17- Trouma & ER Refrence Flashcards
What does the CCrISP three-stage assessment process help with?
Defining the acuity of patients, identifying underlying problems, determining necessary interventions, and establishing the frequency of patient reviews
What does CCrISP help with in managing surgical patients?
Performing organized simultaneous resuscitation, diagnosis, and definitive treatment
What are “track and trigger” systems used for in hospitals?
To aid in the recognition of deteriorating patients, such as the National Early Warning Score (NEWS)
What is the role of the CCrISP course and three-stage assessment process?
To properly assess acutely unwell patients, plan their subsequent care, and ensure simultaneous resuscitation and diagnosis
What should be done for patients who are relatively stable but at risk of deterioration?
They should be re-evaluated and have their management plan updated at least twice daily
When should the three-stage assessment process be applied to patients?
During scheduled ward rounds and in the event of deterioration
What is the CCrISP system of assessment used for?
To determine whether patients are stable or unstable and guide attention to detail in treatment
What is the predictable pattern of life-threatening illnesses?
Obstruction of the airway kills more quickly than lung problems, which kill more quickly than isolated hemorrhage
What does the immediate management process prioritize?
Assessment and treatment of the airway, breathing, circulation, dysfunction of the CNS, and exposure of the patient for full assessment
What are the steps of the ‘Look, Listen and Feel’ clinical assessment for airway obstruction?
Look for central cyanosis, abnormal breathing patterns, use of accessory muscles, tracheal tug, changes in consciousness, and obvious obstructions. Listen for abnormal sounds. Feel for air flow on inspiration and expiration
What precaution should be taken when performing airway maneuvers in patients with a risk of cervical spine pathology?
Maintain manual in-line immobilization of the cervical spine
What should be the immediate goal if objective signs of airway obstruction are present?
To secure the airway, provide adequate oxygenation, and prevent hypoxic brain damage
What are some simple methods to obtain an airway?
Chin lift or jaw thrust to open the airway, suction to remove secretions, and insertion of an oral Guedel airway or a soft nasopharyngeal airway
How can you determine respiratory distress or inadequate ventilation?
Using the ‘Look, Listen and Feel’ technique
What should you look for during breathing assessment?
Central cyanosis, use of accessory muscles, respiratory rate, equality and depth of respiration, sweating, raised jugular venous pressure (JVP), chest drains, and paradoxical abdominal movement
What should you do if signs of immediately life-threatening conditions are present?
Identify and treat them without delay, such as tension pneumothorax, massive haemothorax, open pneumothorax, flail chest, and cardiac tamponade
What should you listen for during breathing assessment?
Noisy breathing, coughing to clear secretions, ability to speak in complete sentences, abnormal breath sounds, heart sounds, and rhythm
What should you feel for during breathing assessment?
Equality of chest movement, position of the trachea, presence of surgical emphysema or crepitus, paradoxical respiration, and tactile vocal fremitus if indicated
What should you consider as potential diagnoses during breathing assessment?
Bronchial obstruction, bronchoconstriction, pulmonary embolism (PE), cardiac failure, and unconsciousness
What should you do if the patient is tiring to the point of respiratory arrest?
Assist ventilation with a bag/mask and perform necessary airway maneuvers until help arrives
What should be considered as the primary cause of circulatory dysfunction in surgical patients?
Hypovolaemia
What is the first step in assessing a patient with circulatory dysfunction?
Rapidly exclude haemorrhage and establish adequate venous access
What is the recommended fluid challenge for normotensive patients?
10ml/kg of warmed crystalloid
What is the recommended fluid challenge for hypotensive patients?
20ml/kg
How can life-threatening circulatory dysfunction be recognized?
Reduced peripheral perfusion, external haemorrhage, and concealed haemorrhage
How can perfusion be assessed?
By measuring capillary refill time
What should be done if a patient is not responding to fluid resuscitation?
Immediate intervention and different treatment
What are the three categories that shocked patients fall into?
Exsanguinating patients, unstable patients, and patients with a relatively minor problem
When should reassessment be performed?
After each intervention
What is the recommended resuscitation fluid for bleeding patients with cardiovascular instability?
Blood
What should be done if a patient is not responding to resuscitation?
Call for senior help, cross-match blood, and prepare for surgery
What are some possible causes of altered consciousness level in surgical patients other than a primary brain injury?
Hypoxia, cerebral underperfusion due to shock, recent administration of sedatives, analgesics, or anaesthetic drugs, and hypoglycaemia
How can the neurological status of a patient be rapidly determined during the initial assessment?
