https://www.blogger.com/blog/post/edit/6486482301949636226/6937353938257075980

Prescribing

Prescribing is an important component of patient care, which unfortunately can very easily go awry. The dangerous nature of prescription medications means that the process of prescribing is heavy regulated through legislation, clinical guidelines, local, regional and national protocols. What may seem like a relatively simple and straightforward process can sometimes be much more complex than it first appears.

Prescriptions represent a request from one healthcare professional to another to administer or supply medication to or for a patient. Some medications do not require a prescription as they are considered safe enough for patients to use without professional supervision and these are legally classified as general sale list medications (GSL). Medications that are considered less safe and require supervision by healthcare professionals are classified as prescription only medications, referred to as POMs and can only be used under the supervision of a prescribing healthcare professional. Anything that is not a GSL or POM is classified as a pharmacy medication or P medicine, which is only available under the supervision of a pharmacist.

Something you should consider first is the practical elements of prescribing. Prescribing can be completed in a range of formats, from the technical methods that use ePrescribing systems or ‘regimen prescribing’ (where users click a button and automatically prescribe a combination of medications) to handwritten prescription using pen and paper, or a combination of both.

The technical aspects of the prescription will vary from place to place but there a few key elements of the prescription that will remain the same, as these are required by law in the United Kingdom (namely the Medicines Act 1968, Misuse of Drugs Act 1971 and Pharmacy Order 2010). This is particularly true for products that are likely to be misused and require extra controls to manage their supply. These products are known as controlled drugs and are grouped into schedules, from 1-5, where 1 indicates a high likelihood for abuse with little clinical application and 5 indicates a clear clinical application with a low likelihood for abuse. This differs from the class system used by Her Majesty’s Courts and Tribunals Service to categorise criminal possession of substances.

Download the prescribing basics PDF OSCE checklist, or use our interactive OSCE checklist. You may also be interested in our controlled drug prescribing OSCE guide.

---

The patient

Any prescription must include the patient’s name. This information is used to identify the patient and ensure that the right medication is given to the right patient. The address of the patient could be their residential address, care home or the ward the patient is on. The age or date of birth of the patient is a useful way to identify the patient, however for patients under the age of 12 years it is a legal requirement to include the age or date of birth. Age is a useful indicator of liver and kidney function as well as fat/water ratio which can alter the distribution, metabolism and elimination of medication from the body. This makes the age of the patient an essential piece of information when deciding if medication is clinically suitable. This is particularly important for children, hence the legal requirement, but also for elderly frail patients so including the age or date of birth of the patient represents good clinical practice.

Summary

• Full name
• Address
• Age or date of birth (must be included if the patient is under 12 years old)

---

The medication

Just like the technical aspects of prescribing, what can be prescribed will depend on where you are working and your level of training. Some medications can only be prescribed by healthcare professionals that are authorised to do so. This is typically the case for very expensive medications or very dangerous medications, such as chemotherapy or intravenous immunoglobulin.

You should check that you are authorised to prescribe the medication(s) you are trying to prescribe. This can be done easily on electronic systems, as the system may only let you select items you are authorised to prescribe, however, if using a manual prescribing process you should check the following resources:

• Clinical supervisor
• Practice or trust formulary
• Local formulary – developed by local and regional drug and therapeutics committees and usually available online
• Nurse Prescribers’ Formulary – for community nurse prescribers, available online
• Dental Practitioners’ Formulary – for dentists, available online

Decisions about which medication should be prescribed should be shared with patients and carers. About 1 out of every 10 prescribed medications are never started and about 50% of medications are not taken as they’re prescribed. Including patients in decisions about their care increases the likelihood that they will start and continue to take their medication.

Information that should be included on a prescription

Name of the drug

It is best practice to use the ‘generic’ or the actual name of the drug, rather than a branded product name, for most medications. As this will be cheaper for pharmacies to supply.

However, some medications should be prescribed using their branded name, particularly if they have a narrow therapeutic range. This means that the metabolism, distribution and elimination may be different between formulations of the same drug. For example, Lithium should be prescribed using the branded names of Priadel, Camcolit and Liskonum to ensure consistent drug serum levels.

The name of the drug must be included for schedule 2 and 3 controlled drug prescriptions.

