Common Urgent Calls: The Intern Survival Bible, Volume 2

The second edition of our Intern Survival Bible focuses on Common Urgent Calls. This will give you a full run down of the most common urgent calls you may need to deal with when on the wards.

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 CHAPTER 1:       

General helpful hints and things you can do:

While on the Phone:

  • Request EWS and the individual parameters/vitals [Heart rate (HR), blood pressure (BP), respiratory rate (RR), temperature, oxygen saturation, FiO2 and AVPU)
  • Ask the nurse the following:
    • Situation – what exactly is the problem (central or pleuritic chest pain, duration and associated symptoms, pyrexia, haemetemesis how much and colour etc.) and why they are concerned
    • Background – post op, reason for admission etc
    • Assessment – this should include the EWS and the individual parameters/vitals above and anything else of importance or that the nurse noticed (also complaining of a pain in his leg, coughing a lot, diabetic patient etc.)
    • Recommendation – what the nurse wants you to do (come and review the patient) AND what you want done now before you get there – ask the nurse to repeat the vital signs, have the old notes ready, perform an ECG, sit the patient up etc.

Arrival on the ward:

  • Gather information initially on the PATIENT and the VITALS
  • Look at the most recent set of vitals on the observation sheet and their trend
  • Look at the patient– position, distressed, colour, level of alertness
  • Talk to the patient and take a focused history as to the nature and duration of their symptoms, previous history and concomitant symptoms
  • In an emergency situation it is important to examine, assess, investigate and manage the patient simultaneously and efficiently

Examine and assess:

  • Take a focused history if patient unstable. If stable you will have time to take a more detailed history and consider risk factors in more depth
  • Do a focused examination of the hands, head and neck, chest, heart, abdomen and legs
  • Remove any TEDS or stockings and remove all surgical dressings if you suspect wound infection
  • Look at all devices connected to the patient:
    • Drains: how full are they, what is the colour and nature of the contents
    • Lines: look at central and long lines as they may be infected
    • Infusions: Look at blood transfusions and fluids and ensure they are correct
    • Urinary catheter: Inspect insertion site and contents of the bag

Investigate:

  • Tailor investigations as appropriate: blood cultures, full blood count, troponins, renal profile and coagulation screen, glucose, arterial blood gas and lactate
  • Remember how much information you can get from an ABG (pO2, pCO2, PH, HCO3, HgB, electrolytes, glucose and lactate – they are brilliant and results are immediate
  • Always consider a group and hold or cross match for an unstable patient and alert the lab to prepare platelets and fresh frozen plasma for a bleeding patient
  • ECG is always useful and should be one of the first investigations done in chest pain
  • The chest x-ray is the only portable x-ray that is any use – you can get it quickly and it is often useful in patients with dyspnoea and/or chest pain

 

 

Management:

  • If unstable put on a monitor (tell the nurse to do this)
  • Oxygen is a good start
    • Use a non-rebreather mask connected to 15L at the wall initially
    • You can tailor it with a venture valve or nasal prongs later
  • Attain IV access
    • Two cannulae are always preferable
    • Start some fluid if no sign of heart failure (500ml – 1000mls of normal saline)
  • Where ongoing fluid resuscitation insert a urethral catheter and monitor fluid output which should be 0.5-1ml/kg/hour minimum
  • Medications to consider
    • Analgesia (IV morphine 2mgs)
    • Aspirin or anticoagulant (MI, PE)
    • Antibiotics
    • Nebulizers (combivent) and hydrocortisone (100mg) for wheeze
    • IV frusemide (4Omg) for fluid overload,
    • Terlipressin for the variceal bleeding
    • Adrenaline (0.5ml of 1:1000) for anaphylaxis
  • For a sick patient, call for help early. Alert your SHO, registrar or anaesthetist

 Common Urgent Calls

 

CHAPTER 2:       

Cardiac chest pain:

  • When called to see a patient with chest pain – decide if it is cardiac or non-cardiac by taking the history, performing an examination and doing an ECG and troponin.
  • In deciding if it is cardiac or not you MUST be able to interpret an ECG so ensure you can do that
  • If cardiac, then the scenarios are:

 

A. NSTEMI or ECG changes suggest ischaemia with high risk:

  • Look at and talk to patient and look at vitals and the trend. Pay particular attention to the BP and the HR before prescribing blockers and nitrates
  • Look for relevant clues in the history – past medical cardiac history, previous stent (especially in the last year), cardiac risk factors
  • Examine patient – look for signs of failure in particular
  • Sit patient upright and call for help
  • Telemetry – get the telemetry box from CCU and put it on the patient – this will monitor the patient for arrhythmias, further ECG changes or ST elevation
  • Oxygen non-rebreather mask 15L
  • Attain IV access – attempt 18G but a 20G may be required if access difficult
  • STAT Aspirin 300mg
  • Low molecular weight heparin (LMWH) (Enoxaparin 1mg/kg BD SC)
  • B blockers (Bisoprolol 2.5mg initially). Avoid in hypotension and heart block.
  • Nitrates – (sublingual spray or 30mg isosorbide mononitrate po)
  • Morphine (give 2mg IV and flush it through – watch RR and BP). You will need to observe the effect over 10 – 15 minutes before administering any more
  • Medications to consider:
    • ACE/ARB –however, these do not reduce chest pain and are not indicated in the acute phase
    • Statins
    • Clopidogrel 300mg loading dose (Plavix) OR
    • Consider GP IIb/IIIa inhibitor- Prasugrel 60mg OR Ticagrelor 180mg loading dose  (“Efient” or “Brilique”)
  • Monitor troponins
  • Consider other bloods – ABG can give you a lot of data rapidly, coagulation screen

