ATSP Re:

Health Education North West

 ATSP Team 2019

Dr Hayley McManus
Miss Shazia Hafiz
Dr Alice Bishop
Dr Alison Maclean
Dr Kristianne Jones
Dr Tom Havenhand

Authors

ATSP is a trainee-led medical education project in patient safety. It was

established in 2010 and is supported by Health Education England. The
project was written and designed by Dr Gillian Jackson, Dr Fran Bennett
and Dr Tom Hannan. Booklet edits by the ATSP Team 2019. Additional
support and guidance provided by Professor Paul Baker.
 Contents

Page 2: Introduction

Page 3: ABDOMINAL PAIN

Page 4: AGITATION/CONFUSION

Page 5: BLOOD IN CATHETER BAG - Example of documentation

Page 6: DECREASED GCS

Page 7: DYING PATIENT

Page 8: FALLS/COLLAPSE

Page 9: FLUID REVIEW & INSULIN SLIDING SCALE

Page 10: HAEMATEMESIS/COFFEE GROUND VOMIT/MALAENA

Page 11: HIGH EWS (General Assessment)

Page 12: HYPERKALAEMIA (stable patient)

Page 13: LOW URINE OUTPUT (catheterised patient)

Page 14: SHORTNESS OF BREATH

Page 15: TACHYCARDIA/PALPITATIONS

Page 16: COMMONLY PRESCRIBED DRUGS

Page 18: PRESCRIBING OUT OF HOURS

Page 20: General Hints and Tips for seeing patients out of hours

1
 Introduction

A note from the authors

Dear all new FY1s!

We know how daunting starting life as a newly qualified junior doctor can be, particularly
if you start your first shift on-call or working nights. During our foundation experience in
medicine we found that medical school had prepared us well for emergency situations
with numerous courses like ILS, AIMS and similar with the main emphasis being on ABCDE
and managing acute presentations.

When you are asked to see patients on hospital wards this sort of training only gets you
so far, it’s a great structure to start with but often the presentations are not that acute and
a basic ABCDE assessment just isn’t enough!

The aim of this teaching material is NOT TO TEACH you medicine you already know. It is
there as a guide and a prompt to help you out in situations you may not have covered as
a student and to make sure you are a safe practitioner. It is also not a substitute for senior
advice.

The individual case scenarios have been presented to you in a layout which should
help with your documentation as well as assessment and management plan for the
patient. The presentation on blood in the catheter bag is set out as an example of good
documentation, whereas the other examples are shortened versions with emphasis on the
most important aspects of each presenting complaint. Make sure you don’t just read them
mindlessly, you still always need to think about your course of action regarding ABCDE
initially! You should also be able to come up with differentials and take an appropriate
history for most scenarios which is why we have not included detailed prompts for this.
We have focused on the areas which ourselves and our colleagues struggled with initially.

Whenever you have an encounter with a patient it really is important that you document
what you have done in a systematic way. This is to firstly protect yourself from a legal
perspective should any harm come to the patient and secondly to help your colleagues
who are in charge of their care. You will understand this soon enough for yourself!

We hope you find this booklet useful and that it provides you with the majority of
information you’ll need when you are ATSP’d! Please always check for local trust guidelines
before following the guidance in this booklet. Also, the guidance in this book applies only
to adult patients. Seek specialist advice when managing children.

If you have any further feedback for us on the material or anything you would like to add
please feel free to contact us with your suggestions.

ATSP Team

2
 ATSP Re: ABDOMINAL PAIN
Initial Assessment
A V P U If ACUTE ABDO i.e. perforation or bleed
ABCDE • BP + feel the pulse
• IV Access & bloods
Is this patient acutely unwell? • Erect CXR+AXR
Are they post-op? • Senior HELP

Examination
· ABDO EXAM
· PR EXAM if appropriate (i.e. if there is history of haematemesis/meleana, if you suspect obstruction,
or if you think the patient may be faecally loaded)
· VASCULAR EXAM – feel the pulses!

History
1. SOCRATES - CHECK BOWELS
For a non-acute situation think about common
Associated symptoms should include
urinary and gynae causes for in-hospital abdominal pain
• Constipation - remember this may present as
2. PMHx including overflow incontinence
• alcohol consumption • Urinary retention
• constipation/diarrhoea • Pre-existing pathology e.g partial obstruction,
• Previous abdo/pelvic surgery Cholecystitis, Pancreatitis, Gastritis (ulcer, GORD,
• BPH infective causes,)
• UTI (catheterised?)
3. REASON FOR ADMISSION
• Infection e.g C.diff
and most recent procedures/operations

Investigations Medication Review

Unless this is an ACUTE situation you
Consider:
should focus on symptom control when
• Bloods - FBC, U&E inc Ca2+, LFT, amylase,
out of hours.
coag, X-match if signs of bleed Consider holding:
• AXR/ erect CXR • NSAIDS if suspect gastritis/GOR
• ECG • OPIATES if constipated
• Dipstick urine, MSU or CSU Consider starting:
• Stool sample (C.diff if on abx) • OMEPRAZOLE/PRN GAVISCON
• Analgesia – Pain ladder (not NSAIDS!)
Discuss need for abdo USS/CT abdo/pelvis Try BUSCOPAN (see BNF) for any cramp
with senior like colicky sounding pain
• Laxatives or enema if constipated. Only
use an enema if patient is faecally loaded.
• Antibiotics if suspect UTI- check previous
MSUs

Plan Hint

Depends on working diagnosis/impression Most in-hospital abdo pain is not an

• Keep NBM until diagnosis made emergency and this plan will be a bit
• IV access +/- FLUIDS excessive for the majority of cases.
• Analgesia Constipation and/or pre-existing chronic
pathology is the leading cause of abdo pain
• Monitor BP & urine O/P ?Catheterise
in this group of patients unless they are
• Consider NGT if vomiting
post-op. Symptomatic treatment is most
• Keep details and check on them later often sufficient.

