acute care refresher - medednhsl.com

Acute Care

Refresher

pathways for clinical learning

Key Points

• We are going to cover:

– COVID-19 clinical presentation

– Respiratory assessment

– A-E assessment and NEWS

– Escalation of care and SBAR

– DNACPR / TELP

– ILS

– PPE

– Practical procedures including cannulation and

venepuncture


Learning Outcomes

• Revise taking a focused history of the respiratory

system in an acute setting

• Review performing a respiratory examination in an

acute setting

• Identify the investigations to carry out in a patient

suspected of having COVID-19

• Refresh A-E assessment of an unwell patient

• Consider appropriateness of escalation and

HACP/DNACPR


COVID-19Consider COVID-19 for current inpatients or patients who require admission who fit the

following criteria:

• requiring admission to hospital

and

• have either clinical or radiological evidence of pneumonia

or

• acute respiratory distress syndrome (ARDS)

or

• influenza like illness (fever ≥37.8°C and at least one of the following

respiratory symptoms, which must be of acute onset: persistent cough (with

or without sputum), hoarseness, nasal discharge or congestion, shortness

of breath, sore throat, wheezing, sneezing)


PPEFor all patients meeting the case definition the following minimum

PPE should be worn:

• Surgical mask (fluid resistant) with eye protection (visor or safety

glasses)

• Apron

• Disposable gloves

Patient should also be wearing a disposable mask during

assessment

For aerosol generating procedures (eg NIV, intubation/extubation,

suction, CPR) require full PPE (see later slides)


Respiratory History

• Dyspnoea

– Exertional vs resting

– Severity

• Cough

– Dry / productive

• Wheeze

• Haemoptysis

• Chest pain

– Site / Radiation / Character


• Systemic symptoms

– Fever (>37.8oC)

– Myalgia

– Rhinorrhoea

– Sore Throat

Further questions

• History of respiratory co-

morbidities

• General medical history

– Is the patient

immunocompromised?

• Onset

• Duration

• Severity

• Course

– Improving? Deteriorating?

• Aggravating/Relieving

factors

• Associated features

• Drug history & allergies

– Immunosuppressive

agents


REMEMBER: IMMUNOCOMPROMISED PATIENTS MAY NOT PRESENT WITH

TYPICAL HISTORY OR SYMPTOMS

Physical examination General inspection

• Foot of the bed inspection

– Respiratory rate

– Oxygen requirement

– Tripod position

– Use of accessory muscles

• Can the patient speak in full sentences?

• Evidence of central/peripheral cyanosis


Physical ExaminationChest Examination

• General Inspection

– Work of breathing / signs of respiratory distress

– Symmetry of chest wall movement

– Tracheal deviation

– Scars / evidence of previous thoracic surgery

– Assess for asterixis / flapping tremor (Evidence

of CO2 retention)



• Chest expansion– Front and back

– Asymmetrical or reduced- signs of pathology on that side



• Percussion– Supra and infraclavicular, throughout chest, axillae

– Resonant- normal

– Dull- consolidation/fluid/tumour/collapse

– Stony dullness- effusion

– Hyper-resonant- pneumothorax



• Auscultation

– Ask the patient to take deep breaths in and out

through their mouth

– Listen throughout the chest, front and back

– Not forgetting apices, bases and axillae



• Auscultation

– Coarse crackles/crepitations

• Infection, cardiac overload (if bilateral)

– Reduced air entry

• Consolidation/lobar collapse/pleural effusion

– Wheeze

• Asthma/COPD

• Stethoscope should remain with the patient or

be cleaned appropriately after use


Investigations

• Observations/NEWS

• Bloods

– FBC, U&E, CRP, LFT,

lactate

– Other bloods guided

by clinical assessment

• Blood cultures

– Performed as per usual

indications

• Chest X-ray- portable if

suspected COVID

• ABG- see local protocol

• COVID:

– WCC often normal

– Lymphopenia common

– CRP ↑

– Nasal & throat swab for

PCR



NEWS

• ‘National Early Warning Score’

– Standardised tool to recognise deteriorating

patients

– Scoring system based upon physiological

measurements:

• Higher number indicates a sicker patient

• Trends help indicate whether patients improving

or deteriorating

• Score corresponds to appropriate escalation plan

NEWS

How it works:

– Based on an aggregate scoring system in

which a score is allocated to physiological

measurements– respiration rate

– oxygen saturation

– systolic blood pressure

– pulse rate

– level of consciousness or new confusion

– temperature

– inspired oxygen



NEWS Escalation

A-E Assessment

• This is a very quick assessment (5-10

minutes) of an unwell patient.

