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Related Subjects: |Assessing Chest Pain |Acute Coronary Syndrome (ACS) General |Aortic Dissection |Pulmonary Embolism |Acute Pericarditis |Diffuse Oesophageal Spasm |Gastrooesophageal reflux |Oesophageal Perforation Rupture |Pericardial Effusion_Tamponade |Pneumothorax |Tension Pneumothorax |Lactic acidosis

Profoundly sick patient, call for help, don't panic instead focus on ABCs and you can work it out

Introduction

• If the patient is conscious and is breathing with a pulse then work quickly and logically.
• Start Oxygen and get IV access and start Observations.
• Find a central pulse and monitor it. Always think ABC.
• Check airway is fine, check breathing and circulation.
• Give Oxygen, direct someone to get IV access, Decompress tension PTX if likely.
• Significant haemorrhage ten pressure and Get O negative blood if bleeding out.
• Comatose and airways issues or hypoventilating Critical care review? Intubation
• Consider inserting a urinary catheter to help fluid I/O in any patient with cardiorespiratory collapse.
• Give broad-spectrum antimicrobial where sepsis considered and moribund e.g. Co-Amoxiclav 1.2 g IV 6-8 hourly or local guidance if not pen allergic
• High yield tests if well enough: Coma CT Scan. Breathless ECG, CXR, Bedside Echocardiogram, Chest pain: ECG, CXR, CT Aorta. Lactate, ABG. Abdominal pain: Erect CXR, CT abdomen

Always keep asking if patient not improving

• Is the diagnosis correct?
• Is the diagnosis complete?
• Could there be more than one diagnosis?
• What information do I need and what test provides that and is hat test available
• Shall I phone a friend - my consultant or HDU registrar

Airway

Breathlessness

• Mechanical Airways Issue: fast bleep anaesthetics/ENT if stridor and suspected epiglottitis do not examine airway. Give oxygen.
• Otherwise Head tilt, chin lift and inspect mouth. Remove any obstruction.
• Hypoventilating: Give naloxone 0.4 mg repeated as needed. Can give up to 2 mg initially and max 10 mg. High flow oxygen, oropharyngeal airway, Ambu bag.
• Anaesthetic help. RSI. Other causes could be neurological? Myasthenia, GBS, MND
• Tension Pneumothorax. Pushes lungs away. Resonant. Decreased air entry. Context e.g. ventilated or trauma. Then decompress with needle 2nd space and mid-clavicular line
• Acute LVF: Crackles, Sitting up, Tachypnoeic. Give GTN and IV Frusemide and get ECG and CXR. If STEMI fast track for reperfusion.
• Acute PE: Type 1 RF. Chest pain. Tachypnoeic. ECG tachycardia. If Hypotensive consider Bedside Echo if available and/or CTPA. Consider IV heparin. Consider thrombolysis if haemodynamic compromised
• Acute Severe Asthma: Tiring patient. Begins to CO2 retain and become hypoxia. Get ITU to see. See section
• Exacerbation of COPD: Known COPD. Wheeze, tachypnoeic. Prolonged expiratory phase. 24-28% oxygen. Consider NIV
• Pneumonia/COVID19: CXR changes, hypoxia
• Hyperventilating: Panic attack. Low PCO2. Diagnose when all else excluded

Decompressing Tension Pneumothorax

Hypotensive

• If no clear cause consider a trial of 500 ml of N-Saline and reassess. If breathless then trial 250 ml unless clearly in pulmonary oedema.
• Haemorrhagic shock: GI bleed, liver disease, varices
• Septic Shock: Infection. Lactate high Start Sepsis 6 with broad-spectrum IV antibiotics
• Leaking AAA: abdominal pain. Palpable aneurysms. IV access. Vascular consult
• Ectopic pregnancy: Fertile female shock and abdominal pain
• Cardiogenic shock: Recent Chest pain but can be silent, Get ECG STEMI, New murmur. Telemetry, Echocardiogram
• Dissection Aortic Aneurysm: chest pain needs CT aorta, BP control and cardiothoracic
• Anaphylaxis: bee sting, drug, penicillin. Urticaria, wheeze, rash. Needs IM Adrenaline and 1L N-Saline over 30 mins
• Cardiac tamponade High JVP, Muffled heart sounds, trauma, anticoagulated, BP fall with inspiration and cannot be palpated (pulsus paradoxus)
• Pulmonary embolism: tachypnoeic. High JVP, Loud P2, DVT, Risk factors, ECG changes. CXR may be normal
• Meningococcal septicaemia: non-blanching rash, fever, malaise, obtunded, meningism
• Addison disease: Pigmentation

Treating Anaphylaxis: See topic

Chest Pain

• Acute coronary syndrome: get CXR. Treat ACS
• Acute Aortic dissection: Get CXR, CT Aortogram/TOE. Avoid antithrombotics until excluded
• Acute Pulmonary Embolism: CTPA
• Oesophageal disease: rupture, inflammation, GORD

Comatose

• Hypoglycaemia: Give Glucose
• Opiates: Give naloxone 0.4 mg (400mcg) repeated as needed. Can give up to 2 mg initially and max 10 mg
• Space Occupying lesion: get CT head
• Alcohol intoxication or other drugs
• Meningitis/Encephalitis: Treat Aciclovir/Ceftriaxone and consider LP
• Massive stroke (ischaemic, haemorrhagic or SAH) or bilateral thalamic infarct
• Post seizure or Non convulsive status
• Cerebral malaria: foreign travel

Arrhythmias

• If rate < 50 or > 120 then ask If the rhythm could be the case.
• See algorithm for bradycardia and tachycardia. Get ECG
• Tachycardia causing hypotension: DC cardioversion
• Bradycardia causing hypotension: Atropine, External or Transvenous Pacing wire

Abdominal Pain

• Leaking AAA: abdominal pain and hypotension. IV access. Vascular surgeons
• Acute Pancreatitis: peritonism, bruising flanks
• Perforated viscus: CXR and CT abdomen to establish cause. NBM . IV fluids, Broad spectrum antibiotics
• Ectopic pregnancy: fertile female. Abdominal pain and collapse
• GI bleed: Needs endoscopy, PPI and vasopressin if varices suspected. Correct coagulopathy. Transfuse as needed