3
 ATSP Re: AGITATION/CONFUSION
Initial Assessment
Is patient in PAIN?
ABCDE Fluid balance
BM TEMP, AMT, GCS
?SEPTIC/LRTI/UTI

Examination
• Chest and Abdo Exam
• NEUROLOGICAL EXAM - Likely to be limited
• Exposure for source of sepsis, including venous access, catheters, wounds/sores.
• Signs of head trauma or fractured neck of femur, especially if patient has fallen
• ?Smelly Urine

History

Is this person normally like this? THINK ABOUT RISK FACTORS for:
Any history of dementia? - Sepsis - Lungs, skin, UTI, recent surgery
How/When have they changed? - Hypoxia - PE, pneumonia, respiratory depression
Any precipitants e.g meds/alcohol - Pain (including constipation / urinary retention)
- CVA/TIA
withdrawal? - Hypoglycaemia
Liaise with family/carers for - Head injury or #NOF (?recent fall)
collateral history to establish the Treat the reversible causes before prescribing any sedatives
patients baseline

Investigations Medication Review

Consider (according to clinical picture) Notorious drugs that cause confusion:
• Bloods: FBC, U&Es inc Ca2+, LFTs • OPIATES especially TRAMADOL
• Dipstick / MSU- check previous MSUs and
• BENZODIAZEPINES
check catheter for signs of infection
• Cultures & Lactate (remember the sepsis six) • INSULIN (too much!)
if temperature has spiked • ZOPICLONE
• CXR
• ABG if patient unwell
• ?CT head (senior decision)

Plan
Only use sedation if you think the patient is putting themselves
or others at risk of harm NOT if they are just being disruptive.
ALWAYS discuss with senior first before prescribing sedatives. Check your trust guidelines
*DO NOT SEDATE PATIENTS WHO HAVE FALLEN AND MAY for the reducing regimen
HAVE SUFFERED A HEAD INJURY*
prescription for alcohol
• Regular (2-4hrly) nursing obs, in well lit room
• Treat suspected cause +/- analgesia if necessary withdrawal. A separate
• Regular ward staff must review bloods/ try and elicit cause prescription chart may be
for change in mood/AMT required.
• Once serious cause excluded:
• For sleeplessness: - Zopiclone 3.75-7.5mg PO
• For agitation: - Lorazepam 500mcg PO or Diazepam 1-2mg PO (discuss with senior if you are unsure)
- Haloperidol check BNF for indications and doses
N.B. NICE Guidelines recommend Haloperidol to treat delirium check BNF for indications and doses

4
 EXAMPLE OF DOCUMENTATION:
ATSP Re: BLOOD IN CATHETER BAG
Name of Dr: Melanie Crowther, FY1 Bleep 1234 Patient Details: NAME, DOB, Hosp No

A V P U Description:
A Speaking full sentences
RR 17 Chest clear
Examination
Good bilat A/E
B Sats 98% on air

HR 86 reg HS + 0
C BP - lying: 139/72 I II I
- standing: 132/74 JVP Not raised
History Calves
Soft and non tender. CRT < 2 secs
Fluid balance No oedema
IN: 1500 ml/12hr Mucus membranes
OUT: 1200 ml/12hr Moist, well hydrated

D Further relevant examinations

Temp 37.2
Inspection of catheter site
AMT 10/10 • No evidence of trauma
E BM N/A ABDO Appearance of urine
EXAM • 520ml in bag.
Agitation/mood no change
• Blood stained but translucent.
• No clots.
BS: normal, Soft and non-tender,
No organomegaly
No ascites
Investigations Medication Review
Bladder not palpable

Investigations History
Bloods
Any relevant PMHx? e.g. TURP No
prev now prev now Past Hx of same thing? None previously
Hb 11.1 Na 138 When was catheter put in? Catheter inserted
WC 8.9 K 4.2 3/7 ago
Any record of difficulties? Doctor was called
Plt 435 Cr 198
to perform as several nurses struggled to pass
MCV 89 Ur 9.8 tube
INR 1.1 CRP 57 Why was pt catheterised? Urinary retention
Any immediate distress or raised EWS? No

Medication Review Plan

1.) Ensure IV access
2.) Send bloods FBC, U&E, CROSS
Consider holding:
MATCH, CLOTTING
Clexane and PO anticoags 3.) Regular obs (2-4 hourly)
4.) Strict fluid balance recording
MUST CHECK WITH SENIOR FIRST (maintain urine o/p >30mls/hr)
5.) Change catheter bag (to re-measure
Patients may be on anticoagulants
with time)
e.g for AVR 6.) Dipstick urine and send for CSU
7.) Consider urology review for 3-way
catheter if clots present
SIGNED M. Crowther GMC 7895432
5
 ATSP Re: DECREASED GCS
Initial Assessment
ABCDE AIRWAY & OXYGEN!! ?COLLAPSE/SEIZURE - ?TRAUMA
GCS ?DRUG TOXICITY
PUPILS Consider anaesthetic support
BM +/- Ketones ?HYPOGLYCAEMIA

Examination
Chest and Abdo Exam (Quick full assessment)
NEUROLOGICAL EXAM
• Reflexes inc plantars
• PUPILS

History

Think about RISK FACTORS for:

Look at medical notes yourself. • Sepsis
• Stroke or MI
Commonly hypoglycaemia or opiate toxicity
• Low or high BM
but must rule out any serious acute events • Drug toxicity (opiates/sedatives)
• Renal Failure

Investigations Medication Review

Consider (according to clinical picture)

• Bloods
Notorious drugs that cause sedation:
• Dipstick Urine
• OPIATES (OD)
• CXR
• BENZODIAZEPINES
• ECG
• ABG

Plan

Treat suspected cause +/- analgesia if necessary

• Opiate OD: Naloxone/”Narcan” 400mcg IV and repeat until responsive
In opioid toxicity reversal with naloxone produces instantaneous results once it has reached therapeutic levels.
Remember it is very short acting and the patient may require a naloxone IVI depending on the amount and
nature of the opiate OD. Refer to the BNF or local trust policy for this and discuss with a senior first.
• Low blood sugars: get senior help if causing significantly reduced GCS. Need to consider 10-25% dextrose
IVIs. If GCS 14+ give lucozade and check BM in 30mins. Nurses should already have given something called
HYPOSTOP if patient is known diabetic before calling you as it does not require a prescription.
• Benzodiazepines: unlikely with in-hospital patients but the reversing agent is FLUMAZENIL. You should
never be using this on your own and most wards do not stock it anyway. Regular (2-4hrly) nursing obs, in well lit
room

If you are in ANY DOUBT or suspect an acute event has occurred you MUST seek SENIOR HELP
IMMEDIATELY!