Formulation

This is the ‘form’ you would like the medication to be in and describes how the drug will get into the patient. For example, as tablets, capsules, solution, elixir, suppository, pessary, cream, powder, pressurised inhaler, dry powder inhaler, subcutaneous injection, intramuscular injection or infusion.

There are many formulations available for most medications and if you’re unsure about which formulation to prescribe you should make a shared decision with the patient, if possible. If you’re not sure what form the medication takes, try and contact a pharmacist or pharmacy technician, who should be able to find out for you.

The formulation must be included for schedule 2 and 3 controlled drug prescriptions.

Strength

This is not the dose! The strength relates to how much drug is in the formulation you have requested. For example, 10mg tablets or 5mg tablets.

The strength must be included for schedule 2 and 3 controlled drug prescriptions.

Dose or instructions

Historically, doses were written using Latin and over time these were abbreviated. For example, omni die or once a day is abbreviated to OD. Many errors relating to prescriptions are caused by folks not just failing to read Latin, but failing to read abbreviated Latin! For example, quatro die or four times a day is abbreviated to QD, which can be misread as OD, if handwritten, leading to sub-therapeutic doses. To avoid errors then, try to write doses using plain English such as once, twice, three times (avoid thrice) or four times per day.

Doses can be ‘licensed’ or ‘unlicensed’. Licensed doses have been approved by regulators who have assessed the evidence for the product at a particular dose for a particular reason (or indication). Unlicensed doses or ‘off licence’ doses have not been approved and the evidence for use of the medication at that dose for that indication has not been assessed. When prescribing ‘off licence’ responsibility for the safety of the products use rests solely with the prescriber.

The dose of the medication should be checked in reliable resources, such as an up to date copy of the British National Formulary.

Some medications require a loading dose to enable a therapeutic serum level to be established quickly. For example, Warfarin requires the patient to be ‘loaded’ with a short term high dose followed by a longer-term lower dose. If you’re unsure if a medication requires a loading dose, contact a pharmacist.

Additionally, some medications have narrow therapeutic ranges, this means that patients can quite quickly build up toxic levels of the drug in their body and professionals need to monitor this. A very common example of this would be the Vitamin K antagonist Warfarin, which we monitor using the International Normalised Ratio or INR for short. The therapeutic range of a medication often depends on the indication and the patient, so make sure to check or set these for each prescription individually. Other approaches to monitoring may focus on the patient’s response to medication, for example monitoring white cell counts with clozapine, liver enzymes with statins or renal function with angiotensin-converting enzyme inhibitors.

Antagonists that block receptors should be introduced at low doses and gradually increased and, when stopping treatment, should typically be withdrawn slowly.

Dose or instructions must be included for schedule 2 and 3 controlled drug prescriptions.

Quantity

Quantity should be used to describe how long you would like the patient to use this medication. Many different units of measure can be used (e.g. days, weeks, months) or the actual quantity of medication you would like to be supplied (e.g. 7 tablets).

For schedule 2 or 3 controlled drugs you must include the actual quantity of medication you would like supplied in words and figures (e.g. SEVEN (7) tablets).

Summary

To summarise, good prescribers include the following information:

• Name
• Form
• Strength
• Dose
• Quantity

Table 1: Common controlled drugs used in practice	Schedule
Morphine	Schedule 2
Codeine	Schedule 5
Tramadol	Schedule 3
Pregabalin	Schedule 3
Temazepam	Schedule 3
Fentanyl	Schedule 2
Oxycodone	Schedule 2
Zopiclone	Schedule 4 Part 1
Somatropin	Schedule 4 Part 2
Cannabis	Schedule 1

---

The professional

Many times as a junior prescriber you may be asked to sign a prescription, however, not every healthcare professional has the authority to prescribe every medication. For example, junior doctors can not prescribe chemotherapy. During the signing of the prescription, it is important that enough information is provided to create a record of which healthcare professional is authorising the supply or administration of a medication. This enables prescribing practices to be audited and ensure that poor practices are identified.

Information about the prescriber that is required by the person signing the prescription is discussed below.

Name

This should be legible and be your ‘professional name’.

Authority to prescribe

This should indicate what qualification the professional has to prescribe. For example, an MBBS degree, a BDS degree or an independent prescribing qualification, membership of an association or accreditation. This could also include a particular role within an organisation.

