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OSCE - skills > A-E > Flashcards

A-E Flashcards

1
Q

What are the steps in the A-E assessment?

A
  1. Airway
  2. Breathing
  3. Circulation
  4. Disability
  5. Exposure
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2
Q

What are the steps of the inspection of the airway in an A-E assessment?

A
  1. Can the patient talk?

If yes, then still listen for stridor which can indicate upper airway obstruction

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3
Q

If the patient cannot talk, what do you do next?

A

Look for signs ofairwaycompromise

Open the mouth and inspect (look for secretions and foreign objects)

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4
Q

What are signs of airway compromise?

A 
Cyanosis
See-saw breathing
Use of accessory muscles
Diminished breath sounds
Added breath sounds
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5
Q

What are causes of airway obstruction or compromise?

A
  1. Inhaled foreign body
  2. Blood in the airway
  3. Vomit or secretions in the airway
  4. Soft tissue swelling
  5. Local mass effect (tumours and lymphadenopathy)
  6. Laryngospasm
  7. Depressed level of consciousness
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6
Q

What interventions would you consider if someone’s airway is compromised?

A

Seek immediate help from an anaesthesiologist

  1. Head-tilt chin-life manoeuvre
  2. Jaw thrust
  3. CPR
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7
Q

What are the steps of the inspection of the breathing in an A-E assessment?

A
  1. Observations: RR, O2 sats
  2. General inspection
  3. Tracheal position
  4. Chest expansion
  5. Percussion of the chest
  6. Auscultation
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8
Q

What is a normal heart rate? And what are causes of brradypnoea and tachypnoea?

A

12-20 breaths per minute

Bradypnoeamay be due to sedation, opioid toxicity, raised intracranial pressure (ICP) or exhaustion in airway obstruction (e.g. COPD).

Tachypnoeamay be due to airway obstruction, asthma, pneumonia, pulmonary embolism (PE), pneumothorax, pulmonary oedema, heart failure, or anxiety.

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9
Q

What are common causes of hypoxaemia?

A 
PE
Aspiration 
COPD
Asthma
Pulmonary oedema
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10
Q

What is part of the general inspection of the breathing?

A

At the end of the bed, look for:

  1. Cyanosis
  2. Shortness of breath
  3. Cough
  4. Stridor
  5. Cheyne-Stokes respiration
  6. Kussmaul’s respiration
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11
Q

What is Cheyne-Stokes respiration?

A

Cyclical apnoeas, with varying depth of inspiration and rate of breathing.

May be caused by stroke, raised intracranial pressure, pulmonary oedema, opioid toxicity, hyponatraemia or carbon monoxide poisoning.

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12
Q

What is Kussmaul’s respiration?

A

Deep, sighing respiration associated with metabolic acidosis (e.g. diabetic ketoacidosis)

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13
Q

What is part of the tracheal position inspection of the breathing?

A

Gently assess theposition of the trachea, which should becentral

Deviation away: tension pneumothorax or large effusions
Deviation towards: lobar collapse and pneumonectomy

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14
Q

How would you assess chest expansion?

A

Assess the patient’schest expansionlooking for evidence ofreduced chest wall movement.

Reduced chest expansion may indicate underlying pathology:

  1. Symmetrical:pulmonary fibrosis reduces lung elasticity, restricting overall chest expansion.
  2. Asymmetrical: pneumothorax, pneumonia and pleural effusion can all cause ipsilateral reduced chest expansion.
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15
Q

What does percussion of the chest tell you?

A

Dullness:suggests increased tissue density (e.g. cardiac dullness, consolidation, tumour, lobar collapse).

Stony dullness:typically caused by an underlying pleural effusion.

Hyper-resonance: the opposite of dullness, suggestive of decreased tissue density (e.g. pneumothorax).

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16
Q

What does auscultation of the chest tell you?

A
  1. Bronchial breathing (consolidation)
  2. Quiet/reduced breath sounds (effusion/pneumothorax)
  3. Wheeze: COPD, asthma, bronchiectasis
  4. Stridor (including foreign body inhalation (acute) and subglottic stenosis (chronic))
  5. Coarse crackles: pneumonia, bronchiectasis, pulmonary oedema
  6. Fine end-inspiratory crackles: pulmonary fibrosis
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17
Q

What investigations would you do at the end of breathing?

A

ABG: iff SpO2 is low

CXR if you suspect lung pathology (e.g. pneumonia, pneumothorax, pulmonary oedema).

18
Q

What interventions arre possible at the end of the breathing assessment?

A
  1. O2
  2. CPR
  3. Escalate if suspected exacerbation of asthma or COPD
19
Q

What are the steps of the inspection of the circulation in an A-E assessment?

A
  1. Observations: HR, BP
  2. Fluid balance
  3. General inspection
  4. Palpation
  5. Pulses and BP
  6. JVP
  7. Auscultation
  8. Ankles and sacrum
20
Q

What are causes of tachycardia?

A

Hypovolaemia, arrhythmia, infection, hypoglycaemia, thyrotoxicosis, anxiety, pain and drugs (e.g. salbutamol).

21
Q

What are causes of bradycardia?

