Table of Contents
Below we have covered some things to consider doing for unwell patients you are bleeped about when on-call (before you escalate to a senior if required).
Fall
Common causes
- Mechanical
- Dehydration
- Postural hypotension
- Confusion (electrolyte abnormality/ dementia/ sepsis)
- Arrhythmia
- Aortic stenosis
Complications
- Mechanical injury
- Cerebral bleed
During call
- Witnessed? Head injury?
- Background
- Observations and GCS
- On anticoagulation?
Before arrival (if possible)
- ECG
- Postural BP
Background
- Read patient notes
- Review latest investigation results
History
- Usual falls history
- NS, CVS, RS systems reviews
- Headache/vomiting/injury
Examination
- Observations & postural BP
- GCS & pupils reactivity to light
- Neurological exam
- Look for injuries
- Skin: bruising/bleeding
- Bone tenderness/shape (inc skull) & flex/rotate hips (fractures)
Investigations
- ECG
- CT head if hit head and: on anticoagulation, 2 or more vomits, focal neurology, suspected skull fracture, GCS decreased by 1 or more, post-traumatic seizure
- Sepsis Ix if differential (see temperature spike)
- X-ray any possible fracture
ABCDE management
- See ABCDE
Specific management
- Treat cause
- Treat injuries
- Neurological observations as per protocol if hit head or unwitnessed
Tachycardia
Common causes
- Dehydration/ hypotension
- Sepsis
- Arrhythmia, e.g. AF
- PE
- Acute pain
Complications
- Reduced myocardial function
- Arrhythmia
During call
- Background
- Observations
Before arrival (if possible)
- ECG
Background
- Read patient notes
- Review latest investigation results
History
- Determine any symptoms
- Full systems review
Examination
- Observations
- Assess fluid balance
- Look for infection sources
- Multi-system exam
- Calves (DVT)
Investigations
- ECG
- U&Es + VBG
- Sepsis Ix if differential (see temperature spike)
ABCDE management
- See ABCDE
Specific management
- Treat cause
- Analgesia
- Correct electrolytes
- Empirical antibiotics if required
- Fluids
- If AF, consider rate limiting medication
- If arrhythmia with SBP<90, get help
Hypotension
Common causes
- Fluid/blood loss
- Sepsis
- Cardiogenic shock
- Anaphylaxis
Complications
- Acute kidney injury
- Reduced GCS
- End organ failure
During call
- Background
- Observations
- Fluid balance
Before arrival (if possible)
- ECG
Background
- Read patient notes
- Review latest investigation results
History
- Determine any symptoms
- Full systems review
Examination
- Observations + GCS
- Assess fluid balance and urine output
- Hydration status exam (inc pul/pedal oedema)
- Look for infection sources: multi-system exam + look at surgical wounds, drains, chest
Investigations
- Image possible sources of fluid loss
- CXR if pulmonary oedema
- Sepsis Ix if differential (see temperature spike)
- VBG (lactate)
Assess end organ perfusion – urine output, lactate, GCS
ABCDE management
- See ABCDE
Specific management
- Fluid challenges
- Monitor urine output
- Treat cause
- May need inotropic support in ITU if in shock (hypotension unresponsive to fluid resuscitation)
Temperature spike
Common causes
- Infections (e.g. chest, UTI)
- SIRS (sepsis most common cause)
- Post-op
- Surgical collections
- <2d = atelectasis
- 2-4d = pneumonia
- 4-6d = anastomotic leak
- 6-8d = wound infection
- 8-10d = DVT/PE
Complications
- Fluid loss
- Overwhelming sepsis
During call
- Background
- Observations
Before arrival (if possible)
- Bloods and cultures
- Urine dip
Background
- Read patient notes
- Review latest investigation results
History
- Determine any symptoms
- Full systems review
Examination
- Observations
- Sepsis signs (cap refill, skin temp, pulse etc)
- Look for infection sources: multi-system exam, iatrogenic causes (surgical wounds, drains, lines), exposure (look at skin, joints, peri-anal area)
Investigations
- Full septic screen:
- Bloods (WCC, Hb, plt (DIC)), blood cultures, VBG (lactate)
- Urine dip
- Culture any other fluids, e.g. drains
- CXR
- Consider other imaging depending on background, e.g. CT abdomen if post-general surgery
ABCDE management
- See ABCDE
