CCrISP Examination

Before you start

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

A: Airway

• Ask the patient a question. A clear reply confirms a patent airway
• If there is no reply, use the look, listen and feel approach
• Give oxygen at 15 L/min, humidified, through a reservoir bag
• Open the airway with a chin lift or jaw thrust, and suction secretions
• Insert a Guedel airway, or a nasopharyngeal airway, if the airway is not maintained
• Use a jaw thrust with in-line immobilisation, not a head tilt, if cervical spine injury is possible
• Avoid a nasopharyngeal airway if a base of skull fracture is possible
• Call an anaesthetist early if you cannot maintain the airway

👩‍⚕️ Do not withhold 15 L/min oxygen from a patient with chronic obstructive pulmonary disease while you resuscitate them. Hypoxia kills long before hypercapnia does.

B: Breathing

• Count the respiratory rate
• Check the oxygen saturation and aim to keep it above 94%
• Look at the exposed chest for cyanosis, accessory muscle use, symmetry and depth of breathing, sweating, a raised jugular venous pressure, chest drain patency and paradoxical abdominal movement
• Feel for equal chest expansion, tracheal position and any surgical emphysema
• Percuss the chest
• Auscultate the breath sounds, and check the patient can talk in full sentences
• Find and treat at once anything that threatens life, such as a tension pneumothorax
• Request a chest X-ray, and consider capnography to confirm ventilation

👩‍⚕️ 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
• Insert two large-bore 16G cannulae, and send blood for cross-match, routine tests and a 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
• Check the temperature. If sepsis is likely, start the sepsis six: give oxygen, intravenous fluids and intravenous antibiotics, and take blood cultures, lactate and hourly urine output
• Insert a urinary catheter and urometer for hourly fluid balance
• Find and control any external bleeding, and check the drains for fresh blood
• 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
• Review the drug chart for opiates and sedatives as a cause of drowsiness

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
• Inspect the wound, any stoma and both calves

Complete the immediate management

• Confirm the patient is on oxygen and intravenous fluids, and attach continuous monitoring
• Reassess from A after every intervention
• Escalate early if the patient is not improving, to the anaesthetist, the surgical registrar on call or the intensive care team
• Document your findings and hand over clearly

Practise this out loud until the sequence is automatic. The CCrISP course gives you supervised practice and the demonstration videos on the e-Learning portal. I have also made a printable PDF of this sequence to work from.

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

• Review the observation charts, including the NEWS2 trend, and the fluid balance charts
• Read the case notes and the operation note, for what was done and what was expected afterwards
• 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, drains and 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 thromboprophylaxis and antibiotics
• Form a problem list, decide on the definitive plan, and agree it with a senior

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

Generalised peritonitis from an anastomotic leak, with sepsis.

Day 6 is the classic timing, and the combination of abdominal pain, shoulder-tip pain and breathlessness fits a leak until proven otherwise.

• Anastomotic leak, the most likely diagnosis at this point
• Intra-abdominal or subphrenic collection
• Postoperative ileus, or mechanical obstruction from adhesions
• Intra-abdominal bleeding or a haematoma
• Wound infection or wound dehiscence
• Mesenteric or anastomotic ischaemia
• Clostridioides difficile colitis after perioperative antibiotics
• Acute pancreatitis
• Perforated peptic ulcer, particularly on steroids or non-steroidal drugs
• Referred pain from a lower lobe pneumonia or a myocardial infarction
• Volvulus, uncommon this early after surgery

• Basal atelectasis, the commonest cause of postoperative breathlessness
• Hospital-acquired pneumonia, or aspiration
• Pulmonary embolism
• Tachypnoea compensating for the metabolic acidosis of intra-abdominal sepsis
• Splinting of the diaphragm by pain and abdominal distension
• Pulmonary oedema from fluid overload or cardiac failure
• Myocardial infarction
• Acute respiratory distress syndrome, ARDS, driven by the abdominal sepsis
• Anaemia from postoperative bleeding
• Pneumothorax, particularly after central line insertion

A collection of pus or bowel content under the diaphragm is irritating the diaphragmatic peritoneum.

Sensation from the central diaphragm travels in the phrenic nerve, which arises from C3, C4 and C5. The same roots supply the skin over the shoulder tip through the supraclavicular nerves. The brain cannot separate the two, so diaphragmatic irritation is felt at the shoulder. This is referred pain, and Kehr's sign after splenic rupture is the same mechanism.

