ATO E ASSESSMENT ATO E ASSESSMENT A AIRWAY Can patient speak? Any added noises? (e.¢. stridor If airway compromised: 1. Head tilt, chin lift / jaw thrust 2. Airway adjunct (naso/ oropharyngeal tub B BREATHING y e Oe <24% = aon non- Srepreatie mask . Chest Salpation; percussion, aascultstion * ABG &CXR 3 C CIRCULATION ol ACCESS 2x wit bore cannulae CRP Clotting, V8G, G&S, Culture * Pulse, WP, Central CRT, Heart sounds * 3-lead cardiac monitor or 12-lead ECG D __ DISABILITY ev * GCS + Pupils (size & refle * Capillary blood glucose EXPOSURE u * Temperature, Any bleeding / Rashes / Injuries * Abdominal palpation & Bowel sounds+A to E Assessment * Anaphylaxis * Acute Asthma * COPD Exacerbation * Deep Vein Thrombosis / Pulmonary Embolism + Diabetic Ketoacidosis * Hyperglycaemic Hyperosmolar State * Hypoglycaemia * Hyperkalaemia i * Addisonian Crisis * Status Epilepticus * Cerebrovascular Accident * Upper GI Bleed * Sepsis + Acute Pulmonary Oedema « Acute Coronary Syndrome * Acute Arrhythmias * Cardiac ArrestDIABETIC KETOACIDOSIS DIABETIC KETOACIDOSIS ABCDE & Confirm diagnosis * Capillary Ketones >3 (urinary ketones >2) * Blood glucose >11mmol/L * pH <7.35 (bic <15mmol/L) ¥ 'V FLUIDS 0.9% Sodium Chloride (1L in 1 hour) then 2L over 2 ours then 2l over ¥ HIGH DOSE FIXED RATE INSULIN 0.1 units/kg/hr ¥ + Potassium replacement (if <5.5) + Glucose replacement (when <14mmol/L) * Blood glucose & ketones ° VBG ° Urine output & UEs + Neurological status * Encourage oral intake * Diabetic nurse review * Switch to SC insulin once stableACUTE CORONARY SYNDROME ACUTE CORONARY SYNDROME ABCDE & confirm diagnosis * History & Examination * 12-lead ECG & TROPONIN * Bloods (FBC, CRP, lipids, glucose, clotting) ¥ Morphine + Metoclopramide (5-10 Oxygen (if <92%) Nitrates (SL GTN spray) rP2o0o6 Aspirin (30: Antiplatelet (c Anticoagulant |e at \ < 120 mins: PCI * GRACE & DAPT scores > 120 mins: thrombolysis * Angiography * +/- Revascolerisation lor) x)CEREBROVASCULAR ACCIDENT CEREBROVASCULAR ACCIDENT ABCDE & confirm diagnosis * History & Neurological Examination * Bloods (FBC, CRP, lipids, glucose, clotting) * ECG * CT/MRI ISCHAEMIC HAEMORRHAGIC <4.5 hours: thrombolysis ree REVERSE <6 hours: thrombectomy * Vitamin K (warfarin) i * Protamine Sulphate (heparin. + ANTIPLATELETS @ * 300mg aspirin (2 weeks) * 75m clopidogrel BP CONTROL Fifel ifelong) IV labetalol ev Neurosurgical review 1° Monitor: BP, 02, Temperature, Glucose ' ' * DVT prophylaxis: IPC stockings ' | + Rehab: SALT, Physio, OT ' | Address Risk Factors: AF, hypertension, CVD 'UPPER GI BLEED UPPER GI BLEED ABCDE A: Secure airway Bs: 15L O2 (if <92%) C: Lie flat, 2 wide bore cannulae ¥ BLOODS FBC, UE, LFT, VBG, Clotting, Cross Match ev FLUID RESUSCITATION 500m! 0.9% sodium chloride bolus ev ACTIVATE MAJOR HAEMORRHAGE PROTOCOL * Packed RBCs * Fresh Frozen Plasma + +/- platelets +/- cryoprecipitate tb Consider IV PPI & Terlipressin if Alert G! Consultant variceal bleed * Calculate Glasgow-Blatchford Score * Keep NBM & order OGD * Consider prophylactic antibioticsDVT/PE DEEP VEIN THROMBOSIS CALCULATE WELLS’ DVT RISK SCORE 4 Score <2 Score 22 Low risk of DVT ea tisk of DVT = D-DIMER rz uss Rule out Ss Urgent uss <5 cou DVT , Repeat USS nag | in5-7days | (DOAC or LMWH) wad out Repeat USS in 5-7 days PULMONARY EMBOLISM CALCULATE WELLS’ PE RISK SCORE Score <4 Score >4 Low risk of PE Moderate/High risk of PE a ne = + D-DIMER) Urgent CTPA | -ve ve /VQSCAN Rule out °° Urgent CTPA i /VQSCAN Consider other causes of symptoms Consider other ANTICOAGULATE* causes of symptoms {DOAC or LMWH) “if massive PE = thrombolysis (altepiase)ACUTE ASTHMA ACUTE ASTHMA O Oxygen (151 non re-breathe) §S Salbutamol (s H_ Hydrocortisone (100mg !v) Prednisolone (50m¢ PO) Ipratropium (0.5 Theophylline / Aminophylline (\v) Ifno improvement Get senior help T M Magnesium sulphate (\v) E Escalate (consider ITU) | DISCHARGE PLAN | * Sdays PO prednisolone | * GP review in 1-2 days | * Respiratory clinic referral Only Discharge When: 1) PEF > 70% 2) Established on PO medications for >12 hoursHYPERKALAEMIA HYPERKALAEMIA >6mmol/L ABCDE & assess for ECG changes * Flattened P wave K+ 6- 6.4 mmol and “Tented | wave * Broad QRS K+ 26.5 mmol or ECG changes CALCIUM GLUCONATE 10ml of 10% calcium gluconate over 5 mins U IV INSULIN + GLUCOSE e.g. 10 units ActRapid in 250ml 10% dextrose y Assess for and treat underlying cause +/- Salbutamol nebs NO ECG changes Tented T wave Flattened P wave a Broad QRSSTATUS EPILEPTICUS STATUS EPILEPTICUS ABCDE & confirm diagnosis + FBC, UE, LFT, CRP, Calcium * GLUCOSE LEVELS * Drug levels * ABG & ECG BENZODIAZAPINE 1-4mg IV lorazepam or PR diazepam Repeat in 5-10 minutes ¥ Call Anaesthetist ev IV ANTICONVULSANT e.g. Sodium Valproate or Phenytoin ¥ ITU for sedation and intubation * If known epileptic, check AED* levels > may ne« cT To: een ' ' ' ' * If no known epilepsy, investigate further if no clear cause i ‘ MRI/ ‘ i ‘ ' ' ' t 'HYPERGLYCAEMIC HYPEROSMALR STATE HYPERGLYCAEMIC HYPEROSMOLAR STATE ABCDE & Confirm diagnosis * Capillary Ketones <3 (normal) * Blood glucose >30mmol/L * pH >7.3 (bicarb >1Smmol/L) * OSMOLALITY* >320 mOsm/kg iy Osmolality = 2Na + venous ie neal glucose + urea 0.9% Sodium Chloride (1L in 1 hour) aim to replace 3-61 in first 12 hours ¥ FIXED RATE INSULIN 0.05 units/kg/hr only if ketones >1 or glucose is falling by / lontrop P / lontropes i & MONITORING | ' t ' * ABG - ECG ' 1 = CXR + Urine output}COPD EXACERBATION COPD EXACERBATION O = Oxygen 88-92% (Venturi mask) S — Salbutamol (5 | Ipratropium (o If 22 of: 0) } sputum T purulence T dyspnoea +/- Antibiotics 5-7 days (e.2. PO doxycycline) ¥ If no improvement consider non-invasive ventilation P Prednisolone (3 | INVESTIGATIONS | | DISCHARGE PLAN ' tot ' * ECG, BP, G2 sats {1 * 7 days PO prednisolone ' te ABG ‘4 . Sie a t 1+ CXR ' +/-5-7 days PO antibiotics ' ' * Sputum MCS ' hd GP/ Respiratory team review ' 1s BLOODS (Fé MiHYPOGLYCAEMIA HYPOGLYCAEMIA <4mmol/L CONSCIOUS / CAN SWALLOW 15-20g fast acting carb (glucogel / 150ml fruit juice) Repeat blood glucose in 10-15 mins mam 15-208 short J acting carb 20g long acting carb (2 biscuits) UNCONSCIOUS / CANNOT SWALLOW ABCDE t 100ml 20% Glucose IV or img Glucagon IM § Repeat blood glucose in 10-15 mins amp 20g long acting carb (2 biscuits)SEPSIS SEPSIS ABCDE *15L02 / eiVAccess _ “iitical Care referral if no improvement s ati bo Bloods * ABG (lactate) * FBC, CRP, UE, LFT, glucose * Clotting screen * BLOOD CULTURES v Other Investigations to identify source CXR, Urine MCS, Sputum MCS, Wound swabs ¥ 1V ANTIBIOTICS As per local guidelines > WITHIN 1 HOUR sv IV FLUIDS 500m! 0.9% sodium chloride if in shock i MONITORING ' | © BP,RR,HR + GCS ' ' * Lactate * Urine output ‘CARDIAC ARREST CARDIAC ARREST DANGER RESPONSE *call for help* AIRWAY — | lif BREATHING — s look, lister CIRCULATION ~ central pulse *call 999 / crash team* START CPR 30:2 Compressions + Bag & Mask ¥ ATTACH AED r Assess Rhythm a SHOCKABLE NON-SHOCKABLE VF or Pulseless VT Asystole or PEA G 3 35 v SHOCK oe ‘Img 1:10000 Continue CPR 2 mins Every IV adrenaline* 35 Then reassess rhythm ite i tb With 3” shock Continue CPR 2 mins ‘mg 1:10000 IV adrenaline* hen emcees stryoe + 300mg IV amioderone *Repeat adrenaline every 3-5 minsADDISONIAN CRISIS ADDISONIAN CRISIS ABCDE * Check 02, BP, ECG * FBC, CRP, TFTs, UEs, Glucose + ACTH & cortisol 4 IV HYDROCORTISONE $1 years: 25mg 1-5 years: 50mg 26 years: 100mg vy IV FLUIDS (1L 0.9% Sodium Chloride) u + DEXTROSE if low glucose + Monitor & correct other electrolyte abnormalitiesACUTE ARRHYTHMIA ACUTE ARRHYTHMIAS UNSTABLE / SHOCK ABCDE SBP<90/chest pain/ = « 02 15L & IV access aa + 12-Mead ECG & BP | | ‘STABLE SYNCHRONISED DCC ASSESS QRS COMPLEX 3 attempts LN - NARROW 300mg IV & repeat shock REGULAR IRREGULAR B IRREGULAR Get Senior Help! VT: Sme/kg fy arnieenonie REGULAR Rate él 7 _ Beta Blocker/ SVT * BBB: 6mg lV Adenosine Rate-limiting CCB Rhythm control VT: ventricular tachycardia svt if <48hrs SVT: supraventricular tachycardia BBB: bundle branch block * Vasovagal manoeuvres AF: atrial fibrillation * 6mg IV AdenosineANAPHYLAXIS ANAPHYLAXIS ABCDE A: Secure airway B: 15L 02 +/- SABA C: Lie flat, legs raised ¥ IM ADRENALINE 1:1000 = 5 years: 150 micrograms = 0.15ml 6-12 years: 300 micrograms = 0.30ml > 12 years: 500 micrograms = 0.50ml Repeat in 5 minutes if no improvement ¥ + CHLORPHENAMINE 10 mg IV + HYDROCORTISONE 200mg IV FURTHER MANAGEMENT ) * 3-5 days PO prednisolone * ECG, BP, O2 sats * Serum tryptase * Allergy clinic referral ' * GP review in 3-5 days