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lc
≥97 on
95–96 on
93–94 on
223EARLY WARNINGSCORES
oxygen
oxygen
oxygen
ore
Physiologica S
parameter 3210123
≥96
88–92
≥93 on air
Oxygen Air
≤8 9–11 12–20 21–24 ≥25
≤91 92–93 94–95
≤83 84–85 86–87
Scale 1 (%)
Respiration rate
(per minute)
SpO
SpO Scale 2 (%)
≤90 91–100 101–110 111–219 ≥220
Air or oxygen?
Systolic blood
pressure (mmHg)
≤40 41–50 51–90 91–110 111–130 ≥131
Pulse (per minute)
Alert CVPU
≤35.0 35.1–36.0 36.1–38.0 38.1–39.0 ≥39.1
Consciousness
Temperature (°C)
Fig.6. National Early Warning Score (NEWS2). Atotal score ≥5, or any individual parameter scoring 3 should
prompt urgent review by a doctor Ask yourself, could this be sepsis? © Royal College of Physicians207.
Box 6. Key updates in NEWS2
In the original NEWS charts, COPD patients might constantly cross
alarm thresholds for low oxygen saturations. As with many persistent
alarms, users might become desensitized to high scores in this patient
cohort. NEWS2 has a separate row (‘SpO
if the patient has been allocated to target saturations of 88–92% to
scale 2’) for saturations
2
ensure that they are appropriately monitored. Additionally, in the original score a patient could be confused, but still be considered as not
at risk since they were ‘alert’ on the AVPU scale. NEWS2 recognizes
new confusion by allocating a score of 3 to this worrying feature as a
new category, ‘
responsive to
C’, in addition to a similar score allocated for patients
Voice or Pain only, or Unresponsive (hence CVPU).
224 CHAPTER6 Resuscitation
Intensivecare
This section aims to provide a brief introduction to the decisions involved in
referring and accepting a patient intoICU (intensive care unit).
What does ICU oer that is dierent fromwardcare?
• Close monitoring using non- invasive and invasive devices (such as
arterial and central venouslines)
• Organ support for vascular, renal, or respiratory failure (some units can
oer cardiac supporttoo)
• : nursing care and frequent, intensive physiotherapy.
Intensivists oer organ support and resuscitation; each patient will have
a parent team overlooking their care who should visit on regular ward
rounds (this will most likely be your rst encounter withICU).
Admitting a patient onto intensive careIt can sometimes seem
that intensivists are ‘reluctant’ to accept patients, but there are certain
questions that must be satised in order to ensure that a patient can
benet from ICU. Patients have frequently described post- traumatic stress
disorder following prolonged ICU stays; this serves to remind us that it is a
tough environment with frequent exposure to painful and invasive procedures. The decision to commit a patient to a rigorous treatment pathway
is a complex process. Apossible referral needs to be discussed with your
consultant, as the decision to admit will be made by an ICU consultant who
will often phone your consultant for further discussion.
The information requiredIncludes any known current/ previous wants and
wishes, details of the current illness and underlying medical conditions,
the response to treatment so far, and the general physical/ functional
baseline. This is put together to decide on likely prognosis and trajectory, and therefore whether the benets will outweigh the risks. What
are the patient’s wishes? (Not always possible in the acute setting, but
some patients are admitted to ICU electively following planned surgical
procedures such as complex open AAA repairs.)
The most dicult aspect ofthe decisionis deciding how likely it is that the patient
in front of you will go on to have a quality of life that they will nd worthwhile. Is ICU really going to make a dierence? (Eg ICU cannot entirely replace liver function, but it can support the respiratory system long enough to
enable the body to recover from an infection.) Intensive care therapies can
be aggressive and unpleasant. You need to ensure that the patient is motivated to endure this, but also has a good pre- existing baseline to relyupon.
Reversibility is another aspect frequently considered. Is the presenting
complaint something that we have the chance of reversing (such as infection)?
Or is this new presentation just the natural sequelae of their existing disease
process? For example, a patient with a degenerative neurological disease
develops an infection. ICU can oer organ support and intensive antibiotics
while the infection is being treated, but there is little that can be oered
if the patient is becoming breathless because of diaphragmatic weakness.
If you need help witha sick patientCall ICU— they may not ne-
cessarily need to take over care but they can advise you on further action.