 

B. The ECG is normal or there are non-specific changes with intermediate to low risk:

  • Look at and talk to patient and look at vitals and the trend
  • Look for clues in the history– past medical cardiac history, previous stent (especially in the last year), risk factors
  • Examine patient
  • Sit patient upright
  • Telemetry – request telemetry to closely monitor the patient for further developments
  • Serial data– arrange for 3 sets of ECGs and troponins to rule out ACS (6hr intervals)
  • Consider a pre discharge stress test

C. STEMI: 

  • These patients usually go straight to the Cath Lab.
  • Contact the cardiology registrar immediately
  • Bring in the arrest trolley and connect the patient to the monitor.  This will monitor for arrhythmias. DO THIS FIRST before initiating any treatment
  • Provide oxygen using a non-rebreather mask, 15L at wall
  • Good IV access – 18G minimum and ideally 2
  • Nitrates: GTN SL spray or isosorbide mononitrate 30mg (watch the PR and BP)
  • Beta blocker 2.5mg initially bisoprolol (watch the PR and BP)
  • Aspirin 300mg
  • Consider Consider GP IIb/IIIa inhibitor- Prasugrel 60mg OR Ticagrelor 180mg loading dose  (“Efient” or “Brilique”)
  • Morphine (give 2mg IV and flush it through – watch RR and BP). You will need to observe the effect over 10 – 15 minutes before administering any more
  • IV fluids – normal saline carefully infused at 80/100mls per hour and monitor for overload

 

 

CHAPTER 3:       

Non-cardiac chest pain:

A. Non-cardiac chest pain

  • You will see a lot of these on call. If you take a history, look for cardiac clues, perform a good examination, run an ECG and troponins and it is not cardiac then out-rule other serious things first and then consider the cause:
  • Aortic dissection – nature and character of pain, blood pressure both arms, murmurs, CXR, haemodynamic stability
  • Pulmonary embolism
  • Pericarditis
  • Lower respiratory tract infection
  • GI causes – reflux, PUD, indigestion
  • Musculoskeletal causes tend to be reproduced by pressing on the chest and asking the patient if that is the same pain as he is experiencing

 

B. Pulmonary Embolism

  • Look at and talk to the patient and look at the vitals and the trend over the previous few hours and days (you may notice O2 sats dipping intermittently). Remember pulmonary embolism can present with a tachycardia and a pyrexia too so keep it in your mind when you think someone has an LRTI
  • Pay particular attention to risk factors for DVT and calculate Well’s score
  • Examine the patient, remember to take off TEDS and look for swelling and feel for tenderness
  • Sit the patient upright
  • Administer oxygen via a non-rebreather mask 15L at wall
  • Ensure good IV access – insert an 18G as some patients can become acutely shocked
  • Fluids if hypotensive: 500mls of saline and monitor response, you are looking for improvements in HR and BP
  • Order a chest x-ray, if unwell order as portable
  • Get an ECG  (the most common finding with PE is sinus tachycardia)
  • Do an ABG and assess level of oxygenation and respiratory failure
  • Other bloods – really these are for out-ruling other causes (FBC, blood cultures)
  • Call for help
  • Anticoagulate with therapeutic dose of LMWH (Enoxaparin 1mg/kg BD) BUT as an intern you need to consult with the SHO/registrar prior to doing this. In addition you need to let the surgeon know that you are doing this is the patient is post op.
  • Commence oral anticoagulant as per local guidelines
  • Unstable PEs may require thrombolysis and/or interventional radiology

 

 

CHAPTER 4:       

Pyrexia:

  • Look at and talk to the patient and look at the vitals and the trend over the previous few hours and days. If previously pyrexic look at the pattern. If spiking temperatures always consider an abscess somewhere. If post operative think carefully about the common causes of post op pyrexia and the timing of these:
    • Early post op think chest
    • A little later post op think urine or line or wound
    • Later again post op think prosthetic infection, anastomotic leak
    • Remember that PE can also present as pyrexia
  • If you think the patient is septic, then do a very thorough examination to locate the source as this will guide antibiotic therapy and further management
  • Assess all potential sites of iatrogenic infection (central and peripheral lines and wounds) if there is an ooze or smell from a wound then remove the dressing to have a look at the wound, get a nurse to help with this
  • You may not be able to easily identify a source. In this case ask yourself if this is unrelated to the reason the patient is in hospital initially? Is there something else going on? Could this patient have developed a tonsillitis, appendicitis or diverticular abscess??
  • If you think this is sepsis then aim to initiate treatment immediatel

