acute confusional state (delirium).is clouding of consciousness. 2.does not open eyes to deep pain Completely unconscious .

2 pts is given to a patient in a decerebrate posture. no response 3 pts is given to a patient demonstrating decorticate posturing. . 5 pts is given to a patient displays purposeful movement with a painful or unpleasant stimulus.* * DEVELOPED TO ASSESS THE STATE OF A PERSON’S CONSCIOUSNESS AFTER A HEAD INJURY. 3 pts. If the patient eyes open upon command 2 pts. GLASGOW COMA SCALE It is based on the client’s response in three areas : Eye Opening Motor Response Verbal Response Motor Response GLASGOW COMA SCALE How to perform the GCS 1. given to patients who opens eyes spontaneously.Assess the patients eye opening 4 pts. Motor Response * * The GCS score reflects the brain’s functional level A fully alert . whereas a score of 7 or less reflects coma 6 pts is given to a patient who moves arms and legs spontaneously on command. 1 pt patient does not move at all . normal person has a score of 15. 4 pts is given to a patient who only withdraws away from pain with no other response. INDICATES LOC RANGING FROM DEEP UNCONSCIOUSNESS TO COMPLETE CONSCIOUSNESS Verbal response . If patient only open eyes on painful stimulus 1 pt.

The eye score ranges from 1 to 4 points The verbal response score ranges from 1 to 5 Use the following statements to ask the person to rate their pain The motor response ranges from 1 to 6 Interpretation of the GCS * * * * * * . from zero to ten. verbal and motor response scores. * It is important to properly instruct the person in how to rate their pain. I would like you to rate your pain on a scale from zero to ten. even those with mild to moderate dementia. 2. ‘Ten’ means the worst possible pain you can image.* The 0 to 10 pain scale is commonly and successfully used with hospitalized and nursing home patients. A GCS of 13 or 14 is a minor brain injury Pain Assessment with the “0—10 Numeric” 4. This scale asks the person in pain to assign a number. ‘Zero’ means you have no pain at all. A GCS score between 9 and 12 moderate brain injury 3. to the severity of their pain. 1. 0-10 NUMERIC PAIN INTENSITY SCALE GCS SCORING * * * * * * * * Calculate the GCS score by summing the points for the eye. A GCS of less than 9 represents severe brain injury. What number would you give to your pain? * Pain Intensity Scale A common administration error is to describe “10” as “the worst pain .

in these circumstances the score is given as 1 person to point to the number that represents their pain. then ask the Intubated patients as well as those patients with severe facial/eye swelling or damage is impossible to tes the verbal and eye response. the worst pain they ever had may have been something minor like a toothache. This may indicate a more serious problem such as stroke and requires a follow up tests.alcohol Tips and Warnings First assess patency by occluding one nostril at a time and asking the person to sniff .and becomes confused or displays change in motor response must be evaluated immediately. and physician notified.” For some people. CRANIAL NERVE TESTING The values on the pain scale correspond to pain levels as follows: 1 – 3 = mild pain CRANIAL NERVES 4 – 6 = moderate pain 7 – 10 = severe pain Cranial nerve 1 Olfactory – sensory nerve.such as coffee. Ask client to close eyes and identify different aromas. persons with dementia may not be able to remember their worst pain Any changes on the GCS should be evaluated and reported to the physician. * * * * * * A variation of this technique is to provide the instructions. and remember.smell .* you ever had. A patient who is