This could also be a registration number with statutory bodies that can be checked to verify a prescribers status, such as the GMC, GPhC, GDC and NMC.

Date

This should include the date that the prescription was issued by the professional. This may be different from the date that the prescription should be started and if the prescription is to begin on a specified date this information should be included under the dose or instruction section of the prescription.

Prescriptions can be pre-dated (for a time in the future) but should not usually be post-dated (to cover a period of use in the past) unless there are exceptional circumstances. For example, pharmacists can make supplies of medication legally if there is an agreement for a prescription to be written within the next 24 hours.

---

What you need to decide: patient safety

The therapeutic decision-making process is influenced by lots of different things. Primarily, all therapeutic decisions should involve the patient and their carers, if possible.

All medication comes with side effects and avoidable adverse drug reactions cost the NHS approximately £98.5 million per year. Whenever you’re prescribing medication, you should always consider the risk and benefits of the medication. A good way to do this is to consider the necessity of the medication.

Dosing

Once necessity has been identified, you should consider how much of the medication is needed for a therapeutic effect. This decision should be evidence-based but person-centred. For example, some randomised controlled trials will identify a therapeutic dose, however, the participants in the trial may be very different to the patient in front of you.

Most medications are prescribed according to actual body weight (mg/Kg) but beware of hydrophilic medications that require dosing via ideal body weight, such as gentamicin.

Watch out for daily versus divided dosing (e.g. Paracetamol 15mg/Kg/dose or 60mg/kg/day).

Prescribing too much medication can lead to dose-dependent side effects, wastage and inappropriate polypharmacy so try to use the smallest dose for the shortest period where possible.

Duration

After dosing, consider the duration. Does the medication require acute or chronic use? Is this acceptable to the patient?

This is a particularly useful consideration for treatments that can cause dependence such as opioids, benzodiazepines, z-drugs, gabapentinoids as well medication where long-term use can lead to complications (e.g. corticosteroids) or resistance (e.g. antimicrobials).

Interactions

Before finalising a prescription, you should dedicate some time to reviewing what other medication the patient takes (if any) and how this newly prescription may interfere with absorption, distribution, metabolism and elimination of other medication. This can be tricky as interactions can be significant or non-significant. Useful resources include Stockley’s Drug Interactions, the BNF, MedicinesComplete Interaction Checker and a pharmacist or pharmacy technician.

Monitoring

The therapeutic effect of medication requires monitoring. This may include regular reviews with the patient regarding their symptoms as well as ordering and reviewing tests such as full blood count, liver and kidney function tests, eye tests, and lung function tests.

When making a plan to monitor medication, always consider and identify who will do this and by when. Pharmacists can help in monitoring long-term conditions and therapeutic outcomes, including making recommendations to deprescribe medications which are no longer beneficial for the patient.ABCDE Approach to Emergency Management

 

ABCDE Approach to Emergency Management

Introduction

https://geekymedics.com/abcde-approach/

The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:

• Airway
• Breathing
• Circulation
• Disability
• Exposure

Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment.

The aim of the ABCDE approach is to improve the clinical outcome of unwell patients, regardless of the definitive diagnosis.

This guide provides a general overview that can be used for any unwell patient in a simulation setting; it may seem intimidating at first, but your patient is highly unlikely to need all of the investigations or interventions mentioned in this overview. More specific cases can be found in the emergency section of the site and are linked to throughout. This guide is written with final year medical students in mind – the assessments, investigations and interventions included are generally expected to be within the competencies of a junior doctor.

This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not intended to be relied upon for patient care.

---

General tips

General tips for applying an ABCDE approach in an emergency setting include:

• Treat all problems as you discover them.
• Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
• Make use of the team around you by delegating tasks where appropriate.
• All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
• Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
• If you require senior input, call for help early using an appropriate SBARR handover structure.
• Review results as they become available (e.g. laboratory investigations).
• Make use of your local guidelines and algorithms in managing specific scenarios (e.g. acute asthma).
• Any medications or fluids will need to be prescribed at the time (in some cases you may be able to delegate this to another member of staff).
• Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical assessment, investigations and interventions.