Indications for intubation Not all patients on ICU are intubated
(Box 6.2), ICU oers patients organ support beyond just managing the
airway. Patients are only intubated in situations where they are unable to
protect their own airway, or it may be that ICU will intubate and ventilate
a patient in order to facilitate treatment (this is what is called ‘an induced
coma’ in layman’s terms).
• Respiratory problems (eg hypoxia, hypercapnia, trauma)
• Neurological problems (eg low GCS so cannot maintain airway,
mandatory sedation is required, eg for agitation)
• Physiological reasons (to reduce the work of breathing in cardiac
failure, respiratory failure, and acidosis, to prevent hypercapnic
cerebral vasodilation in raised ICP, eg head injury, and for
‘neuroprotective measures’, eg in severe encephalitis/ meningitis).
Respiratory wean Refers to the process of reducing ventilatory support in
a patient who is on positive pressure ventilation, in order for the patient
to be able to breathe unaided by themselves. In a patient who has been
on a ventilator for a long period of time, has COPD, or who is weak
and malnourished, this complex process may take several weeks or even
months. There is no universal protocol.
Receiving an‘ICU step- down’ patient onyour ward
When patients no longer need ICU level care, they are ‘stepped down’
to the wards. Generally, a written handover document from ICU should
accompany the patient to the ward and sometimes a telephone handover as well. Some questions to consider:
• What are the priorities of care for this patient and the next stages?
• What happens if they deteriorate? Would ICU readmit them? ICU
patients will often be discharged with a plan for re- escalation
• Physiotherapyplans
• Have all the central venous and arterial lines been removed?
• Are there any drugs prescribed that you are not familiarwith?
• Remember that there are teams from ICU in each hospital who help
with psychological counselling after a prolonged ICUstay.
Most hospitals have an outreach team who review step- down patients.
225INTENSIVE CARE
Box 6.2 Levels ofcare inhospital
Level 0 General medical/ surgicalbed.
Level Patients needing outreach support from ICU for medical advice,
close monitoring, or clinical intervention as they may need escalating
to ICU or have just come fromthere.
Level 2Often called HDU care; provision of single-organ support but
maintaining own airway (eg vasopressors, renal replacement therapy).
Level 3 Patients who are intubated or needing more than one organ
supported.
If the ICU team feel that a patient may benet from ICU but the unit
is full, they will try to accommodate the patient elsewhere, such as
theatre recovery until an ICU bed becomes available, or in some
cases may arrange a transfer to an ICU in another hospital that has
availability.
226 CHAPTER6 Resuscitation
2Peri- arrest
3Call the arrest team if you are concerned about A, B, or C; call for
senior help early. Remember, the cardiac arrest team can be called for
peri- arrest patients where you simply need many more pairs of hands
and some senior support. It’s better to prevent a cardiac arrest! Always
state clearly ‘Adult/ paediatric/ obstetric cardiac arrest team to Ward A’.
Airway
• Look inside the mouth, remove obvious objects/ dentures
• Wide- bore
•
Listen for signs of airway impairment (stridor, snoring, gurgling, or no
airentry)
•
Jaw thrust/ head tilt/ chin lift with cervical spine control intrauma
•
Oropharyngeal or nasopharyngeal airway as tolerated.
Breathing— no respiratory eort? CALL ARREST TEAM
• Look for chest expansion (does R=L?), fogging of mask (Box6.3)
•
Listen to chest for air entry (does R=L?)
•
Feel for expansion and percussion (does R=L?)
•
Non- rebreather (trauma) mask and 5L/ min O
•
Bag and mask if poor or absent breathingeort
•
Monitor O
•
Think tension pneumothorax (in a trauma victim).
Circulation— no palpable pulse? CALL ARREST TEAM
• Look for pallor, cyanosis, distended neckveins
•
Feel for a central pulse (carotid/ femoral)— rate andrhythm
•
Monitor debrillator ECG leadsandBP
•
Venous access, send bloods and perform ABG if timeallows
•
2- leadECG
• Call for senior help early if patient deteriorating.
Disability— GCS ≤8 or falling? CALL ANAESTHETIST
• Assess GCS (E pp. 352–3) and check glucose
•
Look for pupil reexes and unusual posture
•
Feel for tone in all four limbs and plantar reexes.
