DRABCDE acute GI bleed

Question 1

You are the FY1 on the ward. You are called to see a 59 y/o man who has deteriorated. Please assess and treat this patient.

Answer 1

Danger and Initial Obs
Checks safe to approach AND washes hands (both for P, one for B)

Requests initial Obs (all 5 for P, 3 for B)
HR 130 BP 110/70 RR 25 SaO2 98% T 36.7

Calls for help as Obs meet PERT Criteria

Question 2

check response and airway

Answer 2

Response
Checks response
The patient is fully conscious. He is shouting loudly in a foreign language, in apparent pain.

Airway
Recognises that airway is clear as pt can shout. May assess airway but no extra marks.

Question 3

assess breathing

Answer 3

Looks for even chest wall movement, cyanosis, accessory muscle use, tracheal tug, or other reasonable signs. (3 for P, 2
for B)

Feels for chest movement, central trachea, percusses front and back of chest
(3 for P, 2 for B)

Listens to the breath sounds on front and back

Measures RR, SaO2, ABG, peak flow, CXR. (Must have RR and SaO2 for P. Give B if one of these is given AND one other
measurement).

Treats with high flow oxygen via non-rebreathe mask.

Reassesses the patient for Breathing

Look: Rapid chest movement.
Feel: Equal chest expansion, central trachea, Percussion resonant
Listen: Normal air entry. Vesicular breath sounds.
Measure: RR = 25; SaO2 = 98% on air. None else available.
Reassess: No improvement following O2.

Question 4

circulation assessment

Answer 4

Looks for bleeding, pallor, JVP, sweating, peripheral oedema (3 for P, 2 for B)

Feels pulse, temperature of peripheries, clamminess, apex beat (2 for P)

Listens to heart in four regions (APTM)

Measures HR, BP, Temp, U/O, CR, ECG (4 for P, 3 for B)

Treats with 2 wide bore I.V. cannulae, Bloods (must include Group & Save and Cross match), Fluid challenge e.g. 250 ml
over 20 minutes. (All for P, 2 for B.)

Reassesses the patient for Circulation (no new mark, may give previous reassess mark for this)

Treats the patient with another fluid challenge and reassesses.

Look: Pale, sweating, JVP not visible, no blood loss visible
Feel: Rapid pulse, cool peripheries, clammy. Apex Beat not displaced.

Listen: Heart Sounds normal
Measure: HR 150; BP 85/50; T 37.4; no U/O; CR > 3 seconds. ECG not available.

Reassess: BP improves slightly to 90/60. HR reduced to 140 after 1st Fluid Challenge. BP improves to 100/65 after a second fluid challenge if given. Prompt candidate to move on after second challenge.

Candidate must have called for help by this point. If not, do not award mark above for Help

Question 5

disability and everything else

Answer 5

Assesses consciousness using AVPU and offers Blood Glucose test (Both for P, one for B)

Exposes patient head to toe and offers more detailed examination

The patient is alert; BM = 5mmol/L. Extreme tenderness on abdominal palpation.

Management
Examiner asks:

1) What is the most likely diagnosis?
2) Is there anything else you would like to do now you have finished your assessment?

Diagnosis: GI Bleed, perforation. Any other reasonable attempt.

Offers to arrange emergency surgical review, document what has happened, hand over, reassures patient, or other
reasonable plan (1 is enough for P)