Today Dr. Okrainec led us through an interesting case of an unstable patient. The following are some Clinical Pearls about the management of an acutely ill patient:

1) CAB's & MOIF +/- DONT

• Circulation: start by assessing the patient's circulation (pulse, BP and HR), feel the extremities to assess for perfusion (cold vs warm). A cool mottled patient is a sign of peripheral vasoconstriction which occurs with hypovolemia or cardiogenic shock. Warm extremities indicate a distributive picture (sepsis or anaphylaxis). If BP low, consider bolusing IV fluids using a pressurized bag, crystalloids have been shown to be equivalent to colloids.
• Airway/Breathing: Signs of resp distress: tri-poding, paradoxical abdominal breathing (Belly in with inspiration, out with expiration), quiet chest are all indicative of impending resp failure. Also assess GCS for ability to protect the airway. 
• MOIF: Monitor, Oxygen, IV x 2 and Foley. It is important to ensure the patient is being monitored (i.e. cardiac monitor or nurse at bedside to do frequent vitals). The foley catheter is useful for assessing renal perfusion

2) Primary Survey

• Once you have assessed the CAB's and initiated initial management (i.e. IV fluids, CPR and ACLS protocol if pulseless) you can do a primary survey
• The primary survey consists of a quick physical assessment to rule out/in causes of shock:
• GCS: Pupils (look for a toxidrome), focal neuro deficits, meningismus
• CVS: JVP (signs of tamponade, HF, PE), new murmurs (acute valvular rupture, aortic dissection)
• Resp: equal air entry? (signs of pneumothorax)
• Abdo: signs of perforated viscus, intra-abdo or retroperitoneal bleed (ecchymosis), check the diaper for melena/blood
• Extrem: signs of DVT
• Assess around the patient: PCA pump (opiod toxicity)? Heparin drip (bleeding risk)?

3) Initial management:

• DONT: the universal antitodes for decreased LOC (Dextrose, Oxygen, Naloxone, Thiamine)
• IV fluids: wide open and on a pressure bag (or use a BP cuff)
• STAT labs: ABG, CBC, lytes, creat, INR/PTT, lactate, blood C&S, liver enzymes, glucose, troponin/CK. The ABG can tell you roughly the lytes and hgb. Don't forget to look at pt's recent labs
• STAT investigations based on presentation: ECG, portable CXR, bedside ECHO
• Low BP resistant to IV fluids: consider giving empiric Abx (early goal directed therapy), consider stress dose of steroids if risk of adrenal insufficiency
• Low BP resistant to IV fluids: consider giving peripheral inotropic support (phenylephrine 100-200mcg IV bolus, dopamine 10-20mcg/kg/min) can give through peripheral IV for a short period
• Signs of bleeding: give blood.

4) Definitive management:

• Call ICU and arrange for transfer once CAB's are relatively stable