Managing crashing patients on the ward can be totally different than in the ED, ICU, or OR 🔥🏥🔥
Here are some of my top tips for deteriorating patients on the ward 👇
#medtwitter #foamed #icu #foamcc
Here are some of my top tips for deteriorating patients on the ward 👇
#medtwitter #foamed #icu #foamcc
Tip # 1: Decide early on stay and play vs. scoop and run.
Borrowed from my days as a paramedic, some cases are more amenable to staying and managing the patient on the ward for a bit vs. others benefit from rapid transport to the ICU/OR.
Try to identify this within the first several minutes of a call for a deteriorating patient.
Stay and Play
- Cardiac Arrest
- Arrythmia (at least until initial management)
Scoop and Run
- Stroke (after airway secured) --> CTA
- Bleeding patient --> get initial access + blood called for but then transport to definitive control (OR, ICU -->IR)
- Massive GIB --> ABCs then ICU for intervention or more imaging or OR
Lots of exceptions for each. Start with ABCs and go from there.
Borrowed from my days as a paramedic, some cases are more amenable to staying and managing the patient on the ward for a bit vs. others benefit from rapid transport to the ICU/OR.
Try to identify this within the first several minutes of a call for a deteriorating patient.
Stay and Play
- Cardiac Arrest
- Arrythmia (at least until initial management)
Scoop and Run
- Stroke (after airway secured) --> CTA
- Bleeding patient --> get initial access + blood called for but then transport to definitive control (OR, ICU -->IR)
- Massive GIB --> ABCs then ICU for intervention or more imaging or OR
Lots of exceptions for each. Start with ABCs and go from there.
Tip #2: Diagnosis sometimes is less important than stabilization
Ideally, diagnosis and management occur simultaneously. In a more resource constrained setting like a deteriorating patient on the ward you might not be able to achieve both.
There are many rapid response calls I bring down with only a differential and no clear provisional diagnosis.
"Shock NYD that seems to be fluid / vasopressor responsive. Gave some abx. Needs some lines and a POCUS."
"Respiratory failure NYD now on BIPAP. Seems to be related to a pulmonary process but not sure which yet."
For these unstable patients, diagnosis and management must happen concurrently!
Ideally, diagnosis and management occur simultaneously. In a more resource constrained setting like a deteriorating patient on the ward you might not be able to achieve both.
There are many rapid response calls I bring down with only a differential and no clear provisional diagnosis.
"Shock NYD that seems to be fluid / vasopressor responsive. Gave some abx. Needs some lines and a POCUS."
"Respiratory failure NYD now on BIPAP. Seems to be related to a pulmonary process but not sure which yet."
For these unstable patients, diagnosis and management must happen concurrently!
Tip #3: Modify your physical space to maximize success
Many ward rooms have limited space but make the most of what you have.
You can:
1. Remove bedside tables, chairs etc.
2. Try turning the bed diagonally in the room. This gives space at the head of the bed for intubation, and good access to both sides (at the expense of room at the feet but who needs that!)
3. Take the monitor/defib off of the crash cart and onto a bedside table or the patient bed if the crash cart near the bedside is getting too crowded.
4. Politely ask team members not as actively involved to take a step back.
Many ward rooms have limited space but make the most of what you have.
You can:
1. Remove bedside tables, chairs etc.
2. Try turning the bed diagonally in the room. This gives space at the head of the bed for intubation, and good access to both sides (at the expense of room at the feet but who needs that!)
3. Take the monitor/defib off of the crash cart and onto a bedside table or the patient bed if the crash cart near the bedside is getting too crowded.
4. Politely ask team members not as actively involved to take a step back.
Tip #4: Push dose pressors are often more easily accessible than infusions
I often use push dose pressors (phenyl/epi) for deteriorating patients as norepi infusions may be less readily available. These work really well just remember if you are transporting the patient down from the ward to an ICU (for 5-10 min) the drugs might wear off!
Often, I will give a little bonus bolus of vasopressors prior to starting to wheel the patient down the hallway, or in the elevator depending on the transport time / vitals.
I often use push dose pressors (phenyl/epi) for deteriorating patients as norepi infusions may be less readily available. These work really well just remember if you are transporting the patient down from the ward to an ICU (for 5-10 min) the drugs might wear off!
Often, I will give a little bonus bolus of vasopressors prior to starting to wheel the patient down the hallway, or in the elevator depending on the transport time / vitals.
Tip #5: Pause and re-engage goals of care when appropriate.
Even if a patient is listed as full code, when someone is deteriorating, if appropriate and possible, re-engage GOC with the patient or family. They may have had additional conversations or reflections since their last documented conversation.
Also, when someone is deteriorating goals of care change from being a hypothetical (if something were to happen) to the immediate (something is happening NOW!).
Many times, the patient or family more accurately updates values & wishes and aggressive resuscitation or intervention are no longer appropriate or wanted.
Even if a patient is listed as full code, when someone is deteriorating, if appropriate and possible, re-engage GOC with the patient or family. They may have had additional conversations or reflections since their last documented conversation.
Also, when someone is deteriorating goals of care change from being a hypothetical (if something were to happen) to the immediate (something is happening NOW!).
Many times, the patient or family more accurately updates values & wishes and aggressive resuscitation or intervention are no longer appropriate or wanted.
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