Global Recognition and Assessment of the Sick Patient and Initial Treatment

Karibuni

GRASP IT GRASP IT

Who are we?

Sister Hazel Robinson

Matron Ellie Forbes

Dr Mike Swart

Dr Matt Halkes

http://en.wikipedia.org/wiki/File:Devon_UK_location_map.svg

For over a decade it has been well recognised that managing the acutely unwell patient can be a challenge to

both nursing and medical staff.

Why are we here?

• Poor monitoring of vital signs (respirations)

• Abnormalities in Airway, Breathing, Circulation not recognised

• Not acting on clear signs of deterioration

• Failure to use systematic approach to assessment

• Poor teamwork and communication

• Late referrals to senior staff

UK

ALERT (Acute Life Threatening Events Recognition and

Treatment)

SOS (Stabilisation of the Sick)

ALERT (Acute Life threatening Events Recognition and

Treatment)

SOS (Stabilisation of the Sick)

GRASP IT (Global Recognition and Assessment of the Sick

Patient and Initial Treatment)

Early detection

Systematic approach

Minimal equipment

GRASPIT

Early detection

Systematic approach

Minimal equipment

Save lives!

GRASPIT

Survival

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Survival

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Survival

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Survival

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Survival

Cost

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Programme

Patient assessment

Breathing problems

Shock

Paediatric patient

Reduced level of consciousness

Communication

Pain management

Scenarios

Before we start……!!!!

Is it easy to spot a sick patient?

DETERIORATION FOLLOWS POOR RECOGNITION OF ABNORMAL VITAL SIGNS

Respiration

Blood pressure

Pulse

Temperature

Pain

• A irway

• B reathing

• C irculation

• D isability

• E xposure

Use a structured approach when assessing patients.

At each stage…

• Look

• Listen

• Feel

• Start corrective treatment before moving on

• Consider calling for help

Airway• Listen

– Talking– Noises?

• Look– Colour – Paradoxical chest movements– Dentures/food/secretions

• Feel– Air movement

• How to open an airway:– Head tilt/chin lift– Jaw thrust– Suction– Adjuncts– Recovery position

• Don’t forget…

All sick people

need high flow

oxygen

Call for help ?

Breathing

• Look

Colour

– Rate– Rhythm– Depth– Symmetry– Sp02

• On what oxygen?• Good trace?

• Listen– Wheeze– Crackles– Silence

Circulation• Look

– Colour – Pulse– BP– Urine output– Lift bedclothes- blood/diarrhoea

• Listen– ? new murmur

• Feel– Skin temperature

– Pulses

– Capilliary refill• Press centrally for 5 seconds• Release• Should return to normal colour in 2 seconds

Correcting ‘C’ Problems

• Put head down & legs up

• IV access– Bigger the better– Secure ++

• Give fluid bolus– 200-500ml Normal Saline– Give over <5 min– Re-assess

Call for help ?

Disability

• Look– Head injury– AVPU– Pupils– D on’t– E ver– F orget– G lucose

AVPU scale

A Patient is A lert

V Patient responds to V oice

P Patient responds to P ain

U Patient is U nresponsive

Exposure

• Top to toe examination.

• Check temperature- warm/cool?

Call for help ?

What else might you consider?

• Notes (PC, PMH, Drug History)• Have we given everything that has been

prescribed (drugs,fluids,oxygen)• Other tests / investigations

What is your plan?

Questions?

The breathless patient

What might cause an upper airway problem?

What could cause a problem here?

Respiratory assessment

• Look Colour Rate Rhythm Depth Symmetry Sp02

• On what oxygen?

• Good trace?

• ListenWheezeCracklesSilence

Correcting ‘B’ Problems

• High flow oxygen• Sit the patient up• If known asthma/COPD give nebulisers• Treat pulmonary oedema• If reduced level of consciousness + poor

respiratory effort- BVM

Call for help ?

Ongoing assessment

Monitoring (Respirations & SpO2)

?ABGs

Response to treatment.

