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R ecognition of E mergency signs, A ssessment of C ause and T reatments. WELCOME TO REACT!. OUTCOMES OF REACT TRAINING. Multidisciplinary Team approach to Patient Care Sharing of knowledge and skills All singing from the same hymn sheet Use of the MEWS scoring system within HCA

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r ecognition of e mergency signs a ssessment of c ause and t reatments
Recognition of

Emergency signs,

Assessment of

Cause and

Treatments

WELCOMETO REACT!

outcomes of react training
OUTCOMES OF REACT TRAINING

Multidisciplinary Team approach to Patient Care

Sharing of knowledge and skills

All singing from the same hymn sheet

Use of the MEWS scoring system within HCA

Healthcare

the facts
The facts!

NCEPOD (2005) report: ‘An acute problem’

Reviewed 1,677 pts admitted to medical ICU’s in

the UK

  • 560 pts died during the study period; 47%(252) of those pts received care which was classified as poor!
  • 41 of these pts received care which contributed to their

death

the facts1
The facts!

NPSA (2007) report: ‘Safer care for the acutely ill patient: learning from serious incidents’

Reviewed 1,804 serious incidents that result in death. 576 deaths could be interpreted as potentially avoidable!

  • 425 occurred in acute/general wards
  • 71 were reported to diagnostic errors
  • 64 related to patient deterioration not recognised or not acted upon.
  • 43 involved a problem with resuscitation after cardiac arrest
the reasons
The reasons!

Key theme 1: clinical or physiological

deterioration not recognised or not acted upon

Key theme 2: resuscitation after

cardiopulmonary arrest

slide9
What are the clinical signs that this patient is sick?What interventionsshould have been done? Who is responsible?
assessing the critically ill patient
Assessing the Critically Ill Patient

Airway

Breathing

Circulation

Disability

Exposure

systematic approach
SYSTEMATIC APPROACH

A & B : Treat what kills first!

A B C D E

systematic assessment:

  • Look
  • Listen
  • Feel

Communicate results, and document

Achieves a comprehensive & universal approach to caring for sick patients

modified early warning system mews
Modified EARLY WARNING SYSTEM (MEWS)
  • MEWS >4 is a warning sign

= RED FLAG

  • Call for help early!
  • Consider oxygen and fluids!
summary the react course
Summary: the REACT Course

Aims to assist the MDT improve the quality of care provided by:

  • Promoting the track and trigger concept;
  • Promote timely admissions to Intensive Care
  • Units
  • Reduce / avoid preventable patient deaths
  • Promotes the ABCDE concept of a structured
  • approach to patient assessment
  • Assess the need for Oxygen and Fluids
  • Knowing the RED FLAG means get help!!!
airway
Is it clear?

Is it open?

AIRWAY

What do we want to know?

breathing
Effort ?

Effects ?

Breathing

What do we want to know?

assessing breathing
Assessing Breathing

Look Rate, colour, depth, chest movement, agitation, accessory muscle use

ListenSpeech, Noises, Cough, Auscultation.

FeelExpansion, Pulse, Percussion, Palpation

Other Tests: SpO2, CO2, PaO2, Blood Gases

breathing management
Breathing Management

Consider:

  • High flow
  • Oxygen
  • Physiotherapy
  • Positioning
  • Medication
  • Suction
if assessment raises concern
If assessment raises concern!

Respiratory rate <8 WHY?

Respiratory rate >20 WHY?

Is this a red flag?

Give high flow oxygen

Call expert help!

summary a b
Summary: A & B
  • Airway & Breathing is the beginning of the structured approach to patient assessment
  • If concerned call for help early
  • Always assess need for Oxygen
  • Watch out for the RED FLAG!
slide24
Aim

To revise the principles of

circulatory physiology and

place into context for

practice.

components of circulation
Components of circulation

To maintain hemodynamic stability we need to maintain perfusion, transportation and excretion. Therefore we require a healthy:

Volume Together

Heart determine

Vessels Blood Pressure

3 reasons for a low blood pressure
3 reasons for a low blood pressure

Reduced filling due to hypovolaemia (Preload)

Reduced muscle power due to a heart muscle damage (Contractility)

Reduced vessel tone, vasodilatation (SVR)

assessing circulation
Assessing circulation:

