global recognition and assessment of the sick patient and initial treatment karibuni grasp it
TRANSCRIPT
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Global Recognition and Assessment of the Sick Patient and Initial Treatment
Karibuni
GRASP IT GRASP IT
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Who are we?
Sister Hazel Robinson
Matron Ellie Forbes
Dr Mike Swart
Dr Matt Halkes
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For over a decade it has been well recognised that managing the acutely unwell patient can be a challenge to
both nursing and medical staff.
Why are we here?
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• Poor monitoring of vital signs (respirations)
• Abnormalities in Airway, Breathing, Circulation not recognised
• Not acting on clear signs of deterioration
• Failure to use systematic approach to assessment
• Poor teamwork and communication
• Late referrals to senior staff
UK
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ALERT (Acute Life Threatening Events Recognition and
Treatment)
SOS (Stabilisation of the Sick)
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ALERT (Acute Life threatening Events Recognition and
Treatment)
SOS (Stabilisation of the Sick)
GRASP IT (Global Recognition and Assessment of the Sick
Patient and Initial Treatment)
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Early detection
Systematic approach
Minimal equipment
GRASPIT
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Early detection
Systematic approach
Minimal equipment
Save lives!
GRASPIT
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Survival
100%
0%
50%
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Survival
100%
0%
50%
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Survival
100%
0%
50%
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Survival
100%
0%
50%
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Survival
Cost
100%
0%
50%
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Programme
Patient assessment
Breathing problems
Shock
Paediatric patient
Reduced level of consciousness
Communication
Pain management
Scenarios
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Before we start……!!!!
Is it easy to spot a sick patient?
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DETERIORATION FOLLOWS POOR RECOGNITION OF ABNORMAL VITAL SIGNS
Respiration
Blood pressure
Pulse
Temperature
Pain
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• A irway
• B reathing
• C irculation
• D isability
• E xposure
Use a structured approach when assessing patients.
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At each stage…
• Look
• Listen
• Feel
• Start corrective treatment before moving on
• Consider calling for help
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Airway• Listen
– Talking– Noises?
• Look– Colour – Paradoxical chest movements– Dentures/food/secretions
• Feel– Air movement
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• How to open an airway:– Head tilt/chin lift– Jaw thrust– Suction– Adjuncts– Recovery position
• Don’t forget…
All sick people
need high flow
oxygen
Call for help ?
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Breathing
• Look
Colour
– Rate– Rhythm– Depth– Symmetry– Sp02
• On what oxygen?• Good trace?
• Listen– Wheeze– Crackles– Silence
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Circulation• Look
– Colour – Pulse– BP– Urine output– Lift bedclothes- blood/diarrhoea
• Listen– ? new murmur
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• Feel– Skin temperature
– Pulses
– Capilliary refill• Press centrally for 5 seconds• Release• Should return to normal colour in 2 seconds
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Correcting ‘C’ Problems
• Put head down & legs up
• IV access– Bigger the better– Secure ++
• Give fluid bolus– 200-500ml Normal Saline– Give over <5 min– Re-assess
Call for help ?
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Disability
• Look– Head injury– AVPU– Pupils– D on’t– E ver– F orget– G lucose
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AVPU scale
A Patient is A lert
V Patient responds to V oice
P Patient responds to P ain
U Patient is U nresponsive
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Exposure
• Top to toe examination.
• Check temperature- warm/cool?
Call for help ?
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What else might you consider?
• Notes (PC, PMH, Drug History)• Have we given everything that has been
prescribed (drugs,fluids,oxygen)• Other tests / investigations
What is your plan?
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Questions?
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The breathless patient
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What might cause an upper airway problem?
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What could cause a problem here?
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Respiratory assessment
• Look Colour Rate Rhythm Depth Symmetry Sp02
• On what oxygen?
• Good trace?
• ListenWheezeCracklesSilence
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Correcting ‘B’ Problems
• High flow oxygen• Sit the patient up• If known asthma/COPD give nebulisers• Treat pulmonary oedema• If reduced level of consciousness + poor
respiratory effort- BVM
Call for help ?
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Ongoing assessment
Monitoring (Respirations & SpO2)
?ABGs
Response to treatment.
