This page does not aim to be comprehensive. 
It seeks to guide you to think about predictable clinical problems that commonly arise from each of the following conditions.
A search on the internet or delve into text books, research papers and websites specifically addressing a condition, will no doubt list many other possibly crises. However, common things happen commonly.
Let's focus on preparing patients and families for the common stuff before we start looking for unicorn eggs.
Patients may well be aware of possible exacerbations for their conditions. Starting by asking how they were previously managed, how they would like managing in the future and then prepare for that.
If you are looking at this page while managing a patient in hospital, then in many cases they will be there because of an exacerbation, event or crisis, whatever it was it might be a good place to start as there is a high likelihood that it could happen again.
And, the final thing to remember is that we are not thinking about how to manage a problem in hospital (Consultants and Registrars can worry about that), but in the patients home in the wee small hours.

---

---

Organ Failure

• Heart

• Lung

• Liver

• Kidney

• Brain

• 6

• 7

• 8

• 9

• 10

• 11

• 12

• 13

• 14

• 15

• 16

• 17

• 18

• 19

• 20

• 21

• 22

• 23

• 24

• 25

• 26

• 27

• 28

• 29

• 30

• • Encephalopathy

  • Haematemesis

  • Ascites

  • Pruritis / Itch

  • Nutrition & Fluid

  • Infection

  • Produced by . .

  • 8

  • 9

  • 10

  • 11

  • 12

  • 13

  • 14

  • 15

  • 16

  • 17

  • 18

  • 19

  • 20

  • 21

  • 22

  • 23

  • 24

  • 25

  • 26

  • 27

  • 28

  • 29

  • 30

  • Treatment Escalation Level	Encephalopathy (confusion, agitation, drowsiness) ​Management Plan and Wishes :
    ITU	Encourage oral hydration and nutrition Treat constipation with lactulose +/-other laxatives +/-enemas/faecal management system When not constipated consider; Rifaximin Sodium Benzoate Treat any infection with antibiotics Use non-drug measures to manage confusion and agitation Consider low dose haloperidol ​If symptoms severe, intubate
    Hospital	Encourage oral hydration and nutrition Enteral feeding tube if MUST score poor Treat constipation with lactulose/ other laxatives/enemas If encephalopathy despite daily bowel opening, consider; Rifaximin Sodium Benzoate Treat any infection with antibiotics Use non-drug measures to manage confusion and agitation Consider low dose haloperidol
    Home	​Encourage oral hydration and nutrition Treat constipation with lactulose If encephalopathy despite daily bowel opening, consider; Rifaximin Sodium Benzoate Treat any infection with oral antibiotics Use non-drug measures to manage confusion and agitation Consider low dose haloperidol or midazolam if symptoms severe and not improving
    Comfort	​Encourage oral hydration Stop laxatives Rifaximin/Sodium Benzoate if managed Use non-drug measures to manage confusion and agitation Consider low dose haloperidol or midazolam if symptomatic
  • Treatment Escalation Level	Haematemesis (vomiting blood)​ Management Plan and Wishes :
    ITU	Intubation, correct coagulopathy, Terlipressin, antibiotics OGD when resuscitated. Consider IR to achieve haemostasis Sengstaken Tube  and Emergency TIPSS
    Hospital	Intubation, correct coagulopathy, Terlipressin, antibiotics OGD when resuscitated. Consider IR to achieve haemostasis Sengstaken Tube  and Emergency TIPSS
    Home	Re-consider admission for OGD and therapy if able to D/W patient. Have dark towels and bedlinen to hand Consider opioid and midazolam SC injection if distressed. ​ Offer support for family
    Comfort	Consider admission if carers cannot manage the bleeding situation Have dark towels and bedlinen to hand Consider opioid and midazolam SC injection if distressed Carer “ABC” algorithm: A –Assurance B –Be There C –Comfort and Calm
  • Treatment Escalation Level	Ascites (fluid in abdomen)​ Management Plan and Wishes :
    ITU	Give oxygen ​Non-drug measures e.g. positioning & pacing. ​ Paracentesis under Human Albumin Solution cover. Diuretics. Consider TIPSS for refractory ascites
    Hospital	Give oxygen Non-drug measures e.g. positioning & pacing. Paracentesis under HAS cover. Limit dietary sodium, consider diuretics. Low dose oral opioid for pain and breathlessness, haloperidol for nausea. Consider TIPSS for refractory ascites
    Home	Discuss with specialist palliative care team –low volume drainage at home may be appropriate Limit dietary sodium, consider diuretics Non-drug measures e.g. positioning and pacing Low dose oral opioid for pain and breathlessness, haloperidol for nausea.
    Comfort	​Discuss with specialist palliative care team –consider Rocket drain Non-drug measures e.gpositioning and pacing Low dose oral opioid for pain and breathlessness, haloperidol for nausea oxygen is a symbol of medical care for both patients and their families and may be associated with a placebo effect for both
  • Treatment Escalation Level	Pruritis / Itch ​Management Plan and Wishes :
    ITU	Manage associated itch with fan, aqueous cream with 1% menthol, distraction and avoidance of scratching, consider, Cholestyramine/ Colesevelam, rifampicin, naltrexone, sertraline Pruritis
    Hospital	Manage associated itch with fan, aqueous cream with 1% menthol, distraction and avoidance of scratching. Consider, Cholestyramine/Colesevelam, rifampicin, naltrexone, sertraline
    Home	Manage associated itch with fan, aqueous cream with 1% menthol, distraction and avoidance of scratching. ​Consider, Cholestyramine / Colesevelam, rifampicin, naltrexone, sertraline
    Comfort	Manage associated itch with fan, aqueous cream with 1% menthol, distraction and avoidance of scratching. ​Consider, midazolam &/or levomepromazine
  • Treatment Escalation Level	Nutrition & Fluid Management Plan and Wishes :
    ITU	Encourage oral nutrition and hydration. ONS and consider NG feeding. IV fluids for hydration. Consider PN where NGT is not possible. Give fluids if dehydrated 20% salt poor Human Albumin Solution (HAS) if ascites and poor renal output Trial of HAS & Terlipressin for HRS AKI Haemofiltration if hepatorenal syndrome (HRS AKI)
    Hospital	Encourage oral nutrition and hydration. ONS and consider NG feeding. Consider PN where NGT is not possible Consider IV fluids/ 20% salt poor Human albumin solution (HAS) IV for poor urine output Trial of HAS & Terlipressin for HRS AKI Haemofiltration if hepatorenal syndrome (HRS AKI)
    Home	Encourage oral nutrition and hydration. Oral Nutrition. Supplements.
    Comfort	Offer oral comfort hydration. Food/flavour, if requested and able. Administer mouth care including oral cleaning, ice chips, artificial saliva to alleviate symptoms of dry mouth. Rarely thirsty. Moisten the lips/lip moisturizers
  • Treatment Escalation Level	Management Plan and Wishes :
    ITU	Treat infection with oral/IV antibiotics. Consider fungal therapy, prolonged courses may be required as immunocompromised
    Hospital	Treat infection with oral/IV antibiotics. Consider fungal therapy, prolonged courses may be required as immunocompromised Glucocorticoids to treat fever, paracetamol
    Home	Oral antibiotics. Paracetamol for fevers. Prophylaxis
    Comfort	Fans, paracetamol and/or Glucocorticoids to treat fever. Haloperidol to treat any delirium agitation

