Recognition of the
unwell patient
And what to do about it
Dr Mike Nicholls
Emergency Medicine Consultant
Auckland City Hospital
April 2011
Approach in ED

Seek and treat the serious stuff
– (then figure out what could be going on).

Goals in ED:
– Improve their condition
– Move them on (6 hour target, 3-2-1)
– Learn
– Have a good time
A systematic approach can help

The patient
– (Info from old notes)


Presenting complaint
ABCDE(FG)
– OBS!!!
The patient…important background
Past history eg diabetes, ICU asthma
 Medications eg prednisone, beta blockers
 Social history eg lives alone, heavy etoh, ivdu
 Family history eg SAH
 Others…family, friends, ambulance, nurse, clerk,
etc…good sources of info

The presenting complaint…
beware of…

Abdo pain
 Young female, elderly, severe

Headache
 Sudden onset, severe, worst ever, fever

Back pain
 Red flags

Numerous others






Trauma : mechanism
Syncope : unexplained in elderly, febrile
Chest pain : unexplained, “atypical”
Fever : with other abnormal obs
Breathlessness : unexplained
etc
Approach in ED

Exclude the serious stuff then figure out
what could be going on.
Think…ABCDE(FG)
Airway
 Breathing
 Circulation
 Disability
 Exposure
 (don’t ever) Forget Glucose (and other investigations)

The Obs



Most of the important info is in the obs
(observations).
P, BP, RR, SaO2, T, GCS, Gluc, (PEFR)
So ALWAYS look at the obs.
– In the ED notes and ambulance notes

Repeating the obs is useful
– do it yourself if there is likely to be a delay
– Obs which are abnormal MUST BE REPEATED
Airway…recognising problems
Position
 Foreign body
 Anaphylaxis
 Noisy breathing in ED is usually a serious sign
 Voice
 LOC/GCS (<9)

And what you do about it….

Airway
 Oxygen
 Position
 OP/NP
 ETT
Breathing…recognising problems
Respiratory rate >20
 Oxygen sats <92%
 Colour
 Sweating
 Quality of respirations
 Breath sounds

Circulation…recognising problems
Colour
 JVP
 Pulse <50, >90* bpm
 BP <100* systolic
 Cap refill >2 secs
 Peripheral circulation cool
 Heart sounds
 ECG

And what you do about it….

Circulation
 IV access (x2)
 IV fluid 0.9%saline….bolus typically 1000ml stat
 Bed position
 Oxygen
 Aspirin
Disability
GCS (E4, M6, V5) or AVPU
 GCS<9
 Confusion/agitation/delirium
 Cranial nerves
 Peripheral nerves
 Seizure

And what you do about it….

Disability
 Analgesia
 Oxygen
 Position
 Benzodiazepine
Exposure




Temperature 36<normal<38
Abdomen
Limbs
other areas
– ENT
– Perineum/buttock
And what you do about it….

Exposure
 Antipyretic/Paracetamol
 Antiemetic
 Antibiotics
(DEF) Glucose…
(and other investigations)






Low / High
Other lab tests…
– venous gas gives you a lot of information
 Lactate (>2)
 Hb
 Na, K, Ca
 pH
FBC, UEC, LFT, coag, G+H
ECG
Urine (IDC), BHCG
CXR
And what you do about it….

Glucose
 50ml 50% dextrose iv for hypoglycaemia
 Iv saline, insulin for hyperglycaemia
And what you do about it….

Consider
– Patient
– Presenting complaint



ABCDEFG (seek and treat…seek abnormalities and treat them)
Get help
– Senior doctor
– Senior nurse
– Other doctor
– Other nurse
– Bedside alarm
Consider
– Patient location in the ED…do they need higher (or lower) level of care?