Look:

  • Fluid balance
  • Urine output
  • Overall balance
  • Weight
  • JVP
  • MEWS
  • Blood results
  • Skin Colour

Feel:

  • CRT
  • Skin Tone
  • Bounding Pulse
  • Peripheral Oedema
  • Temperature

Listen:

  • Is patient thirsty
  • Confused/ agitated
  • Cardiac sounds (if within
  • remit)
  • Manual BP, HR
treating circulation depends upon results of assessment
Treating circulation- depends upon results of assessment
  • Cannula inserted
  • Volume challenge
    • Give 250-500mls crystalloid IV, monitor result
    • Send bloods
  • Urinary catheter inserted if applicable
    • Bladder scanner
    • Fluid balance chart commenced
  • 12 lead ECG
  • Re-assess frequently:
    • Repeat Vital signs
    • CVP (if applicable)
    • Urine output
summary
Summary…

CONSIDER THE CIRCULATION AS A WHOLE

Heart / peripheries / volume

  • Gather as much information as possible
  • Treat effectively and monitor your interventions
  • BLOOD PRESSURE MAY BE NORMAL EVEN IN THE PRESENCE OF SHOCK, DUE TO COMPENSATORY MECHANISMS – TRENDS!
  • DO NOT allow a low hourly urine volume (<0.5mls/kg/hr) to go untreated for more than two consecutive hours
d is for disability
Dis for Disability

DON’T FORGET…

Assessing the patient’s level of consciousness (LOC)

altered levels of consciousness
Altered Levels of Consciousness

Direct (Neuro) Causes

  • Epilepsy
  • Meningitis
  • Tumour
  • Head Injury
  • CVA
indirect hidden causes
Indirect (Hidden) Causes

The 5 H’s:

  • Hypoxia
  • Hypoxaemia
  • Hypercapnia
  • Hypotension
  • Hypoglycaemia

1-3 result in cerebral oedema which leads to cerebral ischemia.

indirect systemic causes
Indirect (Systemic) Causes

Other Possibilities:

  • Hypothyroidism
  • Uraemia
  • Drugs
  • Renal Failure
  • Liver Failure
slide35

AVPU

  • Eyes open/ talking.
  • Responds to verbal commands.
  • Which methods are used?
  • No response to pain

Awake -

Verbal, responds to voice -

Pain. Responds to painful stimuli -

Unresponsive -

slide36
AVPU

If a patient is only responding to :

Pain

Or is

Unresponsive

Call for help immediately

regardless of any other observation

Pain

Or is

Unresponsive

blood sugar levels
Blood Sugar Levels

Check blood sugar level!

What can cause an altered blood sugar level?

d summary
D…Summary

Don’t forget to assess the patients

conscious level…

AVPU ( Newly confused)

PEARL

BSL

e is for e xposure
Eis for EXPOSURE

Following A…B…C…D…

Fully examine your patient

physical examination
Physical Examination

Look Top to toe

(remember privacy/ dignity)

  • Wounds
    • Drains/ Catheters
    • Injuries / Swelling
    • Skin Colour / Rashes
    • Temperature (CRT)
    • Pain
following abcde secondary assessment
Following ABCDESecondary Assessment
  • Patient History
  • Baseline levels
  • Check Notes
  • DOCUMENT EVERYTHING
  • Meditech
  • Routine Investigations
    • 12 Lead ECG
    • CXR
  • Blood Test Results

U’s & E’s

FBC

Clot

G&S

XM

BSL

abcde summary
ABCDE SUMMARY

ANY QUESTIONS?

Airway

Breathing

Circulation

Disability

Exposure

adding mews assessment to meditech

Adding MEWs Assessment to Meditech

To be completed when ever a patient triggers a MEWs of 4 of more

acknowledgements
Acknowledgements

ALERT (2006) Acute Life Threatening Events

Recognition and Treatment. Portsmouth Hospital

NHS Trust. Alert.course@porthosp.nhs.uk

British Thoracic Society (2008) Guidelines for

Emergency Oxygen use in Adult Patients.

www.Brit-thoracic.org.uk

Dr Terris, M. (2007) Queens University Belfast.

Clinical Skills Education Centre. www.qub.ac.uk