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