---

Initial steps

Acute scenarios typically begin with a brief handover from a member of the nursing staff including the patient’s name, age, background and the reason the review has been requested.

Introduction

Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.

Interaction

Introduce yourself to the patient including your name and role.

Ask how the patient is feeling as this may provide some useful information about their current symptoms.

Preparation

Make sure the patient’s notes, observation chart and prescription chart are easily accessible.

Ask for another clinical member of staff to assist you if possible.

If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.

---

Airway

Clinical assessment

Can the patient talk?

Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.

No:

• Look for signs of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
• Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object.

Causes of airway compromise

There is a wide range of possible causes of airway compromise including:

• Inhaled foreign body: symptoms may include sudden onset shortness of breath and stridor.
• Blood in the airway: causes include epistaxis, haematemesis and trauma.
• Vomit/secretions in the airway: causes include alcohol intoxication, head trauma and dysphagia.
• Soft tissue swelling: causes include anaphylaxis and infection (e.g. quinsy, necrotising fasciitis).
• Local mass effect: causes include tumours and lymphadenopathy (e.g. lymphoma).
• Laryngospasm: causes include asthma, gastro-oesophageal reflux disease (GORD) and intubation.
• Depressed level of consciousness: causes include opioid overdose, head injury and stroke.

Interventions

Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input.

Head-tilt chin-lift manoeuvre

Open the patient’s airway using a head-tilt chin-lift manoeuvre:

1. Place one hand on the patient’s forehead and the other under the chin.

2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.

3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to remove it.

Jaw thrust

If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:

1. Identify the angle of the mandible.

2. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.

3. Using your thumbs, slightly open the mouth by downward displacement of the chin.

Oropharyngeal airway (Guedel)

Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.

An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.

To insert an oropharyngeal airway:

1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.

2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.

3. Advance the airway until it lies within the pharynx.

4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing.

Nasopharyngeal airway (NPA)

A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA.

To insert a nasopharyngeal airway:

1. Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA.

2. Lubricate the NPA.

3. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.

4. If any obstruction is encountered, remove the tube and try the left nostril.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Other interventions

If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in our anaphylaxis guide.

Re-assessment

Make sure to re-assess the patient after any intervention.

---

Breathing

Clinical assessment

Observations

Review the patient’s respiratory rate:

• A normal respiratory rate is between 12-20 breaths per minute.
• Bradypnoea may be due to sedation, opioid toxicity, raised intracranial pressure (ICP) or exhaustion in airway obstruction (e.g. COPD).
• Tachypnoea may be due to airway obstruction, asthma, pneumonia, pulmonary embolism (PE), pneumothorax, pulmonary oedema, heart failure, or anxiety.

Review the patient’s oxygen saturation (SpO₂):

• A normal SpO₂ range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO₂ retention.
• Hypoxaemia may be seen in PE, aspiration, COPD, asthma and pulmonary oedema.

See our guide to performing observations/vital signs for more details.

General inspection

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology:

• Cyanosis: bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
• Shortness of breath: signs may include nasal flaring, pursed lips, use of accessory muscles, intercostal muscle recession and the tripod position which involves the patient sitting or standing whilst leaning forward and supporting their upper body with their hands on their knees or other surfaces. The inability to speak in full sentences is an indicator of significant shortness of breath.
• Cough: a productive cough can be associated with several respiratory pathologies including pneumonia, bronchiectasis, COPD and cystic fibrosis. A dry cough may suggest a diagnosis of asthma or interstitial lung disease.
• Stridor: a high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways. Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).
• Cheyne-Stokes respiration: cyclical apnoeas, with varying depth of inspiration and rate of breathing. May be caused by stroke, raised intracranial pressure, pulmonary oedema, opioid toxicity, hyponatraemia or carbon monoxide poisoning.
• Kussmaul’s respiration: deep, sighing respiration associated with metabolic acidosis (e.g. diabetic ketoacidosis).

Tracheal position

Gently assess the position of the trachea, which should be central in healthy individuals:

• The trachea deviates away from tension pneumothorax and large pleural effusions.
• The trachea deviates towards lobar collapse and pneumonectomy.

Palpation of the trachea can be uncomfortable, so warn the patient and apply a gentle technique.