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Ongoing treatmentSupplemental oxygenTreatment of underlying condition
AntibioticsPositioning (physiotherapy)BronchodilatorsCorticosteroids –
Consider escalating care
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Nasal prongs
- maximum flow rate ~ 4-6 l/min delivers approx 24-50% Oxygen
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Simple face mask
-flow rate 5 – 15 l/min oxygen delivery 35 - 60%
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Venturi masks
oxygen delivery depends on adapter used
24%, 28%, 31%, 35%, 40%, available
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Non-rebreathe mask
-flow rate 15 l/min
- oxygen delivery approx 85%
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PULSE OXIMETER
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• An oximeter measures the oxygen saturation of haemoglobin (Hb) in the arterial blood with each heart beat.
What does a pulse oximeter do?
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• The probe shines light through the tissues to the blood and then measures the light reflected back
• Oxygenated and deoxygenated haemoglobin absorb different amounts of light and the oximeter uses this to determine the SaO2 as a %
• It also measure the heart rate
How does it work?
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• Finger• Earlobe• Toe
• Any skin surface from which a reliable signal can be obtained
• Can cause pressure damage if too tight
Where can the sensors be applied?Where can the sensors be applied?
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> 95% OK
Continue to monitor
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91 to 94% problem?
• Check probe
• A and Oxygen
• B
• C
• D
• Call for help
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< 90% Action!
• Check probe
• Call for help
• A and Oxygen
• B
• C
• D
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• Probe not correctly applied or displaced
• Movement or shivering
• Low blood pressure
• Cold
• Bright light
• Nail varnish or henna dye
• Smoke inhalation (carbon monoxide)
• Unconscious and on oxygen (carbon dioxide)
Errors and problems
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Pulse Oximeter
• Does not replace
A
BB
C
D
E
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Questions?
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Global
Recognition and Assessment of the Sick PAEDIATRIC Patient and Initial Treatment.
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Spotting a sick child
• Effort of breathing
• Exceptions
• Efficacy of breathing
• Effects of respiratory inadequacy
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A B C D E
• STRUCTURE – LOOK, LISTEN & FEEL
• A structured approach is crucial and should be done in a logical, sequential order using:
• Airway ventilation (+/- c spine)
• Breathing hypoxia / oxygenation
• Circulation hypovolaemia / perfusion
• Disability conscious level
• Exposure fully examine child
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A B C D E
• Airway - is the airway clear, compromised or obstructed?
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Anatomically
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Airway differences
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Anatomical differences
• Big head (especially occiput) • Positioning may be affected by relatively large occiput in
infants• Short neck• Big tongue• “Floppy” epiglottis• Larynx is anterior and high in the neck• Narrow point at cricoid ( up to - 10 years)• High heart• Vulnerable abdominal organs
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Why do children desaturate faster than adults?
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Signs of airway compromise
• See-saw respirations
• Stridor
• Drooling
• Increased work of breathing
• Reduced or absent air entry
• Low / falling SaO2
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Breathing
• Respiratory rate• Work of breathing• Accessory muscle use• Nasal flaring• Grunting• Oxygen saturations • Colour.
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Physiological differences
• Babies < 6 months are obligate nasal breathers: blocked nose = blocked airway
• Ventilation is mainly diaphragmatic – if diaphragm movement is impeded tidal volume is reduced (eg full stomach)
• Trachea & bronchi are smaller – a minimal obstruction makes a big difference to flow
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Respiratory
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Circulation
• Pulse• Palpate pulses
peripherally and centrally• Temperature• Capillary refill time• Blood pressure• Accurate fluid intake and
urine output.
Give 20mls/kg bolus of 0.9% normal saline
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Circulatory compromise
capillary refill time
peripheral - central temperature difference
• skin colour
• altered level of consciousness
• poor or absent peripheral pulses
(urine output)
• (blood pressure)
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Disability
• Responsiveness using AVPU are they
Alert
responding to Voice
responding to Pain
or Unresponsive• Pupil size
Don’t Ever Forget Glucose.
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Exposure
• Look front and back and head-to-toe
• For bleeding, bruises, breaks and burns.
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Other Paediatric points
• Unfamiliarity• Communication• Refusal of food /
special toys is BAD!• Perception• Previous experience• Strong survival instinct• Our own anxiety /
uncertainty / fears
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Now what?
• Assess ABCDE• Get help• High flow O2• Positioning – sit up if alert/able• DO NOT distress the child• Treatment for specific problem (eg wheeze)• Reassess
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GRASP IT GRASP IT
The Hypotensive Patient
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Normal blood pressure?
