WARNING: take care if COPD (unless they are in respiratory distress/critically unwell and need high-flow oxygen, start at 24-28% venturi and aim for sats 88-92%. Titrate to ABG results. See notes on oxygen therapy.)
Consider non-invasive or invasive ventilation if hypoxaemic, or hypercapnic respiratory acidosis despite maximal therapy
If respiratory effort is inadequate, it must be supported (e.g. ventilate with bag-mask)
Auscultate heart, check JVP and look for signs of fluid overload
Assess fluid balance and organ perfusion (IN e.g. fluids, intake; OUT e.g. catheter/urine, drains, vomit)
Place wide-bore IV Cannula and take bloods (also do VBG for fast results if ABG not required)
Apply 3-lead cardiac monitoring
ECG (if any concern)
Catheter and fluid balance monitoring (if hypotensive/unwell)
Lay supine and elevate legs
Fluid challenge = 500ml 0.9% saline/Hartmann’s solution STAT and monitor response by HR, BP and UO (see prescribing notes on fluids)
WARNING: take care if significant heart failure history (use 250ml if they need it)
2 large bore IV cannulas
Fluid challenge = 1L 0.9% saline/Hartmann’s solution STAT
Replace blood with blood (can give O negative or urgent typing takes 15 minutes). In massive blood loss, call 2222/lab and activate the massive blood loss protocol to get packed red cells + FFP ± platelets
Further management– use clinical judgement and assessment of fluid status
Respond fully: consider maintenance fluids
Responds but BP falls again: may require further fluids (adequate resuscitation depends on patient and degree of deficit but is usually 20-30ml/kg given quickly)
No response: patient may be fluid overloaded/in cardiogenic shock (avoid further fluids) or very deplete (requiring further fluids)
If patient is hypotensive and overloaded, they need inotropes
If patient is still hypotensive despite adequate fluid resuscitation (20-30ml/kg), they need vasopressors
Refer to other specialty if indicated, for example:
Medical registrar: medical problems
Endoscopist on call: upper GI bleeding
Surgical registrar: surgical problems and bleeding
Cardiology registrar: MI/arrhythmia
Gynaecological registrar: ruptured ectopic
Intensive/high-dependency care registrar: if patient may need higher level of care / airway concerns
Document in patient’s notes
Document with a brief case summary, ABCDE headings with findings and management
Review patient and results as necessary
Test your knowledge
You are reviewing a breathless patient on the acute medical unit waiting to be clerked with known COPD, admitted with breathlessness. You undertake an A-E assessment. His airway is patent. His respiratory rate is 32, and the nurse has put him on 35% oxygen via Venturi mask as he had low oxygen saturations. His chest sounds very wheezy. You perform an arterial blood gas.
What does the ABG show?
What would you do next?
The patient has now had all of the treatment you prescribed and you repeat an ABG. This shows ongoing type 2 respiratory failure with acidosis. What would you do now?
You are in the resuscitation area of the emergency department. A male patient is brought in with a low GCS. The patient’s name, details and medical history are unknown. You immediately undertake a rapid A-E assessment:
A: talking but confused
B: RR 8, Sats 91% on air, chest sounds clear
C: BP 122/80, HR 69, capillary refill <2 seconds, nurses unable to succeed in establishing IV access
D: eyes open in response to pain; pupils pinpoint; withdraws from pain but does not follow commands; confused speech; capillary glucose 5.8
E: unkempt; no rashes or bleeding; needle marks noted in groins
What is the patient’s GCS?
What is the likely cause of the low GCS? Which medication would you give (include dose)?
The patient responds and his GCS improves. You also try to insert an IV cannula and have no success. What are the options for IV access?
IV access is established. A couple of hours later the patient’s GCS drops again. What would you do now?
You are asked to see a 49 year old female patient on a surgical ward who has been admitted for an elective Whipple’s procedure for pancreatic cancer. The procedure was undertaken 6 days previously. She has had no other medical problems previously. The nurse has asked you to see the patient because of a high NEWS score. Observations are as follows:
HR 145, BP 98/68, RR 22, Sats 90% on air (improved to 95% on 4L nasal oxygen), temperature 38.2, GCS 15
The nurse has already performed an ECG prior to your arrival. There was a previous normal pre-op ECG 8 days ago.
You examine the patient and hear coarse crepitations in the left lower zone posteriorly. Heart sounds are normal but irregular. Mucus membranes look dry. You are unable to see the JVP. There is no peripheral oedema or rashes. The surgical wound is clean.