Global Recognition and Assessment of

the Sick Patient and Initial Treatment

Karibuni

GRASP IT
Who are we?
Sister Hazel Robinson

Matron Ellie Forbes

Dr Mike Swart

Dr Matt Halkes
Why are we here?

For over a decade it has been well
recognised that managing the acutely
unwell patient can be a challenge to
both nursing and medical staff.
UK
• Poor monitoring of vital signs (respirations)

• Abnormalities in Airway, Breathing, Circulation not recognised

• Not acting on clear signs of deterioration

• Failure to use systematic approach to assessment

• Poor teamwork and communication

• Late referrals to senior staff
ALERT (Acute Life Threatening Events Recognition and
Treatment)

SOS (Stabilisation of the Sick)
ALERT (Acute Life threatening Events Recognition and
Treatment)

SOS (Stabilisation of the Sick)

GRASP IT (Global Recognition and Assessment of the Sick
Patient and Initial Treatment)
GRASPIT

Early detection

Systematic approach

Minimal equipment
GRASPIT

Early detection

Systematic approach

Minimal equipment

Save lives!
Survival

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50%

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Survival

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Survival

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50%

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Survival

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Survival

100%

50%

Cost
0%
Programme
Patient assessment

Breathing problems

Shock
Scenarios
Paediatric patient

Reduced level of consciousness

Communication

Pain management
Before we start……!!!!

Is it easy to spot a sick patient?
DETERIORATION FOLLOWS POOR RECOGNITION OF
ABNORMAL VITAL SIGNS

Respiration

Blood pressure

Pulse

Temperature

Pain
Use a structured approach
when assessing patients.
• A irway
• B reathing
• C irculation
• D isability
• E xposure
At each stage…
• Look
• Listen
• Feel
• Start corrective treatment before moving
on

• Consider calling for help
Airway
• Listen
– Talking
– Noises?
• Look
– Colour
– Paradoxical chest movements
– Dentures/food/secretions
• Feel
– Air movement
• How to open an airway:
– Head tilt/chin lift
– Jaw thrust
– Suction
– Adjuncts
– Recovery position
• Don’t forget…
All sick people
need high flow
oxygen
Call for help ?
Breathing
• Look • Listen
Colour – Wheeze
– Rate – Crackles
– Rhythm – Silence
– Depth
– Symmetry
– Sp02
• On what oxygen?
• Good trace?
Circulation
• Look
– Colour
– Pulse
– BP
– Urine output
– Lift bedclothes- blood/diarrhoea
• Listen
– ? new murmur
• Feel
– Skin temperature

– Pulses

– Capilliary refill
• Press centrally for 5 seconds
• Release
• Should return to normal colour in 2 seconds
Correcting ‘C’ Problems
• Put head down & legs up
• IV access
– Bigger the better
– Secure ++
• Give fluid bolus
– 200-500ml Normal Saline
– Give over <5 min
– Re-assess
Call for help ?
Disability
• Look
– Head injury
– AVPU
– Pupils
– D on’t
– E ver
– F orget
– G lucose
AVPU scale
A Patient is A lert

V Patient responds to V oice

P Patient responds to P ain

U Patient is U nresponsive
Exposure
• Top to toe examination.

• Check temperature- warm/cool?

Call for help ?
What else might you consider?
• Notes (PC, PMH, Drug History)
• Have we given everything that has been
prescribed (drugs,fluids,oxygen)
• Other tests / investigations

What is your plan?
Questions?
The breathless patient
What might cause an upper airway problem?
What could cause a problem here?
Respiratory assessment
• Look • Listen
Colour Wheeze
Rate Crackles
Rhythm Silence
Depth
Symmetry
Sp02
• On what
oxygen?
• Good trace?
Correcting ‘B’ Problems
• High flow oxygen
• Sit the patient up
• If known asthma/COPD give nebulisers
• Treat pulmonary oedema
• If reduced level of consciousness + poor
respiratory effort- BVM

Call for help ?
Ongoing assessment

Monitoring (Respirations &
SpO2)

?ABGs

Response to treatment.
Ongoing treatment
Supplemental oxygen
Treatment of underlying condition
Antibiotics
Positioning (physiotherapy)
Bronchodilators
Corticosteroids

 Consider escalating care
Nasal prongs
- maximum flow rate ~ 4-6 l/min delivers approx 24-
50% Oxygen
Simple face mask

-flow rate 5 – 15 l/min oxygen delivery 35 - 60%
Venturi masks
oxygen delivery depends on adapter used
24%, 28%, 31%, 35%, 40%, available
Non-rebreathe mask

-flow rate 15 l/min
- oxygen delivery approx
85%
PULSE
OXIMETER
What does a pulse oximeter do?