• Address problems as you find them and

reassess regularly and after interventions


Airway

• Assessment:

– Is the patient talking / obtunded / evidence of airway

obstruction (snoring, gurgling, stridor)

• When to seek help:

– If concerns with airway, seek help immediately (anaesthetics/

arrest team)

• Interventions:

– Whilst awaiting perform basic airway manoeuvres

• Head tilt, chin lift

• Jaw thrust

• Use of airway adjuncts (Oropharyngeal airway, nasopharyngeal

airway)


Breathing• Assessment:

– Respiratory rate

– Oxygen saturations

– Percussion & Auscultation

• Interventions:

– Supplemental oxygen to achieve oxygen saturations (94-98%)

• If risk of type 2 respiratory failure (i.e. COPD), consider aiming for SpO2

of 88-92%

– Consider nebulised salbutamol to treat wheeze


– If unable to achieve target saturations despite high flow

oxygen (6-8L via any oxygen delivery) escalate to senior

decision maker


Circulation• Assessment:

– Heart rate

– Blood pressure

– Warmth of extremities and presence of peripheral pulses

– Consider ECG / telemetry

• Interventions:

– Establish IV access (large bore cannula, consider 2)

– Take appropriate bloods

– If evidence of shock, consider a bolus of IV fluids (i.e. 500ml

Plasmolyte)


– If no/inadequate/transient response to fluid resuscitation,

escalate care to senior decision maker


Disability

• Assessment:

– AVPU/GCS

– Pupillary response

– Blood glucose

• Interventions:

– Treat hypoglycaemia if present

– Consider causes of impaired consciousness and treat

appropriately


– Concerns about consciousness level always warrant senior

input. Re-assess and maintain the airway.


Exposure

• Assessment:

– Temperature

– Top to toe examination including abdomen

– Look for evidence of:

• Rashes

• Injury

• Bleeding

• Interventions:

– Respond and treat based upon clinical findings


– Escalate care if any findings that cause concern.


Reassessment

• Reassess patient following each

intervention.

• Escalate patient care at any time that

you have concerns

• Use ‘SBAR’ handover format when

discussing or escalating a patient


SBARSituation

• Introduce self, check you are speaking to the right person

• Who and where (Identify patient and where you are calling from)

• What the current problem appears to be and why your calling them

Background

• Background information about patient

• Reason/date of admission

• Relevant past medical/surgical/social history

Assessment

• Include specific observations and ABCDE assessment findings

Recommendation

• State specifically what you want the person your calling to do

• What and when? (e.g. I’m going to start the following treatment, would you suggest anything else? I think the patient needs reviewed urgently)


Treatment Excalation/

Limitation Plan(TELP)


• Should be put in place at admission

(ED or ECU)

• Should be done for EVERY patient

admitted, regardless of

age/functionality/fitness

• Should be discussed with patient,

(and family if appropriate) but

ultimately, it is a MEDICAL decision

DNACPR

• “The decision to use any treatment

should be based on the balance of

burdens, risks and benefits to the

individual receiving the treatment,

and that principle applies as much

to CPR as to any other treatment.”

• Treatment is justified only if there

is expected benefit to the patient,

i.e. we must justify attempting

CPR, as opposed to justifying not

attempting it.


Immediate Life Support

Refresher Training

COVID-19

Version: Jan

2016

This session should enable you to:

• Safely deliver standardised CPR in adults

with or without suspected/confirmed

COVID-19

• Deliver safe defibrillation (AED only)

Learning outcomes

Chain of survival

Chain of

Survival

Life Support Algorithm

To confirm cardiac

arrest in non-COVID-19

patients…• Patient response?

• Call for help early

• Open airway

• Check for signs of life

• Feel carotid pulse (if trained)

• Check for normal breathing

10 seconds

• caution agonal breathing

Unresponsive and not

breathing normally

Emergency red buzzer

Head tilt chin lift

Check pulse ONLY if trained to

check for carotid pulse.