By examining the pupils and using the AVPU system: A - Alert, V - responds to Verbal stimulus, P - responds only to Pain, U - Unresponsive to any stimulus
What should be done for shocked or hypotensive patients who are not bleeding?
Avoid blindly giving large amounts of fluid and seek a clear diagnosis and plan
What should be done if the patient is not fully conscious despite considering other causes?
Reassess and review the ABCs (Airway, Breathing, Circulation) to ensure no missed factors
What should be considered when exposing the patient?
Preserving the patient’s dignity and being aware of the risk of the patient becoming cold
What signs should the patient ideally be showing by the end of the immediate assessment and management phase?
Signs of improvement and progressing out of immediate danger
What should be ensured before moving on to the next phase?
The patient should be receiving oxygen and IV fluids, monitoring should be established (pulse oximeter, blood pressure), and oxygen saturation (SaO2) should be above 94%
What should be done if the patient is not showing signs of improvement by this stage?
Call for help and consider transferring the patient to the operating theatre or intensive care
What investigations should be arranged at this stage?
Pressing investigations that have not been done recently and are integral to the immediate assessment, such as arterial blood gases (ABGs), chest X-ray, or ECG
What further actions may be necessary at this stage?
Inserting a urinary catheter if appropriate, alerting senior colleagues if not already done, and quickly reassessing the ABCs
What should be done if the patient’s condition is not deteriorating?
Use the time to continue with the next stage of assessment to determine the underlying cause of deterioration
What should be done if the patient’s condition is deteriorating?
Quickly reassess, call for help, and arrange for further immediate treatment as appropriate
What should be considered during the assessment of a surgical patient?
General aspects of care (cardiorespiratory function, fluid balance) as well as specific aspects related to the surgery (e.g., bile production or drainage, liver function tests, albumin, glucose, clotting factors)
What should be assessed in the respiratory category?
Respiratory rate, inspired oxygen concentration (FiO2), and oxygen saturation (SaO2)
What should be assessed in the circulation category?
Heart rate and rhythm, blood pressure, urinary output, fluid balance, intravenous lines, and cardiac output measurements
What should be considered in the surgical category?
Special requirements specific to the operation, temperature, and drainages (nature and volume)
How should patients about whom you are unsure be managed?
They should be managed as if they were unstable
What is the recommended format for a systematic examination?
It should follow a standard format, starting with the hands and proceeding to the neck, chest, abdomen, limbs, and any wounds or stomas that may require examination
What should be considered when formulating a management plan for stable patients?
Prescribing necessary therapeutic drugs, checking for appropriate prophylaxis, verifying the need for antibiotics, ensuring routine medications are given, and considering comorbid conditions and their implications
What are the characteristics of stable patients?
They have normal signs, are progressing as expected, and have not experienced recent complications
What are the components of the daily plan?
What are the components of the daily plan?
What is the underlying aim of critical care practice?
To begin definitive treatment of life-threatening pathology or complications as quickly as possible
What information should be included in the case notes?
Who saw the patient, why they were seen, information gathered and interpreted, the decision and plan, who will carry it out, and the date of the next review. Additionally, any communication with the patient and their concerns may be recorded if necessary
What is the most common reason for admission to a critical care unit?
Provision of airway management and ventilatory care to critically ill patients
What does the CCrISP system encourage?
Assessing patients in a similar way, identifying those in need of immediate life-saving resuscitation, reaching a diagnosis, formulating and instituting a plan of definitive treatment, planning selective and safe investigations, utilizing repeated clinical assessment, involving senior colleagues, considering the level of care necessary, and communicating and documenting clearly
What are the signs of airway compromise that indicate the need for intervention?
Noisy breathing, inspiratory stridor, seesaw breathing, indrawing of suprasternal, supraclavicular, and intercostal spaces
What are the two golden rules of airway management?
Always give oxygen in the highest concentration possible and use simple methods of airway management first
What is the recommended method for administering oxygen to a spontaneously breathing patient?
Using a mask with a reservoir bag to deliver the highest flow rate of oxygen possible
Why is administering high concentrations of oxygen not a concern during resuscitation?
Hypoxia is more dangerous than the loss of respiratory drive, and the occurrence of a hypoxic drive is rare in surgical patients
What is the target saturation range for maintaining adequate saturations in stable patients?
> 94% (unless there is evidence of a hypoxic drive, in which case the range is 88-92% as recommended by the British Thoracic Society)
What is the limitation of pulse oximetry in assessing ventilation?
It does not provide information about hypercapnia or the effectiveness of ventilatory effort
What are the escalating measures for airway support?