Cranial nerve 5 Unilateral loss of sense of smell in the absence of nasal disease is neurogenic anosmia Cranial nerve 2 * Trigeminal/opthalmic branch.specifically moves eyeball downward and laterally. Optic. allergic rhinitis and coccaine use * Trochlear.motor nerve. extra ocular eye movement.EOM. Assess pupil reaction * Strabismus. Absence of constriction or convergence Papiledema suggests increased intracranial pressure Cranial nerve 3 Asymmetric response Nystagmus occurs with disease of the semicircular canals in the ears. the test indicates loss of peripheral visual field. Ptosis * Oculomotor.motor nerve. Cranial nerve 4 Cranial nerve 5 .sensory elicit blink reflex Abnormal findings This is the gross emasure of peripheral vision It compares the patient’s peripheral vision. about 2 feet away Abnormal findings * * * * * * Dilated /pinpoint and visual fields Ask patient to read the snellen’s chart Ask client to look upward lightly touch the lateral sclera of the eye with sterile gauze.sensory nerve * Sensation of cornea and side of face. Dilated and fixed pupils Constricted pupils * * Unequal or no response to light If the patient is unable to see the target or finger of the examiner as the examiner does. smoking.Do not use alcohol wipes because they are irritating Abnormal findings * * Anosmia.Lid lag In adult. multiple sclerosis or brain lesions. assuming that the examiner’s peripheral vision is normal The exmainer positions herself at eye level withthe patient.loss of sense of smell occurs bilaterally with tobacco. the resting size of the pupil is 3 to 5mm.

vocal cord movt. drooping of one side of the face. * Abducens.use alternating blunt and sharp ends of safety pin over same areas.frown.Facial expression.pitched loss Cranial nerve 9 Glossopharyngeal.muscles of mastication.sensation of skin and face Ask client to clench teeth Cranial nerve 6 * * The patient is unable to hear whispered words. sagging of the lower eyelid.Ask client to identify various taste placed on tip and sides of tongue Abnormal findings * * To test light sensation. Apply taste on the posterior tongue Cranial nerve 10 Cranial nerve 7 * * Vagus – motor and sensory nerve.listen to voice quality.swallow .sensation of skin of face.moves eyeball laterally. Maxillary branch Loss of movement and asymmetry of movement occur with both central nervous system lesions and peripheral nervous system lesiosn (bell’s palsy) Cranial nerve 8 acoustic (vestibulococchlear nearve) * * Sensory nerve.let client close eyes and wipe a wisp of cotton to the client’s forehead * * * Muscle weakness is shown by flattening of a nasolabial fold. Taste(posterior tongue) Ask client to move tongue from side to side up and down.raise eyebrows. . Assess skin sensations Mandibular branch Auditory -vestibular branch sensory nerve.EOM.motor nerve. A whisper is a high-frequency sound and is used to detect high.tongue and teeth.throat sensation.for equilibrium Do the Romberg’s test -cochlear branch. Ask client to smile.motor and sensory nerve.vibrations) whisper tests and tuning fork tests. and escape of air from only one cheek that is pressed in To test for deep sensation.for hearing (assess client’s ability to hear spoken words. Abnormal findings Motor and sensory nerve.puff out cheeks. * Facial-motor and sensory nerve.swallowing activity tongue movt.gag.taste Assessed with CN 9.

Cranial nerve 11 * * * * * * A AIRWAY (with C spine protection in trauma) Accessory.and turn head to side against resistance on your hand.Motor nerve. eyeball the patient – do they look sick? Airway assessment + C-spine Careful assessment is fundamental in order to recognise when a patient is becoming compromised.shrugging of shoulders. the airway is patent) Structured Assessment . PRIMARY SURVEY * * Assessment is the first step in caring for a patient.motor nerve. Ask client to shrug shoulders against resistance from your hands. Cranial nerve 11 B breathing C circulation * Hypoglossal. If possible trauma – protect the C-spine *Can the patient talk normally? (If so.head movt.tongue protrusion D disability (central nervous system function) Ask the client to protrude tongue at midline. control) Assessment * What do you now know? * * ASSESSMENT What nurses know What nurses see * * * * * What nurses find a quick physical assessment. QUIZ E exposure (with temp.then move it side to side.