Bedside

• Observations with a NEWS2 score, and continuous monitoring
• Arterial blood gas, for hypoxia, metabolic acidosis and the lactate
• ECG, to exclude ischaemia or an arrhythmia as the cause of the pain and breathlessness
• Hourly urine output through a catheter
• Swab the wound, and send any drain fluid that looks enteric

Bloods

• Full blood count, urea and electrolytes, liver function and C-reactive protein
• Clotting, and group and save with cross-match since theatre is likely
• Blood cultures before antibiotics, provided they do not delay them
• Amylase, to exclude pancreatitis

Imaging

• Erect chest X-ray, for free gas under the diaphragm and to exclude a respiratory cause
• CT of the abdomen and pelvis with contrast, which is the test that confirms an anastomotic leak
• CT pulmonary angiogram, CTPA, if pulmonary embolism is still likely after the initial assessment
• Ultrasound of the abdomen, useful for a collection but poor at excluding a leak

Specialist

• Water-soluble contrast enema, in selected cases where the CT is equivocal
• Interventional radiology, to drain a localised collection
• Diagnostic laparoscopy or laparotomy, which is both the investigation and the treatment once the abdomen is peritonitic

A patient with peritonitis and sepsis goes to theatre. Do not let a scan delay the operation.

My priorities are resuscitation and source control, and I would run them in parallel while calling for senior help.

Resuscitate

• Assess along ABCDE lines with 15 L/min oxygen and two large-bore cannulae
• Warmed crystalloid guided by response, with a urinary catheter for hourly urine output
• Start the sepsis six, taking blood cultures and lactate before the first dose of antibiotics
• Continuous monitoring, and early referral to critical care for a central line and organ support

Conservative

• Nil by mouth with bowel rest, and a nasogastric tube to decompress the stomach
• Adequate analgesia, and correction of electrolytes and any coagulopathy
• Consent the patient for a laparotomy and possible stoma, and ask the stoma nurse to site it if there is time
• Hold thromboprophylaxis before theatre and restart it afterwards

Medical

• Broad-spectrum intravenous antibiotics to local policy, covering Gram-negative and anaerobic organisms
• Vasopressor support in critical care if the blood pressure does not respond to fluid

Surgical

Source control is the treatment. A small contained leak in a stable patient can be managed with antibiotics and radiological drainage. This patient has generalised peritonitis, so I would take them to theatre.

I would take down the failed anastomosis, resect it, bring out an end colostomy and close off the distal end. I would not trust a fresh anastomosis in a contaminated septic field. I would 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

• Observations with a NEWS2 score, including respiratory rate and oxygen saturation
• ECG, mainly to exclude myocardial infarction
• Arterial blood gas, which typically shows hypoxia with a low carbon dioxide, a respiratory alkalosis

Bloods

• Full blood count, urea and electrolytes, with renal function checked before contrast
• Clotting, and group and save, before anticoagulation is started
• Troponin, which rises with right ventricular strain as well as in myocardial infarction
• C-reactive protein if infection is in the differential
• D-dimer has no role here, since it is raised after any operation

Imaging

• Chest X-ray, often normal, and used to exclude pneumonia, pneumothorax and pulmonary oedema
• CT pulmonary angiogram, CTPA, the definitive test, once renal function allows

Specialist

• Bedside echocardiography if the patient is too unstable for CT, looking for right ventricular strain
• Doppler ultrasound of the legs if a deep vein thrombosis is suspected
• Ventilation perfusion scan if contrast is contraindicated

Score the patient with the two-level Wells score first. A score above 4 makes pulmonary embolism likely and justifies empirical anticoagulation while you wait for the scan.

A normal ECG does not exclude a pulmonary embolism, and the ECG is mainly there to exclude myocardial infarction. The classic pattern is uncommon in practice.

• Sinus tachycardia, the commonest finding
• S1Q3T3, a deep S wave in lead I, a Q wave in lead III and an inverted T wave in lead III
• T-wave inversion in the right precordial leads V1 to V4, from right ventricular strain
• T-wave inversion in the inferior leads II, III and aVF
• Right bundle branch block, complete or incomplete
• Right axis deviation
• P pulmonale, a peaked P wave from right atrial enlargement
• New atrial fibrillation

👩‍⚕️ Say sinus tachycardia first. Candidates who open with S1Q3T3 sound as though they have read about pulmonary embolism rather than seen one.

