emergency medicine Flashcards
delirium
Background:
Very common especially among elderly
Hypoactive - apathy and quiet confusion
Hyperactive - agitation, delusions, disorientation
Always treat as acute delirium until proved otherwise (history of neurodegenerative disease)
One of the most common complications of hospitalisation in the elderly population
Pathology:
Clinical syndrome involving abnormality of thought, perception and levels of awareness
Typically is an acute onset and intermittent but many patients may not return to normal baseline function
Often exhibit feature of hypo and hyperactive delirium
delirium causes and risk factors
(non exhaustive list) UTI Pneumonia Sepsis Viral infections Meningitis and encephalitis Cerebral abscesses Malaria Drugs - benzodiazepines, analgesics, anticholinergics, anticonvulsants, parkinson’s medications, steroids Postoperative Alcohol misuse and withdrawal CO poisoning CVA or haemorrhage or head injury Vasculitis Hypoxia Electrolyte abnormalities Hepatic or renal impairment Thiamine, vitamin B12 or nicotinic acid deficiency Thyroid disturbance Cushing's disease Urinary retention and fecal impaction
Risk factors: Age >65 Male Preexisting cognitive defect like dementia or stroke Severe dementia or comorbidity Previous episode of delirium Hip fracture operation Dehydration, UTI Drug use or dependence Visual or hearing problems Poor mobility Social isolation Stress Terminal illness Movement to a new environment ICU admission Urea or creatinine abnormalities
delirium presentation
Acute or subacute presentation
Fluctuating course
Consciousness clouded or imparied or deteriorating
Poor concentration
Memory deficits
Sleep cycle abnormalities
Hallucinations or delusions
Agitation and emotional lability
Psychotic ideas usually short duration and simple content
Neurological signs usually unsteady gait and tremor
delirium investigations
Investigations/diagnosis:
ABCDE assessment
Refer to previous mental state for other causes of delirium or previous episodes of delirium
Full cardiological and respiratory examination
Full abdominal and genitourinary assessment if needed
Neurological examination
Investigation for underlying suspected cause:
Bloods - FBC, U+Es, TFT, creatinine, LFTs, cardiac enzymes, B12, syphilis and HIV, PSA
Urine dipstick and microscopy
Urine and blood cultures and sensitivities
ECG, CXR, CT scans and LP if needed or EEG
ABCDE assessment: Airway, breathing, circulation Conscious level Vital signs: pulse oximetry, pulse, BP, temperature Capillary blood glucose
delirium management
Management:
Treat underlying cause, if they cannot give consent you may treat them in their best interests under common law
Environment - keep familiar staff, objects, reminders of day, time and location, television, involve family and carers, single room if possible
Antipsychotics for aggressive patients (haloperidol or olanzapine on lowest dose possible)
Benzodiazepines for alcohol withdrawals
Provide family with advice, support and reassurance for those patients who have persistent neurological symptoms after discharged as often effects last longer than the underlying cause
NEWS2 score system uses and benefits
Used for patients aged 16+ and not recommended for pregnancy, may be unreliable in those with spinal cord injury
Provides a single standard early warning score system across the UK for early detection of an acutely unwell patient
Provides a standard score to determine illness severity to support consistent clinical decision making and an appropriate clinical response
Provides a vehicle for the adoption of a standardised scoring system throughout the acute hospital, not solely in the context of acute deterioration but also for continuous monitoring or all patients
Ensures standard means of identifying and responding to patients with unanticipated acute deterioration in their clinical condition whilst in hospital
how to use NEWS2 score
2 main ways of use:
Tracking - continuous record of patient’s physiological status
Trigger - standard platform for initial assessment of acute illness
Steps:
Measure and record parameters
Record score for each parameter
Add all parameter scores together to calculate the total NEWS 2 score and check if any single parameter is >3 (any scores in 3 zone you should write out the actual score to highlight it)
Identify the trigger threshold and clinical response - urgency, clinical competence, monitoring and appropriate clinical setting
NEWS2 score parameters
Respiratory rate
Oxygen saturations: recorded on two scales (1 or 2). Scale 1 is standard non-invasive measure of saturation using a pulse oximetry while 2 is for patients with hypercapnic respiratory failure (sats lower range between 88-92%) and is only used for those confirmed by ABG analysis. Also scored on needing supplemental oxygen to maintain saturation (add a score of 2)
Systolic blood pressure
Pulse
Level of consciousness using ACVPU scale (awake, confused, verbal, pain, unresponsive)
Temperature
**if one of the parameters cannot be completed the score should still be calculated and documented as INCOMPLETE. If one measure is not obtainable despite equipment being used this should trigger an immediate response
**if decided not to act on NEWS2 score - document this in the notes
ACPVU score
Awake - fully awake, spontaneous opening of eyes and respond to voice and has motor function although may be confused
Confusion - disoriented or new onset confusion based on fall in GCS scoring. If there is new onset or worsening delirium this sets off the 4As test for delirium
Verbal - responds to verbal stimulation in some manner
Pain - withdrawal from pain
Unresponsive - unconscious patient gives no eye, vocal, motor responses to voice or pain
codes for recording O2 delivery method on NEWS2 score chart
A - air
N - nasal cannula
SM - simple mask
V - venturi mask and percentage (V24 etc.)
