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:O 2 Fluids PainAnxiety Management: Acute Care

Acute Situations Gross:Airway Obstruction Respiratory Arrest Cardiac Arrest Circulatory Shock Subtle:Precursor States Stop Deterioration

Acute Situations Model:Acute Abdomen Review:Presenting Problem Secondary Effects Intercurrent Disease Severity 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 O 2 Transport Respiration AirwaysLung Integrity Chest WallCentral Control Circulation Heart ActionBlood Volume Vessel ToneControl Systems Haemoglobin concentration

Acute Abdomen: O 2 Transport G-I Bleeding:Anaemia Obstruction:Fluid Depletion Electrolyte Loss Abdo Distension Jaundice:Fluid / Electrolyte Coagulation Nutrition / Drugs

Acute Patient Assessment Methodology History Physical Examination Investigations Skill is in Compression Appropriate to Situation

Dealing with Emergencies – 1 & 2 AssessReassureManage 1 - DangerA - Airway 2 - SituationB - Breathing 3 - ResponseC - Circulation Sixty Second Survey P, BP, R, T, SpO 2 Signs shock Obvious ‘Injury’A V P U

Dealing with Emergencies – 1 & 2 No Response, Breathing or Pulse Cardiopulmonary 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:H 2 0circa 2 L K mM Na + Minimal Ambient Temperature Level of Activity Fluid & Electrolyte Balance

Existing Deficit History:Failure of Intake External Loss Internal ‘Loss’ Examination:Tongue Eyes; Skin Blood 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 BloodPlasmaECFICF 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