Ward Emergencies

Introduction

This guide covers common medical emergencies on the wards and some practical hints and tips for dealing with these situations. 

It is important to remember that in an emergency, you will not be dealing with it alone. Always ensure that a formal emergency call has been put out, and there will be many helping hands on the scene when you complete your initial assessment and management.

Cardiac arrest

The thought of cardiac arrest on the ward is something that can strike fear into the heart of a doctor on one of their first on-call shifts. It can be a stressful experience for all involved. However, you will be extremely well-supported in these situations.

A cardiac arrest call will summon a large medical team to the bedside, and the ultimate responsibility of running the arrest falls to senior, very experienced practitioners.

With better identification of deteriorating patients (e.g. NEWS systems), a cardiac arrest on the ward should be uncommon, and those at high risk of cardiac arrest should be managed in the intensive care unit.

All patients at high risk of cardiac arrest who have been deemed unsuitable for ICU admission should have an appropriate ceiling of care in situ, which may involve a DNACPR decision. Having said this, unexpected cardiac arrests do happen, and it is important to be prepared for them.

Cardiac arrest team roles

The roles of the FY1/junior doctor at an arrest can vary, and it is key to understand what these may be.

Team leader

Responsible for the overall running of the cardiac arrest, usually a senior medical registrar or intensive care doctor positioned at the head of the bed. A junior doctor may be required to take on this role before the arrival of the full resuscitation team.

Airway

Responsible for the protection of the patient’s airway and appropriate ventilation. The anaesthetic team generally performs this and may include endotracheal intubation if indicated.

Again, you may be required to manage the airway before the arrival of the anaesthetic team. In this case, it is sufficient to ensure the airway is positioned appropriately (head-tilt chin-lift vs. jaw thrust) and consider a simple adjunct such as an oropharyngeal airway in the first instance.

Ensure you deliver maximal oxygenation (15L) via a bag-valve mask to ventilate the patient.

Defibrillator

Responsible for safely managing the defibrillator and shock administration (if indicated/instructed by the team leader). 

Compressions

Responsible for ongoing, effective chest compressions. Often, chest compressions will require multiple staff members to avoid tiring, changing every two-minute cycle.

Scribe/timer

Responsible for timing the arrest and alerting the team leader every two minutes in a prolonged CPR cycle. Will document all steps taken and medications given as part of the resuscitation attempt.

IV access

Responsible for obtaining IV access (usually peripheral IV cannulation) and sending off urgent blood investigations (most importantly, venous blood gas). If venous access is difficult, intraosseous access may be considered.

Medication administration

Responsible for giving medications at the team leader’s command. Once given, these medications should be communicated to the team leader to ensure closed-loop communication.

Information gathering

If you find yourself without a role, indicate to the team leader that you are happy to gain further information about the patient from the notes / medical record.

It is essential to look for clues as to why the patient arrested (reversible causes) whilst the team leader focuses on initial resuscitation attempts. This information must be fed back to the team leader at an appropriate time.

Cardiac arrest team members

Each hospital will have a different system to alert the medical team to a ward cardiac arrest (e.g. pager). The exact makeup of the cardiac arrest team can vary but will include:

• Intensive care doctor(s)
• Intensive care nurse(s)
• Medical registrar
• Medical SHO / FY1
• Anaesthetic doctor
• Operating department practitioner (ODP)
• Hospital co-ordinator
• Porter

In addition to the ward nursing/medical team already present, this can create a very busy environment in the ward bay, and it can sometimes be necessary for a team leader to ask those without an immediate role to leave the bedside. This is done to aid clear and effective communication.

First on scene

Even if you are not part of the cardiac arrest team mentioned above, you may end up being the first doctor to arrive at the scene of a cardiac arrest if the emergency buzzer goes off on the ward. In this situation, the nursing staff will often look to you to lead the initial few minutes of the cardiac arrest.

Again, this situation can appear overwhelming the first time it is presented to you. However, the early stages of a cardiac arrest call are relatively straightforward when broken down, and by the time you have followed some simple steps, there will be lots of help on hand.