NIV - NIV system
RM - recevoir mask
TM - tracheostomy mask
CP - CPAP mask
H - humidified oxygen and percentage
OTH - other, specify
NEWS2 score trigger thresholds
total score 0-4 low clinical risk
score >3 in any individual parameter (red score) low to medium risk, consider sepsis
total score 5-6 medium clinical risk, consider sepsis
total score >7 high clinical risk
NEWS2 scoring responses
0 - minimum 12 hourly review, continue routine NEWS monitoring
1-4 - minimum 4-6 hourly review; inform registered nurse who must assess patient and decide if increased frequency of monitoring or escalation is needed
3 in single parameter - minimum 1 hourly review; registered nurse to inform medical team caring for patient who will review and decide to escalate or not
total 5+ urgent response threshold - minimum 1 hourly review; nurse immediately informs medical team and requests urgent assessment with clinician within 60 minutes, consider moving the patient to environment with monitoring facilities
total 7+ emergency response threshold - continuous monitoring(every 30 mins) or vital signs needed. nurse immediately informs medical team at least specialist registrar level. emergency assessment with advanced airway management skills, consider transfer to level 2 or 3 clinical car facility or HDU/ICU with monitoring fascilties.
SBAR handover technique
Situation: brief summary of situation
Introduce yourself, status and location/department
Basic patient details, code status, vital signs, timing
Why you are calling about them, advice needed
Background: overview of patient including relevant medical details:
Reason for admission, date, current diagnosis,
Past med history, medications, allergies,
Investigations and investigation results,
Current management and responses
Assessment: objective clinical assessment of patient: vitals
Clinical examination findings (ABCDE)
Overall current impression or concern.
Recommendation: what you believe is next appropriate and also asking what they would recommend next:
State suspected diagnosis, time frame of actions and what you consider should be best next and confirm what they believe should be next.
When should they next review, what monitoring or tests would they advise? Should they be transferred?
Review/response: ensure all information has been understood:
Check for further questions or further guidance,
Repeat what is said to clarify expectations, when, what, who, where etc. then document all discussions
telephone consultation with a patient
Introduction:
Full name and organisation
Establish identity of caller and relationship to the patient
Try to speak directly to the patient if possible
Be empathetic
Gathering information: What is the problem Where did it occur When did it happen What makes it better or worse? What is the timeframe for the problem?