Chest expansion

Assess the patient’s chest expansion looking for evidence of reduced chest wall movement. Reduced chest expansion may indicate underlying pathology:

• Symmetrical: pulmonary fibrosis reduces lung elasticity, restricting overall chest expansion.
• Asymmetrical: pneumothorax, pneumonia and pleural effusion can all cause ipsilateral reduced chest expansion.

Percussion of the chest

Percuss the patient’s chest, listening to the resulting percussion note which should be resonant in healthy individuals. Abnormal findings on percussion include:

• Dullness: suggests increased tissue density (e.g. cardiac dullness, consolidation, tumour, lobar collapse).
• Stony dullness: typically caused by an underlying pleural effusion.
• Hyper-resonance: the opposite of dullness, suggestive of decreased tissue density (e.g. pneumothorax).

Auscultation

Auscultate the patient’s chest and identify any abnormalities such as:

• Bronchial breathing: harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal and there is a pause between. This type of breath sound is associated with consolidation.
• Quiet/reduced breath sounds: suggest reduced air entry into that region of the lung (e.g pleural effusion, pneumothorax).
• Wheeze: a continuous, coarse, whistling sound produced in the respiratory airways during breathing. Wheeze is often associated with asthma, COPD and bronchiectasis.
• Stridor: a high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways. Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).
• Coarse crackles: discontinuous, brief, popping lung sounds typically associated with pneumonia, bronchiectasis and pulmonary oedema.
• Fine end-inspiratory crackles: often described as sounding similar to the noise generated when separating velcro. Fine end-inspiratory crackles are associated with pulmonary fibrosis.

See our respiratory examination guide more for details.

Investigations and procedures

Arterial blood gas (ABG)

Take an ABG if indicated (e.g. low SpO₂).

See our guides for taking and interpreting an ABG for more details.

Chest X-ray

Order a portable chest X-ray if you suspect lung pathology (e.g. pneumonia, pneumothorax, pulmonary oedema).

See our chest X-ray interpretation guide for more details.

Interventions

If the patient is short of breath, they should be sat upright in the bed if possible to aid inspiration.

Oxygen

Administer oxygen to all critically unwell patients during your initial assessment. This typically involves the use of a non-rebreathe mask with an oxygen flow rate of 15L. You can then trial titrating oxygen levels downwards after your initial assessment.

In COPD, target SpO₂ levels accordingly (88-92%) and consider using a Venturi mask: 24% (4L) or 28% (4L). Consider discussing non-invasive ventilation (NIV) with a senior in acute exacerbations of COPD where there is evidence of type 2 respiratory failure.

If the patient is conscious, sit them upright as this can also help with oxygenation.

See our guide to airway equipment and non-invasive ventilation for more details.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Acute severe asthma

The acute management of asthma may involve interventions such as oxygen, nebulisers, steroids and other agents (e.g. magnesium sulphate, aminophylline).

See our guide to the acute management of asthma for more details.

Acute exacerbation of COPD

The acute management of an exacerbation of COPD may involve interventions such as oxygen, nebulisers, steroids and antibiotics.

See our guide to the acute management of COPD for more details.

Other pathology

Other pathologies which may be identified during the assessment of breathing include pneumonia and pneumothorax. Each problem should be treated as it is identified.

Re-assessment

Make sure to re-assess the patient after any intervention.

---

Circulation

Clinical assessment

Observations

Review the patient’s heart rate:

• A normal resting heart rate (HR) can range between 60-99 beats per minute.
• Causes of tachycardia (HR>99) include hypovolaemia, arrhythmia, infection, hypoglycaemia, thyrotoxicosis, anxiety, pain and drugs (e.g. salbutamol).
• Causes of bradycardia (HR<60) include acute coronary syndrome (ACS), ischaemic heart disease, electrolyte abnormalities (e.g. hypokalaemia) and drugs (e.g. beta-blockers).

Review the patient’s blood pressure:

• A normal blood pressure (BP) range is between 90/60mmHg and 140/90mmHg but you should review previous readings to gauge the patient’s usual baseline BP.
• Causes of hypertension include hypervolaemia, stroke, Conn’s syndrome, Cushing’s syndrome and pre-eclampsia (in pregnant females). Severe hypertension (systolic BP > 180 mmHg or diastolic BP > 100 mmHg) may present with confusion, drowsiness, breathlessness, chest pain and visual disturbances.
• Causes of hypotension include hypovolaemia, sepsis, adrenal crisis and drugs (e.g. opioids, antihypertensives, diuretics).