6
 ATSP Re: DYING PATIENT
Initial Assessment and Examination
A V P U
A - is this obstructed? Are there excess secretions?
B - is respiration regular or agonal?
C - is patient tachycardic? This may be only sign of pain
D - is the patient agitated or uncomfortable?
- is patient vomiting or c/o nausea?
- is the patient having seizures?
E - is the patient itchy?

History
Are the patient and family aware of the situation?
What are their instructions about being contacted if patient deteriorates e.g. in middle of the night?

Medications for symptom control

• Pain/breathlessness: Morphine
• Nausea/vomiting: Levomepromazine
• Secretions: Glycopyronium
• Restlessness/agitation: Midazolam
• Itchiness: Chlorpheniramine(Piriton)
See your local Trust guidelines on end of life prescribing, if available, which should advise on
the conversion of opioids. Don’t forget that doses may need to be adjusted for patients with a
reduced eGFR.
Aim for a senior review as soon as possible to enable an end of life care plan to be made, taking
into consideration the patient’s wishes.
Remember: Tailor your prescription according to your assessment and listen to the nurse caring for
them. Each patient will have different requirements, depending on their symptoms. Prescribe the
medications PRN (or via a syringe pump if necessary – e.g. if the patient has required two or more
doses in the last 24 hours). Do NOT withdraw life-prolonging medications e.g. antibiotics – this is a
consultant’s/MDT decision
Further info available in the NICE Guideline: Care of dying adults in the last days of life.

After Death
Go and see the body.
Document: Your name and bleep number
• “Called to confirm death. No vital signs.”
• Assess for cardiopulmonary arrest for 5 minutes (document combination of no central pulse on
palpation, no heart sounds on auscultation and no respiratory effort).
• Note absence of papillary light reflexes (Fixed dilated pupils).
• Note absence of corneal reflexes.
• Note absence of pain response to supra-orbital pressure.
• Document time of death (this is the time the above criteria are fulfilled).
• Document whether or not patient is fitted with pacemaker / radioactive implant if you have access to this
information
• You DO NOT need to put a cause of death if you don’t know the patient, unless already clearly
documented in notes
• You DO NOT need to write a death certificate
• Whether or not NoK informed
• RIP

7
 ATSP Re: FALLS/COLLAPSE
Initial Assessment and Examination

For Head Trauma ensure you document

ABCDE the following
GCS 1. Mechanism of injury
BM 2. Any LOC/Reduced GCS/Confusion /
Amnesia
3. Any vomiting or seizures
4. Head examination eg. Bruising/
Laceration/Boggy swellings.
Signs of trauma:
5. Full neurological examination
• Head and neck 6. Medication Hx (e.g. warfarin)
• HIPS 7. Always plan for neuro obs
Neuro exam NB. Inform senior if any red flags.
Lying-Standing BP

History

RISK FACTORS for:

• Mechanical Falls
• Always take a FALLS HISTORY but remember • Stroke
you are focussing on making the patient SAFE • Low BM
• Drug toxicity (opiates/sedatives)
rather than diagnosing a cause for their fall.
• Arrhythmias
• Seizure
• Infection

Investigations Medication Review

Depends on history and exam findings. Consider withholding the following:
Consider: • Antihypertensives
• Xray imaging • Sedatives, until head trauma ruled out
• Lying/Standing BP (if safe to stand) • Warfarin /anticoagulants if patient is at
• ECG risk of falling again or if head injury
• Bloods sustained. Discuss with senior first, patient
• Urine Dipstick may have artificial valve replacement.
• CT head – refer to NICE guidelines • Inform nursing staff of any changes
criteria (and discuss with senior first)

Plan

• Regular obs
• Always consider neuro obs if possibility of head injury
• Consider adaptations to bed space or nursing supervision to reduce chance of
further falls
• Address underlying cause if appropriate
Further info available in the NICE Guideline: Head Injury assessment and early
management

8
 ATSP for: FLUID REVIEW
Assessment for repeat prescription
1. The REASON for their fluids: (NBM/sliding scale/unwell/septic/ unsafe swallow) and the
PURPOSE (e.g. resus vs. maintenance)
2. Check FLUID status – check for overload/dehydration. Input -Output chart
3. CHECK U&E paying attention to K+ requirements. Don’t just rewrite fluids without checking
most recent U&Es. If no bloods for >24-48hrs and on regular fluids, repeat U&E before
represcribing. Write a blood card for next appropriate monitoring so it doesn’t get missed.
4. Consider the patient’s Na/K/total fluid/glucose requirements, taking into account their weight.
5. Check drug chart for PO electrolyte supplements and diuretics. If patient is receiving diuretics
and fluids simultaneously, discuss with senior.

More info: NICE guidelines for IV fluid therapy for adults in hospital

History
Ensure patient is not fluid restricted for any reason. i.e. heart failure, oedema and ascites.