Action plan:
Summarise and ask patient to repeat back to check understanding
Come to agreed and realistic plan where possible (management)
Concluding the call:
Agreed outcome between parties
Be confident and assertive gives patient confidence in appropriate outcome
Safety net; set time limit to call back and give clear, specific, follow up instructions
GCS scoring
Background:
The highest response from each category is recorded and scored on the GCS chart
Highest possible score is 15 (fully conscious)
Lowest score is 3 (coma/dead)
A score of <8 is concerning or sudden deterioration from normal/initial scoring
Add sum of all categories as well as displaying individual scores (GCS 15 {E4, V5, M6})
Eye opening: 4pts max Opening spontaneously - 4pts Opening in response to voice - 3pts Open in response to pain - 2pts No response - 1pt Not testable (cannot open their eyes due to oedema, trauma, dressings) document as NT
Verbal response: 5pts max
Engages in conversation and is orientated (name, location, date, time) - 5pts
Confused conversation (confused about date, location, reason for being there) - 4pts
Inappropriate words (not conversation related) - 3pts
Incomprehensible (making sounds rather than words) - 2pts
No response - 1pt
Not testable (NT) due to intubation, unable to verbally communicate beforehand etc. - NT
Motor response: 6pts max
Obeys commands (can you lift your arm and make a fist) - 6pts
Localises pain (trapezius squeeze, sternal rub) causes patient to reach towards site of pain - 5pts
Withdraws to pain (moves hand away from applying pressure to fingernail) - 4pts
Abnormal flexion response to pain (adduction, internal rotation of arm/shoulder and wrist flexion decorticate posturing indicating severe impairment to cerebral hemispheres) - 3pts
Abnormal extension (decerebrate posturing; head extended, arms and legs extended and internally rotated, rigid, teeth clenched in people with lesions in the midbrain or cerebellum) - 2pts
Complete absence of motor response to painful stimulus - 1pt
NT not testable if paralysed
death verification procedure
Can verify but cannot certify death
Prep background of the patient and death complications from the nurse as to make you aware of any complications e.g. family conflicts and treatment difficulties etc.
Check patients notes and resus status (valid and up to date)
Offer family condolences, introduce yourself
Gain consent to proceed, make the family aware you will have to assess them for full range of responses they can choose to stay or leave whatever they are comfortable with
Wash hands and don PPE
Confirm patient identity by checking wrist band
Inspect for obvious signs of life - movement, respiratory effort
Assess response to verbal stimuli - “hello Mr Smith, can you hear me?”
Assess response to pain
Assess pupillary response to light - bilaterally fixed and dilated
Palpate carotid pulse
Auscultate for heart sounds for 3 minutes
Auscultate for lung sounds for 3 minutes
Dispose of PPE and wash hands
death verification documentation
Identity confirmed as …
Patient in bed, eyes closed, no signs of life
No respiratory effort seen
No response to verbal stimuli
No response to painful stimuli
No carotid pulse palpable
Pupils bilaterally fixed and dilated
No heart sounds noted within 3 mins
No breathing/lung sounds noted within 3 mins
Death certified at (date, time)
Any concerns noted from staff or patients family (objective, word for word only)
Write name, role and bleep no. at the end of paperwork
rules for requiring post mortem
Patient must have seen a doctor within the last 6 weeks
Expected or unsurprising death
Must be signed by at least 2 doctors
If this is not met then patient must be sent for a postmortem
sepsis
A life threatening syndrome caused by a dysregulated host immune response to infection causing systemic inflammation
Can lead to tissue damage, organ failure and death (septic shock)
Five people every hour die from sepsis in the UK, it is a leading cause of morbidity and mortality for children worldwide
Severe sepsis is classed as sepsis + one organ system failure, hypoxia, oliguria, AKI, thrombocytopenia, coagulation dysfunction, hypotension or hyperlactatemia (>2mM)
Pathology:
Pathogen recognized by macrophages, lymphocytes and mast cells
These release cytokines (interleukins and tumour necrosis factor) activating other immune cells
Leads to further activation of chemicals like nitrous oxide that causes vasodilation
The full immune response causes systemic inflammation, cytokines increase blood vessel endothelial lining to become more permeable causing oedema and hypovolaemia