By the time the arrest call has been put out, the nursing or allied health staff will have followed the initial basic life support algorithm:

• Check for signs of life
• Assess airway (head tilt, chin lift/jaw thrust)
• Assess for respiratory effort/presence of carotid pulse

If there are no signs of life, no effective breathing or no palpable pulse, chest compressions will be started at a ratio of 30 compressions to 2 breaths (30:2). A cardiac arrest call will summon further help to the ward.

Is there a team leader?

If you are the first doctor to arrive, determine whether or not there is a clear team leader.

A team leader is vital to the smooth running of a cardiac arrest and does not necessarily have to be a doctor. However, depending on the level of nursing staff present, they may be expecting the first medical practitioner to take this role. If there is already a team leader who is confident in the role, they will allocate you a role.

If there is no clear team leader, clearly ask whether anybody is leading the arrest situation. If there is not, it is reasonable to state that you are happy to lead the arrest until the senior team arrive. This will often calm the room and allow more streamlined patient care.

If you step into the role of team leader in the first few minutes of an arrest, there are two clear priorities to focus on that are associated with increased survival in cardiac arrest:

• Effective chest compressions
• Early defibrillation

It is worth allocating two team members to continue compressions and one team member to attach the pads and run the defib for a rhythm check. If you have spare hands at this point, other key early roles include airway and IV access.

Effective continuous chest compressions

Ensure there are ongoing, high-quality chest compressions with minimal interruptions.

If there are no signs of life, there is no need to stop continuous compressions until the defibrillator pads are on, and there can be a rhythm check/defibrillation.

Any short interruption to chest compressions is known to decrease coronary artery perfusion and thus decrease the likelihood of successful defibrillation. Allocate at least two people to continue chest compressions in the first instance so the compressor does not tire.

Early rhythm check +/- defibrillation

Whilst high-quality compressions continue, the key priority is to attach the defibrillator pads and assess the rhythm.

Allocate a senior member of the nursing team to attach the pads. As soon as the pads are connected to the defibrillator, the defibrillator can be charged, and then compressions can be halted for a rhythm check +/- shock. A shockable rhythm (VT/VF) should be shocked as soon as possible.

It is a good idea to get accustomed to the layout and standard settings of the defibrillators on the hospital wards on your very first day. These can vary slightly from hospital to hospital and should be taught to you at orientation. The ‘COACHED’ algorithm is a simple mnemonic that can be used to ensure safe defibrillation in a ward setting.

Compressions should restart as soon as possible after the shock has been delivered, continuing at a 30:2 ratio until a definitive airway can be established (after which compressions can be continuous).

Whilst the initial focus is on effective compressions and early defibrillation, other team members can work in unison with these efforts as directed by the team leader.

The airway team member should ensure good patient positioning to open the airway and consider inserting an oropharyngeal/nasopharyngeal airway. They should then set up a bag-valve-mask attached to high-flow oxygen so they can ventilate the patient.

Once set up to ventilate the patient, if there is a delay to rhythm check/defibrillation, breaths can be delivered with compressions at a rate of 30:2.

Further patient management after the initial rhythm check will then depend on the cardiac rhythm, following either the shockable or non-shockable ALS algorithm. 

Once following the algorithm, the key will be to look for reversible causes of the cardiac arrest. By the time you have got to the point of a rhythm check (and often before), it is highly likely that you will be able to hand over the ongoing running of the cardiac arrest to a more senior colleague and can assist in the ongoing management of the arrest as instructed.

Seizures

A seizure is a common emergency seen on the wards. The medical team will look after patients with epilepsy who require admission to hospital (often due to worsening seizures), and non-epileptic medical patients will often carry several risk factors for decreased seizure threshold (infection, antibiotic therapy, increasing age).

A generalised tonic-clonic seizure (GTC) is associated with loss of consciousness and typical limb-jerking movements. This will warrant an emergency call.

