Common on-call scenarios [advanced]

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

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

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)

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

• 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

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

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