Activation of the coagulation system leads to fibrin deposition compromising tissue and organ perfusion as well as thrombocytopenia and haemorrhage (disseminated intravascular coagulopathy)
Blood lactate increases due to hypoperfusion and tissue starvation (anaerobic respiration switch)
sepsis cause and risk factors
Aetiology:
Infective - bacteria, fungi, viruses
Most common causes of infection - pneumonia, UTI, urolithiasis, skin wounds, burns, cellulitis, diarrhoea, vomiting, neutropenic sepsis (cancer patients)
Risk factors: >75 and <1 YO Instrumentation or surgery Indwelling catheters or lines Alcohol misuse Diabetes Breach of skin integrity - burns Immunocompromised Medications - high dose steroids or chemotherapy Males more prevalent however females have higher mortality IV drug misuse Pregnancy
sepsis presentation
Tachycardia
Changes in conscious levels
BP changes, high pulse rate
Reduced urine output
Mottled or cyanotic skin
May deteriorate rapidly despite correct antibiotic treatment
Meningococcal septicaemia - non blanching maculopapular rash
Arrhythmias or murmurs with new onset
Elderly - confusion, drowsiness
Signs of infection - cough, urinary symptoms, recent travel, lethargy, nausea/vomiting, abdominal pain, diarrhoea
Can mimic - CHF, DKA, PE, thyroid storm, anaphylaxis, adrenal insufficiency, bowel obstruction/ischaemia, GI bleed, aortic dissection, hypovolaemia
Adults: SEPSIS Slurred speech or confusion Extreme shivering or muscle pain Severe breathlessness It feels like you’re going to die Skin mottled or discoloured
Children: Cold to touch Mottled skin Vomiting Loss of appetite Oliguria or anuria
sepsis red flags, ABCDE exam
Red flags: RR >25/min airway O2 <92% breathing HR >130 circulation Systolic BP <90/drop of >40 circulation Lactate >2mmol/l circulation V, P, U, C disability (ACVPU scale) Non-blanching rash exposure Mottled, ashen, cyanotic skin exposure Oliguria (<0.5ml/kg/hr) exposure
Sepsis investigation and diagnosis
NEWS2 screening for initial assessment and regular observations
Bloods - FBC, eGFR, LFTs, glucose, CRP/ESR, clotting screen, cultures (at least two, one for mycobacteria), blood gasses, lactate (metabolic acidosis)
Radiology
Diagnosis: two criteria needed Lactate >2mM Temperature >38 twice within an hour WCC >12/<4 (leukocytosis or leukopenia) HR >90/min tachycardia RR >20/min tachypnea
Sepsis management, prognosis and complications
Sepsis 6 pathway: Administer oxygen Take blood cultures Give IV antibiotics Give IV fluids Check serial lactate Measure urine output
Prognosis:
Can be good with early detection and diagnosis and management
Without early treatment between 10-50% will be fatal depending on severity
Elderly fare less well especially with long term comorbidities
Complications:
DIC: formation of blood clots in small blood vessels throughout the body
Failure of adrenal glands (addisonian crisis)
Multiorgan failure including heart, kidneys, lungs
Septic shock
Background:
Hypoperfusion and sepsis despite adequate fluid treatment
Has greater mortality risk than sepsis alone (>40%)
Associated with profound circulatory, cellular and metabolic abnormalities
Diagnosis:
Systolic BP <90 despite fluid resus
Hyperlactatemia (>4mM)
Management:
Sepsis 6 pathway: give IV fluids, antibiotics and oxygen, take blood cultures, measure urine output and measure lactate levels
Aggressive treatment with IV fluids to improve BP and tissue perfusion
Move to HDU/ICU for treatment with inotropes like noradrenaline
Septicaemia
Background:
Blood poisoning
An infection caused by a large amount of bacteria entering the bloodstream
Presentation:
Fever, fatigue
Rigors
SOB
Diagnosis:
Blood cultures
Management: Give IV fluids Give IV antibiotics Give oxygen Take blood cultures Take blood lactate levels Catheterise - Urine output
Neutropenic sepsis
Background:
Potentially life threatening complication of neutropenia
Defined as a temperature >38 or any symptoms/signs of sepsis in a person with an absolute neutrophil count of <0.5 x 10(9)
Potential fatal complication of systemic anticancer treatment with a mortality of up to 20%
Pathology:
Decreased neutrophil count leading to poor control of infection
Aetiology:
Cytotoxic chemotherapy and other immunosuppressive drugs
Stem cell transplantation
Infections
Bone marrow disorders (aplastic anaemia and MDS)
Nutritional deficiencies
Neutropenic sepsis risk factors and investigations
Risk factors:
All above increase the risk of infection/sepsis via prolonged or severe neutropenia
Investigations/diagnosis:
Systemic anticancer therapy within the last 6 weeks
Vital obs - temperature
Have they had a recent bone marrow transplant
Are they immunocompromised?
