CCrISP Examination

Before you start

• Introduce yourself, wash your hands and gain consent
• Ask for the observation chart and the notes, and call for senior help early if the patient is unwell

A: Airway

• Ask the patient a question. A clear reply confirms the airway is patent
• Otherwise, use the look, listen feel approach
• Give oxygen at 15 L/min, humidified, through a reservoir bag
• If concerns regarding airway: Open the airway with a chin lift or jaw thrust. Suction secretions. Insert a Guedel, or a nasopharyngeal airway
• Call an anaesthetist early if you cannot maintain the airway

👩‍⚕️ In a resuscitation, do not withhold 15 L/min oxygen from a patient with COPD while you assess them. If a cervical spine injury is possible, immobilise the neck in line and use a jaw thrust, not a head tilt. Do not insert a NPA if a basal skull fracture is possible. Consider capnography to confirm ventilation.

B: Breathing

• Count the respiratory rate
• Check the oxygen saturation
• Look at the exposed chest for cyanosis, accessory muscle use, symmetry and depth of breathing, sweating, a raised JVP, chest drain patency and any paradoxical abdominal movement
• Feel for equal chest expansion, the tracheal position and any surgical emphysema or crepitus
• Percuss the chest
• Auscultate the breath sounds, and check the patient can talk in full sentences
• Find and treat at once any condition that threatens life
• Request a chest X-ray

👩‍⚕️ Pulse oximetry does not detect hypercarbia, so a normal saturation does not mean ventilation is adequate.

C: Circulation

• Assess the capillary refill time, and the peripheral and central pulses for rate, quality and regularity
• Check the blood pressure
• Check the temperature ?sepsis. If suspect sepsis then initiate sepsis six: Send blood cultures, measure urine output, check lactate, start antibiotics, administer oxygen and intravenous fluids
• Insert two large 16G cannula and send blood for cross-matching and routine blood test, blood gas
• Give a warmed crystalloid fluid challenge, then reassess: 10 mL/kg if normotensive, 20 mL/kg if hypotensive, or 5 mL/kg if there is cardiac dysfunction or heart failure
• Insert a urinary catheter and urometer for hourly fluid balance
• Raise both legs from flat to test fluid responsiveness, looking for a rise in blood pressure
• Request an ECG

D: Disability

• Assess consciousness with AVPU: Alert, responds to Voice, responds to Pain, Unresponsive
• Examine the pupils for size and reaction
• Check the blood glucose

E: Exposure

• Expose the patient fully to complete the assessment, while preserving dignity and keeping them warm
• Look for drains, catheters, infusions and any bleeding

Complete the immediate management

• Confirm the patient is on oxygen and IV fluids, and attach continuous monitoring
• Reassess from A after every intervention
• Escalate early if not improving, for example to the anaesthetist, the surgical registrar on call or the intensive care team on call

I would gather all the information and move towards a diagnosis and a plan:

• Review the observation charts and fluid charts
• Take an AMPLE history: Allergies, Medications, Past medical history, Last meal, Events leading up to the deterioration
• Examine the patient fully, starting at the hands and including the neck, chest, abdomen and limbs, plus any wounds or stomas
• Review all available results, including blood gases, glucose, blood count, clotting, cross-match, cultures, imaging and the ECG
• Check the drug chart for new, missed or no longer needed drugs, including prophylaxis and antibiotics

👩‍⚕️ Early atelectasis is far more likely to be found clinically than on a film, so do not skip the chest examination.

Generalised peritonitis secondary to anastomotic leakage, leading to sepsis.

• Anastomotic leak
• Subphrenic collection
• Mesenteric ischaemia
• Intestinal obstruction
• Volvulus

• Pulmonary embolism
• Myocardial infarction
• Atelectasis
• Chest infection
• ARDS

An intra-abdominal collection is irritating the diaphragm.

Bedside

• Blood tests: Arterial blood gas, blood culture, and inflammatory markers such as CRP and ESR

Imaging

• Chest X-ray, to exclude a respiratory cause
• Abdominal X-ray, erect and supine
• Abdominal ultrasound ?Abdominal collection
• CT pulmonary angiogram (CTPA) ?Pulmonary embolism
• CT abdomen and pelvis with contrast ?Anastomotic leak

• Monitoring
• Nil by mouth, bowel rest
• Urinary catheter insertion to monitor urine output,
• Nasogastric tube insertion
• Refer to HDU for a central line and monitoring if needed
• Fluid resuscitation with crystalloids
• Intravenous antibiotics
• Surgery: The scenario is a leaking anastomosis on day 6 after a left hemicolectomy, with peritonitis and sepsis. This needs source control back in theatre. You would not trust a fresh re-anastomosis in a contaminated, septic field, so you take down the failed anastomosis, resect, bring out an end colostomy and close off the distal end. You then wash out the peritoneal cavity and leave drains. That operation is a Hartmann's-type procedure.

• Pulmonary embolism
• Myocardial infarction
• Pneumonia or chest infection
• Atelectasis
• Pneumothorax
• Acute pulmonary oedema
• Arrhythmia, such as atrial fibrillation
• Fat embolism, after hip or long bone surgery
• Sepsis from a surgical source

Bedside:

• Arterial blood gas: Respiratory alkalosis
• ECG

Imaging:

• Chest X-ray
• CTPA to exclude a pulmonary embolism, after renal function tests

• Sinus tachycardia, the most common
• S1Q3T3 pattern: A deep S wave in lead I, a Q wave in III, and an inverted T wave in III
• Right ventricular strain: T-wave inversion in the right precordial leads such as V4, and in the inferior leads II, III and aVF
• Right axis deviation

• Documented VTE assessment on admission
• Mechanical prophylaxis with stockings or intermittent pneumatic compression
• Pharmacological prophylaxis with LMWH
• Early mobilisation
• Good hydration

• Severe peripheral arterial disease
• Known or suspected DVT
• Uncontrolled congestive heart failure
• Severe leg oedema
• Compromised local skin conditions such as gangrene, recent skin grafts, severe dermatitis

Resuscitate

• Give oxygen, gain IV access, support the circulation, cardiac monitoring

If clinical suspicious for PE is high (e.g. Well's score > 4) and there is no contraindication, you would give therapeutic anticoagulant empirically whilst awaiting for the CTPA.

If haemodynamically stable:

• Start therapeutic low molecular weight heparin
• Then continue with a direct oral anticoagulant or warfarin

If there is haemodynamic compromise, massive PE:

• Thrombolysis, using alteplase, a recombinant form of human tissue plasminogen activator

... or, if thrombolysis is contraindicated as it would be in this case as the patient is only 6 days post-op,

• Catheter embolectomy
• Surgical pulmonary embolectomy on cardiopulmonary bypass if catheter embolectomy isn't available or hasn't worked, or for a large central clot or clot caught in transit through the right heart

In the case of a cardiac arrest, you continue prolonged CPR allowing for time to treat the pulmonary embolism.

Prophylactic: 40 mg OD SC

Therapeutic: 1 mg/kg BD SC

Prophylactic: 5000 IU SC every 8 to 12 hours

Therapeutic: Load dose of 80 U/kg, then maintenance at 18 U/kg/hour, titrated to an APTT ratio of x1.5 to x2.5, monitored six-hourly