• An oximeter measures the oxygen
saturation of haemoglobin (Hb) in the
arterial blood with each heart beat.
How does it work?

• The probe shines light through the tissues to the
blood and then measures the light reflected back

• Oxygenated and deoxygenated haemoglobin
absorb different amounts of light and the oximeter
uses this to determine the SaO2 as a %

• It also measure the heart rate
Where can the sensors be applied?

• Finger
• Earlobe
• Toe

• Any skin surface from which a reliable signal can
be obtained

• Can cause pressure damage if too tight
> 95% OK
Continue to monitor
91 to 94% problem?
• Check probe
• A and Oxygen
• B
• C
• D
• Call for help
< 90% Action!
• Check probe
• Call for help
• A and Oxygen
• B
• C
• D
Errors and problems
• Probe not correctly applied or displaced

• Movement or shivering

• Low blood pressure

• Cold

• Bright light

• Nail varnish or henna dye

• Smoke inhalation (carbon monoxide)

• Unconscious and on oxygen (carbon dioxide)
Pulse Oximeter
• Does not replace
A
B
C
D
E
Questions?
Global
Recognition and
Assessment of the
Sick
PAEDIATRIC
Patient and
Initial
Treatment.
Spotting a sick child
• Effort of breathing
• Exceptions
• Efficacy of breathing
• Effects of respiratory inadequacy
ABCDE
• STRUCTURE – LOOK, LISTEN & FEEL
• A structured approach is crucial and should be done in a
logical, sequential order using:
• Airway ventilation (+/- c spine)
• Breathing hypoxia / oxygenation
• Circulation hypovolaemia / perfusion
• Disability conscious level
• Exposure fully examine child
ABCDE
• Airway - is the airway clear, compromised or
obstructed?
Anatomically
Airway differences
Anatomical differences
• Big head (especially occiput)
• Positioning may be affected by relatively large occiput in
infants
• Short neck
• Big tongue
• “Floppy” epiglottis
• Larynx is anterior and high in the neck
• Narrow point at cricoid ( up to - 10 years)
• High heart
• Vulnerable abdominal organs
Why do children desaturate
faster than adults?
Signs of airway compromise
• See-saw respirations
• Stridor
• Drooling
• Increased work of breathing
• Reduced or absent air entry
• Low / falling SaO2
Breathing
• Respiratory rate
• Work of breathing
• Accessory muscle use
• Nasal flaring
• Grunting
• Oxygen saturations
• Colour.
Physiological differences
• Babies < 6 months are obligate nasal
breathers: blocked nose = blocked airway

• Ventilation is mainly diaphragmatic – if
diaphragm movement is impeded tidal
volume is reduced (eg full stomach)

• Trachea & bronchi are smaller – a minimal
obstruction makes a big difference to flow
Respiratory
Circulation
• Pulse
• Palpate pulses
peripherally and centrally
• Temperature
• Capillary refill time
• Blood pressure
• Accurate fluid intake and
urine output.

Give 20mls/kg bolus of 0.9%
normal saline
Circulatory compromise
capillary refill time
peripheral - central temperature
difference
• skin colour
• altered level of consciousness
• poor or absent peripheral pulses
(urine output)
• (blood pressure)
Disability
• Responsiveness using
AVPU are they
Alert
responding to Voice

responding to Pain

or Unresponsive
• Pupil size

Don’t Ever Forget Glucose.
Exposure
• Look front and back and head-to-toe
• For bleeding, bruises, breaks and burns.
Other Paediatric points
• Unfamiliarity
• Communication
• Refusal of food /
special toys is BAD!
• Perception
• Previous experience
• Strong survival instinct
• Our own anxiety /
uncertainty / fears
Now what?

• Assess ABCDE
• Get help
• High flow O2
• Positioning – sit up if alert/able
• DO NOT distress the child
• Treatment for specific problem (eg wheeze)
• Reassess
The Hypotensive Patient

GRASP IT
Normal blood pressure?