Hypotension
Shock
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What is a normal blood pressure?
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What is a normal blood pressure?
• Depends on the patient
• Systolic less than 100
• Beware the hypertensive patient
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Shock
Blood pressure insufficient to perfuse
tissues
Hypotension + organ dysfunction
Does not correlate to a set number
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Signs of ShockSigns of Shock
• Hypotension
• Cold, clammy and pale skin
• Rapid, weak, thready pulse
• Shallow, rapid breathing
• Oliguria
• Cyanosis
• Confusion
• Loss of consciousness
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Case Study
Case study
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Assessment/Management• AB Open airway/high flow O2
• C– BP – Pulse– Capillary refill– Skin temp– Urine output– Respiratory rate
• D– Level of consciousness
• E
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Assessment/Management• Head down • IV access• Fluid challenge
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Fluid challenge
• 500ml over <5min
• Assess response– No response– Transient response– Sustained response
• If no/transient response- REPEAT
• If you suspect cardiac cause, or pt known to have heart failure- use 2OOml instead
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What Fluid?
• Colloid vs crystalloid?– Probably no difference– Avoid huge volumes ‘normal’ saline
• Blood – If patient is bleeding – Do not aim to restore normal BP until bleeding
is controlled– Clinically severely anaemic child
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Assessment/Management• Head down • IV access• Fluid challenge
REASSESS• Further fluid? • Increase frequency of monitoring• Urine output
• What is the underlying cause?
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What determines Blood Pressure?
Pump
Pipes
What factors affect the pressure in these pipes?
Volume of water in the system
Effectiveness of the pump
Diameter of the pipes
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How does this help us?
• Is the hypotension caused by a problem with:
– Filling?
– Pump?
– Blood vessels?
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Shock
• Can be divided into types:
– Hypovolaemic (filling)
– Cardiogenic (pump)– Obstructive (pump)
– Distributive (vasodilation)
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Hypovolaemia
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Hypovolaemia
• Haemorrhage
• Sepsis
• Dehydration e.g D&V
• Burns
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Impaired Cardiac Function
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Impaired Cardiac Function
• MI
• Arrythmias
• Valve dysfunction
• Drugs
• Electrolyte disturbance
• Aortocaval compression
• PE
• Tamponade
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Vasodilation
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Vasodilation
• Sepsis
• Drugs
• Regional anaesthesia (spinal/epidural)
• High spinal cord injury
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Case Study • ABCDE assessment
• Initial treatment
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Case Study • ABCDE assessment
• Initial treatment
• Consider underlying cause– ? filling problem– ? pump problem– ? vasodilatation
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Summary• Hypotension can be caused by
– A filling problem– A pump problem– A resistance problem
• Assess and treat according to ABCDE
• Give a fluid challenge and measure response
• Consider the underlying cause
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GRASP IT GRASP IT
Questions?
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The Patient with Oliguria
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Definition of Oliguria
• Production of between 100-400 mls of urine per day.
• Or < 0.5mls/kg/hr
• Early sign of deterioration in a patients condition
• If oliguria is not corrected acute renal failure may occur
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Normal Urine Output
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Normal Urine Output
Depends on
•Adequate blood supply
•Functioning kidney
•No obstruction
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Types of Renal Failure
Pre-Renal
•Inadequate blood supply
Intra-Renal
•Abnormal kidney
Post-Renal
•Obstruction
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Pre-Renal failure
• Dehydration
• Haemorrhage
• Sepsis
• Myocardial Infarction
• Arrhythmias
• Renal artery stenosis; thrombus
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Intra-Renal Failure
• Acute Glomerulonephritis
• Nephrotoxic drugs
• Streptococcal infections
• Acute Tubular Necrosis; severe ischaemia/poisons, toxins
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Post-Renal Failure
• Enlarged prostate gland
• Kidney stones
• Clots
• Tumours
• Urethral obstruction
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Questions to ask yourself
•Is the patient perfusing properly (adequate BP)
•If not, why not?
•Have we poisoned the kidney?
•Could there be an obstruction?
The Patient with Oliguria
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GRASP IT GRASP IT
Questions?
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The patient with a decreased conscious level
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Aims of this sessionDiscuss the causes of reduced level of consciousness
Assessing LOC
Treating LOC
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• Things inside the head
• Things outside the head
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Inside the head
• Infarction
• Injury
• Infection
• Bleed
• Tumour
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Outside the head
• Due to lows
• Due to highs
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Outside the head- Due to lows
• Low oxygen!!