Extremes of heart rate or blood pressure with other concerning features such as syncope, pre-syncope, shortness of breath or evidence of myocardial ischaemia require urgent senior and/or critical care input.

See our guide to performing observations/vital signs for more details.

Fluid balance assessment

Calculate the patient’s fluid balance:

• Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts.
• Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult.
• Causes of oliguria include dehydration, hypovolaemia, reduced cardiac output and acute kidney injury.

General inspection

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology:

• Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure).
• Oedema: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites) and may indicate underlying heart failure.

Palpation

Place the dorsal aspect of your hand onto the patient’s to assess temperature:

• In healthy individuals, the hands should be symmetrically warm, indicating adequate perfusion.
• Cool hands indicate poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome).
• Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.

Measure capillary refill time (CRT):

• In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
• A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.

Pulses and blood pressure

Assess the patient’s radial and brachial pulse to assess rate, rhythm, volume and character:

• An irregular pulse is associated with arrhythmias such as atrial fibrillation.
• A slow-rising pulse is associated with aortic stenosis.
• A pounding pulse is associated with aortic regurgitation as well as CO₂ retention.
• A thready pulse is associated with intravascular hypovolaemia (e.g. sepsis).

Jugular venous pressure (JVP)

Inspect for evidence of a raised JVP which may be caused by:

• Right-sided heart failure: commonly caused by left-sided heart failure (e.g. secondary to fluid overload). Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.
• Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
• Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.

Auscultation

Auscultate the patient’s precordium to assess heart sounds:

• An ejection systolic murmur is associated with aortic stenosis.
• An early diastolic murmur is associated with aortic regurgitation.
• A mid-diastolic murmur is associated with mitral stenosis.
• A pan-systolic murmur is associated with mitral regurgitation.
• A murmur of recent onset may suggest recent myocardial infarction (e.g. papillary muscle rupture) or endocarditis.
• A pericardial rub or muffled heart sounds may indicate underlying pericarditis.
• A third heart sound is typically associated with congestive heart failure.

Ankles and sacrum

Assess the patient’s ankles and sacrum for evidence of oedema which is typically associated with heart failure.

Investigations and procedures

Intravenous cannulation

Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.

See our intravenous cannulation guide for more details.

Blood tests and blood cultures

Request FBC, U&Es and LFTs for all patients regardless of their presentation and consider additional blood tests such as:

• Sepsis: CRP, lactate and blood cultures
• Haemorrhage or surgical emergency: coagulation and cross-match
• Acute coronary syndrome: troponin
• Arrhythmia: calcium, magnesium, phosphate, TFTs, coagulation
• Pulmonary embolism: D-dimer (if appropriate based on Well’s score)
• Overdose: toxicology screen (e.g. paracetamol levels)
• Anaphylaxis: consider serial mast cell tryptase levels

See our blood culture, blood bottle and investigation panel guides for more details.

ECG

Record a 12-lead ECG if appropriate (e.g. if the patient has chest pain, arrhythmia, a murmur, or suspected electrolyte imbalance).

Consider continuous ECG monitoring for critically unwell patients (e.g. myocardial infarction, severe electrolyte abnormalities requiring replacement).

See our guides to recording and interpreting an ECG for more details.

Bladder scan

Perform a bladder scan in suspected urinary retention or obstruction.

Urine pregnancy test

Perform a urine pregnancy test in any female of childbearing age presenting with clinical evidence of shock, abdominal pain or gynaecological symptoms.

Other cultures/swabs

Ask the nursing staff to collect and send other appropriate cultures (e.g. sputum, urine, line cultures).

Fluid output/catheterisation

Ask the nursing staff to initiate a strict fluid balance if not already in place.

Consider catheterisation to allow accurate monitoring of urine output or to relieve urinary retention where appropriate.

See our guide to catheterisation for more details.

Interventions

Hypovolaemia

Hypovolaemic patients require fluid resuscitation (the below guidelines are for adults):

• Administer a 500ml bolus Hartmann’s solution or 0.9% sodium chloride (warmed if available) over 15 mins.
• Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure).

