Common on-call scenarios [advanced]

Common causes

1. Mechanical
2. Dehydration
3. Postural hypotension
4. Confusion (electrolyte abnormality/ dementia/ sepsis)
5. Arrhythmia
6. 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

Common causes

1. Dehydration/ hypotension
2. Sepsis
3. Arrhythmia, e.g. AF
4. PE
5. 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

Common causes

1. Fluid/blood loss
2. Sepsis
3. Cardiogenic shock
4. 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)

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)

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

Common causes

1. Musculoskeletal
2. Arrhythmia
3. PE
4. MI/angina
5. 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

Common causes

1. Anxiety
2. COPD/asthma
3. PE
4. Pneumonia
5. Pneumothorax
6. Atelectasis
7. Arrhythmia
8. 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

Common causes

1. Dementia
2. Delirium
3. Drugs (e.g. opiates)
4. Sepsis
5. Electrolyte abnormality
6. Neurological pathology (e.g. cerebral haemorrhage)
7. Respiratory acidosis if CO2 retainer
8. 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