• Low BP
• Low glucose
common
• Low sodium• Low temperature• Low thyroid
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Outside the head- Due to highs
• High CO2
• High Temperature
• High level of drugs, alcohol, poisons
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Assessment of the patient
AirwayBreathing
Circulation
Disability
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Assessing- D
Conscious level
Pupils
Blood sugar
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Assessment Of Conscious Level
• AVPU
• GCS
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Assessment Of Conscious Level
• Is the patient Alert?
• Does the patient respond to Voice?
• Does the patient respond to Pain?
• Is the patient Unresponsive?
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New Onset Confusion
This does not form part of the AVPU assessment but new onset confusion should always prompt concern about
potentially serious underlying causes and warrants urgent clinical evaluation
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Assessment Of Conscious Level
Pupils
• What size?
• Are they equal?
• Are they reactive?
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Assessment Of Conscious Level
Blood Sugar
ABC…
•Don’t
•Ever
•Forget
•Glucose!
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Summary
• A decreased level of consciousness is common in acute illness.
• Hypoxaemia, hypoglycaemia and hypotension are common causes.
• Treatment is focused on care of airway, breathing and circulation prior to assessing the patients conscious level.
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GRASP IT GRASP IT
Questions?
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PAIN MANAGEMENT
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‘no-one ever died of pain’
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‘no-one ever died of pain’
System Effect Consequence
General
Respiratory
Cardiovascular
GI
Neuroendocrine
Psychological
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‘no-one ever died of pain’
System Effect Consequence
General Immobility PneumoniaThromboembolusMuscular atrophyPressure sores
Respiratory HyperventilationHypoventilationPhysio intolerable
PneumoniaHypoxaemia
Cardiovascular HypertensionTachycardiaVasoconstriction
cardiac workO2 deliveryIschaemia & infarction
GI NauseaIleus
DehydrationElectrolyte imbalancesMalnutrition
Neuroendocrine stress responseImunosuppression
healinginfection risk
Psychological Anxiety, Fear Loss of confidence
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Basic Principles
Pain assessment
Provide appropriate treatment
Review regularly and change if necessary
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Assessment of Pain
• Best method involves self-reporting
• Observation is unreliable
• Functional assessment important– deep breathing, coughing, – physio, mobilisation
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Measuring pain1.Visual analogue pain scale
2.Wong and Baker faces
3.Pain scoreMild =1
Moderate =2
Severe =3
0 10
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Assessment
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Torbay Observation Chart
PAIN the 5th VITAL SIGN (1992)
American Pain Society (1992)
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Link Pain Intensity to Strength of Analgesia
SIMPLE ANALGESIA
INTERMEDIATE ANALGESIA
ADVANCED ANALGESIA
MILD
MODERATE
SEVERE
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ANALGESIC LADDER STEP 4 Paracetamol + NSAID Oral opioid IV / IM Opioids LA/ Blocks Epidural STEP 3 Paracetamol + NSAID Oral opioid STEP 2
Paracetamol + NSAID STEP 1
Paracetamol
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SYNERGYCombinations of drugs are more effective
than using one alone
Due to different mechanisms of action and
effect on different types of pain
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SIDE-EFFECTS• Codeine
– constipation
• NSAIDS– gastric bleeding
renal impairment
anticoagulants
heart failure
• Opiates– nausea / vomiting
sedation
respiratory depression
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SIDE-EFFECTS
Addiction to Opioids
Almost never occurs when
treating acute pain
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GRASP IT GRASP IT
Questions?
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Using a communication tool to boost patient outcome
SBAR
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SBAR
SITUATION
BACKGROUND
ASSESSMENT
RECOMENDATION
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SITUATION
Who you are
Where are you phoning from
Name of the patient
Main problem!
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BACKGROUND
Admitting diagnosis
PMH
Treatment to date
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ASSESSMENT
Your assessment of the situation
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RECOMMENDATION
What do you want from the person?
Is there anything I can do before you get here?
Document the call!
If you don’t get a timely response try again and consider escalating to a more senior person.
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Preparationis
key
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SUMMARY
Dr Michael Swart [email protected]
Dr Matt Halkes [email protected]
Hazel Robinson [email protected]
Ellie Forbes [email protected]
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Thank you all for listening