Week 1: Consulting and acute emergencies Flashcards
Why remote consulting?
- More efficient use of time
- More efficient use of space
- Reduced carbon footprint
- Reduced risk of infectious disease (COVID-19)
pitfalls of remote consulting
- Not appropriate consultation method
- Confusing landscapes for patient
- Not accessible for everyone
- IT literacy
- language barriers
- disabilities
- confidentiality
- new way of consulting: new skills required
types of remote consulting
- asynchronous
- telephone
- video
before you start consultation
“Is face to face necessary”
- Is this mode of consulting right?
- What is the consultation for?
- Triage
- Acute illness
- Chronic disease management
- Follow uo
- Do you have the right equipment
- IT
- Phone/video
- Headset
When remote consultation may be appropriate
- straightforwar treatment reques
- access to PMH
- can give pt all information they want and need remotley
- dont need to examine patient
- safe system in place to prescribe
- patient has capabity
face to face preferable when
- complex clinical needs
- not patient susual GP and they have no guven consent to share info
- you do not have access to patients medical record
- you need to examin patient
- unsure of patients capacity to decide about treatment
Telephone consulting
- Most common now
- May be for triage
- Complete consultation without need for face to face
- Suits some patients more than others
- Telephone triage may increase overall workload
top tips for telephone consultation
- Empathetic statements
- Echoing patient words
- Summarising
- Tone important
- Chunking and checking pieces of info
- Avoid jargon
undertaking telephone consultation
-
Initiating
- Confirm identify (3 point check)
- Introduce yourself
- Gain consent
- Establish where the patient is and who is with them
-
Bulk of consultation
- Same as face to face
- Remember golden minute
- Start with open questions
- Pay attention to verbal causes
- Ideas, concerns, expectations
-
Examination
- How is the pt speaking? Short of breath?
- Home BP machine or thermometer
- Can they describe rash
-
Explaining
- Keep explanations clear and confirm understanding
-
Ending
- Be clear with diagnosis and plan
- Ensure you have given patient an appropriate safety net
- Send information
-
Record keeping
- Record that the consultation was over the phone
video consultation when
(don’t need to use when telephone consult will do)
- Assessing an unwell child e.g. observing behaviour and resp effort
- Seeing rash
- Establishing/maintaining rapport
human factors definition
Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings.
understanding human error
All humans make mistakes, we get distracted, we are susceptible to fatigue and performance can vary depending on the time of day, length of shift and if we are hungry, angry or emotional. To exacerbate the issue we live and work in complex social structures that are often hierarchical.
Traditionally in healthcare fallible human beings are then tasked with providing a skilled service in a high stress and high workload health service with very little defence against mistakes beyond their own vigilance.
This idea is probably best known through the “Swiss cheese” model of organisational accidents (Reason 1990). The idea is that within healthcare there are a number of defences against error. These defences are not perfect and have little holes in known as “latent conditions”. The size of these holes depends upon the design of the defences. Poorly designed defences increase the size of the holes and place a greater burden on the frontline staff to avoid errors through vigilance alone.
reducing human error
ABCDE approach: rapid primary survery involes
airway
breathing
circulation
disability
exposure
general principles of rapid primary survey
Treat life-threatening problems before moving to the next part of the assessment
- Recognise when you need extra help
- Use all members of the team
- First step: is this cardiac arrest
Airway
- Check for obstruction i.e. can the patient speak normally
- Listen for obstruction e.g. stridor or gurgling → do jaw thrust
- Intubate if needed
- Give O2 if required
Breathing
- Look, listen and feel for signs of resp distress (chest expansion)
- Count RR
- Look at depth and pattern of breathing
- Note any chest deformity
- Record pO2
- Listen to the chest
- Check position of the trachea
- Feel chest wall to detect surgical emphysema
Circulation
- Colour of hands
- Temp of limbs
- CRT
- Radial pulse
- BP
- Heart rate
- JVP
- ECG
- Give fluid resus if needed
Disability
- AVPU
- Check pupil
- Blood glucose
- Plantar reflexes
Exposure
- Fully expose the body → look for trauma or rashes
- Inspect posterior
- Respect dignity of pt and minimise heat loss
Is this cardiac arrest?