Exposure
• Remove all clothing, checktemp
•
Look all over body including perineum and back for rash or injuries
•
Cover patient with a blanket.
suction under direct vision if secretions present
initially in all patients
2
satsandRR
2
2Box 6.3 Signs oflife
• Regular respiratoryeort
• Coughing
• Opening eyes
• Purposeful movement
• Speaking.
IN- HOSPITAL RESUSCITATION
2In- hospital resuscitation
227
Fig.6.2 In- hospital resuscitation algorithm; 202 guidelines.
Reproduced with the kind permission of the Resuscitation Council(UK).
2Box 6.4 Commoncauses
Arrhythmia E p. 262 Hypoxia E pp. 284–97
Myocardial infarction E p. 258 Pulmonary oedema E p. 296
Hypovolaemia E p. 401 Pulmonary embolism E p. 292
Sepsis (UTI/ pneumonia) E p. 484 Metabolic (idK
Hypoglycaemia E p. 336 (Tension) pneumothorax E p. 293
+
) E p. 406
228 CHAPTER6 Resuscitation
2Advanced Life Support(ALS)
2 Airway
2
Breathing
2 Circulation
Basic Life Support (BLS)Should be initiated and the cardiac arrest
team called as soon as cardiac or respiratory arrest is suspected.
Advanced life supportThis is centred around a ‘universal algorithm’
(Fig.6.3) which is taught on a standardized course oered by most hospitals.
The cardiac arrest team This usually consists of a team leader
(medical registrar), F, anaesthetist, CCU nurse, and senior hospitalnurse:
• Team leader— gives clear instructions to other members
• F— provides BLS, cannulates, takes arterial blood, debrillates if
trained, gives drugs, performs chest compressions (Box6.5)
• Anaesthetist— airway and breathing, they may choose to bag- and- mask
ventilate the patient, insert a laryngeal mask, or intubate (Epp. 570–1)
• Nurses— provide BLS, debrillate if trained, give drugs, perform chest
compressions, record observations, note time points, and takeECGs.
Needle- stick injuries(E p. 03.) Commonest in times of emer-
gency. Have the sharps box nearby and never leave sharps on thebed.
Cannulation Can be very dicult during a cardiac arrest. The ante-
cubital fossa is the best place to look rst; alternatively try feet, hands,
forearms, or consider external jugular if all else fails. Take bloods if you are
successful, but don’t allow this to delay the giving ofdrugs.
Blood tests Occasionally useful in cardiac arrests, especially K
can often be measured by arterial blood gas machines. Use a blood gas syringe to obtain a sample (the femoral artery with a green needle (2G) is
often easiest— NAVY E p. 544) and ask a nurse to take the sample to the
machine. Other blood tests depend on the clinical scenario; if in doubt, ll all
the common blood bottles (Ep. 545).
Debrillation
under taken unless trained. The use of automated external debrillators
(AEDs; E p. 560) is becoming routine in non- clinical areas as rigorous
training is not required.
Cardiac arrest drugs These are now prepared in pre- lled syr-
inges:adrenaline (epinephrine) mg in 0mL (:0,000), atropine (several
preparations available), amiodarone 300mg in 0mL.
ush (20mL saline) after each dose to encourage it into the central circulation
E inside back cover of this handbook for further emergency drugdoses.
Cardiac arrest trolleys Found in most areas of the hospital. Know
where they are for your wards. Ask the ward sister if you can open the
trolley and have a good look at the equipment within it as they dier between hospitals. They are often arranged so the top drawer contains
Airway equipment, the second contains Breathing equipment, the third
contains Circulation equipment, and the lower drawer contains the drugs
and uids. You’ll seldom need anything that isn’t on the trolley.
Check airway is patent; consider manoeuvres/ adjuncts
with C- spine control in trauma
If no respiratory eort— CALL ARREST TEAM
If no palpable pulse— CALL ARREST TEAM
Taught on specic courses (eg ILS, ALS) and must not be
Always give a large
+
which
.
ADVANCED LIFE SUPPORT(ALS)
229
Fig.6.3 Adult Advanced Life Support algorithm; 202 guidelines.
Reproduced with the kind permission of the Resuscitation Council(UK).
2Box 6.5 What can youdo?
