INTRODUCTION TO CLINICAL PRACTICE AND CLINICAL SKILLS 3rd Year

PRIMARY ASSESSMENT OF THE CRITICALLY ILL IN- PATIENT

OBJECTIVES 1. Describe the components of Primary Assessment 2. Demonstrate knowledge of appropriate interventions to stabilise a critically ill (nontrauma) patient and evaluate effectiveness.

METHODS Facilitation of small groups of 4 students to systematically assess and manage a critically ill (non-trauma) patient according to ALERT Guidelines (2003).

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Primary Assessment using ALERT Guidelines (2003) assists students to PREDICT PREVENT TREAT COMMUNICATE

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Recognise the ‘at risk’ patient Identify problems early Initiate simple treatment Improve communication skills to team members

Any patient is potentially ` AT RISK ` of becoming acutely unwell with conditions such as shock, post operative bleeding, acute shortness of breath, chest pain, reduced consciousness, reduced urine output. Use Primary Assessment A-B-C-D-E to assess, monitor and treat the patient. A = AIRWAY B = BREATHING C = CIRCULATION D = DISABILITY (CNS FUNCTION) E = EXPOSURE (FULL PATIENT EXAMINATION) THIS PART OF THE ASSESSMENT IS DIRECTED TOWARDS MAKING THE PATIENT SAFE RATHER THAN REACHING A DEFINITE DIAGNOSIS. REMEMBER also Airway adjuncts, oxygen, bag-valve –mask ventilation, fluids, recovery position, blood glucose, monitoring – pulse oximeter, ECG and BP, pulse, respirations.

When assessing any patient a simple question such as “How are you?” can provide significant information. For instance, a normal verbal response from the patient immediately informs you that the patient has a patent airway, is breathing and is perfusing his/her brain.

A -AIRWAY ASSESSMENT - Look, Listen, Feel NB – AIRWAY OBSTRUCTION IS A MEDICAL EMERGENCY! LOOK Chest rise and fall- equality of movement on each side See-saw- paradoxical chest and abdominal movements indicates complete obstruction Use of accessory muscles – shoulder girdle and neck muscles, tracheal tug Central cyanosis is a LATE sign of obstruction Causes of airway obstruction 1. Upper airway obstruction Vomit, secretions- blood/gastric fluid Swelling-trauma, allergy, infection 2. Lower airway obstruction Laryngeal oedema-burns, allergy Page 2 of 7

Laryngeal spasm- foreign body, secretions Tracheobronchial obstruction- secretions, inhaled gastric contents, pulmonary oedema LISTEN No sounds - Complete obstruction Crowing – laryngeal spasm Partial obstruction – diminished/noisy Gurgling – fluid in mouth or upper airway Snoring – partial obstruction of pharynx by tongue Inspiratory stridor - obstruction above level of larynx Expiratory wheeze – airway collapse during expiration (asthma) FEEL Place your hand or face immediately in front of the patient’s mouth AIRWAY MANAGEMENT Use head tilt/chin lift manoeuvre ( or jaw-thrust in a patient with a suspected neck injury) Airway Adjuncts - oropharyngeal or nasopharyngeal airways. Suction to remove secretions If the above fail to open airway – CALL FOR HELP - Tracheal intubation/cricothyroidectomy B - BREATHING ASSESSMENT- Look, Listen, Feel LOOK Deformity of chest – may negatively impact on the capacity to breath normally thorax Rate and depth of breaths- normal resting rate 12-20/min Use of accessory muscles (shoulder girdle and neck muscles) Sweating Central Cyanosis Abdominal breathing Equality of chest movements on each side Raised JVP= acute severe asthma or tension pnemothorax Presence and patency of chest drains Abdominal distention – may limit diaphragmatic movement LISTEN NEAR FACE – note presence of secretions, stridor/wheeze Auscultate – note depth/equality and breath sounds FEEL Position of trachea- is it central in the suprasternal notch or deviated to one side Palpate the chest wall for crepitus/emphysema= pneumothorax until proven otherwise Assess depth and equality of movement of each side of the chest Percussion of the chest – hyper-resonance= pneumothorax; dullness= fluid/consolidation.

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TYPICAL PHYSICAL SIGNS IN RESPIRATORY DISORDERS

Movement Trachea

Percussion Breath Sounds

Consolidation

Collapse

Reduced on affected side Central

Reduced on affected side Shifted towards lesion

Dull Bronchial

Dull Bronchial or diminished

Pneumothorax Pleural Fluid Reduced on Reduced on affected side affected side Central or Central or shifted away shifted away from lesion from lesion Hyper-resonant Stony dull Reduced or Reduced absent

BREATHING MANAGEMENT PRESENT Effective – 100% O2 via non re-breather mask (15 litres/minute) Ineffective-100% O2, assist ventilations, intubate ABSENT Ventilate with bag-valve-mask devise with 100% O2. Assist with endotracheal intubation