Variable Rate IV insulin Infusion (VRIII) re-prescription

Most hospitals have their own guidance – use this if available. Re-prescribe the VRIII on the fluid chart,
if your trust does not have a standard prescribing proforma. Some patients will have an individualised
VRIII. BMs are monitored every hour by nursing staff and infusion rate is altered accordingly.
In the infusion pump:
• 49.5mls 0.9% NaCI + 50 Units Actrapid insulin (this provides concentration 1 unit/1ml)
• KCl may also be added depending on the patient’s levels. If <3 add 20mmol if 3-5 add 10mmol.
Blood Glucose Level mmol/L Standard scale Augmented scale
Units of insulin/hour Units of insulin/hour
<4 0* 0*
4-8 1 2
8.1-12 2 4
12.1-16 4 6
16.1-20 5 7
20. 1-24 6 8
>24 8 10
* Treat hypoglycaemia and stop infusion for 20 minutes. Re-check BM again before restarting. Prompt
restarting minimises risk of ketosis.
More info: diabetes.org.uk

High BM
A high BM is rarely an emergency in hospitalised patients. However, make sure you:
1. Check BM charts for previous readings. Is this a new problem?
2. Check urine or blood for ketones.
3. Check ABG if patient looks unwell. If this is the case they are likely to have a high EWS so manage
appropriately. Consider whether this could be DKA or HHS (hyperosmolar hyperglycaemic state)/
HONK.
4. Document your findings and action taken (if any)
Actrapid is sometimes prescribed if patients are not on a VRIII, but seek senior advice before doing
so.

9
 ATSP Re: HAEMATEMESIS/COFFEE GROUND VOMIT/MALAENA
True Haematemesis or Malaena is a medical emergency and will often be accompanied with a high EWS.
Treat accordingly if this is the case. In-hospital patients often suffer simple coffee ground vomits without
any systemic disruption but must still be considered as a potential emergency

Initial Assessment
A V P U IV Access and bloods
ABCDE Work out EWS

Examination
Chest Exam
ABDO EXAM
• Any signs of perforation? Tender?
• PR EXAM – ALWAYS check for evidence YOURSELF even Haematemesis/coffee ground vomit

History
If pt has had significant upper GI bleed: RISK FACTORS for GI Bleed:
1. Assess for tachycardia. A significant • Gastric irritant medications
postural drop (>20mmHg) in BP may be (NSAIDS)
noted • Alcohol/Alcohol-related liver
2. The urea will usually become disease
proportionally higher than creatinine, • Lack of gastro-protective
often with little other evidence of renal medication
failure • Ulcers
• Reflux/GORD
• Remember Hb won’t drop immediately • Persistent vomiting
after a GI bleed - therefore normal Hb isn’t • Endoscopy/stenting procedures
reassuring. • Post abdo surgery

Investigations Medication Review

Mandatory:
• Bloods - FBC, U&E including Ca2+, WITHOLD:
LFT, INR and clotting, X-match send as • Any anti-coagulants
URGENT • NSAIDS
Consider:
• AXR/ erect CXR CONSIDER:
• Urgent endoscopy if Hb has taken • Antiemetic
massive drop from previous or is very • PPI (lansoprazole is indicated for
low i.e. <7 Seniors definitely need to patients on aspirin and clopidogrel,
be informed before considering this! omeprazole if not)
• Check BP lying and standing if patient
stable enough to do so
• VBG

Plan
• Consider activating massive haemorrhage protocol if large bleed (each trust has a local trust
haemorrhage protocol)
• Keep NBM until ward team assessment / until you are satisfied the patient is stable
• IV access +/- FLUIDS
• Regular nursing obs - recheck one hour later and 2 hourly thereafter
• Fluid balance. Monitor urine O/P and maintain to >30ml/hr.
• Keep details and check on them later
NB Patients are not normally transfused blood products over night unless it is an emergency. IV
fluids will prevent hypovolaemia and its consequences. If you think your patient looks a bit dry or
is slightly tachycardic etc then stay on the safe side and run through some saline (unless otherwise
contraindicated!)

10
 ATSP Re: HIGH EWS (General Assessment)
EWS. NB always ask nurses for VALUES OF PARAMETERS and what they are COMPARED TO NORMAL
hout
Familiarise yourself with your trust guidelines on response to EWS

Initial Assessment Examination Possible CAUSES to consider

CHEST- THOROUGH Respiratory
A Patients own or clinical respiratory exam - Pneumonia - Asthma
compromised is vital to guide further - PE - COPD
B RR, sats management - Pneumothorax - Respiratory failure
HS Cardiovascular:
C HR,
JVP - MI - Renal failure
BP, - Heart failure - Dehydration
CRT, Calves
Mucus membranes - Pulmonary - Fluid overload
fluid balance CRT oedema

D Temp, Abdominal/other
BM, - AAA - DVT
GCS or AVPU - Bowel perforation - Sepsis
E Exposure - Peritonitis

Investigations-depend on scoring parameters

Consider SEPTIC SCREEN
• ECG
• Urine dip • CXR
• ABG • Urine Dipstick
• Bloods, blood cultures, lactate • Cultures: Blood, Urine (MSU), Sputum,
• G&S and X-match if bleeding suspected Medication Review
Stool
• CXR • Swabs from likely sources e.g wound, bed
sore, throat, eye, cannula, catheter/drain site.

Medication Review History - ALWAYS look in the notes!

Review Kardex for any IATROGENIC causes of
above e.g NSAIDS/warfarin, bleed. Has the patient suffered an acute
Is the patient over sedated?
event?
SYMPTOM control
Has anything CHANGED and HOW/
• Is the patient in pain?- analgesia
• Is the patient vomiting?- antiemetic (IV/IM) WHY has this happened?
• Is the patient dehydrated? – PO/IV fluids
• Is the patient septic? – What is the source? working diagnosis
- Antibiotics (see trust guidance)
Should the patient have been on
prophylactic LMWH?-?PE

Plan
A high EWS can often resolve with SYMPTOM control. E.g bring the BP up and tachy/high RR may
resolve.
1. Regular nursing obs
2. Treat suspected cause
3. Strict fluid balance +/- catheterisation if patient is unwell enough
4. Analgesia and general symptom control
5. Review your treatment/action- has it had an effect?
Senior review if worried

11
 ATSP Re: HYPERKALAEMIA (stable patient)
If patient is symptomatic/unstable this is a medical EMERGENCY and needs a senior doctor involved

Initial Assessment

A V P U
ABCDE ECG Unwell or stable?
Fluid balance

Examination

CHEST and CVS

Hydration
ECG
ECG changes in hyperkalaemia:
History • Arrythmias
• Prolonged PR interval with flattened
- Is this acute?
Pwaves
- Is it a chronic accumulation?
• Wide QRS with slurry ST segment
- Does the patient have CRF? • Tall, tented T waves
- CARDIAC history
- LOOK at FLUID Px charts
- Is patient diabetic?
- Is the patient septic? Medication Review
- Symptoms e.g palpitations/dizziness
• Diuretics- K+ sparing or losing?
Investigations • ACE/A2RB inbitors e.g. ramipril/
losartan.
• ECG • NSAIDS
• ABG - helpful if you suspect a spurious • IV Fluids
result. If pH <7.2 consult senior advice
urgently. • Potassium supplements IV/PO
• Bloods – Repeat sample if unsure of • Nutritional drinks
accuracy of hyperkalaemia e.g. haemolysis.