Prevention starts with a documented risk assessment, not with a drug.

• Venous thromboembolism, VTE, risk assessment on admission and again within 24 hours, weighing thrombosis risk against bleeding risk
• Mechanical prophylaxis with anti-embolism stockings or intermittent pneumatic compression
• Pharmacological prophylaxis with low molecular weight heparin, LMWH, once the bleeding risk allows
• Extended prophylaxis for 28 days after major abdominal or pelvic surgery for cancer
• Early mobilisation and adequate hydration
• Regional anaesthesia where it is suitable, and avoiding a long operation with the legs dependent

• Known or suspected peripheral arterial disease, or previous peripheral arterial bypass grafting
• Known or suspected deep vein thrombosis, DVT
• Uncontrolled cardiac failure with pulmonary oedema
• Severe leg oedema
• Peripheral neuropathy or any sensory impairment of the leg
• Local skin problems such as gangrene, recent skin grafts, severe dermatitis or fragile skin
• Major limb deformity, or a leg shape that prevents a correct fit
• Known allergy to the material

Check the ankle brachial pressure index before applying stockings if arterial disease is possible, and never fit a stocking you have not measured for.

Resuscitate

• Sit the patient up, give high-flow oxygen and attach cardiac monitoring
• Gain intravenous access, take bloods including clotting, and support the circulation
• Give fluid cautiously, since an overloaded right ventricle fails further, and use a vasopressor with critical care input if hypotension persists
• If suspicion is high, a two-level Wells score above 4 with no contraindication, I would anticoagulate empirically while waiting for the CT pulmonary angiogram

If the patient is haemodynamically stable

• Apixaban or rivaroxaban first line as a direct oral anticoagulant, since neither needs a heparin lead-in
• Low molecular weight heparin for at least 5 days first if edoxaban or dabigatran is chosen
• Warfarin still needs bridging heparin until the international normalised ratio is in range
• On day 6 after surgery I would often use therapeutic low molecular weight heparin first, then convert to the oral agent
• Continue anticoagulation for at least 3 months, since this is a provoked pulmonary embolism after surgery

If there is haemodynamic compromise, a massive pulmonary embolism

• Thrombolysis with alteplase, a recombinant tissue plasminogen activator
• Recent surgery is a relative contraindication, not an absolute one
• On day 6 I would weigh the bleeding risk with a senior rather than rule thrombolysis out
• Catheter-directed thrombolysis or catheter embolectomy where systemic thrombolysis is too risky
• Surgical pulmonary embolectomy on cardiopulmonary bypass for a large central clot, or for clot caught in transit through the right heart
• Embolectomy is also the option when catheter treatment fails or is unavailable
• An inferior vena cava filter if anticoagulation is contraindicated, for example active bleeding or a laparotomy in the next few hours

In cardiac arrest I would continue cardiopulmonary resuscitation for 60 to 90 minutes after thrombolysis, to give the drug time to work.

Enoxaparin is a low molecular weight heparin, given subcutaneously.

• Prophylactic dose: 40 mg once daily
• Therapeutic dose: 1 mg/kg twice daily, or 1.5 mg/kg once daily

Enoxaparin is cleared renally, so the dose falls in renal impairment. Below a creatinine clearance of 30 mL/min, prophylaxis becomes 20 mg once daily and treatment becomes 1 mg/kg once daily. Routine monitoring is not needed. Anti-Xa levels are reserved for renal impairment, pregnancy and extremes of body weight. Doses vary between trusts, so quote the local policy.

• Prophylactic dose: 5000 units subcutaneously every 8 to 12 hours
• Therapeutic dose: a loading bolus of 80 units/kg, then an infusion of 18 units/kg/hour

Titrate the infusion to an activated partial thromboplastin time ratio of 1.5 to 2.5. Check the ratio 6 hours after starting and 6 hours after every rate change.

Unfractionated heparin is preferred when renal function is poor, or when the patient may need theatre soon. Its half-life is short and protamine sulfate reverses it. Check the platelet count during treatment, since heparin-induced thrombocytopenia is a recognised complication.