Global Recognition and Assessment of

the Sick Patient and Initial Treatment

Karibuni

GRASP IT
Who are we?
Sister Hazel Robinson

Matron Ellie Forbes

Dr Mike Swart

Dr Matt Halkes
Why are we here?

For over a decade it has been well

recognised that managing the acutely
unwell patient can be a challenge to
both nursing and medical staff.
 UK
Poor monitoring of vital signs (respirations)

Abnormalities in Airway, Breathing, Circulation not recognised

Not acting on clear signs of deterioration

Failure to use systematic approach to assessment

Poor teamwork and communication

Late referrals to senior staff

ALERT (Acute Life Threatening Events Recognition and
Treatment)

SOS (Stabilisation of the Sick)

ALERT (Acute Life threatening Events Recognition and
Treatment)

SOS (Stabilisation of the Sick)

GRASP IT (Global Recognition and Assessment of the Sick

Patient and Initial Treatment)
GRASPIT

Early detection

Systematic approach

Minimal equipment
GRASPIT

Early detection

Systematic approach

Minimal equipment

Save lives!
Survival

100%

50%

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Survival

100%

50%

0%
Survival

100%

50%

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Survival

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Survival

100%

50%

Cost
0%
Programme
Patient assessment

Breathing problems

Shock
Scenarios
Paediatric patient

Reduced level of consciousness

Communication

Pain management
Before we start!!!!

Is it easy to spot a sick patient?

DETERIORATION FOLLOWS POOR RECOGNITION OF
ABNORMAL VITAL SIGNS

Respiration

Blood pressure

Pulse

Temperature

Pain
Use a structured approach
when assessing patients.
A irway
B reathing
C irculation
D isability
E xposure
At each stage
Look
Listen
Feel
Start corrective treatment before moving
on

Consider calling for help

Airway
Listen
Talking
Noises?
Look
Colour
Paradoxical chest movements
Dentures/food/secretions
Feel
Air movement
 How to open an airway:
Head tilt/chin lift
Jaw thrust
Suction
Adjuncts
Recovery position
Dont forget
All sick people
need high flow
oxygen
Call for help ?
Breathing
Look Listen
Colour Wheeze
Rate Crackles
Rhythm Silence
Depth
Symmetry
Sp02
On what oxygen?
Good trace?
Circulation
Look
Colour
Pulse
BP
Urine output
Lift bedclothes- blood/diarrhoea
Listen
? new murmur
 Feel
Skin temperature

Pulses

Capilliary refill
Press centrally for 5 seconds
Release
Should return to normal colour in 2 seconds
Correcting C Problems
Put head down & legs up
IV access
Bigger the better
Secure ++
Give fluid bolus
200-500ml Normal Saline
Give over <5 min
Re-assess
Call for help ?
Disability
Look
Head injury
AVPU
Pupils
D ont
E ver
F orget
G lucose
AVPU scale
A Patient is A lert

V Patient responds to V oice

P Patient responds to P ain

U Patient is U nresponsive
Exposure
Top to toe examination.

Check temperature- warm/cool?

Call for help ?

What else might you consider?
Notes (PC, PMH, Drug History)
Have we given everything that has been
prescribed (drugs,fluids,oxygen)
Other tests / investigations

What is your plan?

Questions?
The breathless patient
What might cause an upper airway problem?
What could cause a problem here?
Respiratory assessment
Look Listen
Colour Wheeze
Rate Crackles
Rhythm Silence
Depth
Symmetry
Sp02
On what
oxygen?
Good trace?
Correcting B Problems
High flow oxygen
Sit the patient up
If known asthma/COPD give nebulisers
Treat pulmonary oedema
If reduced level of consciousness + poor
respiratory effort- BVM

Call for help ?

Ongoing assessment

Monitoring (Respirations &

SpO2)

?ABGs

Response to treatment.
 Ongoing treatment
Supplemental oxygen
Treatment of underlying condition
Antibiotics
Positioning (physiotherapy)
Bronchodilators
Corticosteroids

Consider escalating care

Nasal prongs
- maximum flow rate ~ 4-6 l/min delivers approx 24-
50% Oxygen
Simple face mask

-flow rate 5 15 l/min oxygen delivery 35 - 60%

Venturi masks
oxygen delivery depends on adapter used
24%, 28%, 31%, 35%, 40%, available
Non-rebreathe mask

-flow rate 15 l/min

- oxygen delivery approx
85%
 PULSE
OXIMETER
What does a pulse oximeter do?