Plan
Hyperkalaemia treatment - always follow any local guidelines if available. As a general rule:
• If <6.5 AND WITHOUT ECG changes:
Insulin and dextrose IVI- refer to local trust policy for exact instructions. If unable to find then
10 units of soluble insulin in 250ml of 10% dextrose IV over 30-60 mins. (50% dextrose no longer advised)
• If >6.5 OR WITH ECG changes:
Calcium gluconate 10ml of 10% IV over 5 min for cardiac protection (more slowly if patient
takes Digoxin). Ensure patient is on cardiac monitoring.
Insulin and dextrose IVI then INFORM A SENIOR as patient may well need:
Calcium resonium PO 15mg QDS. Causes constipation so write up a laxative PRN.
Salbutamol 5-10mg neb
Hold medications as appropriate (see above)
REPEAT BLOODS post treatment, - Haemodialysis may be required in persistent hyperkalaemia
(>7mmol/L), metabolis acidosis (pH <7.2), encephalopathy. Consult senior advice.

12
ATSP Re: LOW URINE OUTPUT (catheterised patient)
Initial Assessment

ABCDE
CATHETER- IS IT BLOCKED? ?SEPTIC

Assessment of fluid balance

1. Check the fluid chart and work out total input and output (usually over 24hrs but patient is
commonly post-op so calculate from the time since they returned from theatre if this is the case).
2. Remember the urine output should be 0.5ml/kg/hr minimum.
Don’t forget to account for parenteral feeds, stoma output and insensible losses.
Fluid balance over 4 hours e.g post op
Input 500ml Output Urine: 100 ml
Insensible losses: 200 ml
Stoma: 500 ml
TOTAL 500ml TOTAL 800 ml
FLUID BALANCE = - 300ml i.e patient is DRY!!

Examination
CHEST - is the patient fluid overloaded?
ABDO EXAM
• Tender? Urinary retention? Note post-op ileus can cause urinary retention
• Stoma site – is it infected?
Look for acute serious pathologies and try to correct these

History
• Always remember to look at the notes. Think about RISK FACTORS for:
This problem is commonly seen in post op • Dehydration. Look for potential fluid losses e.g.
surgical patients. vomiting, diarrhoea, poor oral intake, high stoma
• Check which operation they’ve had and output
any important details on the op notes • Urinary obstruction e.g nature of op/co-morbidities
before you speak to senior doc. • Infection/Sepsis
• Ensure that the patient is not fluid • Drugs e.g. anticholinergics
restricted e.g. CCF, ascites.

Investigations
Consider:
• Bloods - FBC and U&Es to monitor renal function
• AXR
• Dipstick urine, MSU or CSU
• Stool sample (stool sample if diarrhoea present)
• Septic screen
Discuss the need for imaging with senior if suspecting intra-abdominal sepsis

Plan
• Often all that’s needed is a fluid challenge of crystalloid e.g. 0.9% NaCl, (check local guidelines for first line
fluid choice) Get nurses to run it through stat and check o/p no more than 1hr later. If patient is simply
dehydrated their urine o/p should have picked up from this. CAUTION IN CCF/CRF patients!!!
• Correct underlying cause once diagnosed
• Monitor BP & urine O/P (maintain urine o/p to 0.5mg/kg/hr and document this instruction.)
• Consider diuretics (stat dose 40mg furosemide IV) if you think the patient is fluid overloaded (usually with
positive fluid balance), however use with caution and always check previous U+E’s. Consult with senior doc
before doing this, you could easily exacerbate the problem!

13
 ATSP Re: SHORTNESS OF BREATH
Make a very quick decision as to whether or not you are confident in treating this patient on your own.
Patients who are short of breath can deteriorate very quickly indeed. Call for a Senior immediately if you are unsure

A V P U
Anaphylaxis??
ABCDE
Pneumothorax??
OXYGEN!! (If oxygen saturations <94%
give high flow oxygen via non rebreathable Compare sats to normal or target
mask initially, then reassess following sats, if documented
further investigations. )
Cardiac or respiratory cause?
ABG

Examination

· THOROUGH exam is vital to guide management JVP and ankles

· Hydration assessment Calves / Thighs

History

Ask about ASSOCIATED FEATURES and RISK

- Onset FACTORS for:
· DVT/PE
- Duration · Overload, e.g. recent transfusion/fluid therapy
- Exacerbating or relieving factors · MI
· Infection (hospital acquired??)
- Check clerking proforma for Medication Review
· Anxiety
co-morbidities · Asthma/COPD exacerbation
· Recent surgery (atelectasis)

Investigations- depending Medication Review

on scoring parameters
Is patient on thromboprophylaxis?
• ABG – immediately, then repeat after What can I give?
treatment? • Think about your choices for Oxygen
• CXR: Check most recent one. Don’t Therapy depending on patient’s chronic
be afraid to repeat CXR if things have disease status and ABG result!
changed clinically. Order a portable film • Wheeze: Salbutamol 5mg neb+/-
if you feel the patient is too unstable to be
atrovent 500mcg neb (can be given with
transported - discuss this with the nurses.
• ECG O2)
• Cultures: Blood and sputum if • LRTI/CAP/HAP: Antibiotics (check
appropriate and/or check previous for local guidelines)
sensitivities • Pulm Oedema: Furosemide 40mg IV
• Bloods