When you start to attend arrest calls as a Foundation doctor, you can often
feel out of your depth and a little useless. That’s not the case at all! Here is a
list of incredibly useful things to start immediately when you arrive:
• Announce that you will scribe (keep a timed record of drugs and
shocks given) and communicate the need for the next dose/ shock
loudly to yourteam
• Be a tourniquet for your colleague, this steadies the hand during
CPR so IV access is gainedfaster
• Find the notes and start looking through the background so that you
can educate the team on the patient’s clinical background which can
give signicant clues about why the cardiac arrest has takenplace.
230 CHAPTER6 Resuscitation
2Arrest equipment andtests
Airway
Jaw thrust Pull the jaw forward with your index and middle ngers at
the angle of each mandible. Pull hard enough to make your ngersache.
Head tilt Gently extend the neck, avoid if C- spine injuryrisk.
Chin liftPull the chin up with two ngers, avoid if C- spine injuryrisk.
Oropharyngeal airway (Guedel) Arigid, curved plastic tube; choose the
size that reaches the angle of the mouth from the tragus of the ear.
Insert upside down to avoid pushing the tongue back, then rotate 80°
when inside the mouth (do not insert upside down in children).
Nasopharyngeal airwayA exible, curved plastic tube, not to be used with
signicant head injury. Choose the size that will easily pass through the
nose (size 6– 7mm in most adults); insert by lubricating and pushing horizontally into the patient’s nostril (not upwards). Use a safety pin through
the end to prevent the tube beinglost.
Suction Cover the hole on the side of a wide- bore suction catheter to
cause suction at the tip. Secretions in the parts of the oropharynx that
can be seen directly can be cleared. A thinner catheter can be used to
clear secretions in the airway of an intubated patient.
Breathing
Non- rebreather mask A plastic mask with a oppy bag attached; used in
acutely ill patients to give 780% O
Standard mask (Hudson mask) A plastic mask that connects directly to
O
tubing; delivers 750% O2 with a 5L/ min owrate.
2
Venturi A mask that connects to the O
plastic, delivering either 24%, 28%, 35%, 40%, or 60% O
ow rate according to the instructions on the coloured plastic connector, eg 4L/ min with the 28% Venturi connection.
Bag and mask (Ambu bag) A self- inating bag and valve that allows
you to force O
O
tubing to the bag with a 5L/ min ow rate then seal the mask
2
over the patient’s nose and mouth. Easiest with two people; one
into an inadequately ventilating patient. Attach the
2
person stands at the head to get a rm seal with both hands while the
other squeezes the bag. The mask can be removed to attach the bag
to an ETT or LMA (Ep. 572).
Pulse oximeterPlastic clip with a red light that measures blood O
ations. Clip onto the patient’s index nger. Do not rely on the reading
unless there is an even trace on the monitor and the patient has a pulse;
use on the dierent arm from the BPcu.
NebulizerThis is a 3cm- high cylinder that attaches beneath a mask. The
cylinder is made of two halves that can be untwisted so that the uid to
be nebulized can be inserted. The nebulizer can be connected to a pump
or directly to an O
or medical air supply.
2
with a 5L/ min owrate.
2
tubing via a piece of coloured
2
. Adjust the
2
satur-
2
ARREST EQUIPMENT ANDTESTS
Circulation
Debrillation(E p. 560.) Successful debrillation requires ECG monitoring
to identify a shockable rhythm, and delivery of current through electrodes
attached to the chest wall. Previously, monitoring was performed using ECG
leads: red to right shoulder, yellow to left shoulder, and green to apex (E
p. 556). Separate paddles were applied to deliver current. Most NHS trusts
now use hands- free adhesive debrillation electrodes which are safer and
also double as monitoring leads (E p. 557). Only debrillate if you have
been trained, otherwise many debrillators have an automated mode (AED)
that can provide computerized rhythm analysis and advice.
• Check the adhesive electrodes are correctly applied to thechest
• Switch the debrillator to ‘monitor’mode
• If a shockable rhythm is identied, select required debrillation energy
using the circular dial, then charge debrillator using ‘charge’button
• Tell sta to stand clear and stand clear yourself—chest compressions
should continue until the latest possiblemoment
• Check the O
• Check the rhythm is still shockable then press the ‘shock’ button to
, sta, and you are clear (O2, top, middle, bottom,self)
2
deliver the charge. Resume CPR, without pausing to check rhythm.