After each fluid bolus, reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).

Repeat administration of fluid boluses up to four times (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time.

Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t responding adequately to repeated boluses (e.g. persistent hypotension).

See our fluid prescribing guide for more details on resuscitation fluids.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Acute coronary syndrome (ACS)

The management of suspected ACS can involve interventions such as pain relief (e.g. morphine), nitrates, aspirin, clopidogrel and oxygen.

See our ACS guide for more details.

Sepsis

If any clinical signs of sepsis are present, you should commence the sepsis 6 pathway which includes the following investigations and interventions:

1. Oxygen
2. Blood cultures
3. IV antibiotics
4. IV fluids
5. Serial lactates
6. Ongoing monitoring of urine output

See our sepsis guide for more details.

Haemorrhage

The management of haemorrhage involves interventions such as the replacement of intravascular volume with fluid and blood products as well as measures to slow or stop bleeding.

See our post-operative bleeding guide and upper gastrointestinal bleeding guide for more details.

Fluid overload

The management of fluid overload typically involves interventions such as the administration of diuretics (e.g. furosemide) and strict fluid balance monitoring.

See our pulmonary oedema guide for more details.

Atrial fibrillation (AF)

The management of acute atrial fibrillation involves interventions to control heart rate and rhythm.

See our atrial fibrillation guide for more details.

Re-assessment

Make sure to re-assess the patient after any intervention.

---

Disability

Clinical assessment

Consciousness

Assess the patient’s level of consciousness using the AVPU scale:

• Alert: the patient is fully alert, although not necessarily orientated.
• Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt).
• Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure).
• Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.

If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).

Causes of depressed consciousness

Acute deterioration in a patient’s level of consciousness may be due to a number of causes including:

• Hypovolaemia
• Hypoxia
• Hypercapnia
• Metabolic disturbance (e.g. hypoglycaemia)
• Seizure
• Raised intracranial pressure or other neurological insults (e.g. stroke)
• Drug overdose
• Iatrogenic causes (e.g. administration of opiates)

Pupils

Assess the patient’s pupils:

• Inspect the size and symmetry of the patient’s pupils (e.g. pinpoint pupils in opioid overdose, dilated pupils in tricyclic antidepressant overdose). Asymmetrical pupillary size may indicate intracerebral pathology (e.g. stroke, space-occupying lesion, raised intracranial pressure).
• Assess direct and consensual pupillary responses which may reveal evidence of intracranial pathology (e.g. stroke).

Drug chart review

Review the patient’s drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives, anxiolytics).

Investigations and procedures

Blood glucose and ketones

Measure the patient’s capillary blood glucose level to screen for abnormalities (e.g. hypoglycaemia or hyperglycaemia). The normal reference range for capillary blood glucose is 4.0-11.0 mmol/L.

A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).

If the blood glucose is elevated, check ketone levels which if also elevated may suggest a diagnosis of diabetic ketoacidosis (DKA).

See our blood glucose measurement, hypoglycaemia and diabetic ketoacidosis guides for more details.

Imaging

Request a CT head if intracranial pathology is suspected after discussion with a senior.

See our guide on interpreting a CT head for more details.

Interventions

Maintain the airway

Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway as explained in the airway section of this guide.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Opioid toxicity

If opioid toxicity is suspected as the cause for the patient’s reduced level of consciousness (e.g. pinpoint pupils) interventions such as naloxone should be considered.

See our opioid toxicity guide for more details.

Hypoglycaemia

The management of hypoglycaemia involves the administration of glucose (e.g. oral or intravenous).

See our hypoglycaemia guide for more details.

Diabetic ketoacidosis (DKA)

The management of DKA involves interventions such as intravenous fluids and insulin.

See our DKA guide for more details.

Re-assessment

Make sure to re-assess the patient after any intervention.

---

Exposure

It may be necessary to expose the patient during your assessment: remember to prioritise patient dignity and conservation of body heat. 

Clinical assessment

Begin by asking the patient if they have pain anywhere, which may be helpful to guide your assessment.

Inspection

Inspect the patient’s skin for evidence of rashes (e.g. adverse drug reaction, meningococcal sepsis), bruising (e.g. coagulation disorders, trauma, surgery) and signs of infection (e.g. cellulitis).