Plan
In patients with shortness of breath
• Stay with patient until you are happy they are stable
in the last days of life/end stage
• Regular observations (such as 1-2 hourly) respiratory failure, an opioid can be
• Keep a watchful eye on their bloods/CXR etc considered for symptomatic relief.
Always consult a senior doctor
CALL FOR SENIOR HELP IF YOU ARE UNSURE: before prescribing, as per nice
THESE PATIENTS CAN DETERIORATE VERY QUICKLY INDEED guideline on care of dying adults in
the last days of life.
14
 ATSP Re: TACHYCARDIA/PALPITATIONS
TACHYARRYTHMIAS ARE A MEDICAL EMERGENCY If patient has developed a new tachyarrhythmia
on ECG (SVT/Fast AF), a senior needs to be involved. Make sure you perform the following:

Initial Assessment

A V P U EXPOSE for sources of sepsis

ABCDE BP PULSE: REGULAR OR IRREGULAR?

Examination

· Chest and Abdo Exam

· Fluid balance - is patient dehydrated?

History
• Is the patient symptomatic?
Possible reasons for simple tachycardia
• CARDIAC HISTORY • Pain
• Previous cardiac history and RISK FACTORS for • Anxiety
MI, AF, Arrhythmias • Sepsis
• Hypovolaemia – bleed/dehydration
• Previous ECGs • PE
• For arrhythmias: IS THIS NEW? Assume it is • MI
unless proven otherwise • Medication side FX
• Look at Kardex for any anti-arrhythmic • Has patient been on any drugs which put them
medications for clues at increased risk of the above? E.g Warfarin/
NSAIDs- bleed. Should the patient have been on
• How much tea and coffee has the patient had? prophylactic LMWH?-?PE

Investigations - depending on scoring Medication Review

parameters and clinical judgement
IATROGENIC causes of tachycardia
Mandatory: • SALBUTAMOL overuse
• ECG • EYEDROPS e.g PHENYLEPHRINE
Consider: • THEOPHYLLINE toxicity
• DIPYRIDAMOLE
• Routine bloods +/- CULTURES +
lactate for septic screen (remember MEDICAL MANAGEMENT
the sepsis six) if temp spiked (check the BNF for interactions)
• X-match if suspect patient is bleeding Consider Digoxin or Bisoprolol (unless
• Urine Dipstick contraindicated e.g. low BP / Asthma) once
• Troponin cause has been identified, but discuss with
• D Dimer senior first.

Plan - very different for acutely unwell patients and those who are stable
1. IV access +/- fluids and bloods
2. Follow Tachyarrhythmia algorithm if appropriate- senior should really be involved in this!
3. Regular nursing obs (can do temp only every 30mins/half hour if you think have RFs for sepsis)
4. Treat suspected cause, often this is actually SYMPTOM CONTROL and you may find that simple,
stable tachycardias resolve once you have the following under control:
• PAIN • DEHYDRATION
• AGITATION • SEPSIS
• ANXIETY • VOMITING

15
 COMMONLY PRESCRIBED DRUGS AND DOSES

Below is a list of commonly prescribed drugs to aid your memory. Please always check in the
latest BNF if you are prescribing for the first time or if you haven’t prescribed a drug for a while,
as doses, cautions and contraindications can change. Many Trusts have prescribing guidelines
for the groups of medications below and these should be adhered to.
Always eye-ball a patient before doing so- the nurses may have the diagnosis wrong!
Don’t forget to check for ALLERGIES, PMH and RENAL FUNCTION (if indicated). Look at KARDEX
for any obvious interactions.
Most drugs you will prescribe on-call should be written in the PRN or ‘once only’ section if you
do not know the patient.

ANALGESIA MEDICATION ROUTE DOSAGE MAX/DAY Pts with

PARACETAMOL PO or IV 500mg – 1g QDS renal colic
Caution NSAIDs in respond
IBUPROFEN PO 200-400mg TDS
asthma/PU/CRF/IHD well to PR
DICLOFENAC/’Voltarol’ PO / IM / PR 75mg-150mg
daily in divided doses diclofenac
Diclofenac is

contraindicated in IHD,
PAD, cerebrovascular
CO-CODAMOL
disease and CHF
(8/500 OR 30/500) PO 1-2 TABLETS QDS

Buscopan is an anti- CO-DYDRAMOL (10/500) PO 1-2 TABLETS QDS

spasmodic and works CODEINE PHOSPHATE PO or IM 30-60mg QDS

on smooth muscle. BUSCOPAN PO or IV 10-20mg QDS

Great for cramping
abdo pain. TRAMADOL PO 50-100mg QDS
MORPHINE IV or PO 5-10mg STAT
NB Opiates can cause nausea/vomiting and constipation. Always prescribe a PRN antiemetic and
simple laxative

ANTI-EMETICS METOCLOPRAMIDE/’Maxalon’ PO or IM or IV 10mg TDS Metoclopramide

(dopamine antagonist- works directly on GIT) 10mg dose only if weight >60kg should not be
You can try most of these CYCLIZINE PO or IV 50mg TDS used post GI
in various combinations
if (antihistamine – works centrally) surgery for 3 days.
previous attempts to control It can also cause
symptoms have failed. PROCHLORPERAZINE/‘Stemetil’ PO 5 - 10mg BD-TDS
extra-pyramidal
‘Buccastem’ BUCCAL 3 - 6mg BD
reactions and
Domperidone can cause (dopamine antagonist- works centrally on chemo receptor trigger zone)
oculogyric
ventricular arrhythmias.
It is DOMPERIDONE PO max 10mg TDS QDS
contraindicated in
crises. Beware
patients (acts centrally on chemo receptor trigger zone) of this though,
with cardiac conditions, severe
or those
hepatic impairment ONDANSETRON PO or IM or IV 4 - 8mg BD-max 5 days the antidote

taking other medication which (5HT3 antagonist) is procyclidine
can prolong QT interval or
5-10mg IV/IM.
potent CYP3A4 inhibitors

Ondansetron is
very expensive!
Its often reserved GASTIC GAVISCON PO 5-10ml TDS
for chemo REFLUX RANITIDINE PO 150mg BD
patients, don’t OMEPRAZOLE PO 20mg OD
use it as first-line.

