Phase 2; Year 2; G-I Block

Acute Patient Assessment

Acute Care Theme Topic

Prof J A W Wildsmith

Dundee U/G Medical Curriculum

• Phase 1: Basic Sciences

• Phase 2: Systems Blocks

• Phase 3: Clinical Practice

• Outcomes: Integration

Development

Patient Management:

Acute Care

Practical Training (GMC)

• Resuscitation Skills

• Emergency Medicine

• Practical Experience

• Supportive Rx: O2 Fluids

Pain Anxiety

Management: Acute Care

Acute Situations

• Gross: Airway ObstructionRespiratory ArrestCardiac ArrestCirculatory Shock

• Subtle: Precursor StatesStop Deterioration

Acute Situations

• Model: Acute Abdomen

• Review: Presenting ProblemSecondary EffectsIntercurrent DiseaseSeverity of Illness

• Ask (& Answer) 4 Questions

Four Vital Questions

• How ill is this patient?

• How quickly must I act?

• Do I need (senior) help?

• What is the physiological problem threatening life?

Physiology of O2 Transport

• RespirationAirways Lung IntegrityChest Wall Central Control

• CirculationHeart Action Blood VolumeVessel Tone Control Systems

• Haemoglobin concentration

Acute Abdomen: O2 Transport

• G-I Bleeding: Anaemia

• Obstruction: Fluid DepletionElectrolyte LossAbdo Distension

• Jaundice: Fluid / ElectrolyteCoagulationNutrition / Drugs

Acute Patient Assessment

Methodology• History• Physical Examination• Investigations

Skill is in Compression

Appropriate to Situation

Dealing with Emergencies – 1 & 2

Assess Reassure Manage

1 - Danger A - Airway

2 - Situation B - Breathing

3 - Response C - Circulation

Sixty Second Survey

P, BP, R, T, SpO2 Signs shock

Obvious ‘Injury’ A V P U

Dealing with Emergencies – 1 & 2

• No Response, Breathing or PulseCardiopulmonary Resuscitation

• Pulse, no Response or Breathing

Expired Air Ventilation

• Pulse & Breathing, No Response

• Pulse, Breathing & Response

• All need further Assessment

• Focus on Relevant System(s)

• Identify +ve & -ve indicators of CVS, RS & Fluid Status

• Start appropriate action

• Record findings regularly

• Re-assess at intervals

Dealing with Emergencies - 3

• Assessment of requirements

Normal Requirement

+

Existing Deficit

+

Anticipated Loss

• Water, Potassium, Sodium, H+

Fluid & Electrolyte Balance

• Normal Daily ‘Requirement’

70 kg Adult: H20 circa 2 L

K+ 40-80 mM

Na+ Minimal

Ambient Temperature

Level of Activity

Fluid & Electrolyte Balance

• Existing Deficit

History: Failure of IntakeExternal LossInternal ‘Loss’

Examination: TongueEyes; SkinBlood Volume

Lab Tests: Hb; U&E; (ABG)

Fluid & Electrolyte Balance

• Anticipate Losses

Continued Failure of Intake

Urine Output

Sweat (Pyrexia)

Surgical Wound Bleeding

Tissue & Wound Oedema

Fistulae

Fluid & Electrolyte Balance

Action: Generic Aspects

• High flow oxygen therapy

• Position: Shock: Head down

Dyspnoea: Sitting

• Venous Access & Therapy

• Get HELP early

• Primum non nocere

• Assess Volume Requirement

• Consider Content Needed

Blood Plasma ECF ICF

• Expand Blood Volume Stat

• 25 % of deficit in 2 hr or so

• Monitor Urine (> 20 ml/hr)

• Monitor Hb; U&E; (ABG)

Fluid & Electrolyte Regimen