Remember: If the patient is unconscious, unresponsive, and is not breathing normally (occasional gasps are not normal) start CPR according to the resuscitation guidelines. If you are confident and trained to do so, feel for a pulse to determine if the patient has a respiratory arrest. If there are any doubts about the presence of a pulse start CPR.
- Listen for normal breathing
- Is there a carotid pulse
common emergency presentations
- Coma,
- Difficulty breathing,
- Chest pain,
- Collapse with hypotension,
- Collapse with altered consciousness,
- GI bleeding,
- Abdominal pain,
- Headache,
- Seizures
The SOAPC system of care
- Subjective information: the history
- Objective information: the examination, tests, records
- Analysis: working diagnosis or differential diagnosis
- Plan: treatment and ongoing care.
- Communication: with the patient, carers, and other healthcare professionals.
SBAR handover
- Situation
- Background
- Assessment
- Recommendations
the acute abdomen definition
Rapid onset of severe symptoms that indicate life-threatening intra-abdominal pathology
- Pain is usually is a feature but may be pain-free in children and elderly
- Wide differentials
acute abdomen major causes
how can the acute abdomen be classified
red flags for the acute abdomen
- Hypotension.
- Confusion/impaired consciousness.
- Signs of shock/systemically unwell/septic-looking.
- Signs of dehydration.
- Rigid abdomen.
- Patient lying very still or writhing.
- Absent or altered bowel sounds.
- Associated testicular pathology.
- Marked involuntary guarding/rebound tenderness.
- Tenderness to percussion.
- History of haematemesis/melaena or evidence of latter on examination per rectum (PR).
- Suspicion of a medical cause for abdominal pain.
assessment of the acute abdomen: initial observations
- Does the patient look ill, septic or shocked
- Lying very still (peritonitis) or rolling in agony (intestinal, biliary or renal colic)
- ABC
- If emergency: assess quickly, arrange early investigations and rapid transfer
assessment of the acute abdomen
- Pain (SOCRATES)
- Associated symptoms (vomiting, haemtemesis or melaena, stool/urine colour, new lumps in abdominal region, eating and drinking, bowels (diarrhoea, constipation and flatus), fainting, palpitations, fevers/rigors, rash, urinary symptoms, recent weight loss
- Gynaecological history: contraception, last menstrual period, STI/PID, surgery, previous ectopic pregnancy, vaginal bleeding
- PMH, drugs, allergies
assessment of the acute abdomen: examination
-
Inspection
- Jaundice/anaemia
- Abdominal distension
- Bruising around umbilicus (cullens) or flanks (grey-turners)
- Dehydration (skin turgor/dry mucous membrane)
-
Auscultation
- Abdomen in all four quadrants
- Absent bowel sounds suggests paralytic ileus, generalised peritonitis or intestinal obstruction.
- High pitched= subacute intestinal obstruction
- Abdominal and iliac bruits
- Abdomen in all four quadrants
-
Percussion
- Swelling/distention due to gas or ascites
- Tenderness to percussion- peritonitis
- Shifting dullness
- Size of organomegaly
-
Palpation
- Gentle/deep palpation of 9 areas ( feel for masses, tenderness, involuntary guarding and organomegalpy (inc bladder)
- Rebound tenderness
- Examine scortum in men
- Supraclavicular and groin lymph nodes
further examinations for the acute abdomen
- Rectal or pelvic exam
- Lower limb pulses as there could be an AAA
- Dipstick urine and send for culture
- Childbearing age- assume she is pregnant until proven otherwise- do pregnancy test
- Examine other relevant system e.g. resp or cardio
Prehospital/emergency department care of suspected acute abdomen
*
- Keep patient nill by mouth
- Give o2 if appropriate
- IV fluid if patient in shock
- NG tube if: severe vomiting, signs of intestinal obstruction or at danger of aspiration
- Analgesia e.g. morphine
- Antiemetic
- Antibiotics (if sepsis, peritonitis (IV cephalosporin+ metronidazole) or UTI )
- Urgent surigal/gynaecological review
- Arrange ECG
- Admit:
- If surgery needed
- Unable to tolerate fluirds
- Pain control required
- Medical cause possible
- IV abx required
Investigations for the acute abdomen
- Bloods: FBC, U&E, LFTS, amylase, glucose, clotting and calcium, ABG
- Group and save
- Blood culture
- Pregnancy test
- Urinalysis
- Radiology (abdominal X-ray, CXR, intravenous pyelogram (IVP), CT scan, ultrasound scan)
- Consider ECG and cardiac enzymes e.g. troponin)
- Peritoneal lavage if history of abdominal trauma
- laparoscopy
Acute abdomen: Special situations- pregnancy
- Always consider ectopic pregnancy in women of childbearing age
- Labour pain
- Pre-eclampsia
- Placental abruption
- Uterine rupture
- Uterine torsion
- miscarriage
Acute abdomen: Special situations- older patients
- Less specific signs
- Present later
- Higher mortality
- Lower threshold of referral
- AAA and bowel ischaemia more prevalent
- Angiodysplasia of the colon is more common and can cause GI haemorrhage
- Top 5 medical causes of pain in older patients
- Inferior MI
- Lower lobe pneumonia/ PE
- DKA
- Pyelonephritis
- IND
- Biliary tract disease
Chest pain (focussing on cardiac)
It is often difficult to be certain as to whether chest pain is of cardiac or non-cardiac cause. A full history should be taken from the patient to assess the need for either immediate hospital admission or urgent hospital referral.