Feel. Consider suctioning (call chest physio) if evidence of retained secretions i.* * * * * * * * * * * Stridor/gurgling/snoring (partial airway obstruction) * Look. gurgling noises Mini assessment Airway Assessment Snoring occurs during partial occlusion of the oropharynx due to relaxation of the oropharyngeal muscles and tongue High pitched crowing sounds occur during laryngeal spasm Determine patency of the airway. Rate.e. BREATHING LOOK .Count the Resp. Listen. Chest wall movement Feel for breath Look in mouth *Oxygen if patient sick AIRWAY OBSTRUCTION * Airway problems: If evidence of actual or potential airway obstruction – get anaesthetics help early Inspiratory Stridor : a rasping sound heard during inspiration as a result of obstruction above or involving the larnyx * * * * * Wheeze : is usually heard on expiration as a result of the lower airways collapsing AIRWAY OBSTRUCTION Don’t wait for O2 saturations to drop – by that stage your patient may be in big trouble Remember airway adjuncts if inability to maintain an airway due to decreased conscious level Gurgling occurs when secretions or liquid is present in the upper airways.

but if <97% in a normally healthy young person.* * * * * * * * * * * * * * LISTEN *Oxygen Saturations (aim for >93%. it can be secondary to a metabolic acidosis or a CNS problem Percussion O2 Sats of 97% might be ok on room air. Tracheal tug/deviation O2 Saturations of 92% in a young. bronchospasm) *Obvious distress? Pulmonary oedema Use of accessory muscles? Pulmonary embolus Cyanosis? Pneumothorax *Respiratory rate (This is the single most useful marker of critical illness) These can co-exist.e. think about why) Breathing problems: * FEEL Breathing assessment There are only a few things that commonly cause lifethreatening breathing problems: * * * * * * * * * Pneumonia – look/feel/listen COPD + Asthma (i. but if it takes high-flow oxygen to achieve this. something is badly wrong with gas exchange in the lungs *Air entry/breath sounds *Added sounds Circulation Vocal resonance . previously healthy patient are not ok. Chest wall movement + expansion Not everyone with tachypnoea has a primary respiratory problem.

Things that can go wrong: * * * * * *Cool. high intrathoracic pressures) *Central pulse – rate. bleeding. not just hypotension. regular (Need SBP>80mmHg for radial pulse) . volume.signs of *BP haemorrhage/fluid loss Heart sounds ?DVT Listen : accurate assessment of the heart Peripheral oedema – ankles/legs/arms/flanks rate. Dehydration * * * * * * * JVP drug chart.electrolytes. Think of the cardiovascular system as plumbing.g. clammy/warm and flushed? * * * Not enough fluid (Hypovolaemia e. cardiac tamponade. valve disease. cardiomyopathy. vomiting) Colour – pale? Grey? Mottling? Pump failure (Cardiogenic shock – MI.pulse blood pressure Peripheral pulses *IV access Circulatory problems: Circulation * Feel : pulse why? What can it tell us? Circulation assessment (Hands-face-chest-abdomenlegs) * * Shock is a failure to adequately perfuse organs. arrhythmia. fluid overload.* * * * * * Look : skin colour. Hypotension means advanced shock. myocardial depression due to drugs or acidosis) *Peripheries warm or cool Capillary refill time Blocked pipes (Obstruction to flow – PE.

posturing *Check capillary blood glucose Disability problems Disability . Never use hypotonic fluids e. causing vasodilatation and bradycardia. Disability assessment * * * * Unless there is obvious pulmonary oedema. Voluven or Gelofusin over15-30mins.spine injuries. ANURIA.X KG. Quick neurological screen – time to do a full assessment later: AVPU score – Alert/Responsive to Voice/Responsive to Pain/Unresponsive Pupils – equal & reactive? * * *GCS (E.* Leaky or poorly functioning pipes (Vasodilatation – septic shock. urine output and CVP if available).M.V) esp. * HALF A ML. BP. 5% dextrose for resuscitation purposes. and assess response – HR. due to loss of sympathetic input in C/T. If bleeding + hypotensive. neurogenic shock . but not always.g. a fluid challenge is worthwhile (250-500mls of colloid e. * * Finally. OLIGURIA. Below 100mls in 24hrs * ABSOLUTE ANURIA NO URINE In cardiogenic shock. and the management is to treat any immediate cause eg arrhythmia or MI. X 24HRS. fluids will tend to make a bad situation worse. and/or use inotropes. anaphylaxis) * * Neurological assessment Disability URINE OUTPUT. fluid resuscitation is the first-line treatment for shock.rare. use blood.g. Production of between 100 – 400mls x 24hrs. In most cases. ideally cross-matched.

