A-E, ABG, consent

Question 1

What is an A-E assessment?

Answer 1

Focussed examination, detects life-threatening problems in a sequential fashion

Find - Stop - Treat - Back to start

Question 2

When do we do an A-E assessment?

Answer 2

Any patient who looks unwell, altered conscious level, sudden deterioration, high NEWS

Question 3

AIRWAY

Answer 3

Is the airway patent?

Can the patient talk?

Causes of acute obstruction

• Reduced consciousness: loss of soft tissue tone esp. soft palate
• Foreign body
• Oedema
• Tumour/ abscess

Airway management

• Head tilt, chin lift
• Evidence of blood or vomit? Suction
• Adjuncts

> If the above fail or are likely to fail - get anaesthetist

Signs of obstruction

• Partial: snoring, gurgling, stridor
• Complete: seesaw movement of chest and abdomen - trying but failing to get air in

Question 4

BREATHING

Answer 4

Look: colour, resp. rate and pattern, O2 sats

Feel: trachea, chest wall movement, percussion

Listen: equal air entry, absent breath sounds, added sounds

Actions

• O2 15L NRBM
• Target sats 94-98 unless T2RF
• Request ABG/ VBG/ CXR if indicated

Question 5

Types of pathological respiration

Answer 5

Seesaw/ paradoxical: chest falls on inspiration and rises on expiration: usually due to type 3 resp. failure

Cheyne-stokes: cyclical increase and decrease in depth of respiration associated with CHF, cerebrovascular insufficiency

Kussmaul: slow, deep breathing, hyperventilation, gasping and laboured due to ketoacidosis

Biot’s breathing: totally irregular with no pattern - CNS injury

Question 6

CIRCULATION

Answer 6

Look: colour and temp of hands, cap refill time, JVP

Feel: peripheral and central pulse and rhythm, strength of pulse, temp

Listen: heart sounds, measure BP

Question 7

How do we calculate MAP?

Answer 7

MAP = systolic BP + diastolic BP + diastolic BP / 3

Question 8

Causes of hypotension

Answer 8

Problem with the pump

Arrhythmias, acute coronary syndrome, acute LV failure

Problem with the fluid

Hypovolaemia

Problem with the pipes

Sepsis, anaphylaxis

Question 9

Most common cause of circulatory disturbance?

Answer 9

Hypovolaemia

Give 500ml bolus of either Hartmann’s or 0.9% NaCl and repeat up to 2L (or 30ml/kg)

If patient has known cardiac or renal failure consider giving 250ml instead

Question 10

DISABILITY

Answer 10

Conscious level

Pupils

Glucose (DON’T EVER FORGET GLUCOSE)

AVPU

A - is patient alert?

V - responding to voice?

P - responding to pain?

U - unresponsive

GCS is useful if patient has had head injury

Question 11

Action regarding disability

Answer 11

• Pin point pupils? Overdose? Do we have an antidote?
• Intracranial event - urgent CT head?
• Hypoglycaemia if blood glucose <4mmol/L - give 100ml 20% IV dextrose if you have access
• What should blood glucose be? 4.0-11.0mmols/L - if it is >15mmols/L check ketones because patient may be in diabetic ketoacidosis
• Reduced conscious level?
• Risk of airway obstruction and aspiration, place in left lateral position, airway should be protected if their GCS is less than 8

Question 12

EXPOSURE

Answer 12

Here we perform a detailed examination of the rest of the patient while maintaining their dignity - screen for anything else abnormal

• Temperature
• Rash
• Calf swelling/ bruises
• Bleeding
• Abdominal palpation
• Use information from hx to guide you
• Collateral hx from bystanders or ambulance drivers

Once you have completed E it is important to go back to A and ensure airway is patent

Question 13

Differences in airway between adults and children

Answer 13

Kids have large heads, tongues and floppy epiglottis so minor flexion and extension can kink off the airway, the tongue will also obstruct the airway more easily in a child than an adult

Question 14

Mural causes of airway failure

Answer 14

Mural = in the wall

Angioedema

Burns to mouth

Infection

Neoplasm

Question 15

Intraluminal causes of airway failure

Answer 15

Foreign body

Laryngospasm

Tongue obstruction

Bilateral recurrent laryngeal nerve palsy

Large tonsils

Question 16

What % of airway is obstructed if a stridor can be heard?

Answer 16

~ 70%

Question 17

How do patients sometimes compensate for partial airway obstruction?

Answer 17

• Sitting up and leaning forwards - tripod position
• Reluctant to speak or cough
• Nasal flaring
• Accessory muscles
• Pursed lips
• Paradoxical chest movements

Question 18

What can make bag and mask ventilation difficult?

Answer 18

• Previous difficulty
• Beards
• Short, fat necks
• Obstructive sleep apnoea
• Dentures - keep them in
• Structural facial abnormalities

Question 19

Causes of bradypnoea?

Answer 19

Sedation

Opioids

Raised ICP

Exhaustion in airway obstruction

Question 20

Causes of tachypnoea

Answer 20

Obstruction

Asthma

Pneumonia

PE

Pneumothorax

Pulmonary oedema

Heart failure

Anxiety

Question 21

Normal values for an ABG

Answer 21

pH: 7.35 – 7.45

pO2: 10 – 14kPa

pCO2: 4.5 – 6kPa

Base excess (BE): -2 – 2 mmol/l

HCO3: 22 – 26 mmol/l

Question 22

What does a value outside of the normal base excess indicate?