Review any in situ intravenous lines for evidence of surrounding erythema or discharge.

Assess the patient’s calves for erythema, swelling and tenderness which may suggest a deep vein thrombosis.

Review any surgical wounds for evidence of haematoma, active bleeding or infection (e.g. purulent discharge).

Review the output of the patient’s catheter and any surgical drains for blood loss, fluid loss and evidence of infection (e.g. pus).

Bleeding

If active bleeding is identified:

• Estimate the total blood loss and the rate of blood loss.
• Re-assess for signs of hypovolaemic shock (e.g. hypotension, tachycardia, pre-syncope, syncope).

Temperature

Review the patient’s body temperature:

• A normal body temperature range is between 36°c – 37.9°c.
• A temperature of >38°c is most commonly caused by infection (e.g. sepsis).
• A temperature < 36°c may also be caused by sepsis or cold exposure (e.g. drowning, inadequate clothing outside).
• Consider warming (e.g. Bair Hugger™) in hypothermia (seek senior input).

Investigations and procedures

Cultures/swabs

Ask the nursing staff to take relevant swabs/samples of any potential infection source (e.g. line tip culture).

Interventions

Haemorrhage

If the patient is actively bleeding seek urgent senior input (e.g. surgical registrar, anaesthetics) and consider the need for blood products (e.g. packed red cells, platelets).

Large-bore intravenous access (x2) should be established and relevant blood tests should be sent (e.g. FBC, U&Es, coagulation studies, group and crossmatch) if not done so already.

In severe haemorrhage, consider initiating the major haemorrhage protocol (with senior approval).

See our post-operative bleeding, upper gastrointestinal bleeding and blood transfusion guides for more details.

Infection

If an infection is suspected (e.g. a surgical wound is leaking pus) re-assess the patient for clinical evidence of sepsis and perform the sepsis 6 if appropriate.

Consult local guidelines and/or microbiology advice to guide appropriate antibiotic treatment.

See our sepsis guide for more details.

Deep vein thrombosis (DVT)

If a DVT is suspected, calculate the patient’s Well’s score and manage as per guidelines (e.g. arranging USS, commencing anticoagulation).

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

---

Re-assessment and seeking help

Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.

Deterioration should be recognised quickly and acted upon immediately.

Seek senior help if the patient shows no signs of improvement or if you have any concerns.

Support

You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate.

You may need further help or advice from a senior staff member and you should not delay seeking help if you have concerns about your patient.

Use an effective SBARR handover to communicate the key information effectively to other medical staff.

Examples of who you may be able to contact

If a patient is critically unwell (e.g. peri-arrest, cardiac arrest) the cardiac arrest team should be alerted (the team typically consists of an anaesthetist, medical registrar and junior doctors).

Airway problems:

• On-call anaesthetist

Breathing problems:

• Medical registrar on call
• Critical care team

Circulation problems:

• Medical registrar on call
• Critical care team
• Other specialists depending on the suspected pathology (e.g. microbiologist, cardiologist, surgeon, gastroenterologist)

Disability problems:

• Medical registrar on call
• Anaesthetist on call if the airway is threatened (e.g. GCS<8)
• Other specialists depending on the suspected pathology (e.g. neurosurgeon, endocrinologist, neurologist)

Exposure problems:

• Medical registrar on call
• Other specialists depending on the suspected pathology (e.g. surgeon, dermatologist, microbiologist)

---

Next steps

Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…

Take a history

Take a thorough history to help narrow the differential diagnosis.

See our history taking guides for more details.

Review

Review the patient’s notes, charts and recent investigation results.

Review the patient’s current medications and check any regular medications are prescribed appropriately.

Document

Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.

See our documentation guides for more details.

Discuss

Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.

Questions which may need to be considered include:

• Are any further assessments or interventions required?
• Does the patient need a referral to HDU/ICU?
• Does the patient need reviewing by a specialist?
• Should any changes be made to the current management of their underlying condition(s)?

Handover

The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.

---

References

1. Resuscitation Council (UK): ABCDE Approach. Available from: [LINK].
2. Resuscitation Council (UK): Peri-arrest arrhythmias. Available from: [LINK].