Assessment

When arriving at a patient with ongoing seizure activity, the most important first step is to perform a focused ABCDE assessment. Ask a member of the allied health team to start timing the seizure.

Airway

The acutely seizing patient may be tongue biting or hypersalivating and is unlikely to be adequately protecting their airway. Most seizures will terminate before any specific airway intervention is necessary. However, ensure an emergency call has been put out so that airway specialist help is on the way should it be required (i.e status epilepticus).

All seizing patients should be started on a non-rebreather mask with maximal (15L) oxygen flow.

Ideally, a patient should be positioned laterally (recovery position) to help prevent aspiration of any excess secretions. However, this is not always possible in an actively seizing patient, and the patient should not be forced into any specific position.

Suction may be useful to remove upper airway secretions if possible, and a nasopharyngeal airway can be a good initial airway in tongue-biting patients who need airway intervention.

Breathing

Ensure the patient is connected to SpO2 monitoring +/- waveform capnography. As mentioned above, ensure that high-flow oxygen is administered via a facemask.

If the patient is maintaining a reasonable oxygen saturation, a full respiratory examination is not required in the first instance, as the primary focus needs to be on treating the underlying seizure.

Circulation

Ensure that the patient is attached to cardiac monitoring with cyclical BP monitoring.

Again, without evidence of profound haemodynamic instability, a full cardiovascular examination is not required in the first instance. Assess whether there is IV access, as this will determine the route of administration for medications if required.

It may not be appropriate to attempt to immediately try to gain IV access in an acutely seizing patient due to patient/staff safety risks. Initial medications can always be given via alternate routes in the first instance. Ultimately, if the seizure continues, IV / IO access will be required, and this may require many experienced hands.

Disability

Assess pupils for symmetry and response to look for evidence of an intracranial cause. It is important to perform a basic GCS examination (ensure that the patient is non-responsive, in keeping with a GTC). No further neurological assessment will likely be possible in an acutely seizing patient.

Always check blood glucose at this stage, as this is a common and easily reversible cause of seizure / neurological impairment.

Exposure

Expose the patient from top to toe to look for any other clues as to the cause of the seizure (e.g. purpuric rash in meningococcal meningitis or clear signs of head trauma). Ensure a temperature has been checked and documented.

Ensure that no items of danger are around the patient (e.g. sharps or solid objects).

Early management

Most seizures will terminate within five minutes, and those that do not are at high risk of being prolonged (status epilepticus). You should always prepare as though your patient will develop status epilepticus from the onset of seizure to enable timely escalation of treatment as needed.

During your A-E assessment, ask the nursing staff to prepare an appropriate benzodiazepine based on the presence/absence of IV access (see below).

Given that seizures are a common ward emergency ensure you are up to date with your local guidelines on acute seizure management. Most guidelines will recommend the administration of a benzodiazepine agent after the seizure has continued for 3 minutes or longer:

• If IV access is available, lorazepam is often the preferred agent (100 micrograms/kg, to a maximum of 4mg).
• If IV access is not available, alternate options include buccal / IM midazolam or PR diazepam.

Further management

By the time the decision has been made to administer first-line therapy, the remainder of the medical emergency team will be present.

Seizure activity that extends beyond five minutes will meet the criteria for status epilepticus, and these patients require management led by an experienced medical registrar/critical care doctor.

The priorities at this point will be airway management, establishing IV access, considering reversible/treatable causes and preparing for escalation of therapy as per the status epilepticus protocol.

Again, ensure you are familiar with your hospital’s status epilepticus guidelines. Most guidelines will call for a repeat dose of benzodiazepine if the patient is still seizing at 10 minutes before escalation to further anti-epileptic therapies (often levetiracetam/valproate loading in the next instance).

If the seizure terminates, there needs to be a clear plan from the senior medical team for ongoing management, including the need for investigations such as neuroimaging or lumbar puncture. Patients with prolonged seizures on the ward should ideally be discussed with the on-call neurology team to optimise ongoing management.