What chemotherapy are they on and when was the last treatment/tablet
ABCDE approach
NEWS2 scoring
Urgent bloods - FBC, U+Es, LFT, CRP, blood cultures, blood gasses
Consider MSU, sputum culture, throat swabs, CXR, stool sample if indicated
Neutropenic sepsis management
Sepsis 6: start antibiotics IV ASAP max 1 hour to initiate treatment aim for 30 mins
Side room/isolate patient
Antibiotics usually piperacillin-tazobactam (Tazocin) 4.5g IV/8 hours +/- gentamicin or amikacin
Intra-abdominal sepsis or severe mouth ulcers - metronidazole 500mg/IV 8 hourly for 7 days added onto treatment
If there is a response within 48 hours then continue until infection resolves
If no evidence of infection continue for a total period of 4 days
Severe neutropenia - continue treatment until >0.5 x 10(9)/L
ABCDE approach
Initial steps:
Brief handover of patients name, DOB, age, background and reason for assessment
Introduce yourself
Look at the notes, obs chart, prescription chart, Pmx if available
If unconscious and unresponsive start BLS
Airway: Can they talk? No - look for signs of compromise: see-saw breathing, cyanosis, accessory muscles, breath sounds and added sounds Open mouth to inspect for obstruction or swellings Reassess after any interventions Suction for obvious obstructions Head tilt chin lift manoeuver Jaw thrust Oropharyngeal airway Nasopharyngeal airway CPR if no signs of life
Breathing: Respiratory rate Oxygen saturation Signs of cyanosis, SOB, cough, stridor, apnoeas, kussmaul’s respiration (metabolic acidosis) Assess tracheal position Chest expansion Chest percussion and auscultation Reassess after any interventions ABG CXR Oxygen Asthma - nebulisers, steroids COPD - nebulisers, steroids, antibiotics CPR for no signs of life
Circulation: HR BP Fluid balance assessment General inspection - pallor, oedema Palpation - temperature, capillary refill time, pulses, JVP Auscultate for heart sounds Ankles and sacrum for pitting oedema Reassess after any interventions IV cannula fluid resus Blood tests and cultures ECG Bladder USS Urine pregnancy test Fluid output/catheterisation CPR for no signs of life
Disability: ACVPU scale for conscioussness GCS score if time Pupil size, symmetry, direct and consensual response Drug chart review for medications which may cause neurological abnormalities Reassess after any interventions Blood glucose and ketones Imaging - CT head Maintain airway CPR for no signs of life
Exposure:
Do they have any pain anywhere?
Inspect skin for rashes, bruising, signs of infection
Temperature
Review any IV lines for erythema or discharge
Surgical wounds for haematoma, active bleeding, infection
Review urine output, surgical drain output for blood/fluid loss and infection
Bleeding - estimate blood loss and rate, assess for hypovolemic shock
Reassess after any interventions
Swabs and samples for potential infection sources
IV fluids for haemorrhage or fluid loss
Bloods - FBC, coagulation, G+S
Sepsis 6 for sepsis
Wells score for DVT/PE
CPR for no signs of life
Next stages:
Take thorough history
Review notes, charts, recent investigations and current medications
Document ABCDE assessment
Discuss case with senior clinician (SBARR)
Handover to anyone at end of shift if needed
ABCDE support to call
Airway problems: anaesthetist
Breathing problems: medical registrar or critical care team
Circulation problems: medical registrar, critical care team, specialist of pathology
Disability: medical registrar on call, anaesthetist if airway threatened (GCS <8), specialist of pathology
Exposure: medical registrar, specialist of pathology
FGHIJKLMNOPQ!!
Fluids: have you given a fluid challenge? Measure urine output and consider catheter
Gas: check ABG or VBG; when does it need to be repeated?
Haematology: lab tests taken and sent?
Imagine: order any X-rays, CT’s etc. and review them?
Jobs: have you allocated jobs appropriately? Can nursing staff help? (YES THEY ALWAYS CAN)
K (ECG): look, interpret and compare to previous
Location: does the patient need to be moved e.g. to ICU
Monitoring: how often is it needed? Any need for neurological obs?
Next of kin: has anyone informed the NoK? Do they need to be informed?
Oh, shit: stop, think, are you ok? Do you need help? (probably yeah)
Plan: document your plan and inform nursing staff
Questions: does the patient have any questions about what’s happened or about the plans put in place?