An oximeter measures the oxygen

saturation of haemoglobin (Hb) in the
arterial blood with each heart beat.
 How does it work?

The probe shines light through the tissues to the

blood and then measures the light reflected back

Oxygenated and deoxygenated haemoglobin

absorb different amounts of light and the oximeter
uses this to determine the SaO2 as a %

It also measure the heart rate

Where can the sensors be applied?

Finger
Earlobe
Toe

Any skin surface from which a reliable signal can

be obtained

Can cause pressure damage if too tight

> 95% OK
Continue to monitor
91 to 94% problem?
Check probe
A and Oxygen
B
C
D
Call for help
< 90% Action!
Check probe
Call for help
A and Oxygen
B
C
D
Errors and problems
Probe not correctly applied or displaced

Movement or shivering

Low blood pressure

Cold

Bright light

Nail varnish or henna dye

Smoke inhalation (carbon monoxide)

Unconscious and on oxygen (carbon dioxide)

Pulse Oximeter
Does not replace
A
B
C
D
E
Questions?
Global
Recognition and
Assessment of the
Sick
PAEDIATRIC
Patient and
Initial
Treatment.
Spotting a sick child
Effort of breathing
Exceptions
Efficacy of breathing
Effects of respiratory inadequacy
ABCDE
STRUCTURE LOOK, LISTEN & FEEL
A structured approach is crucial and should be done in a
logical, sequential order using:
Airway ventilation (+/- c spine)
Breathing hypoxia / oxygenation
Circulation hypovolaemia / perfusion
Disability conscious level
Exposure fully examine child
ABCDE
Airway - is the airway clear, compromised or
obstructed?
Anatomically
Airway differences
 Anatomical differences
Big head (especially occiput)
Positioning may be affected by relatively large occiput in
infants
Short neck
Big tongue
Floppy epiglottis
Larynx is anterior and high in the neck
Narrow point at cricoid ( up to - 10 years)
High heart
Vulnerable abdominal organs
Why do children desaturate
faster than adults?
Signs of airway compromise
See-saw respirations
Stridor
Drooling
Increased work of breathing
Reduced or absent air entry
Low / falling SaO2
Breathing
Respiratory rate
Work of breathing
Accessory muscle use
Nasal flaring
Grunting
Oxygen saturations
Colour.
 Physiological differences
Babies < 6 months are obligate nasal
breathers: blocked nose = blocked airway

Ventilation is mainly diaphragmatic if

diaphragm movement is impeded tidal
volume is reduced (eg full stomach)

Trachea & bronchi are smaller a minimal

obstruction makes a big difference to flow
Respiratory
Circulation
Pulse
Palpate pulses
peripherally and centrally
Temperature
Capillary refill time
Blood pressure
Accurate fluid intake and
urine output.

Give 20mls/kg bolus of 0.9%

normal saline
Circulatory compromise
capillary refill time
peripheral - central temperature
difference
skin colour
altered level of consciousness
poor or absent peripheral pulses
(urine output)
(blood pressure)
 Disability
Responsiveness using
AVPU are they
Alert
responding to Voice

responding to Pain

or Unresponsive
Pupil size

Dont Ever Forget Glucose.

Exposure
Look front and back and head-to-toe
For bleeding, bruises, breaks and burns.
 Other Paediatric points
Unfamiliarity
Communication
Refusal of food /
special toys is BAD!
Perception
Previous experience
Strong survival instinct
Our own anxiety /
uncertainty / fears
Now what?

Assess ABCDE
Get help
High flow O2
Positioning sit up if alert/able
DO NOT distress the child
Treatment for specific problem (eg wheeze)
Reassess
 The Hypotensive Patient

GRASP IT
Normal blood pressure?

