Where you Are:
You are an FY2 in the Orthopaedic department.Who the patient is:
Mr. Gary Penman is a 75 year old male, who had a fall 1 week ago from height. He was diagnosed with low back trauma. Fracture was excluded. He was prescribed two doses of oral Morphine. He has a past medical history of CKD 4.What you must do:
The nurses asked you to assess him because he is feeling sleepy.
Monitor:
O2 = Normal or Low, BP = 120/89, H.R. = 94, RR 6.
History:
- Patient can answer questions with full sentences:
- Ask about Morphine use: dose? When did he last take it?
- Ask about regular medications, medical conditions and allergies.
Patient can’t talk in full sentence:
- Postpone history and start your assessment.
Assessment:
A - Airway:
- Check for any obstruction.
- SO2 Low: give oxygen via non-rebreather mask 100% oxygen 15L/min.
B - Breathing:
- Examine the chest in order: Inspection, palpation, percussion, auscultation.
- RR will be low.
- Verbalise that you suspect morphine toxicity and check the pupils which will be pinpoint.
- Give Naloxone 0.4mg IV
- Order Chest X-ray and ABG.
C - Circulation:
- Check: Capillary Refill + Pulse + BP + Insert 1 cannula.
- Request routine bloods.
- Request ECG.
- Re-assess the patient: if still unconscious then give 0.8mg of Naloxone IV.
D - Disability
- Check blood sugar and temperature.
- Re-assess the patient: if still unconscious then give another 0.8mg of Naloxone IV.
E - Exposure
- Examine the abdomen, legs and private area.
- Re-assess the patient: if still unconscious then give 2mg of Naloxone IV.
- Re-assess the patient after 1 minute: if still unconscious then give 4mg of Naloxone IV.
- Start your discussion with the patient.
Management:
- Review the Morphine dose.
2 mins SBAR handover:
Situation:
I am Dr (—). I managed a 75-year-old male patient, Garry Penman, who was found by the nurses to be drowsy.
Background:
Garry had a fall from height and got low back trauma 1 week ago. He has been taking two types of oral morphine two doses a day. He has a CKD stage 4. He has no known allergies.
Assessment:
On initial assessment, his vitals were unstable with SPO2 of 88% on room air. I\ gave him 100%O2 at 15L via a non-rebreather mask. When I checked his respiration, the respiratory rate was very low, which is 7. So, I suspected morphine overdose and checked his pupils which were pinpoint and had no response to light. I immediately gave him IV Naloxone 0.4 mg. I have ordered
baseline investigations plus chest x-ray, ECG and ABG.
Recommendation:
After the initial treatment, his vitals improved. Now, his vitals are (------). My recommendation is to continue monitoring his vital signs and response to the treatment closely. If it is needed we may need to give another dose of IV Naloxone 0.4 mg.