Emergency history taking format: AMPLE
Allergies
Medications
Past medical history and last relevant treatments
Last ate and drank
Events leading up to admission (recent infections, presentation etc.)
DNACPR
A legal document that formalises decision-making about whether an individual should be treated with CPR in the event of a cardiac arrest
Key consideration in the management of patients with progressive life limiting illnesses, those approaching the end of life and significantly frail patients
It is a clinical decision, you have a duty to determine the chance of survival using CPR once the heart has stopped and it does not relate to any other medical decisions or affect any other treatments regarding current treatments
It is also your clinical duty to explain the reasoning and procedures for this decision to the patient and family
It is appropriate for when the potential benefits outweigh the risks - less than 20% of patients survive in-hospital cardiac arrests, survival for elderly and frail patients is much less.
It is important to consider each decision on a case by case basis based solely of comorbidities
It is an anticipatory decision and should be made in advance of when it is needed to be applied
Discussing a DNAR form
A discussion about DNACPR may be appropriate in a wide variety of contexts including:
as part of advance care planning in the community with a well patient
whilst discussing treatment and prognosis with a patient with a chronic disease
in an acute setting with a patient who is deteriorating
When explaining it is crucial to put across that this conversation does not imply that you expect them to rapidly decline nor does it change any efforts or managements to sustain their life and treat them.
It should ideally be held in the presence of family or other individuals important to the patient to help them all understand why this is important and everyone is aware and has a good understanding of future management
If not possible the family should be informed at the next available opportunity
Explaining:
Do not ask them to sign or ask direct consent as this can confuse them as to how the decision is made
Introduce yourself
Confirm patients identity
Explain purpose of the conversation - wish to discuss resuscitation in the event of a cardiac arrest
Gain consent and ensure they are willing to have the conversation, come back another time if too distressed
Establish if there is anyone else they would live to have present
Explain what is meant by a cardiac arrest: “As your illness progresses, you may become so unwell that your heart stops beating, this is called a cardiac arrest”.
Explain what is meant by CPR and what it involves including chest compressions, ventilation, defibrillation, and intravenous drugs. It is important to emphasise it is an invasive process and to explain this in non-medical terms.
Explain what a DNACPR is, and why it is appropriate for this patient
Important information to convey includes:
CPR is likely to be futile
It is likely to lead to poor outcomes for the patient
Explain that a DNACPR means that in the event of a cardiac arrest, CPR would not be administered. It is important to emphasise it is specific to CPR as a treatment and does not apply to other interventions or treatments.
Patients may interpret a DNACPR as “giving up” on them – if a patient expresses this concern it is crucial to reassure them otherwise.
Explain that a DNACPR is a standard part of advance care planning – this helps the patient to understand that the discussion is a normal part of care, rather than something exceptional about their treatment.
Finalising the discussion
Check the patient’s understanding of the conversation.
Invite the patient to ask any further questions.
Summarise the conversation.
If the patient, next of kin or carers object to or disagree with the decision, you should listen to their concerns and attempt to address them through a further explanation. If they continue to disagree, the guidance from the GMC is to escalate to a senior for a second opinion rather than continue to try to convince the patient otherwise.
Thank the patient for their time and check how they are feeling emotionally, as they may want to discuss the matter further with either yourself, another member of the team, or their family or carers.
Patients who do not have capacity DNAR discussion
In a scenario in which a patient does not have capacity, this discussion should instead be had with their next of kin, or the person nominated to have decision-making power on their behalf (such as a medical Lasting Power of Attorney). The same principles apply – it is not this person who is able to make this decision, but the rationale for it should be fully explained.
If a representative for the patient is not available, then a DNACPR form can be completed without having had this discussion – although the patient’s next of kin or a representative should be informed of the decision at the nearest available opportunity.
7 Ws for postoperative fever
Wind - respiratory infection like pneumonia or atelectasis
Wound - surgery site infection
Water - UTI
Walking - VTE like PE or DVT
Wonder drugs - antibiotics or sulfur drugs as well as IV line inflammation/phlebitis
Withdrawal - alcohol withdrawal
Wonky glands - thyrotoxicosis and adrenal insufficiency