Hypotension

Shock
What is a normal blood
pressure?
What is a normal blood
pressure?
• Depends on the patient

• Systolic less than 100

• Beware the hypertensive patient
Shock

Blood pressure insufficient to perfuse
tissues

Hypotension + organ dysfunction

Does not correlate to a set number
Signs of Shock
• Hypotension
• Cold, clammy and pale skin
• Rapid, weak, thready pulse
• Shallow, rapid breathing
• Oliguria
• Cyanosis
• Confusion
• Loss of consciousness
Case Study

Case study
Assessment/Management
• AB Open airway/high flow O2
• C
– BP
– Pulse
– Capillary refill
– Skin temp
– Urine output
– Respiratory rate
• D
– Level of consciousness
• E
Assessment/Management
• Head down
• IV access
• Fluid challenge
Fluid challenge
• 500ml over <5min
• Assess response
– No response
– Transient response
– Sustained response
• If no/transient response- REPEAT
• If you suspect cardiac cause, or pt known
to have heart failure- use 2OOml instead
What Fluid?
• Colloid vs crystalloid?
– Probably no difference
– Avoid huge volumes ‘normal’ saline

• Blood
– If patient is bleeding
– Do not aim to restore normal BP until bleeding
is controlled
– Clinically severely anaemic child
Assessment/Management
• Head down
• IV access
• Fluid challenge

REASSESS
• Further fluid?
• Increase frequency of monitoring
• Urine output

• What is the underlying cause?
What determines Blood Pressure?

Volume of water
What factors affect in the system
the pressure in
these pipes?
Pump
Effectiveness of
the pump

Diameter of the
pipes

Pipes
How does this help us?
• Is the hypotension caused by a problem
with:

– Filling?

– Pump?

– Blood vessels?
Shock
• Can be divided into types:

– Hypovolaemic (filling)

– Cardiogenic (pump)
– Obstructive (pump)

– Distributive (vasodilation)
Hypovolaemia
Hypovolaemia

• Haemorrhage
• Sepsis
• Dehydration e.g D&V
• Burns
Impaired Cardiac Function
Impaired Cardiac Function
• MI
• Arrythmias
• Valve dysfunction
• Drugs
• Electrolyte disturbance
• Aortocaval compression
• PE
• Tamponade
Vasodilation
Vasodilation
• Sepsis
• Drugs
• Regional anaesthesia (spinal/epidural)
• High spinal cord injury
Case Study
• ABCDE assessment
• Initial treatment
Case Study
• ABCDE assessment
• Initial treatment

• Consider underlying cause
– ? filling problem
– ? pump problem
– ? vasodilatation
Summary
• Hypotension can be caused by
– A filling problem
– A pump problem
– A resistance problem

• Assess and treat according to ABCDE

• Give a fluid challenge and measure response

• Consider the underlying cause
Questions?

GRASP IT
The Patient with Oliguria
Definition of Oliguria
• Production of between 100-400 mls of
urine per day.

• Or < 0.5mls/kg/hr

• Early sign of deterioration in a patients
condition

• If oliguria is not corrected acute renal
failure may occur
Normal Urine Output
Normal Urine Output
Depends on
•Adequate blood supply

•Functioning kidney

•No obstruction
Types of Renal Failure
Pre-Renal
•Inadequate blood
supply

Intra-Renal
•Abnormal kidney

Post-Renal
•Obstruction
Pre-Renal failure
• Dehydration
• Haemorrhage
• Sepsis
• Myocardial Infarction
• Arrhythmias
• Renal artery stenosis; thrombus
Intra-Renal Failure
• Acute Glomerulonephritis

• Nephrotoxic drugs

• Streptococcal infections

• Acute Tubular Necrosis; severe
ischaemia/poisons, toxins
Post-Renal Failure
• Enlarged prostate gland

• Kidney stones

• Clots

• Tumours

• Urethral obstruction
The Patient with Oliguria

Questions to ask yourself

•Is the patient perfusing properly (adequate BP)

•If not, why not?

•Have we poisoned the kidney?

•Could there be an obstruction?
Questions?