A
  1. Acute coronary syndrome (ACS)
  2. Ischaemic heart disease
  3. Electrolyte abnormalities (e.g. hypokalaemia)
  4. Drugs (e.g. beta-blockers).
22
Q

What are causes of hypertension?

A
  1. Hypervolaemia
  2. Stroke
  3. Conn’s
  4. Pre-eclampsia
23
Q

What are causes of hypotension?

A
  1. Hypovolaemia
  2. Sepsis
  3. Adrenal crisis
  4. Drugs (opioids, antihypertensives, diuretics)
24
Q

How would you assess someone’s fluid balance?

A

Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts.

Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult.

Causes of oliguria include dehydration, hypovolaemia, reduced cardiac output and acute kidney injury.

25
Q

What is part of the general inspection during the circulation assessment?

A

Pallor:a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure).

Oedema:typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites) and may indicate underlying heart failure.

26
Q

How would you palpate during the circulation assessment?

A

Place thedorsal aspectof your hand onto the patient’s to assesstemperature (cool: poor perfusion; sweaty or clammy: ACS)

Measure CRT (>2 seconds suggestspoor peripheral perfusion(e.g. hypovolaemia, congestive heart failure))

27
Q

How would you assess the pulses during the circulation assessment?

A

Assess the patient’sradialandbrachialpulseto assessrate,rhythm,volumeandcharacter

28
Q

How would you assess the JVP during the circulation assessment?

A

Inspect for evidence of araisedJVPwhich may be caused by:

  1. Right-sided heart failure: commonly caused by left-sided heart failure (e.g. secondary to fluid overload)
  2. Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
  3. Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.
29
Q

How would you auscultate the chest as part of the circulation assessment?

A

Auscultatethe patient’s precordium to assessheart sounds

30
Q

How would you assess the ankles and sacrum during the circulation assessment?

A

Assess the patient’s ankles and sacrum for evidence of oedema which is typically associated with heartfailure.

31
Q

What investigations would you do for the circulation assessment?

A

ALWAYS insert 14G or 16G cannula

RequestFBC,U&EsandLFTs and other bloods based on presentation

12-lead ECG

Pregnancy test

Fluid output and catheter

Other cultures and swabs

32
Q

What bloods would you request based on presentation?

A
  • Sepsis: CRP, lactate and blood cultures
  • Haemorrhage or surgical emergency: coagulation and cross-match
  • Acute coronary syndrome: troponin
  • Arrhythmia: calcium, magnesium, phosphate, TFTs, coagulation
  • Pulmonary embolism: D-dimer (if appropriate based on Well’s score)
  • Overdose: toxicology screen (e.g. paracetamol levels)
  • Anaphylaxis: consider serial mast cell tryptase levels
33
Q

What interventions would you do for the circulation assessment?

A
  1. Hypovolaemia: fluid reuses with 500ml bolus Hartmann’s solution or 0.9% sodium chloride (warmed if available) over 15 mins. Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure)
  2. CPR
  3. Sepsis: sepsis 6 pathway
  4. Haemorrhage: stop bleeding and administer blood
  5. Fluid overload: diuretics (furosemide)
  6. AF: cardioversion
34
Q

What are the steps of the inspection of disability in an A-E assessment?

A

Assess the patient’slevel of consciousnessusing theACVPU scale

Pupils: size and symmetry, direct and consensual pupillary response

Review drug chart

35
Q

What are causes of depressed consciousness?

A
  1. Hypovolaemia
  2. Hypoxia
  3. Hypercapnia
  4. Metabolic disturbances
  5. Seizure
  6. Raised intracranial pressure
  7. Drug overdose
  8. Iatrogenic causes
36
Q

What investigations would you do for the disability assessment?

A
  1. Blood glucose and ketones

2. Imaging if intracranial pathology is suspected

37
Q

What potential interventions would you do for the disability assessment?

A
  1. Maintain airway: A GCS of8 or belowwarrantsurgent expert helpfrom ananaesthesiologist
  2. Opioid toxicity: naloxone (pinpoint pupils)
  3. Hypoglycaemia
  4. Diabetic ketoacidosis (DKA): The management of DKA involves interventions such asintravenous fluidsandinsulin.
38
Q

What are the steps of the inspection of exposure in an A-E assessment?

A
  1. Ask if there is any pain
  2. Inspect for rashes, bruising, infection. Review IV lines. Assess calves for erythema, swelling, tenderness. Review surgical wounds, review output of catheter
  3. Temperature
39
Q

What is hypothermia and hyperthermia caused by?

A

A temperature of >38°c is most commonly caused by infection (e.g. sepsis).

A temperature < 36°c may also be caused by sepsis or cold exposure (e.g. drowning, inadequate clothing outside).

40
Q

What investigations would you do for the exposure assessment?

A

Ask the nursing staff to take relevantswabs/samplesof any potentialinfectionsource(e.g. line tip culture).

41
Q

What potential interventions would you do for the exposure assessment?

A

If the patient isactivelybleedingseekurgent senior inputand consider the need forbloodproducts(e.g. packed red cells, platelets).

Infection: sepsis 6

DVT: well’s score

OSCE - skills (13 decks)

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