Key:
PU = peptic ulceration; CRF = chronic renal failure; IHD = ischaemic heart disease;
PAD = peripheral vascular disease”; CHF = congestive heart failure; GIT = gastrointestinal tract
16
 SOB SALBUTAMOL NEB 5mg STAT/PRN
IPRATROPIUM BROMIDE (Atrovent) NEB 500mcg STAT/PRN (Max 2mg/day)
Salbutamol causes
PREDNISOLONE PO 30-40mg STAT/OD
tachycardia!
(5-7 days max)
HYDROCORTISONE IV 100mg QDS
(if acute SOB or angiodema)
FUROSEMIDE PO/IV 40-80mg STAT

LAXATIVES
Stimulants: SODIUM DOCUSATE PO 50-200mg TDS (Max 500mg/day)
BISACODYL PO 5-10mg ON,
PR 10mg OD
SENNA PO 7.5-15mg ON (Max 30mg/day)
Osmotic: MOVICOL PO 1-2 sachets BD/TDS
LACTULOSE PO 15ml BD
If faecal loading: GLYCERINE SUPPOSITORY PR 4g STAT
PHOSPHATE ENEMA PR 128ml STAT

In-hospital patients are often constipated often due to decreased activity and medications. Try tackling
constipation using different pharmacological approaches i.e. don’t Px movicol if already on lactulose.

ITCH/RASH CHLORPHENAMINE PO 4mg TDS

(also known as “Piriton”. Note side effects include drowsiness)

AGITATION DIAZEPAM PO/SLOW IV 5-10mg

SLEEPLESSNESS ZOPICLONE PO 3.75-7.5mg
AGGRESSION HALOPERIDOL Check BNF for indications and doses
Do not prescribe sedatives without first seeking senior advice

ALCOHOL
WITHDRAWAL Guidance differs between trusts, so refer to local guidelines if available.

CHLORDIAZEPOXIDE (reducing regimen)

Day 1 and 2: 20-30mg QDS
Day 3 and 4: 15mg QDS
Day 5: 10mg QDS
Day 6: 10mg BD
Day 7 10mg Nocte

For antibiotic prescribing advice refer to your Trust policy. Remember to check
for any available microbiology results which may guide you on antibiotic
sensitivities.

17
 PRESCRIBING OUT OF HOURS
Warfarin
You will often get bleeped to prescribe warfarin for patients you don’t know especially over the
weekend/evenings if your colleagues haven’t done them. If your local Trust has guidelines on
Warfarin prescribing, use them. CHECK PATIENT IS NOT BLEEDING!
Are you prescribing maintenance or loading dose?
LOADING: this is the regimen prescribed initially until INR stable and in target range. If rapid
anticoagulation is required, NICE guidelines suggest 5-10 mg once a day for 2 days then check INR
on day 3. (Instant anticoagulation requires heparin therapy – discuss with senior). For AF, less rapid
anticoagulation is acceptable over a few weeks and doses can start at 1 or 2 mg each day.
MAINTENANCE: usual dose once INR established to keep within target range. Check yellow book for
regular prescriptions.
• Once an INR has been obtained for one of your patients make sure you prescribe the warfarin for
about 3-4 days then re-check. Mark open brackets on warfarin charts to indicate when you want the
next INR to be checked (usually between 3-4 days in the initial period, or more frequently if there are
difficulties establishing a maintenance dose.)
• INR high (but <5) - reduce the dose and/or 1-2 doses may need omitting.
• INR <6 but >0.5 units above target – reduce dose or stop. Restart when INR <5
• If INR is 6-8 and patient not actively bleeding Stop Warfarin. Restart when INR <5. Discuss with
senior to lower maintenance dose. Recheck INR at least 48hrs after as it takes between 48-72hrs for
your change to have an effect.
Reason for LT warfarin Tx? AF 2-3
Recurrent DVT 2-3
PE 2-3
Recurrent PE 3-4
Prosthetic heart valve 3-4

Check drug chart for INTERACTIONS which may affect INR. Discuss
with senior/ day team/ pharmacy before stopping any drugs.
Common interactions:
• Inducers reduce effect of Warfarin. REDUCES INR (PCBRAS)
– Phenytoin, Carbamazepine, Barbiturates, Rifampicin, Alcohol
(chronic excess), Sulphonylureas.
• Inhibitors increase effect of Warfarin. INCREASES INR (ODEVICES)
– Omeprazole, Disulfiram, Erthromycin/Clarithromycin, Valproate,
Isoniazid, Cimetidine/Ciprofloxacin, Ethanol intoxication,
Sulphonamides.

If actively bleeding and/or INR >8 discuss urgently with Senior for advice

Digoxin

You will occasionally get bleeped to review digoxin levels:

Toxicity is very worrying and would normally require the use of ‘Digibind’ which is basically
an antidote for digoxin OD. You will need to get an ECG and assess the patient clinically before
proceeding/getting senior help.
Sub-therapeutic levels are common! They are not so worrying but you should clinically assess
the patient in particular their CVS paying particular attention to their pulse as you will definitely get
asked about this if you ask for senior help.
If digoxin levels are out of range make sure you check their K+ and keep a regular eye on it as this
needs to be stable for digoxin to be a safe and effective choice of therapy.

18
 Gentamicin

You may get bleeped to check the gentamicin levels of ward patients and subsequently
prescribe the next dose. You may have Trust guidelines on this. If in doubt, discuss with your
ward or on call pharmacist.