Ongoing treatmentSupplemental oxygenTreatment of underlying condition

AntibioticsPositioning (physiotherapy)BronchodilatorsCorticosteroids –

Consider escalating care

Nasal prongs

- maximum flow rate ~ 4-6 l/min delivers approx 24-50% Oxygen

Simple face mask

-flow rate 5 – 15 l/min oxygen delivery 35 - 60%

Venturi masks

oxygen delivery depends on adapter used

24%, 28%, 31%, 35%, 40%, available

Non-rebreathe mask

-flow rate 15 l/min

- oxygen delivery approx 85%

PULSE OXIMETER

• An oximeter measures the oxygen saturation of haemoglobin (Hb) in the arterial blood with each heart beat.

What does a pulse oximeter do?

• The probe shines light through the tissues to the blood and then measures the light reflected back

• Oxygenated and deoxygenated haemoglobin absorb different amounts of light and the oximeter uses this to determine the SaO2 as a %

• It also measure the heart rate

How does it work?

• Finger• Earlobe• Toe

• Any skin surface from which a reliable signal can be obtained

• Can cause pressure damage if too tight

Where can the sensors be applied?Where can the sensors be applied?

> 95% OK

Continue to monitor

91 to 94% problem?

• Check probe

• A and Oxygen

• B

• C

• D

• Call for help

< 90% Action!

• Check probe

• Call for help

• A and Oxygen

• B

• C

• D

• Probe not correctly applied or displaced

• Movement or shivering

• Low blood pressure

• Cold

• Bright light

• Nail varnish or henna dye

• Smoke inhalation (carbon monoxide)

• Unconscious and on oxygen (carbon dioxide)

Errors and problems

Pulse Oximeter

• Does not replace

A

BB

C

D

E

Questions?

Global

Recognition and Assessment of the Sick PAEDIATRIC Patient and Initial Treatment.

Spotting a sick child

• Effort of breathing

• Exceptions

• Efficacy of breathing

• Effects of respiratory inadequacy

A B C D E

• STRUCTURE – LOOK, LISTEN & FEEL

• A structured approach is crucial and should be done in a logical, sequential order using:

• Airway ventilation (+/- c spine)

• Breathing hypoxia / oxygenation

• Circulation hypovolaemia / perfusion

• Disability conscious level

• Exposure fully examine child

A B C D E

• Airway - is the airway clear, compromised or obstructed?

Anatomically

Airway differences

Anatomical differences

• Big head (especially occiput) • Positioning may be affected by relatively large occiput in

infants• Short neck• Big tongue• “Floppy” epiglottis• Larynx is anterior and high in the neck• Narrow point at cricoid ( up to - 10 years)• High heart• Vulnerable abdominal organs

Why do children desaturate faster than adults?

Signs of airway compromise

• See-saw respirations

• Stridor

• Drooling

• Increased work of breathing

• Reduced or absent air entry

• Low / falling SaO2

Breathing

• Respiratory rate• Work of breathing• Accessory muscle use• Nasal flaring• Grunting• Oxygen saturations • Colour.

Physiological differences

• Babies < 6 months are obligate nasal breathers: blocked nose = blocked airway

• Ventilation is mainly diaphragmatic – if diaphragm movement is impeded tidal volume is reduced (eg full stomach)

• Trachea & bronchi are smaller – a minimal obstruction makes a big difference to flow

Respiratory

Circulation

• Pulse• Palpate pulses

peripherally and centrally• Temperature• Capillary refill time• Blood pressure• Accurate fluid intake and

urine output.

Give 20mls/kg bolus of 0.9% normal saline

Circulatory compromise

capillary refill time

peripheral - central temperature difference

• skin colour

• altered level of consciousness

• poor or absent peripheral pulses

(urine output)

• (blood pressure)

Disability

• Responsiveness using AVPU are they

Alert

responding to Voice

responding to Pain

or Unresponsive• Pupil size

Don’t Ever Forget Glucose.

Exposure

• Look front and back and head-to-toe

• For bleeding, bruises, breaks and burns.

Other Paediatric points

• Unfamiliarity• Communication• Refusal of food /

special toys is BAD!• Perception• Previous experience• Strong survival instinct• Our own anxiety /

uncertainty / fears

Now what?

• Assess ABCDE• Get help• High flow O2• Positioning – sit up if alert/able• DO NOT distress the child• Treatment for specific problem (eg wheeze)• Reassess

GRASP IT GRASP IT

The Hypotensive Patient

Normal blood pressure?

Hypotension

Shock

What is a normal blood pressure?

What is a normal blood pressure?