inform them early. * * * * Medications Generalised deterioration in conscious level. ABG analysis is not just for diagnosing respiratory failure – it gives information on perfusion and lots of other useful things. TEMP. Are you competent to deal with this patient by yourself? Also a top to toe assessment allow us to see any areas that may have been missed in the initial ABCD eg wounds.1 CNS cause. Check capillary blood glucose Find out normal state – ask nurses/check notes/call relative EXPOSURE * * * * Are they an ICU/HDU candidate? If so. or a response to other pathology? CXR / ECG / ABG / Blood tests / Other investigations – as indicated Confusion/agitation can be a manifestation of hypoxia/shock/hypoglycaemia/lots of other things for which sedation is not the treatment. areas of inflammation E-exposure (SECONDARY ASSESSMENT + INVESTIGATIONS) Conclusion * * * ABCDE * * * History (Chest pain/SOB/palpitations/thirst/pain/fatigue/dizziness) Coupled with the MINI ASSESSMENT TOOL.* * * * New focal neurology? Is it haemorrhage? – this is the most treatable cause. Examine abdomen including for Neuro or other exam as indicated Input/output chart – consider urinary catheter and hourly urometry Provides a structured approach to patient .

atropine. diet. buffers. reassess rhythm & pulse..if within 12 hrs (still may help up to 24 hrs) and ST elevation. previous allergic reaction. Attach defib/monitor. Reversible causes: Contraindications to Thrombolytics (Variation between clinicians – these are typical): * Hypoxia Hypovolaemia Hypokalaemia. Aspirin 300mg Morphine (5-10mg IV) or Diamorphine (2-5mg IV) + Antiemetic. * ECG Monitor O2 (High flow) IV Access. BUT no internal bleeding. don't give streptokinase if it is 5 days to 1 year since last administration. BP not over 200/120mmHg. Cardiac enzymes.. eg: Metoclopramide (10mg IV) GTN spray or Buccal Suscard (unless hypotensive) Beta-blocker (eg. FBP. unless asthma or LVF) Thrombolysis (Streptokinase or Alteplase. U+E. atenolol 5mg IV. IV access. no surgery in past 2 weeks. CPR 1 minute. hyperkalaemia Hypothermia Tension pneumothorax Tamponade Toxic/therapeutic disturbance Thromboembolic/mechanical obstruction. but no contraindications) Stop smoking (exercise.. reaccess rhythm & pulse. Lipids. reshock 3 x 360 joules.. CXR Prophylaxis . If non-VF or VT-with-pulse => 3 minutes CPR. 200. Myocardial Infarction Thank you. Prepared by: MMSANTOS Specific Management of Some Common Emergencies * * * Cardiac Arrest Management: (BOOMASS) Bed rest Oxygen Opiates Monitor rhythm (ECG) Aspirin (300mg) (GTN and Beta-blockers can help) Steptokinase or tPA (if within 12hr and elevated ST. If there are thrombolysis contra-indications. physio) In more detail: Basic Life Support (BLS): Call for Help A: Head tilt + chin lift/jaw thrust. consider intubation. BLS. give 1mg IV Adrenaline each 3 minutes. DVT Prophylaxis Stop Calcium channel antagonists Advanced Life Support (ALS): * If witnessed arrest . During CPR: correct reversible causes. Clear mouth. * Recent trauma/surgery . pregnancy.* Assessment and a basis for further intervention / treatment. If VF or pulseless-VT => DC Shock 200.give 2 breaths C: If no pulse .give Precordial thump.Management of any existing Diabetes. pacing. 2. 360 joules. rt-PA) . consider urgent angioplasty instead.. per 2 breaths. B: If not breathing .. Consider amiodarone. Glucose.give 15 chest compressions at 100/minute.