Chin lift/jaw thrust, suction, oropharyngeal/nasopharyngeal airways, laryngeal mask or endotracheal tube, surgical airway
What are the basic manoeuvres that can improve gas exchange through a compromised airway?
Chin lift/jaw thrust without airway adjuncts
What should be inserted if basic manoeuvres are not sufficient to improve gas exchange?
An oral Guedel airway
How should a Guedel airway be inserted in adults?
Upside down and rotated into place over the tongue, sized from the tragus of the ear to the angle of the mouth
What is necessary for ventilation if the patient is apneic or has shallow respiration?
Using a bag/valve/mask system
What can be attempted as an alternative to intubation in certain situations?
Insertion of a laryngeal mask airway
What should be done if intubation fails or manual ventilation is not possible?
Perform a surgical airway by surgical cricothyroidotomy for life-saving oxygenation and ventilation
What is a tracheostomy?
A hole in the trachea through which a person can breathe or be ventilated
What are the two distinct types of tracheostomy?
1) Tracheostomy after laryngectomy (upper airway absent) 2) Surgical tracheostomy or percutaneous dilational tracheostomy (upper airway present)
Where are tracheostomies often performed?
On long-stay ICU patients
What should be checked for each type of tracheostomy tube?
Tube size, length, and dimensions
What are the recommended tube sizes for females and males?
Females: 7-8mm internal diameter tube; Males: 8-9mm internal diameter tube
Why is selecting the appropriate tube size important?
To maximize internal tube dimensions and reduce the work of breathing through the tube
What is the risk of using an oversized tracheostomy tube?
Pressure necrosis and damage to the tracheal mucosa
What is the purpose of the aspiration port above the cuff in cuffed tracheostomy tubes?
To keep the area clear of secretions and reduce the risk of ventilator-acquired pneumonia
Why is humidification and regular suction essential for tracheostomy patients?
To prevent blockage of the tracheostomy tube
How long should tubes be changed after a surgical procedure or percutaneous procedure?
Surgical procedure: at least 3 days; Percutaneous procedure: ideally 7-10 days
Why are single lumen tubes generally undesirable on the wards?
Due to the risk of blockage
What should single lumen tubes be replaced with?
Tracheostomy tubes with a removable inner tube for easier cleaning
What algorithm can be used to determine if the tracheostomy tube is still required?
The CCrISP algorithm
What is the most important difference between a laryngectomy stoma and other forms of tracheostomy?
In a laryngectomy stoma, there is no remaining upper airway
What are some reasons for a tracheostomy?
Upper airway obstruction, post laryngectomy/upper airway surgery, musculoskeletal disorders affecting ventilation, assist weaning from ventilation, incompetent swallow/impaired upper airway reflexes
What are the different types of tracheostomy tubes available?
Cuffed, uncuffed, unfenestrated, fenestrated
What are the common problems with tracheostomies?
Displacement, obstruction, haemorrhage
What should you do if you haven’t received training to change tracheostomy tubes?
Do not plan to undertake the procedure unsupervised
How should haemorrhage from a tracheostomy tube be managed?
Call for help, apply 100% oxygen, inspect stoma site, apply manual pressure to bleeding sites, consider dilute adrenaline infiltration, apply pressure to sternal notch and hyperinflate tracheostomy cuff if bleeding is significant
What should be done in case of desaturation with a tracheostomy and an existing airway?
Call for help, administer 100% oxygen, assess tracheostomy patency, manage upper airway, attempt bag and mask ventilation at tracheostomy stoma site, perform upper airway intubation (by skilled clinician)
Call for help, apply 100% oxygen, inspect stoma site, apply manual pressure to bleeding sites, consider dilute adrenaline infiltration, apply pressure to sternal notch and hyperinflate tracheostomy cuff if bleeding is significant
Securing the airway
What tests should be performed in case of tracheostomy-related bleeding?
Full blood count (FBC), ABG analysis, cross-matching
What is the process called when removing a tracheostomy tube?
Decannulation
What is the recommended post-removal care for dilational percutaneous tracheostomies?
Occlusive stoma site dressing
What factors should be assessed before removing a tracheostomy tube?
Neurological status, ventilation and oxygenation needs, quality of upper airway, ability to cough and clear secretions, successful treatment of the original indication for tracheostomy, overall stability of the patient
What may be required for surgical tracheostomies after removal?
Formal operative closure
What assessments may be needed before resuming an oral diet?
Formal speech and language therapy and swallowing assessments
What are the common complications of tracheostomies?
Displacement, obstruction, haemorrhage (DOH)
What is the critical point on the oxygen dissociation curve for rapid desaturation to occur?
PaO2 of 8kPa
What determines if Type 2 respiratory failure is acute or chronic?