Look, listen and feel for breath

sounds for 10 seconds

Look, listen and feel

Cardiac arrest confirmedUnresponsive and not

breathing normally

Call resuscitation

team

CPR 30:2

Attach defibrillator/monitorMinimise interruptions

Chest compression• 30:2

• compressions

• centre of chest

• 5-6 cm depth

• 2 per second (100-120 min-1)

• maintain high quality

compressions with minimal

interruptions (<5 s)

• continuous compressions

once airway secured

• switch CPR provider every 2

min cycle to avoid fatigue

Bag valve mask technique

Pad positioning

https://www.firstaidforfree.com/correct-aed-pad-placement/120819-01pre-2/

https://www.firstaidforfree.com/correct-aed-pad-placement/120819-01pre-2/

AP pad position

Automated External

Defibrillation• Use an AED

• Start CPR whilst awaiting AED to arrive

• Switch on and follow AED prompts

Local AED

START PAUSE

CPR

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Assess rhythm

Shockable

(VF/Pulseless VT)

Non-shockable

(PEA/Asystole)

Reversible causes of cardiac

arrest

Vascular access

• Peripheral versus central

veins

• Intraosseous

Assess rhythm

Return of spontaneous

circulation

Immediate post cardiac

arrest treatment Use ABCDE approach

Aim for SpO2 of 94-98%

Aim for normal PaCO2

12-lead ECG

Treat precipitating cause

Targeted temperature

management

Resuscitation team

• Roles planned in advance

• Identify team leader

• Importance of

non-technical skills

• task management

• team working

• situational awareness

• decision making

• Structured communication

• SBAR or RSVP

Non-COVID-19 Summary

• ILS providers should use those skills in which

they are proficient

• If using an AED – switch on and follow the

prompts

• Ensure high quality chest compressions

• Ensure early defibrillation

• Treat any reversible causes

• Ensure expert help is coming

COVID-19(Suspected and confirmed)

Personal Protective Equipment

Full PPE required to start CPR:

• FFP3 respirator

• Gloves for tight-fitting cuffs

• A single-use, disposable, fluid resistant, full-

sleeve gown

• Eye protection (a full face visor or single use

goggles)

AND patient should be wearing a surgical mask.

Minimum PPE Requirements

For anything NOT involving aerosol:

• Fluid resistant (surgical) facemask

• Eye protection

• Plastic apron

• Gloves

To confirm cardiac

arrest in COVID-19

patients…• Patient response?

• Call for help early

• Open airway

• Check for signs of life

• Feel carotid pulse (if trained)

• Check for normal breathing

10 seconds by observing

chest rising and falling ONLY

Unresponsive and not

breathing normally

Check pulse ONLY if trained to

check for carotid pulse.

Look, listen and feel for breath

sounds for 10 seconds

Look, listen and feel

EVERYTHING ELSE REMAINS THE

SAME

Summary

• ILS providers should use those skills in

which they are proficient

• If COVID-19 suspected/positive: don

PPE before any intervention and do not

listen and feel for breaths

Summary

• If using an AED – switch on and follow

the prompts

• Ensure high quality chest compressions

• Ensure early defibrillation

• Treat any reversible causes

• Ensure expert help is coming

Work within your skillset and escalate

as appropriate.


Useful links and apps

• GGC Medicines App

– login: ggcstaff

– password: medicines

• BNF App

• Quick Medicine App (GP Notebook content)

• BMJ Best Practice App

– Athens login

• MD Calc

• Antimicrobial Companion (NHSL Antibiotic Guidelines)

• Geeky medics clinical examination app

• NHS Scotland NEWS App


Online Learning• LearnPro modules

– SIPSEC (infection control)

– Certification of Death

– Antibiotic Prescribing Today's Practitioners

– Intro to Delirium

– AWI

• Resuscitation Council

• ECG revision: LITFL (Life in The Fast Lane) for ECGs

• X-ray interpretation: Radiology Masterclass

• General Revision: GeekyMedics


https://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/healthcare-associated-infections/learnpro.aspx

https://www.resus.org.uk/

https://litfl.com/ecg-library/

https://www.radiologymasterclass.co.uk/

https://geekymedics.com/

Any questions?

acute care refresher - medednhsl.com

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