major causes of cardiac pain
- ACS and angina
- Aortic dissection
- Pericarditis
major causes of non-cardiac pain
- Gall stones
- GORD
- PE
MSK - Anxiety and depression
Risk factors of CHD
- Smoking
- Hypertension
- Hyperlipidaemia
- DM
- Obesity
assessment of cardiac pain
- Smoking history
- Past history of cardiovascular disease
- Comorbidities e.g. DM, hypertension and hyperlipidaemia
Assessment for possible ACS
- Consider history of pain , risk factors and history of IHD
- Symptoms of ACS
- Pain in the chest (+-arms, back jaw) lasting longer than 15 mins
- Nausea and vomiting, sweating and breathlessness
- New onset chest pain
ischaemic pain presentation
retrosternal or epigastric, tight and crushing, may radiate to arms neck or jaw
aortic dissection pain
- Aortic dissection- pain with tearing quality
Pericarditis and pulmonary pain
worse on inspiration (pleuritic)
-→ pericarditis- pain relieved on sitting forward
examination in patient with cardiac pain
- Pulse rate and rhythm, BP, auscultate heart sounds and chest
- Look for non-cardiac chest pain
- Tenderness of chest wall
- Epigastric tenderness due to peptic ulcer
- Focal lung signs associated with pneumonia
investigations for non cardiac chest pain
- CXR (pneumonia), abdominal US (gallstones), serum amylase (acute pancreatitis)
investigations for cardiac chest pain
- Bloods: troponin, fasting lipids, fasting glucose and FBC
- Resting and exercise ECG
- CXR – HF
presentation of gall stones
- 40 year old female
- Dull right lower chest pain radiating to shoulder tip
- Started 3 days ago
- Approx. 2 hours after meal
- Nausea, vomiting and fever
Eats fatty food, excess etoh, obese
presentation of aortic dissection
- Sudden onset (always thing AD)
- 10/10 tearing chest pain radiating to back
- Syncope, pallor, clammy
Previous HTN, smoker, connective tissue disorder
presentation of angina
- Gradual onset central dull chest pain induced by exercise and relived by rest
Past history HTN, smoker, DM, hyperchol, obese
PE presenation
- Sudden onset sharp localised chest pain and SOB
- Worse on inspiration and coughing
- Haemoptysis
Past history recent surgery, smoker, take OCP
MSK presentation in chest pain
- Localised sharp chest pain worse on movement and breathing
- Better with NSAIDS
Manual job difficult to do
MI presentation
- Gradual onset severe crushing central chest pain started 45 minutes ago
- Radiating to left arm
- Sweaty and nauseous
- Known hypertension and diabetes
Smoker
pericarditis presentation
- Retrosternal sharp stabbing chest pain radiating to shoulder and neck
- Fever
- Worse on inspiration and coughing
- Relieved by sitting forward
SOB
GORD presentation
- Retrosternal chest pain radiating to the neck
- Worse after food and lying down after meal
- Takes NSAIDs for arthritis
- Better with antacids
Smoker, excess etoh, pregnant