• Depends on the patient

• Systolic less than 100

• Beware the hypertensive patient

Shock

Blood pressure insufficient to perfuse

tissues

Hypotension + organ dysfunction

Does not correlate to a set number

Signs of ShockSigns of Shock

• Hypotension

• Cold, clammy and pale skin

• Rapid, weak, thready pulse

• Shallow, rapid breathing

• Oliguria

• Cyanosis

• Confusion

• Loss of consciousness

Case Study

Case study

Assessment/Management• AB Open airway/high flow O2

• C– BP – Pulse– Capillary refill– Skin temp– Urine output– Respiratory rate

• D– Level of consciousness

• E

Assessment/Management• Head down • IV access• Fluid challenge

Fluid challenge

• 500ml over <5min

• Assess response– No response– Transient response– Sustained response

• If no/transient response- REPEAT

• If you suspect cardiac cause, or pt known to have heart failure- use 2OOml instead

What Fluid?

• Colloid vs crystalloid?– Probably no difference– Avoid huge volumes ‘normal’ saline

• Blood – If patient is bleeding – Do not aim to restore normal BP until bleeding

is controlled– Clinically severely anaemic child

Assessment/Management• Head down • IV access• Fluid challenge

REASSESS• Further fluid? • Increase frequency of monitoring• Urine output

• What is the underlying cause?

What determines Blood Pressure?

Pump

Pipes

What factors affect the pressure in these pipes?

Volume of water in the system

Effectiveness of the pump

Diameter of the pipes

How does this help us?

• Is the hypotension caused by a problem with:

– Filling?

– Pump?

– Blood vessels?

Shock

• Can be divided into types:

– Hypovolaemic (filling)

– Cardiogenic (pump)– Obstructive (pump)

– Distributive (vasodilation)

Hypovolaemia

Hypovolaemia

• Haemorrhage

• Sepsis

• Dehydration e.g D&V

• Burns

Impaired Cardiac Function

Impaired Cardiac Function

• MI

• Arrythmias

• Valve dysfunction

• Drugs

• Electrolyte disturbance

• Aortocaval compression

• PE

• Tamponade

Vasodilation

Vasodilation

• Sepsis

• Drugs

• Regional anaesthesia (spinal/epidural)

• High spinal cord injury

Case Study • ABCDE assessment

• Initial treatment

Case Study • ABCDE assessment

• Initial treatment

• Consider underlying cause– ? filling problem– ? pump problem– ? vasodilatation

Summary• Hypotension can be caused by

– A filling problem– A pump problem– A resistance problem

• Assess and treat according to ABCDE

• Give a fluid challenge and measure response

• Consider the underlying cause

GRASP IT GRASP IT

Questions?

The Patient with Oliguria

Definition of Oliguria

• Production of between 100-400 mls of urine per day.

• Or < 0.5mls/kg/hr

• Early sign of deterioration in a patients condition

• If oliguria is not corrected acute renal failure may occur

Normal Urine Output

Normal Urine Output

Depends on

•Adequate blood supply

•Functioning kidney

•No obstruction

Types of Renal Failure

Pre-Renal

•Inadequate blood supply

Intra-Renal

•Abnormal kidney

Post-Renal

•Obstruction

Pre-Renal failure

• Dehydration

• Haemorrhage

• Sepsis

• Myocardial Infarction

• Arrhythmias

• Renal artery stenosis; thrombus

Intra-Renal Failure

• Acute Glomerulonephritis

• Nephrotoxic drugs

• Streptococcal infections

• Acute Tubular Necrosis; severe ischaemia/poisons, toxins

Post-Renal Failure

• Enlarged prostate gland

• Kidney stones

• Clots

• Tumours

• Urethral obstruction

Questions to ask yourself

•Is the patient perfusing properly (adequate BP)

•If not, why not?

•Have we poisoned the kidney?

•Could there be an obstruction?

The Patient with Oliguria

GRASP IT GRASP IT

Questions?

The patient with a decreased conscious level

Aims of this sessionDiscuss the causes of reduced level of consciousness

Assessing LOC

Treating LOC

• Things inside the head

• Things outside the head

Inside the head

• Infarction

• Injury

• Infection

• Bleed

• Tumour

Outside the head

• Due to lows

• Due to highs

Outside the head- Due to lows

• Low oxygen!!

