managing common ward calls

Managing Common

Ward Calls

Dr Lauren Wimetal

Emergency Consultant - Casey Hospital

Hypotension

• A and B come before C!

• Consider the cause

• Normal for patient

• Hypovolaemic shock

• Haemorrhagic shock

• Obstructive shock

• Neurogenic shock

• Cardiogenic shock

• Distributive shock

Hypotension

• Assess end-organ perfusion

• Mentation

• Urine output

• Assess volume status

• JVP, capilliary return, mucous membranes, skin turgor.

Hypotension

• Treat underlying cause

• Hypovolaemic – Give volume, assess ongoing losses.

• Haemorrhagic – Blood, FFP, platelets, cryo

• Obstructive – Thrombolysis/anticoagulation in PE, treat PTx, pericardiocentesis

• Cardiogenic – optimise volume cautiously, treat rhythm disturbances, ?Cath lab

• Distributive – adrenaline in anaphylaxis, fluids and Abx in sepsis, inotropes if fluids fail.

Hypotension

• Keeping it simple…

• Most patients who are not volume overloaded will tolerate a small fluid bolus whilst

treating the cause

• How much to give?

• Which fluid to use?

• What end points to aim for?

Hypotension

• Example 1:

• 89 year old lady with BP 85/50, HR 120 in AF with rapid ventricular rate. PHx CCF,

DM.

• Example 2:

• 25 year old woman admitted with pyelonephritis. BP 85/50, HR 120 sinus rhythm. Nil

significant PHx.

Hypotension

• Which fluid?

• Scheirhout, G et al (1998) Fluid Resuscitation with colloid or crystalloid solution in

critically ill patients: A systemcatic review of RCT’s. BMJ 316:961-4

• Increaesed mortality with colloids

• Choi et al (1999) Crystalloids vs colloids in fluid resuscitation: A systematic review.

Critical Care Medicine 27:200-10

• No difference in pulmonary oedema/mortality/LOS in ICU

• CHEST trial: crystalloids Vs hydroxythyl startch

• No difference in 90 day mortality

Hypotension

• End points

• Blood pressure

• Heart rate

• Urine output

• Conscious state

• Lactate clearance

• Development of signs of overload!

Hypotension

• Need to escalate immediately!

• Obtunded patient

• Serious dysrhythmia

• Refractory hypotension

• Concerning underlying cause

• High-risk patient

• If your heart rate is faster than the patient’s.

Hypertension

• Important assessment points

• Usual BP and recent trend

• Current antihypertensives and recent changes

• Other possible causes (pain, anxiety, toxidromes)

• Features of malingnant hypertension - CNS: HA, vomiting, visual disturbance, hypertensive encephalopathy, ACS, seizure

- Cardiac: AMI, APO, Dissection

- Renal: oliguria/renal failure.

Hypertension

• Oral treatment options

• Give missed doses of current meds

• Increase dose of current meds

• Optimise volume status (Lasix if overloaded)

• Give a temporising measure

• Amlodipine 5-10mg

• Avoid GTN patches!

Hypertension

• Cautions

• Don’t block all channels at once!

• Beta-blockers relatively CI in asthma/COAD

• Beware precipitous drop in BP with nitrates

• Beware they hypertensive pregnant woman (pre-eclampsia)

Fasting diabetics

• Management depends on:

• Type 1 or 2

• OHG’s or insulin

• Bowel prep or not

• Varies sometimes with metformin

• Policies available on PROMPT

Hypoglycaemia

• BSL<3.9mmol/L

• Symptoms/signs

• Sweating

• Pallor

• Tremor

• Weakness

• Altered conscious state

• Seiuzres

Hypoglycaemia

• Cause

• Too much insulin

• Too much sulphonylurea

• Rarely due to other OHG

• Fasting in setting of the above

• Non-diabetic patient – sepsis, liver failure, etc.

Hypoglycaemia

• If conscious and not vomiting

• Oral glucose (eg 60ml glucoscan, or 15g glucose gel)

• If unconscious/impaired/vomiting

• ABC!

• IV glucose OR IM glucagon

• 25-50ml 50% glucose IV, flushed.

• 1mg IM glucagon if no IV access (onset time approx. 10 minutes)

Hypoglycaemia

• Re-check BSL within 10 minutes

• Repeat Rx if needed

• Give longer-acting CHO (eg, sandwich)

• Consider need for ongoing dextrose infusion

• Repeat BSL again 1-2 hourly

• Consider dose-adjustment of insulin – never withhold in T1DM

Hyperglycaemia

• Diabetic Vs non-diabetic

• Causes:

• Missed OHG/insulin

• Corticosteroid use

• Sepsis

• Food intake

• Beware HONK/DKA – inform registrar, treat as per protocol

Hyperglycaemia

Give supplemental dose of rapid-acting insulin pre-meals TDS (eg novorapid)

Hyperglycaemia

Urinary Retention

• Definitions vary

• Consider volume on bladder scan, symptoms, and PHx.

• No evidence for ural/diazepam, just insert IDC.