3.exclude pneumothorax. or coma Normal or high PaCO2. * * Signs of Severe attack: Cannot complete sentences Resp rate > 25/minute Pulse > 110/minute Peak flow < 50% of predicted or best 4. Heart: Tachycardia. Low pH. If severe. Low PaO2. CXR . Acute severe Asthma * Symptoms & signs: Skin: Itching. Aminophylline or salbutamol infusion. Laryngeal obstruction. Prolonged CPR Warfarin therapy (relative C/I) 3.exclude pneumothorax. Repeat continuously if needed. Acute severe Asthma Consider Magnesium infusion. warn ITU. warn ITU. Erythema. Hydrocortisone (200mg IV) Ipratropium Bromide (500mcg) neb. Repeat continuously if needed. feeble respiratory effort Bradycardia or Hypotension Exhaustion. CXR . Breathing: Wheeze.* * * * * * * * * Bleeding disorder * * Treatment: Sit patient up. 100% O2 Salbutamol (5mg) with O2. Oedema. Management: . Hydrocortisone (200mg IV) Ipratropium Bromide (500mcg) neb. Head injury Previous haemorrhagic CVA Consider Magnesium infusion. Hypotension. cyanosis. CVA within 6 months Brain tumour Treatment: Active peptic ulcer Active bleeding (not menstruation) * * Sit patient up. If severe. Aminophylline or salbutamol infusion. 100% O2 Salbutamol (5mg) with O2. Anaphylactic Shock Signs of Life-threatening attack: Peak flow < 33% of predicted or best Silent chest. confusion. Urticaria.

treat for asthma.5ml of 1:1000 (=0. coma. NG Tube if nausea/vomiting/unconscious. osmolality. 5. Notify surgeons (Endoscopy for diagnosis/control bleeding). 1L over 1hr. Draw bloods (FBP. Tests: Lab glucose. Be guided by clotting screen results. urine ketones & MSU. HCO3. May need ventilatory support. Correct clotting: Vit K. * Assess for shock: Cold nose and fingers Slow capillary refill Pulse>100/min Systolic BP < 100mmHg Urine output < 30ml/hr * If shocked: Protect airway. Rapid IV colloids If still shocked: group specific or O-ive blood until cross-match. Management: Cross-match 6 units. FBP. Be guided by the response. and Intensive care. U+E. Nil by mouth. Acute upper GI bleed * * * * Call Crash Team Open airway – position. blood gases. lethargy. Respiratory Arrest ABCDE. vomiting. Ischaemic Chest Pain . hyperventilation. Expect tachypnoea and signs of dehydration +/. (If not still shocked and not liver failure. adjuncts Bag-valve-mask ventilation with supplementary oxygen Definitive Airway – LMA or ETT 8. Careful if >65years or CCF. 7. High-flow O2. repeat each 5 minutes if needed IV Access Chlorpheniramine 10mg IV Hydrocortisone 200mg IV IV fluid resuscitation with saline or colloid (eg 500ml per 15 minutes). Diabetic Ketoacidosis Dehydration is more life threatening than any hyperglycaemia. ketotic breath. Monitor vitals each 15 minutes. If > 20mmol/L give 10 units soluble insulin (actrapid) IV. 1L over 4hr. FFP. Plasma glucose. Insulin sliding scale with hourly blood glucose tests. 0. 1L over 2hr. and urine output (>30ml/hr). 2 large cannulae. U+E.5mg). Be guided by response to successive fluid challenges If wheeze. * * Signs & symptoms: Polyuria. glucose.* Secure Airway High-flow Oxygen If respiratory obstruction imminent – intubation & ventilation Adrenaline IM.shock IV Fluids (Saline 1 litre stat. IV saline to keep lines open). abdominal cramp. manoeuvres. dehydration. LFT. Dextrose saline when glucose<15mmol/L). clotting screen). Potassium replacement – be guided by regular U+E measurement 6. blood culture.

MAN.5mg/kg SC OD If shocked or hypoxic despite high-flow oxygen – consider thrombolysis or surgical embolectomy TED stockings VQ scan or CT Pulmonary Angiography to confirm diagnosis . SANTOS R. Aspirin 9. Nitrate PREPARED BY: MARILYN M.* * * * Morphine * Warfarin for 6 months Oxygen Thank you…….N. Pulmonary Embolus * * * * * * * * A/B/C/D as usual Oxygen Fluid challenge if shocked ABG/CXR/ECG LMW Heparin eg Enoxaparin 1.