1. Recognition of the unwell patient And what to do about it Dr Mike Nicholls Emergency Medicine Consultant Auckland City Hospital April 2011

2. Approach in ED Seek and treat the serious stuff Seek and treat the serious stuff –(then figure out what could be going on). Goals in ED: Goals in ED: –Improve their condition –Move them on (6 hour target, 3-2-1) –Learn –Have a good time

3. A systematic approach can help The patient The patient –(Info from old notes) Presenting complaint Presenting complaint ABCDE(FG) ABCDE(FG) –OBS!!!

4. The patient…important background Past history eg diabetes, ICU asthma Past history eg diabetes, ICU asthma Medications eg prednisone, beta blockers Medications eg prednisone, beta blockers Social history eg lives alone, heavy etoh, ivdu Social history eg lives alone, heavy etoh, ivdu Family history eg SAH Family history eg SAH Others…family, friends, ambulance, nurse, clerk, etc…good sources of info Others…family, friends, ambulance, nurse, clerk, etc…good sources of info

5. The presenting complaint… beware of… Abdo pain Abdo pain  Young female, elderly, severe Headache Headache  Sudden onset, severe, worst ever, fever Back pain Back pain  Red flags Numerous others Numerous others  Trauma : mechanism  Syncope : unexplained in elderly, febrile  Chest pain : unexplained, “atypical”  Fever : with other abnormal obs  Breathlessness : unexplained  etc

6. Approach in ED Exclude the serious stuff then figure out what could be going on. Exclude the serious stuff then figure out what could be going on.

7. Think…ABCDE(FG) Airway Airway Breathing Breathing Circulation Circulation Disability Disability Exposure Exposure (don’t ever) Forget Glucose (and other investigations) (don’t ever) Forget Glucose (and other investigations)

8. The Obs Most of the important info is in the obs (observations). Most of the important info is in the obs (observations). P, BP, RR, SaO2, T, GCS, Gluc, (PEFR) P, BP, RR, SaO2, T, GCS, Gluc, (PEFR) So ALWAYS look at the obs. So ALWAYS look at the obs. –In the ED notes and ambulance notes Repeating the obs is useful Repeating the obs is useful –do it yourself if there is likely to be a delay –Obs which are abnormal MUST BE REPEATED

9. Airway…recognising problems Position Position Foreign body Foreign body Anaphylaxis Anaphylaxis Noisy breathing in ED is usually a serious sign Noisy breathing in ED is usually a serious sign Voice Voice LOC/GCS (<9) LOC/GCS (<9)

10. And what you do about it…. Airway Airway  Oxygen  Position  OP/NP  ETT

11. Breathing…recognising problems Respiratory rate >20 Respiratory rate >20 Oxygen sats <92% Oxygen sats <92% Colour Colour Sweating Sweating Quality of respirations Quality of respirations Breath sounds Breath sounds

12. Circulation…recognising problems Colour Colour JVP JVP Pulse 90* bpm Pulse 90* bpm BP <100* systolic BP <100* systolic Cap refill >2 secs Cap refill >2 secs Peripheral circulation cool Peripheral circulation cool Heart sounds Heart sounds ECG ECG

13. And what you do about it…. Circulation Circulation  IV access (x2)  IV fluid 0.9%saline….bolus typically 1000ml stat  Bed position  Oxygen  Aspirin

14. Disability GCS (E4, M6, V5) or AVPU GCS (E4, M6, V5) or AVPU GCS<9 GCS<9 Confusion/agitation/delirium Confusion/agitation/delirium Cranial nerves Cranial nerves Peripheral nerves Peripheral nerves Seizure Seizure

15. And what you do about it…. Disability Disability  Analgesia  Oxygen  Position  Benzodiazepine

16. Exposure Temperature 36<normal<38 Temperature 36<normal<38 Abdomen Abdomen Limbs Limbs other areas other areas –ENT –Perineum/buttock

17. And what you do about it…. Exposure Exposure  Antipyretic/Paracetamol  Antiemetic  Antibiotics

18. (DEF) Glucose… (and other investigations) Low / High Low / High Other lab tests… Other lab tests… –venous gas gives you a lot of information  Lactate (>2)  Hb  Na, K, Ca  pH FBC, UEC, LFT, coag, G+H FBC, UEC, LFT, coag, G+H ECG ECG Urine (IDC), BHCG Urine (IDC), BHCG CXR CXR

19. And what you do about it…. Glucose Glucose  50ml 50% dextrose iv for hypoglycaemia  Iv saline, insulin for hyperglycaemia

20. And what you do about it…. Consider Consider –Patient –Presenting complaint ABCDEFG (seek and treat…seek abnormalities and treat them) ABCDEFG (seek and treat…seek abnormalities and treat them) Get help Get help –Senior doctor –Senior nurse –Other doctor –Other nurse –Bedside alarm Consider Consider –Patient location in the ED…do they need higher (or lower) level of care?