Managing Common

Ward Calls
Dr Lauren Wimetal
Emergency Consultant - Casey Hospital
 Hypotension
• A and B come before C!
• Consider the cause
• Normal for patient • Neurogenic shock
• Hypovolaemic shock • Cardiogenic shock
• Haemorrhagic shock • Distributive shock
• Obstructive shock
 Hypotension
• Assess end-organ perfusion
• Mentation
• Urine output
• Assess volume status
• JVP, capilliary return, mucous membranes, skin turgor.
 Hypotension
• Treat underlying cause
• Hypovolaemic – Give volume, assess ongoing losses.
• Haemorrhagic – Blood, FFP, platelets, cryo
• Obstructive – Thrombolysis/anticoagulation in PE, treat PTx, pericardiocentesis
• Cardiogenic – optimise volume cautiously, treat rhythm disturbances, ?Cath lab
• Distributive – adrenaline in anaphylaxis, fluids and Abx in sepsis, inotropes if fluids fail.
 Hypotension
• Keeping it simple…
• Most patients who are not volume overloaded will tolerate a small fluid bolus whilst
treating the cause
• How much to give?
• Which fluid to use?
• What end points to aim for?
 Hypotension
• Example 1:
• 89 year old lady with BP 85/50, HR 120 in AF with rapid ventricular rate. PHx CCF,
DM.
• Example 2:
• 25 year old woman admitted with pyelonephritis. BP 85/50, HR 120 sinus rhythm. Nil
significant PHx.
 Hypotension
• Which fluid?
• Scheirhout, G et al (1998) Fluid Resuscitation with colloid or crystalloid solution in
critically ill patients: A systemcatic review of RCT’s. BMJ 316:961-4
• Increaesed mortality with colloids
• Choi et al (1999) Crystalloids vs colloids in fluid resuscitation: A systematic review.
Critical Care Medicine 27:200-10
• No difference in pulmonary oedema/mortality/LOS in ICU
• CHEST trial: crystalloids Vs hydroxythyl startch
• No difference in 90 day mortality
 Hypotension
• End points
• Blood pressure
• Heart rate
• Urine output
• Conscious state
• Lactate clearance
• Development of signs of overload!
 Hypotension
• Need to escalate immediately!
• Obtunded patient
• Serious dysrhythmia
• Refractory hypotension
• Concerning underlying cause
• High-risk patient
• If your heart rate is faster than the patient’s.
 Hypertension
• Important assessment points
• Usual BP and recent trend
• Current antihypertensives and recent changes
• Other possible causes (pain, anxiety, toxidromes)
• Features of malingnant hypertension
- CNS: HA, vomiting, visual disturbance, hypertensive encephalopathy, ACS, seizure
- Cardiac: AMI, APO, Dissection
- Renal: oliguria/renal failure.
 Hypertension
• Oral treatment options
• Give missed doses of current meds
• Increase dose of current meds
• Optimise volume status (Lasix if overloaded)
• Give a temporising measure
• Amlodipine 5-10mg
• Avoid GTN patches!
 Hypertension
• Cautions
• Don’t block all channels at once!
• Beta-blockers relatively CI in asthma/COAD
• Beware precipitous drop in BP with nitrates
• Beware they hypertensive pregnant woman (pre-eclampsia)
 Fasting diabetics
• Management depends on:
• Type 1 or 2
• OHG’s or insulin
• Bowel prep or not
• Varies sometimes with metformin
• Policies available on PROMPT
 Hypoglycaemia
• BSL<3.9mmol/L
• Symptoms/signs
• Sweating
• Pallor
• Tremor
• Weakness
• Altered conscious state
• Seiuzres
 Hypoglycaemia
• Cause
• Too much insulin
• Too much sulphonylurea
• Rarely due to other OHG
• Fasting in setting of the above
• Non-diabetic patient – sepsis, liver failure, etc.
 Hypoglycaemia
• If conscious and not vomiting
• Oral glucose (eg 60ml glucoscan, or 15g glucose gel)
• If unconscious/impaired/vomiting
• ABC!
• IV glucose OR IM glucagon
• 25-50ml 50% glucose IV, flushed.
• 1mg IM glucagon if no IV access (onset time approx. 10 minutes)
 Hypoglycaemia
• Re-check BSL within 10 minutes
• Repeat Rx if needed
• Give longer-acting CHO (eg, sandwich)
• Consider need for ongoing dextrose infusion
• Repeat BSL again 1-2 hourly
• Consider dose-adjustment of insulin – never withhold in T1DM
 Hyperglycaemia
• Diabetic Vs non-diabetic
• Causes:
• Missed OHG/insulin
• Corticosteroid use
• Sepsis
• Food intake
• Beware HONK/DKA – inform registrar, treat as per protocol
 Hyperglycaemia
Give supplemental dose of rapid-acting insulin pre-meals TDS (eg novorapid)
Hyperglycaemia
 Urinary Retention
• Definitions vary
• Consider volume on bladder scan, symptoms, and PHx.
• No evidence for ural/diazepam, just insert IDC.
• Consider precipitants
• Pain
• Constipation
• UTI
 Oliguria
• Useful definition <0.5ml/kg/hour
• Consider risk
• Single kidney
• Rhabdo
• Consider causes
• Pre-renal
• Renal
• Post-renal
 Oliguria
• Pre-renal
• Dehydration (reduced intake, increased losses)
• Consider iatrogenic causes – fasting, inappropriate IV fluids, diarrhoea from meds
• Cardiogenic shock
• Sepsis
• Haemorrhagic shock
 Oliguria
• Renal
• Medications
