I was reading a neat little book called "Resident Readiness - Internal Medicine."
There was this scenario in there, presumably something realistic that would happen on night float.
The scenario was pretty much as follows:
60-something woman who smokes a bazillion packs per day is in hospital for knee replacement. She is placed on 2 L/min LFNC and PCA with morphine post operatively as part of "orthopedic care protocol." Said lady does well initially but at 2:30am, nurse find her unresponsive and rapid response is called. Her vital signs are normal and POC glucose at bedside is also normal. You are the responding intern, what do you do?
Well I read this thinking, hmm seems like a commonplace scenario.... yet I dont know wtf to do. Im about to graduate later this year and I dont think I would have much of a clue how to handle this... other than: examining and trying to arouse her, and if unsuccessful give Narcan. Hopefully she responds.... If not....... uh then... idk... intubate her? CT scan? CMP??
I mean honestly it seems like a straightforward situation , but I'm sure its more complex than this. So what is the appropriate course of action in a situation like this?
I disagree with some of the advice above. Why is the new intern intubating? Why not just ventilate with an nasopharyngeal airway? Or a dead-simple LMA at most? And why have the nurse pop the legs up? Why not trade that therapeutically useless maneuver for a diagnostically useful one (like the passive leg raise test)?
For a new intern at a teaching hospital, help is probably on the way (if not, let your resident know immediately after you've done your initial exam and common-sense management). Right now, I'd imagine you basically have three jobs: 1) initiate initial resuscitation as indicated, 2) rule out anything immediately life-threatening and reversible, and 3) organise for the first lot of interventions/tests.
The first pulse to check is your own, and you need a simple, systematic approach. Analysis paralysis and cognitive fixation are major issues here. (Like jumping straight to Narcan... and then... what else?) Have a system so you don't miss silly things. This is what I use (very open to correction or feedback):
ABCDC. Airway, breathing, circulation, disability, and crew-resource management. Look, feel, listen/test, manage for each one. Just circle round those 5 things over and over again in broadening fashion. Treat something immediately life-threatening before moving on.
Examination is so key here and will guide everything. There is no one-size fits all solution; but there is a system.
Get the story and then in less than a minute:
Airway. Look for obstruction, oedema (altered mental state can be a sign of anaphylaxis), signs of an unprotected airway, and factors that might make this a difficult to ventilate situation (you don't have to intubate--at least
you don't--just ventilate). Feel for tracheal deviation. Listen for wheezes, stridor or rattles. Manage. Crank up the oxygen, slap on the pulse ox, suction if needed, slip in an nasopharyngeal airway with BVM if indicated. Anything immediately life-threatening?
Breathing. Look for tachypnea (RR is a highly sensitive for a PE, just gestalt it), equal chest excursion, diaphoresis, accessory muscles (is this COPDer getting tired?), depth and pattern of breathing (consistent with over-analgesia?), JVP, engorged veins (I've seen one clinically-apparent tamponade s/p cholecystectomy missed initially), chest drains? (are they patent? yes, it's easy to miss the obvious). Feel the chest wall for surgical emphysema or crepitus. Listen for breath sounds bilaterally. Equal air entry? Manage. Check the SpO2. Titrate O2 accordingly or consider a different oxygenation strategy is the sats are abysmal. Try the Narcan. Anything immediately life-threatening?
Circulation. Look at the digits (blue, pink, pale?), if the veins are collapsed, what's going in and out (drugs, drains, bloods, abx, fluids, catheter, whatever--cease whatever you can; check for concealed haemorrhages). Feel if the patient is wet and clammy or warm and well-perfused, what the central cap-refill is, check the BP (narrow or wide PP?), palpate central pulses (bounding or flat?), check the legs for asymmetrical swelling. Listen to the heart. Does the heart sound distant? Murmurs? Rubs? Mange. Check that there's a 14 or 16 gauge cannula in place (much better for volume resuscitation than a central line even). Normal BP is not reassuring, since people can compensate extremely well--until they can't. That's why you have to look at the whole clinical picture. And if you're going to give a fluid challenge, be sure to monitor vitals. This person might not be fluid responsive. Anything immediately life-threatening?
Disability. Now you worry about your neuro stuff (including glucose). The principle is the same, and people have already described a quick exam plus common-sense interventions. Anything immediately life-threatening?
Crew-resource management: Often overlooked. You've done your minute assessment. Now it's time to take control of the team. Point. Be assertive. You, get the ABG and bloods done. You, pop on the FM for this COPD patient or manage the BVM or whatever. You, pop in the 14G cannula. You, get the EKG. You, do X, Y, and Z. Obviously, prioritise based on your clinical exam. And then call your resident.
Reassess. ABCDC. Airway, breathing, circulation, disability, and crew-resource management. Look, feel, listen/test, manage. Keep going and keep thinking but keep going. As you gather more data, you start thinking better. The differentials become more or less likely, and you're being systematic in your approach, and your patient hopefully won't die of something easily reversible, and you can be meaningfully communicative with your resident.
I think the shotgun of tests is pretty routine and in every handbook. I've noticed the better clinicians are systematic in their approach and they see the big picture--which is, initially, to keep air going in and out, and blood going round and round.