• Low BP

• Low glucose

common

• Low sodium• Low temperature• Low thyroid

Outside the head- Due to highs

• High CO2

• High Temperature

• High level of drugs, alcohol, poisons

Assessment of the patient

AirwayBreathing

Circulation

Disability

Assessing- D

Conscious level

Pupils

Blood sugar

Assessment Of Conscious Level

• AVPU

• GCS

Assessment Of Conscious Level

• Is the patient Alert?

• Does the patient respond to Voice?

• Does the patient respond to Pain?

• Is the patient Unresponsive?

New Onset Confusion

This does not form part of the AVPU assessment but new onset confusion should always prompt concern about

potentially serious underlying causes and warrants urgent clinical evaluation

Assessment Of Conscious Level

Pupils

• What size?

• Are they equal?

• Are they reactive?

Assessment Of Conscious Level

Blood Sugar

ABC…

•Don’t

•Ever

•Forget

•Glucose!

Summary

• A decreased level of consciousness is common in acute illness.

• Hypoxaemia, hypoglycaemia and hypotension are common causes.

• Treatment is focused on care of airway, breathing and circulation prior to assessing the patients conscious level.

GRASP IT GRASP IT

Questions?

PAIN MANAGEMENT

‘no-one ever died of pain’

‘no-one ever died of pain’

System Effect Consequence

General

Respiratory

Cardiovascular

GI

Neuroendocrine

Psychological

‘no-one ever died of pain’

System Effect Consequence

General Immobility PneumoniaThromboembolusMuscular atrophyPressure sores

Respiratory HyperventilationHypoventilationPhysio intolerable

PneumoniaHypoxaemia

Cardiovascular HypertensionTachycardiaVasoconstriction

cardiac workO2 deliveryIschaemia & infarction

GI NauseaIleus

DehydrationElectrolyte imbalancesMalnutrition

Neuroendocrine stress responseImunosuppression

healinginfection risk

Psychological Anxiety, Fear Loss of confidence

Basic Principles

Pain assessment

Provide appropriate treatment

Review regularly and change if necessary

Assessment of Pain

• Best method involves self-reporting

• Observation is unreliable

• Functional assessment important– deep breathing, coughing, – physio, mobilisation

Measuring pain1.Visual analogue pain scale

2.Wong and Baker faces

3.Pain scoreMild =1

Moderate =2

Severe =3

0 10

Assessment

Torbay Observation Chart

PAIN the 5th VITAL SIGN (1992)

American Pain Society (1992)

Link Pain Intensity to Strength of Analgesia

SIMPLE ANALGESIA

INTERMEDIATE ANALGESIA

ADVANCED ANALGESIA

MILD

MODERATE

SEVERE

ANALGESIC LADDER STEP 4 Paracetamol + NSAID Oral opioid IV / IM Opioids LA/ Blocks Epidural STEP 3 Paracetamol + NSAID Oral opioid STEP 2

Paracetamol + NSAID STEP 1

Paracetamol

SYNERGYCombinations of drugs are more effective

than using one alone

Due to different mechanisms of action and

effect on different types of pain

SIDE-EFFECTS• Codeine

– constipation

• NSAIDS– gastric bleeding

renal impairment

anticoagulants

heart failure

• Opiates– nausea / vomiting

sedation

respiratory depression

SIDE-EFFECTS

Addiction to Opioids

Almost never occurs when

treating acute pain

GRASP IT GRASP IT

Questions?

Using a communication tool to boost patient outcome

SBAR

SBAR

SITUATION

BACKGROUND

ASSESSMENT

RECOMENDATION

SITUATION

Who you are

Where are you phoning from

Name of the patient

Main problem!

BACKGROUND

Admitting diagnosis

PMH

Treatment to date

ASSESSMENT

Your assessment of the situation

RECOMMENDATION

What do you want from the person?

Is there anything I can do before you get here?

Document the call!

If you don’t get a timely response try again and consider escalating to a more senior person.

Preparationis

key

SUMMARY

Dr Michael Swart michael.swart@nhs.net

Dr Matt Halkes matthew.halkes@nhs.net

Hazel Robinson hazel.robinson1@nhs.net

Ellie Forbes ellie.forbes@nhs.net

Thank you all for listening