Hypotension

Shock
What is a normal blood
pressure?
What is a normal blood
pressure?
Depends on the patient

Systolic less than 100

Beware the hypertensive patient

Shock

Blood pressure insufficient to perfuse

tissues

Hypotension + organ dysfunction

Does not correlate to a set number

Signs of Shock
Hypotension
Cold, clammy and pale skin
Rapid, weak, thready pulse
Shallow, rapid breathing
Oliguria
Cyanosis
Confusion
Loss of consciousness
Case Study

Case study
Assessment/Management
AB Open airway/high flow O2
C
BP
Pulse
Capillary refill
Skin temp
Urine output
Respiratory rate
D
Level of consciousness
E
Assessment/Management
Head down
IV access
Fluid challenge
Fluid challenge
500ml over <5min
Assess response
No response
Transient response
Sustained response
If no/transient response- REPEAT
If you suspect cardiac cause, or pt known
to have heart failure- use 2OOml instead
What Fluid?
Colloid vs crystalloid?
Probably no difference
Avoid huge volumes normal saline

Blood
If patient is bleeding
Do not aim to restore normal BP until bleeding
is controlled
Clinically severely anaemic child
Assessment/Management
Head down
IV access
Fluid challenge

REASSESS
Further fluid?
Increase frequency of monitoring
Urine output

What is the underlying cause?

 What determines Blood Pressure?

Volume of water
What factors affect in the system
the pressure in
these pipes?
Pump
Effectiveness of
the pump

Diameter of the
pipes

Pipes
How does this help us?
Is the hypotension caused by a problem
with:

Filling?

Pump?

Blood vessels?
Shock
Can be divided into types:

Hypovolaemic (filling)

Cardiogenic (pump)
Obstructive (pump)

Distributive (vasodilation)
Hypovolaemia
Hypovolaemia

Haemorrhage
Sepsis
Dehydration e.g D&V
Burns
Impaired Cardiac Function
Impaired Cardiac Function
MI
Arrythmias
Valve dysfunction
Drugs
Electrolyte disturbance
Aortocaval compression
PE
Tamponade
Vasodilation
Vasodilation
Sepsis
Drugs
Regional anaesthesia (spinal/epidural)
High spinal cord injury
Case Study
ABCDE assessment
Initial treatment
Case Study
ABCDE assessment
Initial treatment

Consider underlying cause

? filling problem
? pump problem
? vasodilatation
Summary
Hypotension can be caused by
A filling problem
A pump problem
A resistance problem

Assess and treat according to ABCDE

Give a fluid challenge and measure response

Consider the underlying cause

 Questions?

GRASP IT
The Patient with Oliguria
Definition of Oliguria
Production of between 100-400 mls of
urine per day.

Or < 0.5mls/kg/hr

Early sign of deterioration in a patients

condition

If oliguria is not corrected acute renal

failure may occur
Normal Urine Output
Normal Urine Output
Depends on
Adequate blood supply

Functioning kidney

No obstruction
Types of Renal Failure
Pre-Renal
Inadequate blood
supply

Intra-Renal
Abnormal kidney

Post-Renal
Obstruction
Pre-Renal failure
Dehydration
Haemorrhage
Sepsis
Myocardial Infarction
Arrhythmias
Renal artery stenosis; thrombus
Intra-Renal Failure
Acute Glomerulonephritis

Nephrotoxic drugs

Streptococcal infections

Acute Tubular Necrosis; severe

ischaemia/poisons, toxins
Post-Renal Failure
Enlarged prostate gland

Kidney stones

Clots

Tumours

Urethral obstruction
 The Patient with Oliguria

Questions to ask yourself

Is the patient perfusing properly (adequate BP)

If not, why not?

Have we poisoned the kidney?

Could there be an obstruction?

 Questions?

GRASP IT
The patient with a decreased
conscious level
Aims of this session
Discuss the causes of reduced level of
consciousness

Assessing LOC

Treating LOC
 Things inside the head

Things outside the head

Inside the head
Infarction
Injury
Infection
Bleed
Tumour
Outside the head

Due to lows

Due to highs
Outside the head- Due to lows

Low oxygen!!
Low BP
Low glucose Low sodium
Low temperature
common Low thyroid
Outside the head- Due to highs

High CO2

High Temperature

High level of drugs, alcohol, poisons

Assessment of the patient

Airway
Breathing
Circulation

Disability
Assessing- D
Conscious level

Pupils

Blood sugar
Assessment Of Conscious Level

AVPU

GCS
Assessment Of Conscious Level
Is the patient Alert?