Bicarbonate level and patient’s history
What is respiratory failure?
Inadequate pulmonary gas exchange resulting in abnormal blood oxygen and carbon dioxide levels
What are common causes of respiratory failure in surgical patients?
1) Acute fall in functional residual capacity (FRC) without pulmonary vascular dysfunction, 2) Acute fall in FRC with pulmonary vascular dysfunction, 3) Airflow obstruction
How is respiratory failure classified based on CO2 levels?
Type 1 failure: Hypoxia with normal or reduced PaCO2; Type 2 failure: Hypoxia and hypercarbia
What factors increase the risk of respiratory problems?
Pre-existing respiratory disease, obesity, smoking, thoracic surgery, upper abdominal surgery, older age
How can patients with respiratory failure be easily recognized?
Dyspnea, tachypnea, apnea, inability to speak in complete sentences, use of accessory muscles of respiration, central cyanosis, sweating and tachycardia, decreased level of consciousness
What is the recommended initial oxygen therapy for patients who are still spontaneously breathing?
High-flow oxygen via a reservoir bag
What is the rule for oxygen therapy once the patient has stabilized?
Give the minimum added oxygen necessary to achieve optimal oxygenation
What should be considered during resuscitation in terms of oxygen therapy for patients with chronic pulmonary disease?
Do not worry about potentially depressing ventilation; prioritize preventing hypoxia over hypercarbia
What is the purpose of pulse oximetry in the monitoring of critically ill surgical patients?
To continuously monitor oxygen saturations
How does pulse oximetry work?
It combines principles of light transmission and reception through tissue to detect pulsatile flow and differentiate between oxygenated and reduced hemoglobin
What does pulse oximetry display?
Heart rate and arterial oxygen saturation (SaO2)
Does saturation equate to the partial pressure of oxygen?
No, saturation does not equate to the partial pressure of oxygen responsible for gas exchange
What is the advisable SaO2 level to maintain?
Above 94%
What is the potential delay between actual and displayed values in pulse oximetry?
Around 20 seconds
What can impede accurate pulse oximetry readings?
Movement, peripheral vasoconstriction, cardiac arrhythmias, profound anemia, SaO2 below 70%, diathermy, bright lights, dirty skin or pigmentation, use of nail varnish
What should be assessed during chart examination in a patient with respiratory problems?
Changes in respiratory rate, temperature, pulse rate, blood pressure, level of consciousness, oxygen saturation, ABGs, fluid balance
What information should be obtained from the patient regarding respiratory difficulty?
Changes in the color or amount of sputum
What is the initial approach to examine the patient for respiratory problems?
Clinical examination using “Look, Listen, and Feel” techniques
How can correction of anemia impact oxygen delivery to tissues?
It can improve oxygen delivery to the tissues if the hemoglobin is less than 80g/L
Which blood test is most useful in cases of respiratory failure?
ABG analysis
What can an elevated white cell count in the blood indicate?
Concurrent infection, potentially of pneumonic origin
When should CT pulmonary angiography (CTPA) be used?
When a patient is hypoxic and there is no clear cause for the deterioration
What lung function tests are useful in predicting a patient at risk?
Peak expiratory flow rate, vital capacity, and forced expiratory volume in 1 second (FEV1)
What is the most common cause of respiratory failure?
Infection
What samples should be obtained before commencing antibiotic therapy in cases of respiratory failure?
Blood samples for culture
What should be assessed in stable patients as part of the daily management plan?
Respiratory rate, SaO2, cyanosis, ability to cough and deep breathe, adequacy of analgesia, signs of respiratory distress, sweatiness, tachycardia, and regular chest examination
What should be assessed during a chart review in a patient assessment?
Changes in respiratory rate, temperature, pulse rate, blood pressure, level of consciousness, oxygen saturation, and ABGs
What measures can be taken to prevent respiratory problems in patients at risk?
Early mobilization, sitting up, patient positioning, exercises to encourage deep breathing, suction of respiratory secretions, and use of devices such as incentive spirometry and cough incentive machines
What should be prescribed for stable patients requiring oxygen therapy?
Humidified oxygen therapy by mask at an appropriate concentration
What should be prescribed for patients who develop wheezing?
Nebulized salbutamol and ipratropium
Why is adequate analgesia important in respiratory patients?
To enable patients to cough and deep breathe
What are the steps for preventing respiratory deterioration following surgery?
- Identify those at risk. 2. Examine and assess. 3. Encourage early mobilization. 4. Provide adequate analgesia. 5. Arrange for chest physiotherapy. 6. Administer nebulized saline. 7. Administer humidified oxygen at a titrated dose. 8. Take sputum for culture. 9. Reassess regularly.