For once daily doses: The blood level needs to be taken 6-14 hours after the start of the first
IVI. You are basically looking for the levels to be within therapeutic range. If they are not you
need to refer to the Hartford Normogram. This is a chart which indicates WHEN the next dose
should be according to how out of range the levels are. You DO NOT change the DOSE, just
the TIMING of the next one (either 24, 36 or 48hrs later). Make sure, if you have been asked to
take the blood yourself you note exactly how many hours post IVI the blood has been taken on
the blood card, it may be another of your peers who has to review the level!

Hartford Once Daily Dosing Nomogram Toxicity may

cause: (Gent/Tobra 7mg/kg
14 · Deafness/
13
tinnitus
12
11 · Nystagmus
10 · Vertigo
q48h
Level (mc g/ml)

9 · Renal Failure
8
7 q36h Monitor U/Es
6
DAILY
5
4 q24h
3
2
1
0
6 7 8 9 10 11 12 13 14 15 16
Time between start of infusion and sample draw (hours)
Nicolau DP, Freeman CD, Belliveau PP, Nightingale CH, Ross JW, Quintiliani R. Experience with
a once-daily aminoglycoside program administered to 2,184 adult patients. Antimicrob Agents
Chemo 1995:29:3:650-655

For TDS doses: The first level that needs to be recorded is after the 3rd/4th dose ensuring at
least 24 hours of treatment is given. It should be taken 1 hour post IVI i.e. the PEAK or POST
level and be between 3-5mg/L. A trough or PRE Dose level is taken approx 1 hour before any
administered dose and should be <1mg/L. The reason for this is that they are on a TDS regimen
so renal function needs to be closely monitored. It is important that gentamicin levels do not
rise to toxic amounts, which is more common in patients with renal impairment.

19
General Hints and Tips for seeing patients out of hours

When answering your bleep find out:

1. Reason for bleep

2. Quick background info
3. Further relevant clinical info e.g. OBSERVATIONS and compare these to how they normally run.
If it’s a patient with high EWS just inform a senior to make them aware and ready for action!
4. What they want you to DO (PURPOSE of call)
5. Ask for the following things to be ready when you arrive:
• Notes
• Kardex
• Obs chart/nursing file
• Equipment e.g cannulas/bloods/catheter etc

6. Give appropriate instructions if they need to do anything acutely before you arrive. For example
if reason for bleep is Haematemesis ask for IV access and bloods to be taken or if a patient has
spiked a temp of >38˚C get the nurses or night practitioner to do cultures/bloods/lactate (remember
sepsis six) before you arrive. It saves a lot of time and faffing around once you are on the ward.

7. Decide where this lies in your list of priorities or whether it is a job nurse practitioners can do
to help you.

NB: Try not to have arguments with nurses on the phone, some of them are just starting out like
you and may also be petrified, sometimes they need reassurance too!

When you get there:

Find the nurse who bleeped you (or requested the bleep!) and get a more detailed account of
what’s going on.
Eye-ball the patient before delving into notes or looking on the computer following the standard
ABCDE assessment. It won’t take you long to figure out if they are acutely unwell/ unstable or
not!

Once you have done your initial assessment and any immediate management, document what
you have done using a logical and systematic approach. This way you won’t forget anything. You
will also look really slick and competent, plus, you might find you paint yourself a picture of what’s
going on, even if you were clueless initially!

Sit down at a computer with the nursing file and medical notes and go straight for the clerking. It
should give you a succinct list of P/C and other co-morbidities to create a more complete clinical
picture. Flick through the ward notes and find anything you can read, it may be of some use. Look
at the last entry in particular as there may be a plan of what to do should the situation you have
been bleeped for arises!

Check PACS and the lab system for any recent imaging or tests. NB ALWAYS compare recent results
to previous ones! Just go down the lists looking for cultures, unusual blood tests, INRs etc and
document what you find. Sometimes the best summaries of a patient are created when someone
manages them on-call! Be thorough at the beginning but if you are hard pushed for time refer back
to the help sheets- they are designed to make you SAFE, not to make you a brilliant diagnostician
who can cowboy their way through FY1 ‘House’ style!

20
Have a good browse through the KARDEX looking at which meds may have contributed to the
situation, which may have prevented it if they had been given and which ones you might need
to initiate to make sure the patient is SAFE.

Once you have all this information create a PROBLEM list and from this document your
IMPRESSION of the situation. Write a PLAN and document whether you involved a senior and
their name and grade. Also document the amount of time you were there, sometimes you need
to stay with a patient to see if your treatment works e.g fluids for low BP meanwhile you can
scribble down everything you’ve done to save time!

Whenever you are assessing a patient think to yourself:

‘What do I need to DO to make sure this patient is SAFE?’ If this patient deteriorates or
dies unexpectedly and you were the last doctor to see them you need to make sure your
documentation is adequate. Your management, appropriate or not, will mean nothing if it
has not been written down in the eyes of the law!

In summary:

• Answer your bleep in a systematic way- it will help you prioritise and become more efficient.

• Delegate certain tasks to nurses, don’t be afraid of asking them, you are part of a TEAM!

• Prioritise your jobs and don’t be afraid to off-load some onto your ward SHO, YOU are the one
who gets bleeped first so you will be asked to do EVERYTHING!

• When you get to a patient:

1. ABCDE approach ALWAYS!
2. Document your initial assessment and management
3. Review the nursing file for obs chart, fluid balance, warfarin charts, fluid prescriptions
4. Review medical notes and clerking then summarise
5. Review KARDEX
6. Problem list
7. Working diagnosis
8. ACTION PLAN (use tick boxes for investigations you have ordered)
9. Keep their details (sticker on handover sheet) and make sure you check on them
later or handover to day team.

ALWAYS MAKE SURE YOU ARE SAFE, IF IN ANY DOUBT WHATSOEVER YOU MUST INFORM
A SENIOR.

21
 Disclaimer
The findings and conclusions in this document are those of the authors, who are
responsible for its content. All information is to be interpreted on an individual
basis in context with the clinical situation to which it refers. The information is not
a replacement for local guidelines and protocols, nor is it a document with any
legal standing. No statement in this document can be construed as an official
position of Health Education England.

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