Specific management
- Treat cause e.g. targeted Abx
- Oxygen/saline nebs/ salbutamol nebs/physio if chest
- If septic:
- Sepsis six
- Surgery may be needed in some cases (joint/abdo/necrosis sepsis)
Low urine output
Common causes
- Hypovolaemia
- Blocked catheter
- Acute kidney injury
- Pre: hypotension
- Renal: acute tubular necrosis, nephrotoxic medications, GN
- Post: urinary obstruction/retention
Complications
- Acute tubular necrosis/acute kidney injury
During call
- Background
- Observations
- Fluid balance
- Bladder scan (if done)
Before arrival (if possible)
- Flush/change catheter
- Bladder scan
Background
- Read patient notes
- Review latest investigation results
History
- Determine any symptoms
- Full systems review
Examination
- Observations
- Assess fluid balance
- Multi-system exam
- Hydration status exam (esp pulmonary/peripheral oedema)
- Examine/flush catheter
Investigations
- U&Es + VBG (acidosis/low bicarb/hyperkalaemia)
- Urine dip
- Bladder scan (to determine if it’s urinary retention i.e. >500ml or true low UO)
- Consider renal USS
ABCDE management
- See ABCDE
Specific management
- Fluid bolus and reassess (repeat bladder scan if no ↑UO)
- Stop renal excreted drugs
- Catheterise (relieve retention /accurately monitor fluid balance) or flush catheter
- Treat cause e.g. fluids for pre-renal, relieve obstruction for post-renal
Chest pain
Common causes
- Musculoskeletal
- Arrhythmia
- PE
- MI/angina
- Oesophagitis/ oesophageal spasm
During call
- Background
- Observations
Before arrival (if possible)
- ECG
- BP in both arms
Background
- Read patient notes
- Review latest investigation results
History
- SOCRATES
- RS & CVS system review
- Risk factors
Examination
- Observations
- BP in both arms
- Cardiorespiratory exam
- Examine calves
Investigations
- Bloods, inc. D-dimer if low wells score if PE concerns, cardiac enzymes (now and at 3-12 hours depending on assay) if cardiac
- CXR
- ECG
ABCDE management
- See ABCDE
Specific management
- Treatment-dose clexane if PE likely
- Initial ACS management + Cardiology referral if MI
- Analgesia
- Oxygen if hypoxic
Shortness of breath
Common causes
- Anxiety
- COPD/asthma
- PE
- Pneumonia
- Pneumothorax
- Atelectasis
- Arrhythmia
- Cardiac failure/ overload
Complications
- Cerebral hypoxia
During call
- Background
- Observations
Before arrival (if possible)
- Oxygen if hypoxic
- ECG
Background
- Read patient notes
- Review latest investigation results
History
- Determine any symptoms
- RS & CVS system review
Examination
- Observations
- Cardiorespiratory exam
- Examine calves
Investigations
- Bloods, inc. D-dimer if low wells score and PE concerns, cardiac enzymes where relevant, ABG if low sats
- Sputum culture
- CXR
- ECG
ABCDE management
- See ABCDE
Specific management
- Treat cause
- Sit up
- Oxygen/saline nebs/ salbutamol nebs/ chest physio
- Treatment-dose LMWH if PE likely
Confusion of low GCS
Common causes
- Dementia
- Delirium
- Drugs (e.g. opiates)
- Sepsis
- Electrolyte abnormality
- Neurological pathology (e.g. cerebral haemorrhage)
- Respiratory acidosis if CO2 retainer
- Hypoglycaemia
Complications
- Falls
- Reducing GCS
- Airway compromise
- Progressive disease
During call
- Background
- Pre-morbid state
- Observations
- Drugs given
Before arrival (if possible)
- Capillary glucose
Background
- Read patient notes
- Review latest investigation results
History
- Determine any symptoms
- Full systems review
- Collateral history
- Drug chart (?opiates)
Examination
- Observations & cap glucose
- GCS & pupils & orientation
- Neurological exam
- Sepsis signs (cap refill, skin temp, pulse etc)
- Look for infection sources: multi-system exam + look at surgical wounds, drains, chest, etc
Investigations
- Bloods (inc. calcium) + VBG (lactate)
- ABG if could be CO2 retaining
- Urine dip
- Sepsis Ix if differential (see temperature spike)
- CT head if neurological pathology or excluded all other causes
ABCDE management
- See ABCDE
Specific management
- Treat cause (e.g. antibiotics if infection)
- Airway placement if GCS <8
- Suspend/reverse any causative drugs e.g. opiates