C - CIRCULATION – ASSESSMENT LOOK Signs of compromise- cool pale digits, decreased capillary refill, peripheral cyanosis, decreased level of consciousness. Signs of external haemorrhage LISTEN BP - may be normal! Low diastolic BP suggests arterial vasodilation/sepsis Narrowed pulse pressure (difference between systolic and diastolic pressures – normally 3545 mmHg) indicates arterial vasoconstriction (cardiogenic shock or hypovolaemia) FEEL Palpate peripheral and central pulses – rate, rhythm, regularity and equality Thready pulses suggests poor cardiac output Bounding pulse may indicate sepsis CIRCULATION MANAGEMENT Aim is fluid replacement, haemorrhage control and restoration of tissue perfusion Adequate Venous Access – insert two 14-16g cannula Rapid fluid challenge – 500mls over 5-10 minutes Repeat 500mls over 5-10 minutes if hypotensive – systolic BP below 100mmHg Page 4 of 7

Reassess pulse rate and BP every 5 minutes Take bloods- FBC, U&E, clotting. Obtain blood for typing- determine ABO & Rh group. D - DISABILITY

Initial assessment- AVPU SCALE Examine the pupils – size, shape & reaction to light NB An acutely, widely dilated, uncreative pupil on one side suggests a unilateral space – occupying lesion- THIS IS A MEDICAL EMERGENCY .

AVPU-

ALERT – patients eyes open and speaking spontaneously VOICE- patient opens eyes in response to your voice PAIN- patient opens eyes and responds only after application of painful stimulus UNRESPONSIVE- patient does not respond to your voice or painful stimulus

Glasgow Coma Score – GCS is more commonly used for assessment of a patients conscious level . The patients best response to stimuli is scored out of 15 and has 3 components- best motor response (max 6 points), best verbal response (max 5 points); and eye opening (max 4 points). The maximum GCS value is 15 ( Fully alert and responsive) and the lowest is 3 .

When using the GCS quantify the patients response to stimulation in descriptive terms, rather than numerical values. More information is conveyed to other healthcare workers, if the conscious level is described as ` makes incomprehensible sounds, localises to pain and opens eyes to pain or ` V2,M5,E2, rather than ` GCS =9` .

Eye Opening

spontaneous to speech to pain nil

4 3 2 1

Best Motor Response

obeys commands localises to pain withdraws to pain abnormal flexion to pain extensor response to pain nil

6 5 4 3 2 1

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Best verbal response orientated confused conversation uses inappropriate words makes incomprehensible sounds nil

MAXIMUM SCORE = 15

5 4 3 2 1

LOWEST SCORE

=3

NB IF GCS < 9 OR FALLS BY 2 POINTS - INFORM INTENSIVE CARE UNIT Consider hypoxaemia, hypoglycaemia, hypercapnia, cerebral hypoperfusion or depressant drugs as potential causes of reduced conscious level. MANAGEMENT OF REDUCED CONSCIOUSNESS Place patient in the recovery position to protect airway Hypoglycaemia must be excluded – if blood glucose is below 3 mmol/l give 25-50mls of 50% glucose solution IV.

E - EXPOSURE Full body exposure is required for examination Ensure dignity is respected and heat loss prevented Perform focused examination of frontal and dorsal aspects of the body

DO YOU NEED HELP? COMMUNICATION AND ORGANISATIONAL SKILLS Ensure communication is carried out once the patient is assessed, examined and initial treatment given. Ensure the message is clear and succeeds in attaining your intended goal – getting help to you quickly! “He is very unwell, I want you to come and review him. I am very worried that he is deteriorating” FOLLOWING PRIMARY A- B- C- D- E do a FULL PATIENT ASSESSMENT Review patient’s notes and charts – TPR, BP, neuro-obs, fluid balance and drug chart Obtain patient history ‘AMPLE’- Allergies, Meds, PMH, Last ate/drank, Events leading to presentation

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Review routine investigations – X-rays/ECG/Bloods/Micro

DO YOU NEED HELP? DECISIONS AND PLANNING Is patient improving or not? – REASSESS A-B-C-D-E

DO YOU NEED HELP? Once patient is stable DOCUMENT all events in the Medical Records.

NB

IN ALMOST ALL SURGICAL AND MEDICAL EMERGENCIES HYPOVOLAEMIA SHOULD BE CONSIDERED TO BE THE PRIMARY CAUSE OF SHOCK Signs – Tachycardia, tachypnoea, altered LOC, uncontrolled external bleeding, distended/flattened jugular veins/pale, cool diaphoretic skin and distant heart sounds.

REFERENCES ALERT – Acute Life – Threatening Events Recognition and Treatment (2003). 2nd Edition, University of Portsmouth and NHS Trust. ATLS – Advanced Trauma Life Support, American College of Surgeons, 7th Edition. USA. Dolan. B, Holt. L (2003) – Accident and Emergency Theory into Practice , 4th Edition London. Bailliere Tindall. Lim. E, Loke. Y.K, & Thompson. A (2007)- Medicine and Surgery an Integrated Textbook. London. Churchill Livingstone.

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