    During each hospital admission,  explore patient and family thoughts, understanding and wishes. Then, based upon mortality scores to determine life expectancy and frailty scores, a clinical decision should be made whether to intervene or accept the complication as a terminal event the next time it occurs. With agreement, add this decision to the TEP section of the patients discharge letter.
    Any patient "Expectations of their care and What Matters to them" information that may come to light, particularly if changed from previously should also be shared in the discharge letter.
  • Dr Shehzad Amir, Locum Consultant Hepatologist
    Dr Aqeel Jamil PhD, MRCP,MBBS(Lon),BSc (Hons), Consultant in Hepatology & Nutrition
    
    Portsmouth Hospitals University NHS Foundation Trust
    2023
    

Cancers

• Brain

• Head & Neck

• Lung

• Oesophagus

• Stomach

• 6

• 7

• 8

• 9

• 10

• 11

• 12

• 13

• 14

• 15

• 16

• 17

• 18

• 19

• 20

• 21

• 22

• 23

• 24

• 25

• 26

• 27

• 28

• 29

• 30

• Hepatic

• Pancreatic

• Bowel

• Renal

• Ovarian

• 6

• 7

• 8

• 9

• 10

• 11

• 12

• 13

• 14

• 15

• 16

• 17

• 18

• 19

• 20

• 21

• 22

• 23

• 24

• 25

• 26

• 27

• 28

• 29

• 30

• Uterine

• Bladder

• Prostate

• Rectal

• Sarcoma

• 6

• 7

• 8

• 9

• 10

• 11

• 12

• 13

• 14

• 15

• 16

• 17

• 18

• 19

• 20

• 21

• 22

• 23

• 24

• 25

• 26

• 27

• 28

• 29

• 30

Metastases

MND, Parkinsons Disease Associated conditions, ​