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A decrease in systolic BP ≥20 mmHg or a decrease in the level of systolic AM_C01 12/15/10 10:16 Page 33 ACUTE MEDICINE: PACES STATIONS AND ACUTE SCENARIOS BP to <90 mmHg is defined as orthostatic hypotension regardless of whether or not symptoms occur. • Does the patient have a pacemaker? • Heart murmur: in particular of aortic stenosis. • Peripheral pulses: including auscultation of carotid arteries. antiepileptics, but these should not be given as a therapeutic trial when the clinical picture is not compelling.
Can she speak in full sentences, only in words or is she unable to speak? If only in words or unable to speak, get help quickly. • Is she cyanosed? If she is, she is nearly dead. Respiratory rate must be interpreted in the context of the whole patient: a normal respiratory rate is consistent with imminent death in the asthmatic who is becoming exhausted. Widespread wheezing indicates airways obstruction, but beware the asthmatic who has a silent chest on auscultation: the tidal volume may be reduced so much that insufficient flow is being generated to create a wheeze.
It is important to remember that early review by the ICU is important. If the patient is admitted in extremis or does not improve with treatment, get help. The move to the ICU should be a cool elective decision, not a panic when the patient is close to respiratory arrest. Important pointers to a deterioration may include: • previous admission to an ICU/HDU; • exhaustion, feeble respirations, confusion or drowsiness; • deteriorating PEFR; • worsening or persisting hypoxia or hypercapnia. rate, heart rate and BP; obtain intravenous access; and give fluid bolus if hypotensive.
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