Does the patient respond to Voice?

Does the patient respond to Pain?

Is the patient Unresponsive?

New Onset Confusion

This does not form part of the AVPU

assessment but new onset confusion
should always prompt concern about
potentially serious underlying causes and
warrants urgent clinical evaluation
Assessment Of Conscious
Level

Pupils
What size?

Are they equal?

Are they reactive?

Assessment Of Conscious
Level

Blood Sugar
ABC
Dont
Ever
Forget
Glucose!
Summary

A decreased level of consciousness is common in

acute illness.

Hypoxaemia, hypoglycaemia and hypotension are

common causes.

Treatment is focused on care of airway, breathing

and circulation prior to assessing the patients
conscious level.
 Questions?

GRASP IT
PAIN MANAGEMENT
no-one ever died of pain
no-one ever died of pain
System Effect Consequence
General

Respiratory

Cardiovascular

GI

Neuroendocrine

Psychological
no-one ever died of pain
System Effect Consequence
General Immobility Pneumonia
Thromboembolus
Muscular atrophy
Pressure sores

Hyperventilation Pneumonia
Respiratory Hypoventilation Hypoxaemia
Physio intolerable
Hypertension cardiac work
Cardiovascular Tachycardia O2 delivery
Vasoconstriction Ischaemia & infarction
Nausea Dehydration
GI Ileus Electrolyte imbalances
Malnutrition

Neuroendocrine stress response healing

Imunosuppression infection risk

Anxiety, Fear Loss of confidence

Psychological
Basic Principles

Pain assessment

Provide appropriate treatment

Review regularly and change if necessary

Assessment of Pain

Best method involves self-reporting

Observation is unreliable

Functional assessment important

deep breathing, coughing,
physio, mobilisation
Measuring pain
1.Visual analogue pain scale
0 10

2.Wong and Baker faces

3.Pain score
Mild =1
Moderate =2
Severe =3
Assessment
Torbay Observation Chart

PAIN the 5th

VITAL SIGN (1992)

American Pain Society (1992)

 Link Pain Intensity to Strength
of Analgesia
S
E ADVANCED ANALGESIA
V
E
M R
O E
D
E INTERMEDIATE ANALGESIA
R
A
T
M E
I SIMPLE ANALGESIA
L
D
ANALGESIC LADDER
STEP 4
Paracetamol + NSAID
Oral opioid
IV / IM Opioids
LA/ Blocks Epidural
STEP 3
Paracetamol + NSAID
Oral opioid
STEP 2
Paracetamol + NSAID
STEP 1
Paracetamol
 SYNERGY
Combinations of drugs are more effective
than using one alone

Due to different mechanisms of action

and
effect on different types of pain
 SIDE-EFFECTS
Codeine
constipation

NSAIDS
gastric bleeding
renal impairment
anticoagulants
heart failure

Opiates
nausea / vomiting
sedation
respiratory depression
 SIDE-EFFECTS

Addiction to Opioids

Almost never occurs when

treating acute pain
 Questions?

GRASP IT
Using a communication tool to
boost patient outcome

SBAR
S SITUATION

B BACKGROUND

A ASSESSMENT
R RECOMENDATION
SITUATION
Who you are

Where are you phoning from

Name of the patient

Main problem!
 BACKGROUND

Admitting diagnosis

PMH

Treatment to date
ASSESSMENT

Your assessment of the

situation
 RECOMMENDATION

What do you want from the person?

Is there anything I can do before you get here?

Document the call!

If you dont get a timely response try again and consider

escalating to a more senior person.
Preparation
is
key
 SUMMARY

Dr Michael Swart michael.swart@nhs.net

Dr Matt Halkes matthew.halkes@nhs.net

Hazel Robinson hazel.robinson1@nhs.net

Ellie Forbes ellie.forbes@nhs.net

Thank you all for listening