Emergency
Saturday, 1 February 2020 6:07 PM
Assessment
•It’s secure if patient is speaking
A
•It’s not if there are secretions,
the patient has aspirated, or is
snoring/ GCS<8
Airway
•Pulse oximetry
B
•RR
•Chest exam: cyanosis, tracheal
deviation, chest inspection
(accessory muscles, deformities),
expansion, percussion,
auscultation
•Calves
Breathing
•BP (for all observations,
C
especially BP, look at trends)
•HR and central and peripheral
pulse volume
•Central cap refill (and hands
warmth) •Auscultate heart, JVP &
look for signs of fluid overload
•Fluid balance and organ
Circulation perfusion (IN e.g. fluids, intake;
OUT e.g. catheter/urine, drains,
vomit)
•Place wide-bore IV Cannula and
take bloods (including VBG for fast
results)
ABCDE_man
agement
A
Management
•Consider: suction, airway opening manoeuvres
e.g. jaw thrust/head-tilt chin lift,
oropharyngeal/nasopharyngeal airways,
intubation (if GCS <8)
•15L/min O2 through non-rebreather mask (see
oxygen note)
WARNING: take care if COPD (unless they are in
respiratory distress and hence need 15L, start
on 24-28% i.e. 2-4L venturi and aim for sats
88-92%. Titrate to ABG results)
•Consider non-invasive or invasive ventilation if
hypoxic or hypercapnic despite maximal
therapy (see NIV notes)
•Sit up if SOB
•Treat any obvious causes (e.g. tension
pneumothorax, asthma exacerbation, opiate
overdose, anaphylaxis)
Arrhythmia
•Apply 3-lead cardiac monitoring – further
management in arrhythmia notes Hypotension
•Fluid challenge = 500ml crystalloid STAT and
monitor response by HR, BP and UO (see fluids
notes)
WARNING: take care if significant heart failure
history (use 250ml challenge initially)
Shock
•2 large bore IV cannulae (+take bloods
including G&S/crossmatch)
•Fluid challenge = 1L crystalloid STAT
•Replace blood with blood (can give O negative
or typing takes 15mins). In massive blood loss,
call 2222/lab and activate ‘massive blood loss
protocol’ to get packed red cells + FFP ±
platelets
Further management
•Respond fully: give maintenance fluids
•Responds by BP falls again: more fluids
(adequate resus depends on padent and fluid
Airway Management

•DEFG!!!!!!!!! - Don’t Ever Forget
call 2222/lab and activate ‘massive blood loss
protocol’ to get packed red cells + FFP ±
platelets
Further management
•Respond fully: give maintenance fluids
•Responds by BP falls again: more fluids
(adequate resus depends on padent and fluid
deficit but is usually ̴ 20-30ml/kg given quickly)
•No response: patient is either fluid overloaded
(don’t give any more fluids) or very depleted
(give lots of fluids)
Escalation
•If patient his hypotensive and overloaded,
they need inotropes
•If patient is still hypotensive despite adequate
fluid resuscitation (30ml/kg), they need
vasopressors
•Correct glucose

D
Glucose •Give analgesia if pain (e.g. morphine 10mg in
•Temperature 10ml saline titrated to pain slowly IV)
•GCS/AVPU score
•Pupils reactivity and symmetry
•Pain assessment

Disability
•Exposure (look for bleeds, rashes, •Manage any other abnormal findings as

E
injuries) if necessary but avoid appropriate
heat loss •Focussed exam of
relevant systems

Everything
Else

Investigations to find cause

• Review patients notes
• BOXES
o Bloods (mark as urgent): ABG (if low sats), venous bloods (group&save, FBC, U&Es, CRP, LFTs, clotting
etc), capillary glucose, blood cultures (if pyrexial)
o Orifice tests: urine dip, urine/sputum/faeces culture
o X-rays/imaging: portable CXR
o ECG ± 3-lead cardiac monitoring
o Special tests: depending on likely cause
Condition specific treatment
See OSCEstop acute management section e.g. MONAC for MI, furosemide for HF, LMWH/thrombolysis
for PE, ABx for pneumonia/sepsis, fluids and insulin for DKA, terlipressin & OGD for bleeding varices
Request help as required
• Inform senior
• Refer to other specialty if indicated
o Medical registrar: medical problems
Airways
copy
 See OSCEstop acute management section e.g. MONAC for MI, furosemide for HF, LMWH/thrombolysis
for PE, ABx for pneumonia/sepsis, fluids and insulin for DKA, terlipressin & OGD for bleeding varices
Request help as required
• Inform senior
• Refer to other specialty if indicated
o Medical registrar: medical problems
o Surgical registrar: surgical problems and bleeding
o Cardiology registrar: MI
o Intensive/high-dependency care registrar: if likely to be required
Document in patients notes
• Document with a brief case summary, ABCDE headings with findings and management
• Review patient and results as necessary