Blood pressureAttach the cu to the patient’s left arm so it is out of the
way and leave in place. If it does not work or is not believable (eg irregular or tachyarrhythmia) then obtain a manual reading.
Venous access Ideally an orange/ grey venon in each antecubital fossa;
however, get the best available (biggest and most central). Remember to
take bloods but don’t let this delay givingdrugs.
Disability
GlucoseUse a spot of blood from the venous sample or a skin prick to
get a capillary sample; clean skin rst with water to avoid false readings.
Examination GCS, pupil size and reactivity to light, posture, tone of all
four limbs, plantar reexes.
Exposure Take all the patient’s clothes o; have a low threshold for
cutting them o. Inspect the patient’s entire body for clues as to the cause
of the arrest, eg rashes, injuries. Measure temp. Remember to cover the
patient with a blanket to prevent hypothermia and for dignity.
Other investigations
Arterial blood gas Attempts to sample radial artery blood in a patient in
extremis may be futile and waste valuable time. Instead, attach a green
(2G) needle to a blood gas syringe, feel for the femoral pulse (½ to
⅔ between superior iliac spine and pubic symphysis) and insert the
needle vertically until you get blood. Press hard after removal. Even if
the sample is venous, it can still oer useful information.
Femoral stab(E p. 544.) If no blood has been taken you can insert a
green needle into the femoral vein which is medial to the artery (NAVY).
Feel for the artery then aim about cm medially. If you hit the artery
take 20mL of blood anyway and send for arterial blood gas and normal
blood tests, but press hard after removal.
ECGAttach the leads as shown on Ep. 557.
CXR Alert the radiographer early so that they can bring the X- ray
machine for a portableCXR.
231
232 CHAPTER6 Resuscitation
2Advanced Trauma Life Support(ATLS)
ATLSThis is designed to quickly and safely stabilize the injured patient.
The purpose of ATLS is not to provide denitive care of all injuries, but to
recognize the immediate threats to life and to address these. Remember
to act immediately:70% of trauma deaths arise from airway obstruction.
As with ALS, in ATLS the patient’s care is delivered by a team which will
consist of a leader and various members. Details of how to undertake an
ATLS course are given in Box 6.6; it is really useful if you are considering a
career in the acute services or surgery.
The primary surveyThis involves rapid <C>ABCDE assessment. If
a life- threatening issue is found this must be treated before moving on to
the next step of the primary survey. The primary survey is as follows:<C>
for catastrophic haemorrhage (Box 6.7); Airway with cervical spine protection (E OHCS11 p. 576); Breathing: ventilation and oxygenation
(E OHCS11 Thoracic trauma, p. 592); Circulation (E OHCS11
Management of shock in trauma, p. 582); Disability: brief neurological
examination; Exposure/ Environment. Reassess patient’s ABCDE and
consider need for patient transfer. Once stablized, patients with multiple
injuries should have rapid whole body imaging, eg trauma protocol CT.
The secondary surveyOnce life- threatening issues have been iden-
tied and dealt with, the secondary survey involves a more complete history and a top- to- toe examination looking for other important injuries.
Thorough examination is particularly important in an unconscious patient
who may not be able to report an important injury themselves. The secondary survey is as follows:
medical history, Last meal, Events leading to presentation) and mech-
anism of injury; Head and maxillofacial; Cervical spine and neck; Chest;
Abdomen; Perineum/ rectum/ vagina; Musculoskeletal; Neurologic.
Trauma and theFoundation doctorIt is highly unlikely the Foun-
dation doctor will be the rst person to attend to a major trauma patient, though ATLS can be applied in principle to any patient who has
sustained an injury. Having a logical, step- wise approach to injured patients minimizes the risk of missing life- threatening complications or injuries which subsequently may become debilitating if left unrecognized
and untreated. If you are working in the ED you will likely be involved
in gaining IV access or perhaps conducting parts of the primary survey
under supervision. Get involved with conducting the secondary survey; it
is often poorly performed as all the adrenaline of performing life- saving
interventions wears o. This bit is essential though, as the unconscious
patient will be unable to report a nger fracture, or damaged genitalia.
AMPLE history (Allergies, Medications, Past