 

Management:

    • Administer oxygen via non-rebreather mask, 15L at wall
    • Insert 2 large bore cannulas, the antecubital fossa is often the best site for good access
    • IV fluids – 1000mls normal saline stat and monitor (PR, BP)
    • Urinary catheter
    • Blood cultures (ideally 2)
    • ABG and look at the lactate
    • Other bloods – FBC, renal and coag
    • Consider group and hold
    • Septic screen
    • Deal with the infection site if possible – if a central line is the source then it may need to be removed (be careful here as you may not have any other access if you do this- contact anaesthetics about this). If there is an abscess, then it may need to be drained in theatre etc.
    • Portable CXR if chest is the focus
    • IV antibiotics as per guidelines
    • Call for help early – anaesthetics most useful here (for IV access initially and if no response to initial fluid challenge – give up to 2L, after this the patient is likely to need vasopressors with central venous monitoring)

 

 

CHAPTER 5:       

Gastrointestinal haemorrhage:

  • Look at and talk to the patient and look at the vitals and the trend over the previous few hours. Look for tachycardia or widened pulse pressure that suggest decompensated shock
  • Ascertain the patient’s most recent haemoglobin value
  • The history is really important here so get the story from the patient and the nurse:
    • Volume of blood
    • Colour of blood
    • Presence of melaena or haematochezia – inspect as the patient may be unaware it
    • Previous history of GI bleeding
    • Known liver failure
    • Precipitating factor – stress ulcer, NSAIDS, anticoagulants
  • In the presence of liver failure assume variceal bleeding and get help STAT
  • In very large bleeds, remember to protect the airway, call the anaesthetist early as the patient can loose their airway very quickly.
  • Administer oxygen via non-rebreather mask, 15L at wall
  • Insertion of 2 large bore IV cannulas
  • IV fluids – 1000mls normal saline stat and monitor HR, BP. Give a second bag of 1000mls if patient doesn’t respond and call for blood
  • Urinary catheter insertion to monitor fluid output
  • Immediate bloods: FBC, coag, group and cross match (if high risk of bleeding or unstable then order 6 units blood)
  • Oesophageal varices : – IV terlipressin and IV antibiotics (check local guidelines)
  • Consider Vitamin K IV if abnormal coagulation screen
  • Proton pump inhibitors are not used in variceal bleeds and acute PUD bleed. However, they may be used post scope to prevent rebleeding. Should be discussed with seniors
  • Contact surgical or gastro registrar and arrange for urgent OGD if unstable or large bleed

 

 

CHAPTER 6:       

Oxygen desaturations and dypnoea:

  • Look at the patient and the vital signs (all of them) – pay attention to the trend and the RR, SpO2 in particular but look at the other parameters & vitals too (signs of shock may point to a PE and sepsis. Pyrexia may point towards sepsis or LRTI)

Assessment:

  • Talk to the patient and the nurse. Get a good history if possible and ask if known COPD, asthmatic or admission with a cardiac complaint
  • Spend some time on the history and associated symptoms. Remember to consider respiratory causes first but also think about
    • Blood loss
    • Sepsis
    • Anaphylaxis if patient is desaturating and his upper airway is in trouble (look for facial swelling, rash, listen for stridor). Call for anaesthetics stat, give IM adrenaline in the thigh every 5 mins and lots of IV fluids
  • Examine patient carefully and always remember to examine lower limbs
  • Listen to his chest and heart in particular but remember to do a full examination – this includes his abdomen

Management:

  • Put patient on oxygen or increase what he is currently on
  • Consider a nebulizer if there is audible wheeze (combivent)
  • Put in an IV (you will need it for resus if shocked, antibiotics if sepsis and frusemide if in failure)
  • Consider using non-invasive ventilation if there is type 1 or 2 respiratory failure and you are making no progress with supplemental oxygen. Call the respiratory physiotherapist to set this up for you if you are unfamiliar with it. Patients are most comfortable on BiPAP and the physiotherapist will help you to adjust the settings initially. You will need to repeat the ABG after about 20 minutes to see if things are improving and readjust settings as required

Investigations:

  • Perform an ABG, which is essential in the desaturating patient. It will tell you type 1 or type 2 respiratory failure and can alert you to sepsis if there is elevated serum lactate
  • Request a CXR (portable – ring the on call radiologist or the radiologist in the ED)
  • An ECG may help you to make a diagnosis (or out-rule a cardiac cause)
  • Consider other bloods – cultures, FBC, renal profile, coagulation screen, glucose
  • Look at the CXR for infection, collapse, failure, pneumothorax
  • Look at the O2 saturations on increased oxygen and consider repeating an ABG to see if you are making progress
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