Why is a chest radiograph important in the management of critically ill patients?
It provides valuable confirmatory and complementary diagnostic evidence (or reassurance) in many clinical scenarios and diagnoses.
What is the recommended view for assessing the heart in a chest X-ray?
A straight, erect posteroanterior (PA) film taken at full inspiration
What are the components of the example system for assessing a chest X-ray?
- Soft tissues (air, foreign bodies, disruption of contours). 2. Bony structures (ribs, clavicles, scapulae, sternum). 3. Lung markings (extension to chest wall, presence of pneumothorax or haemothorax, volume of parenchyma). 4. Examine lung fields for opacities. 5. Check costophrenic angles for fluid. 6. Look for air beneath the diaphragm and intra-abdominal abnormalities. 7. Note position of trachea and heart size, check mediastinum and presence of tubes or lines.
What does the presence of an air bronchogram suggest?
Oedema, infection, or other infiltrates in the surrounding lung tissue
What are Kerley B lines?
Horizontal lines that meet the pleural surface at right angles, caused by increased fluid or tissue within the intralobular septa
What are the signs of pleural effusion on a chest X-ray?
Blunting of the costophrenic angle, lung compression, displacement of the mediastinum to the opposite side, and flattened diaphragm on the affected side
Can bronchitis and emphysema be present without chest X-ray abnormalities?
Yes
What are some possible chest X-ray findings in bronchitis and emphysema?
Increased lucency of the lung, regional or general loss of vascularity in the peripheral lung fields, and increased size of the lung fields
Why may an effusion appear as a faint diffuse opacity on a supine chest X-ray?
Because the fluid is spread thinly over a wide area
What should be done to confirm an effusion if it is not clearly visible on a supine chest X-ray?
Repeat the X-ray after the patient has been sitting up for 15 minutes or obtain an ultrasound scan
What conditions may cause an enlarged cardiac silhouette on a chest X-ray?
Ventricular hypertrophy, pericardial effusion, and ventricular aneurysm
What can be done to confirm a pericardial effusion if there is doubt?
Echocardiography
What are some signs of cardiac failure on a chest X-ray?
Upper lobe blood diversion, cardiomegaly, pleural effusions, Kerley B lines, and parenchymal shadowing (diffuse or hilar ‘bat’s-wing’ shadowing)
What should be the initial treatment for respiratory failure?
Conventional mask oxygen therapy
Up to what inspired oxygen concentration are fixed-delivery oxygen masks available?
60% (FiO2 of 0.6)
Why should all oxygen delivery systems be humidified?
To prevent thickening of the patient’s secretions and promote sputum retention
What can help prevent worsening of incipient respiratory failure?
Nebulized 0.9% saline (with bronchodilators if indicated) and regular treatment from a respiratory physiotherapist
What is the importance of treating the underlying cause of respiratory failure?
Oxygen is only one aspect of treatment; treating the underlying cause is necessary
What are high-flow nasal oxygen therapy devices?
Devices that provide higher flows and concentrations of oxygen than conventional facemasks, along with gas humidification
What treatments may be needed for respiratory failure?
Appropriate antibiotics, physiotherapy, diuretics, bronchodilators, and cardiac or other drugs as necessary
What factors should be considered in treating respiratory function?
Systemic factors (mobility, nutrition) and clearance of secretions
What should be considered if the patient has confusion or a depressed level of consciousness?
Hypoxia and hypercarbia as possible causes, rather than assuming it is due to opiate analgesia
What are some indications of failure of mask oxygen therapy at high FiO2?
Increasing respiratory rate, increasing distress, dyspnea, exhaustion, sweating, confusion, oxygen saturation 80% or less (late sign), PaO2 less than 8kPa, and PaCO2 greater than 7kPa
What should be done if a patient is tachypneic and showing signs of tiring and arrest?
Intervene before this stage by acting on early symptoms and signs, particularly tachypnea, and transfer the patient to a higher level of care for further therapy to improve gas exchange
Who should be closely monitored for potential problems in respiratory failure?
Patients with severe chronic lung disease (e.g., vital capacity less than 15ml/kg or FEV1 less than 10ml/kg)
What may be required for frequent blood gas analysis in patients with respiratory failure?
Insertion of an arterial line
What is the purpose of CPAP (Continuous Positive Airway Pressure)?
To help with type 1 respiratory failure
What is the range of airway pressure that can be maintained with CPAP?
2.5 to 10cmH2O
How is CPAP administered?
Through a tight-fitting facemask with expiratory valves that maintain a set airway pressure