GRASP IT
The patient with a decreased
conscious level
Aims of this session
Discuss the causes of reduced level of
consciousness

Assessing LOC

Treating LOC
• Things inside the head

• Things outside the head
Inside the head
• Infarction
• Injury
• Infection
• Bleed
• Tumour
Outside the head

• Due to lows

• Due to highs
Outside the head- Due to lows

• Low oxygen!!
• Low BP
• Low glucose • Low sodium
• Low temperature
common • Low thyroid
Outside the head- Due to highs

• High CO2

• High Temperature

• High level of drugs, alcohol, poisons
Assessment of the patient

Airway
Breathing
Circulation

Disability
Assessing- D
 Conscious level

 Pupils

 Blood sugar
Assessment Of Conscious Level

• AVPU

• GCS
Assessment Of Conscious Level
• Is the patient Alert?

• Does the patient respond to Voice?

• Does the patient respond to Pain?

• Is the patient Unresponsive?
New Onset Confusion

This does not form part of the AVPU
assessment but new onset confusion
should always prompt concern about
potentially serious underlying causes and
warrants urgent clinical evaluation
Assessment Of Conscious
Level

Pupils
• What size?

• Are they equal?

• Are they reactive?
Assessment Of Conscious
Level

Blood Sugar
ABC…
•Don’t
•Ever
•Forget
•Glucose!
Summary

• A decreased level of consciousness is common in
acute illness.

• Hypoxaemia, hypoglycaemia and hypotension are
common causes.

• Treatment is focused on care of airway, breathing
and circulation prior to assessing the patients
conscious level.
Questions?

GRASP IT
PAIN MANAGEMENT
‘no-one ever died of pain’
‘no-one ever died of pain’
System Effect Consequence
General

Respiratory

Cardiovascular

GI

Neuroendocrine

Psychological
‘no-one ever died of pain’
System Effect Consequence
General Immobility Pneumonia
Thromboembolus
Muscular atrophy
Pressure sores

Hyperventilation Pneumonia
Respiratory Hypoventilation Hypoxaemia
Physio intolerable
Hypertension cardiac work
Cardiovascular Tachycardia O2 delivery
Vasoconstriction Ischaemia & infarction
Nausea Dehydration
GI Ileus Electrolyte imbalances
Malnutrition

Neuroendocrine  stress response  healing
Imunosuppression infection risk

Anxiety, Fear Loss of confidence
Psychological
Basic Principles

Pain assessment

Provide appropriate treatment

Review regularly and change if necessary
Assessment of Pain

• Best method involves self-reporting

• Observation is unreliable

• Functional assessment important
– deep breathing, coughing,
– physio, mobilisation
Measuring pain
1.Visual analogue pain scale
0 10

2.Wong and Baker faces

3.Pain score
Mild =1
Moderate =2
Severe =3
Assessment
Torbay Observation Chart

PAIN the 5th
VITAL SIGN (1992)

American Pain Society (1992)
Link Pain Intensity to Strength
of Analgesia
S
E ADVANCED ANALGESIA
V
E
M R
O E
D
E INTERMEDIATE ANALGESIA
R
A
T
M E
I SIMPLE ANALGESIA
L
D
ANALGESIC LADDER
 STEP 4
Paracetamol + NSAID
Oral opioid
IV / IM Opioids
LA/ Blocks Epidural
 STEP 3
Paracetamol + NSAID
Oral opioid
 STEP 2
Paracetamol + NSAID
 STEP 1
Paracetamol
SYNERGY
Combinations of drugs are more effective
than using one alone

Due to different mechanisms of action
and
effect on different types of pain
SIDE-EFFECTS
• Codeine
– constipation

• NSAIDS
– gastric bleeding
renal impairment
anticoagulants
heart failure

• Opiates
– nausea / vomiting
sedation
respiratory depression
SIDE-EFFECTS

Addiction to Opioids

Almost never occurs when
treating acute pain
Questions?

GRASP IT
Using a communication tool to
boost patient outcome

SBAR
S SITUATION

B BACKGROUND

A ASSESSMENT
R RECOMENDATION
SITUATION
Who you are

Where are you phoning from

Name of the patient

Main problem!
BACKGROUND

Admitting diagnosis

PMH

Treatment to date
ASSESSMENT

Your assessment of the
situation
RECOMMENDATION

What do you want from the person?

Is there anything I can do before you get here?

Document the call!

If you don’t get a timely response try again and consider
escalating to a more senior person.
Preparation
is
key
SUMMARY

Dr Michael Swart michael.swart@nhs.net

Dr Matt Halkes matthew.halkes@nhs.net

Hazel Robinson hazel.robinson1@nhs.net

Ellie Forbes ellie.forbes@nhs.net
Thank you all for listening