The unresponsive patient

An approach to the patient with confusion / decreased Glasgow Coma Score (GCS) is outlined in our guide to deranged observations (link).

The GCS represents a continuum from normal (GCS 15) to completely unresponsive (GCS 3). Any patient who is newly unresponsive on the ward represents a medical emergency, and the emergency team should be summoned.

Assessment

The differential diagnosis of unresponsiveness is broad. Common ward situations include cerebral hypoperfusion (arrhythmia/hypotension/vasovagal response), hypoglycaemia, opiate toxicity and CO₂ narcosis. Primary neurological insult (CVA / ICH) must always be considered.

As usual, an ABCDE assessment is necessary in the first instance. Quickly check for signs of life, i.e. normal breathing and pulse, to ensure you are not dealing with a cardiac arrest scenario.

Airway

Traditional teaching states that any patient with a GCS <8 can lose airway protective reflexes and be at risk of aspiration. Whether to proceed with definitive airway protection (i.e. intubation) should always lie with a specialist, and many elderly patients may have pre-determined ceilings of care that intubation is not appropriate.

In the first instance, if concerned about a patient’s ability to protect their airway (e.g. snoring, grunting), administer a jaw thrust or head-tilt chin-lift and consider a simple airway adjunct (oropharyngeal/nasopharyngeal) whilst awaiting more help to arrive.

Breathing

Measure the respiratory rate and apply continuous oxygen saturation monitoring. While gathering further information, applying high-flow oxygen via a face mask is generally appropriate. In a patient with a history of COPD and CO₂ retention, it is reasonable to aim for a target saturation of 88-92%, as CO₂ retention would be high on the differential for a decreased level of consciousness.

Circulation

Attach the patient to cardiac monitoring and cyclical BP monitoring. Assess the cardiovascular system to determine volume status and treat any hypotension/arrhythmia as appropriate. Ensure that the patient has adequate IV access.

Disability

Perform an accurate GCS assessment. Remember that the GCS is scored at best, so the patient’s best responses should be recorded.

Assess the pupils for any inequality in size or reaction that could suggest an intracerebral cause. Pinpoint pupils can be suggestive of opiate toxicity.

Perform a neurological examination within the limits of the patient’s GCS, again with any new focal neurology suggesting an intracranial cause. Carefully inspect the face/limbs for any rapid movements that may suggest seizure activity.

Exposure

Expose the patient from top to toe to assess for occult causes (e.g. evidence of rash / nuchal rigidity in meningitis). Check the temperature to assess for any infective causes, and look for any evidence of a fall or recent head trauma that may suggest a traumatic cause.

Investigations

For a patient with new onset loss of consciousness, some essential investigations can be started while awaiting further help. These include:

• Blood glucose: correct any hypoglycaemia immediately with IV glucose / IM glucagon.
• Venous/arterial blood gas: VBG is acceptable in the first instance. If there is evidence of raised CO₂ on the venous blood gas (VBG), start appropriate treatment (likely non-invasive ventilation at the discretion of senior members of the medical team) and consider an arterial blood gas (ABG).
• ECG
• Neuroimaging: unless there is a reversible cause found (e.g. hypoglycaemia). This is an urgent priority in the setting of an unresponsive patient and may require the on-call CT radiographer. Non-contrast CT is usually sufficient (rule out intra-cerebral haemorrhage or structural cause); however, if there is high suspicion of CVA, then stroke protocol may be required at the discretion of senior doctors.

Whilst the above investigations are pending, it is essential to check the drug chart to see if there has been recent administration or increase in opiates or other sedative medication. Check the patient’s medical notes and recent blood test investigations, which will often also give clues as to the possible underlying cause.

In reality, in a truly unconscious patient with airway concerns, multiple experienced pairs of hands are required quickly. If you end up supporting the patient with airway manoeuvres, this will likely be all you can do before more help arrives.

If you are happy that the patient is (for the moment) maintaining their airway, you can continue your A-E assessment whilst awaiting further help to arrive and arrange initial investigations to look for a potential cause for this change in consciousness level.