Answer 22

That there is a metabolic cause for the alkalosis or acidosis

Base excess of >2 = metabolic acidosis

Base excess <2 = metabolic alkalosis

Question 23

Patient has a chronic T2RF - what happens to their bicarbonate levels?

Answer 23

To counteract the respiratory acidosis caused by hypercapnia, the kidneys produce more bicarbonate

This is why a pH can be normal despite a raised CO2

Question 24

If there is an acute respiratory or metabolic acidosis, what happens to the bicarbonate?

Answer 24

Levels fall, ions are used to buffer the acids

Question 25

Discuss respiratory compensation

Answer 25

• If a metabolic acidosis develops the change is sensed by chemoreceptors centrally in the medulla oblongata and peripherally in the carotid bodies.
• The body responds by increasing depth and rate of respiration therefore increasing the excretion of CO2 to try to keep the pH constant.
• The classic example of this is ‘Kussmaul breathing’ the deep sighing pattern of respiration seen in severe acidosis including diabetic ketoacidosis. Here you will see a low pH and a low pCO2 which would be described as a metabolic acidosis with partial respiratory compensation (partial as a normal pH has not been reached).

Question 26

Discuss metabolic compensation

Answer 26

• In response to a respiratory acidosis, for example in CO2 retention secondary to COPD, the kidneys will start to retain more HCO3 in order to correct the pH.
• Here you would see a low normal pH with a high CO2 and high bicarbonate.
• This process takes place over days.
• It is important to ensure that the compensation that you see is appropriate, i.e. as you would expect. If not then you should start to think about mixed acid base disorders.

Question 27

How to present an ABG

Answer 27

1. State that this is an arterial blood gas sample (rather than venous).
2. State the patients name and outline history/pertinent examination findings.
3. State the time the sample was taken and how much oxygen the patient was on at the time.
4. Present your findings: e.g. this showed type one respiratory failure with a p02 of 7
5. Present any abnormal findings or important negatives from the rest of the values.
6. A one line summary of your findings

Question 28

Cooperation with a procedure amounts to applied consent in which scenarios?

Answer 28

Minor procedures e.g. venepuncture, physical examination, small wound closure, ECG etc

Question 29

What should happen if the completion of a consent form will result in an inappropriate delay to the patients care?

Answer 29

Record the consent discussion in the patient’s notes

Question 30

What if its an emergency and the patient’s wishes can’t be ascertained?

Answer 30

Treatment can be provided without consent provided it is immediately necessary to save their life or to prevent serious deterioration

Question 31

What is needed for consent to be valid?

Answer 31

Given voluntarily and freely without pressure or undue influence being exerted to accept or refuse treatment. The person must be appropriately informed and have capacity to consent

Question 32

Who can give consent?

Answer 32

Consent may only be provided by the patient, someone authorised to do so under a Lasting Power of Attorney, or someone who has the authority to make treatment decisions, such as a court appointed deputy in England and Wales, or a guardian with welfare powers in Scotland.

No one else can make a decision on behalf of an adult who has capacity

Question 33

What is restraint?

Answer 33

The use or threat of using force to make a person do something they are resisting, the restriction of liberty of movement whether or not the person resists

Question 34

When is restraint considered acceptable?

Answer 34

• The person using it believes it is necessary to prevent harm to the person lacking capacity
• The restraint used is a proportionate response to the likelihood and seriousness of harm
• The action does not conflict with a previous decision made by an attorney

Question 35

What if a clinician feels the patient needs to be restrained but it is not clear whether or not they are lacking capacity?

Answer 35

If the patient might have capacity, but assessment is not possible immediately, then restraint may be used lawfully in certain emergency circumstances (as a last resort)

Question 36

What is the Bolam test?

Answer 36

The Bolam test is a test that can be carried out to ascertain whether a doctor or other medical professional has breached their duty of care to a patient. states that if a doctor reaches the standard of a responsible body of medical opinion, they are not negligent. If a person falls below the appropriate standard and is negligent they are failing to do what a reasonable person would do

Question 37

What is the Montgomery judgement?

Answer 37

• Basically outlines that when providing consent for anything, patients need to be told all of the risks and not just those the doctor sees as necessary to inform of - this is because the person experiencing the procedure or intervention or treatment may be significant to the patient but not significant to the doctor.
• Material risk is a risk that is deemed to be of significance by an individual patient rather than by a body of doctors. In order to discover what may concern a patient, it is imperative that a doctor endeavours to find out what matters to each patient. “A material risk is one that a reasonable person in the patient’s position is likely to attach significance to, or if the doctor is or should reasonably be aware that their patient would be likely to attach significance to it.”
• As a result, it is advisable to inform the patient of all significant possible and/or unavoidable risks however unlikely, the potential benefits of treatment, the risks of procedural failure, details of alternatives to that particular treatment, and the risks incurred by doing nothing.

Question 38

What if patients say they don’t want to know in detail about their condition or what is planned treatment-wise?

Answer 38

If competent, they must still receive the basic information required in order to give valid consent. Such information is likely to include whether the procedure is invasive, what level of pain they might experience, what can be done to minimise this, and if it involves any serious risks. Patient refusal to know in detail about the proposed treatment should be carefully documented in the patient’s notes

Question 39

When can consent be obtained from a child?

Answer 39

If they are deemed to be competent

• Competency does not just relate to age and maturity of the child but also to the specific treatment
• At 16 children are generally presumed to have capacity to give consent
• Parents cannot override competent consent given by a child
• If parents are trying to override competent refusal of a child then legal advice should be sought