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Common Junior Doctor On-call Bleeps

Table 1: Things to consider doing for unwell patients you are bleeped about when on-call (before you escalate to a senior if required)
Fall Tachycardia Hypotension Temperature spike Low urine output Chest pain Shortness of breath Confusion / GCS

Common causes 1. Mechanical 1. Dehydration/ 1. Fluid/blood loss 1. SIRS (sepsis most common 1. Hypovolaemia 1. Musculoskeletal 1. Anxiety 1. Dementia
2. Dehydration hypotension 2. Cardiogenic shock cause) 2. Blocked catheter 2. Arrhythmia 2. COPD/asthma 2. Delirium
3. Postural hypotension 2. Sepsis 3. Sepsis 2. Infections (e.g. chest, UTI) 3. Acute kidney injury 3. PE 3. PE 3. Sepsis
4. Confusion (electrolyte 3. Arrhythmia e.g. AF 4. Anaphylaxis Post-op -Pre: hypotension 4. MI/angina 4. Pneumonia 4. Electrolyte abnormality
abnormality/ dementia/ 4. PE Surgical collections -Renal: acute tubular 5. Oesophagitis/ 5. Pneumothorax 5. Neurological pathology (e.g.
sepsis) 5. Acute pain <2d = atelectasis necrosis, nephrotoxic oesophageal spasm 6. Atelectasis cerebral haemorrhage)
5. Arrhythmia 2-4d = pneumonia medications, GN 7. Arrhythmia
6. Aortic stenosis 4-6d = anastomotic leak -Post: urinary obstruction/ 8. Cardiac failure
6-8d = wound infection retention
8-10d = DVT/ PE
Complications Mechanical injury Reduced myocardial Acute kidney injury Fluid loss Acute tubular necrosis/ acute - Cerebral hypoxia Falls
Cerebral bleed function Reduced GCS Overwhelming sepsis kidney injury Reducing GCS
Arrhythmia End organ failure Airway compromise
Progressive disease

During call Witnessed? Head injury? Background Background Background Background Background Background Background
Background Observations Observations Observations Observations Observations Observations Pre-morbid state
Observations Fluid balance Fluid balance Observations
GCS
Before arrival ECG ECG Fluid challenge (if no Hx Bloods Flush/ change catheter ECG Oxygen Capillary glucose
(if possible) Postural BP of heart failure) Urine dip Bladder scan BP in both arms ECG

Background Read patient notes + latest investigation results

History Usual falls history Determine any symptoms SOCRATES Determine any Determine any symptoms
NS, CVS, RS systems Full systems review RS & CVS system symptoms Full systems review
reviews review RS & CVS system Collateral history
Headache/vomiting/injury Risk factors review
Examination Observations & postural BP Observations Observations Observations Observations Observations Observations Observations & cap glucose
GCS & pupils reactivity to Assess fluid balance Assess fluid balance Sepsis signs (cap refill, skin Assess fluid balance BP in both arms Cardiorespiratory GCS & pupils & orientation
light Look for infection GCS temp, pulse etc) Multi-system exam Cardiorespiratory exam Neurological exam
Neurological exam sources Hydration status exam Look for infection sources: Hydration status exam (esp exam Examine calves Sepsis signs (cap refill, skin
Look for injuries Multi-system exam (inc pulmonary/ multi-system exam, pulmonary/ peripheral Examine calves temp, pulse etc)
Skin: bruising/bleeding Calves (DVT) peripheral oedema) iatrogenic causes (surgical oedema) Look for infection sources:
Bone tenderness/shape Look for infection wounds, drains, lines), Examine/flush catheter multi-system exam + look at
(inc skull) & flex/rotate sources: multi-system exposure (look at skin, surgical wounds, drains,
hips (fractures) exam + look at surgical joints, peri-anal area) chest, etc
wounds, drains, chest
Investigations ECG ECG Image possible sources Full septic screen: B: U&Es + VBG (acidosis/low B: bloods, D-dimer if B: bloods, D-dimer if Bloods (inc calcium) + VBG
Bloods CT if: 2 or more vomits, U&Es + VBG of fluid loss B: bloods (WCC, Hb, plt bicarb/hyperkalaemia) low wells score, low wells score, (lactate)
Orifice tests pupils problem, severe Sepsis Ix if CXR if pulmonary (DIC)), blood cultures, VBG O: urine dip cardiac enzymes cardiac enzymes, Urine dip
X-rays/imaging headache, GCS decreased differential (see oedema (lactate) X: bladder scan (to (now and at 12 ABG if low sats Sepsis Ix if differential (see
ECG by 1 or more temperature spike) Sepsis Ix if differential O: urine dip, culture any determine if its urinary hours) O: sputum culture temperature spike)
Special tests Sepsis Ix if differential (see (see temperature spike) other fluids retention i.e. >500ml or true O: - X: CXR CT head if neurological
temperature spike) X: CXR, CT abdo if may low UO), consider renal USS X: CXR E: ECG pathology
have surgical collection E: - E: ECG S: -
E: - S: - S: -
S: -
ABCDE See OSCEstop ABCDE notes
management
Specific Treat cause Treat cause Fluid challenges Sepsis six Fluid bolus and reassess Treatment-dose Treat cause Treat cause (e.g. antibiotics
management Neurological observations Analgesia Treat cause of fluid loss Empirical antibiotics as per (repeat bladder scan if no clexane if PE likely Sit up if infection)
as per protocol if hit head Correct electrolytes hospital protocol UO) MONAC + Cardiology Oxygen/ saline nebs/ Airway placement if GCS <8
Empirical antibiotics Crystalloids (20-30ml/kg) Stop renal excreted drugs referral if MI salbutamol nebs/
if required Oxygen/saline nebs/ Catheterise (relieve retention Analgesia chest physio
Fluids salbutamol nebs/physio / accurately monitor fluid Oxygen Treatment-dose
If AF, consider rate Catheterise balance) or flush catheter clexane if PE likely
limiting medication Surgery may be needed Treat cause e.g. fluids for
(joint/ abdo/ necrosis pre-renal, relieve obstruction
sepsis) for post-renal
Other common bleeps include: Assess critically unwell patients (see OSCEstop ABCDE notes); Review blood results or chest x-rays (see OSCEstop interpretation notes); Clerking a new admission (see OSCEstop admission clerking notes); Clerk a patient for operation the following day (see OSCEstop pre-op
assessment notes); Post-operative complications (see OSCEstop post-op complications notes); Fluid prescriptions (see OSCEstop fluids notes); Narrow therapeutic range drug prescriptions (see OSCEstop monitoring narrow therapeutic range drugs notes)
2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students finals OSCE revision