• Consider precipitants

• Pain

• Constipation

• UTI

Oliguria

• Useful definition <0.5ml/kg/hour

• Consider risk

• Single kidney

• Rhabdo

• Consider causes

• Pre-renal

• Renal

• Post-renal

Oliguria

• Pre-renal

• Dehydration (reduced intake, increased losses)

• Consider iatrogenic causes – fasting, inappropriate IV fluids, diarrhoea from meds

• Cardiogenic shock

• Sepsis

• Haemorrhagic shock

Oliguria

• Renal

• Medications

• Rhabdo

• Post-renal

• Prostatic enlargement

• Tumour

• Stone

Altered Conscious State

• Causes

• CNS

• Hypoperfusion (low BP)

ICH

CVA

Encephalopathy

Hydrocephalus

Post-ictal/ictal

• Metabolic (COATPEGS)

• CO2 O2 Ammonia Temp pH Electrolytes (urea, Na, Ca) Glucose Serum osmolarity


• Sepsis

• Medication/drugs

• Especially narcotics

• Antipsychotics, benzodiazepines, anticonvulsants

• Hypoxia/hypercapnoea


• Assessment and management occur concurrently

• Management:

• ABCDEFG and treat reversible causes

• Call MET/Code if required

• Assessment

• GCS (do it yourself)

• Full set of vitals

• BSL


• Get some background info

• Reason for admission, recent progress/issues. Phx.

• Review med chart

• Review most recent pathology


• 65 year old man

• GCS 8 (E1V2M5 – no eyes, incomprehensible sounds, localises to pain).

• Multiple comorbidities including IHD, COAD, T2DM.

• Day 2 post-op from laparotomy for bowel Ca.

• Usually GCS 15

• For full resus


• 5 most likely causes:

• Hypoglycaemia

• Medications (eg, morphine PCA)

• Hypoxia

• Hypercapnoea

• Sepsis


• Management

• Airway

• Patent? Great

• Not patent

• Airway manoeuvres (jaw thrust, chin lift)

• Airway adjuvants (guedel, NPA)

• Breathing

• SpO2, colour, RR

• Auscultate chest

• Can supplement with VBG to check pCO2


• Circulation

• BP, HR, rhythm (ECG)

• DEFG

• Glucose!

• Disability

• Pupils, C-spine precautions if head trauma


• Our patient

• Airway – obstructed, cleared with jaw thrust

• Breathing – SpO2 85%, RR 6, chest clear.

• Circulation – BP 100/60, HR 65

• DEFG – Glu 5.5

• Disability – pupils pinpoint and reactive.


• Thoughts? Likely cause?

• What do we do next?


Airway managed

Breathing

- O2

- naloxone 40-400mcg IV stat (I use 50-100mcg). Repeat 2 minutely PRN.

- assist breathing if needed

Circulation ok for now

BSL ok


• You give the patient 50mcg of IV naloxone, and his GCS returns to 15. O2

and RR also normalise. He complains of pain.

• 2 hours later…

• Same patient, GCS 8 again

• What happened?

Management of Agitated Patient

• Seek and treat underlying cause

• Hypoxia

• Hypoglycaemia

• Pain

• Drug/alcohol withdrawal

• Urinary retention

• Sepsis/encephalopathy

Management of Agitated Patient

• Consider non-pharmacological methods

• Reassurance

• Food/water

• Distraction

• Company of relatives

• Call a code grey/black if required

Management of Agitated Patients

Mangement of Agitated Patients

Respiratory Distress

• 4 main causes of hypoxia

• Hypoventilation

• CVA, seizures, hypercapnoea, opiate medications

• Neuromuscular weakness (eg, MG, GB)

• Pain/chest wall trauma

• VQ mismatch – dead space (alveolus is ventilated but not perfused)

• PE


• VQ mismatch - Shunt (an area with perfusion but no ventilation)

• Anatomical (eg, VSD)

• Physiological (APO, pneumonia, atelectasis, asthma, COAD)

• Diffusion impairment

• Interstitial lung disease


• Management

• ABC

• Oxygen delivery

• Nasal prongs

• Hudson mask

• Non-rebreather mask

• Other

• Treat underlying cause (eg. Abx, Ventolin, steroid, pleural tap)


• Investigations to consider

• Portable CXR on ward

• VBG/ABG

• Other pathology

Falls

• Need to consider CAUSE and CONSEQUENCE

• Cause:

• Poor baseline mobility, non-compliance with gait aid/assistance requirements

• Mechanical

• Medication

• Hypotension/postural hypotension

• Systemic unwellness of any type (eg. Infection, metabolic disturbance, hypoglycaemia)

• CNS event

Falls

• Management

• Assess for injuries

• Primary survey – ABC

• Secondary survey

• Chest (breathing, rib/sternal tenderness)

• Abdomen

• Limbs/pelvis

• C-spine/head

• Investigate and treat underlying cause (eg. UTI). Reassess meds.

Falls

• Who requires imaging of head?

• Canadian CT head rule

• Only included patients with witnessed LOC, disorientation or amnesia

• Included patients aged >16 up to 99yo

• 36% specific

• 100% sensitive for lesion requiring neurosurgical intervention

• Rule not applicable for GCS 13 (scan anyway) or anticoagulated patient (scan anyway)

• Either way, request hourly neuro-obs for 4 hours if head strike.

Falls

• C-spine - ?imaging required

• NEXUS criteria

• Focal neurologic deficit

• Midline tenderness

• Altered level of consciousness

• Intoxication

• Distracting injury

• 83-100% sensitive across

varying studies

• 13% specific

• Studied in all ages, but thought

to be less sensitive in elderly

• 99-100% sensitive

• 42.5% specific

• Note – images all aged

65 and older!

Thank you

• And good luck!

managing common ward calls

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