• Rhabdo
• Post-renal
• Prostatic enlargement
• Tumour
• Stone
 Altered Conscious State
• Causes
• CNS • Metabolic (COATPEGS)
• Hypoperfusion (low BP) • CO2
ICH O2
CVA Ammonia
Encephalopathy Temp
Hydrocephalus pH
Post-ictal/ictal Electrolytes (urea, Na, Ca)
Glucose
Serum osmolarity
 Altered Conscious State
• Sepsis
• Medication/drugs
• Especially narcotics
• Antipsychotics, benzodiazepines, anticonvulsants
• Hypoxia/hypercapnoea
 Altered Conscious State
• Assessment and management occur concurrently
• Management:
• ABCDEFG and treat reversible causes
• Call MET/Code if required
• Assessment
• GCS (do it yourself)
• Full set of vitals
• BSL
 Altered Conscious State
• Get some background info
• Reason for admission, recent progress/issues. Phx.
• Review med chart
• Review most recent pathology
 Altered Conscious State
• 65 year old man
• GCS 8 (E1V2M5 – no eyes, incomprehensible sounds, localises to pain).
• Multiple comorbidities including IHD, COAD, T2DM.
• Day 2 post-op from laparotomy for bowel Ca.
• Usually GCS 15
• For full resus
 Altered Conscious State
• 5 most likely causes:
• Hypoglycaemia
• Medications (eg, morphine PCA)
• Hypoxia
• Hypercapnoea
• Sepsis
 Altered Conscious State
• Management
• Airway
• Patent? Great
• Not patent
• Airway manoeuvres (jaw thrust, chin lift)
• Airway adjuvants (guedel, NPA)
• Breathing
• SpO2, colour, RR
• Auscultate chest
• Can supplement with VBG to check pCO2
 Altered Conscious State
• Circulation
• BP, HR, rhythm (ECG)
• DEFG
• Glucose!
• Disability
• Pupils, C-spine precautions if head trauma
 Altered Conscious State
• Our patient
• Airway – obstructed, cleared with jaw thrust
• Breathing – SpO2 85%, RR 6, chest clear.
• Circulation – BP 100/60, HR 65
• DEFG – Glu 5.5
• Disability – pupils pinpoint and reactive.
 Altered Conscious State
• Thoughts? Likely cause?
• What do we do next?
 Altered Conscious State
 Airway managed
Breathing
- O2
- naloxone 40-400mcg IV stat (I use 50-100mcg). Repeat 2 minutely PRN.
- assist breathing if needed
 Circulation ok for now
 BSL ok
 Altered Conscious State
• You give the patient 50mcg of IV naloxone, and his GCS returns to 15. O2
and RR also normalise. He complains of pain.
• 2 hours later…
• Same patient, GCS 8 again
• What happened?
 Management of Agitated Patient
• Seek and treat underlying cause
• Hypoxia
• Hypoglycaemia
• Pain
• Drug/alcohol withdrawal
• Urinary retention
• Sepsis/encephalopathy
 Management of Agitated Patient
• Consider non-pharmacological methods
• Reassurance
• Food/water
• Distraction
• Company of relatives
• Call a code grey/black if required
Management of Agitated Patients
Mangement of Agitated Patients
 Respiratory Distress
• 4 main causes of hypoxia
• Hypoventilation
• CVA, seizures, hypercapnoea, opiate medications
• Neuromuscular weakness (eg, MG, GB)
• Pain/chest wall trauma
• VQ mismatch – dead space (alveolus is ventilated but not perfused)
• PE
 Respiratory Distress
• VQ mismatch - Shunt (an area with perfusion but no ventilation)
• Anatomical (eg, VSD)
• Physiological (APO, pneumonia, atelectasis, asthma, COAD)
• Diffusion impairment
• Interstitial lung disease
 Respiratory Distress
• Management
• ABC
• Oxygen delivery
• Nasal prongs
• Hudson mask
• Non-rebreather mask
• Other
• Treat underlying cause (eg. Abx, Ventolin, steroid, pleural tap)
 Respiratory Distress
• Investigations to consider
• Portable CXR on ward
• VBG/ABG
• Other pathology
 Falls
• Need to consider CAUSE and CONSEQUENCE
• Cause:
• Poor baseline mobility, non-compliance with gait aid/assistance requirements
• Mechanical
• Medication
• Hypotension/postural hypotension
• Systemic unwellness of any type (eg. Infection, metabolic disturbance, hypoglycaemia)
• CNS event
 Falls
• Management
• Assess for injuries
• Primary survey – ABC
• Secondary survey
• Chest (breathing, rib/sternal tenderness)
• Abdomen
• Limbs/pelvis
• C-spine/head

• Investigate and treat underlying cause (eg. UTI). Reassess meds.

 Falls
• Who requires imaging of head?
• Canadian CT head rule
• Only included patients with witnessed LOC, disorientation or amnesia
• Included patients aged >16 up to 99yo
• 36% specific
• 100% sensitive for lesion requiring neurosurgical intervention
• Rule not applicable for GCS 13 (scan anyway) or anticoagulated patient (scan anyway)
• Either way, request hourly neuro-obs for 4 hours if head strike.
 Falls
• C-spine - ?imaging required
• NEXUS criteria
• Focal neurologic deficit • 83-100% sensitive across
• Midline tenderness varying studies
• Altered level of consciousness • 13% specific
• Intoxication
• Studied in all ages, but thought
• Distracting injury
to be less sensitive in elderly
• 99-100% sensitive
• 42.5% specific
• Note – images all aged
65 and older!
 Thank you
• And good luck!