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Common on-call scenarios

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
  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
Specific management
  • Treat cause
  • Treat injuries
  • Neurological observations as per protocol if hit head or unwitnessed

Tachycardia

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
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
  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
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
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
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
  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
Specific management
  • Treatment-dose clexane if PE likely
  • Initial ACS management + Cardiology referral if MI
  • Analgesia
  • Oxygen if hypoxic

Shortness of breath

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
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
  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
Specific management
  • Treat cause (e.g. antibiotics if infection)
  • Airway placement if GCS <8
  • Suspend/reverse any causative drugs e.g. opiates
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