Читать книгу Essential Guide to Acute Care - Nicola Cooper - Страница 22

Airway

Examine for signs of upper airway obstruction

If necessary, do a head tilt‐chin lift manoeuvre

Suction (only what you can see)

Simple airway adjuncts may be needed

Give oxygen if needed (see Chapter 2 for more details)

Breathing

Look at the chest

Assess rate, depth, and symmetry of movement

Measure SpO₂

Quickly listen with a stethoscope (for air entry, wheeze, crackles)

You may need to use a bag and mask if the patient has inadequate ventilation

Treat wheeze, pneumothorax, fluid, collapse, infection, etc. (is a physiotherapist needed?)

Circulation

Assess limb temperature, capillary refill time, blood pressure, pulse, urine output

Insert a large bore cannula and send blood for tests

Give a fluid challenge if needed (see Chapter 5 for more details)

Disability

Make a note of the AVPU scale (alert, responds to voice, responds to pain, unresponsive)

Check pupil size and reactivity

Measure capillary glucose

Examination and Planning

Are ABCD stable? If not, go back to the top and call for help

Complete any relevant examination e.g. heart sounds, abdomen, full neurological exam

Treat pain

Gather information from notes, charts, and eyewitnesses

Do tests e.g. arterial blood gases, X‐rays, ECG

Do not move an unstable patient without the right monitoring equipment and staff

Make ICU and CPR decisions

You should have called a senior colleague by now, if you have not done so already.

Patients with serious abnormal vital signs are an emergency. The management of such patients requires proactivity, a sense of urgency, and the continuous presence of the attending doctor. For example, if a patient is hypotensive and hypoxaemic from pneumonia, it is not acceptable for oxygen, fluids, and antibiotics simply to be prescribed. The oxygen concentration may need to be changed several times before the PaO₂ is acceptable. More than one fluid challenge may be required to get an acceptable blood pressure – and even then, vasopressors may be needed if the patient remains hypotensive due to septic shock. Intravenous antibiotics need to be given immediately. ICU and CPR decisions need to be made at this time – not later. The emphasis is on both rapid and effective intervention.

Integral to the management of the acutely ill patient is the administration of effective analgesia. This is extremely important to the patient but also has a range of physiological benefits and is discussed further in Chapter 10.