A&E + anaesthetics

Question 1

A-E assessment

• things to remember
• the assessment - what you physically would do

Answer 1

first of all:

• treat all problems as you come to them
• re-assess after every intervention to monitor treatment response eg if you give 02 start from A again and repeat all initial assessments
• make sure to delegate tasks when you can
• make sure they have continuous monitoring on
• clearly communicate how often you want patient obs to be relayed to you by other staff
• call for help early using SBAR
• make use of local guidelines
• meds and fluids will need to be prescribed at the time
• DOCUMENT EVERYTHING CLEARLY IN NOTES
• of at any point there are no signs of life commence CPR

THE A-E:

first - get the handover from the nurses that called you
speak to the patient- how are they feeling - they can give you loads of info (if unconcious start BLS straight away)
- check notes, obs chart, prescription chart

A- AIRWAYS
can they talk? move on
no? - look for airway compromise - cyanosis, see-saw breathing, accessory muscles, decreased/increased sounds
interventions-
1. head-tilt chin-lift
2. jaw thrust - in significant trauma use this instead (fingers behind mandible thumb on chin)
3. guedel/igel - oropharyngel for soft tissue obstruction - sits between tongue and hard palate
4. nasopharyngeal - better for partly conscious people, NEVER IN SKULL BASE FRACTURE
5. CPR + crash call
6. signs of anaphylaxis -> follow that pathway

B - BREATHING
RR -> 12-22 normal
02 - >94%
general obs -> breathing technique, colour etc
tracheal position
chest expansion
percussion
ascultate 
ABG
CXR - order a portable one
interventions:
1. o2 - 15L non-rebreathe, then trial titrating down once stable (NOTE: if COPD and target sats are 88-92% then use venturi 24% 4L or 28% 4L or NIV with a senior.
2. sit them upright if conscious
3. acute asthma + COPD mx pathways should be commenced here

C- CIRCULATION
HR - <60 or >100
BP - <90/60 or >140/90
if extremes of this + syncope/SOB/MI = must get urgent SENIOR INPUT
fluid balance - to inform resus efforts
check for oedema - ankles + sacrum
CRT
temp of peripheries
pulse
JVP
ascultate
ECG - continuous in critically unwell patients
bladder scan if retention
preg test if indicated
swab sputum/urine/line (ask nurses)
interventions:
1. 2 x wide-bore IV cannula (14/16G) and take blood tests from it - FBC, U&E + LFTs regardless
2. catheter - ask nurses to initiate strict fluid balance
3. hypovolaemia? - 500ml bolus hartmann’s solution/0.9% NaCl over 15 mins (250mls if at risk of overload). after each bolus reassess (listen to lungs for overload/JVP). repeat up to 4 times, if still not responding CALL FOR HELP
4. initiate ACS/sepsis/haemorrhage/fluid overload/AF management pathway if suspected

D - DISABILITY
consciousness - ACVPU/GCS
pupils - light response, size, symmetry
drug chart review
IX + interventions:
1. glucose + ketones
2. imaging - CT head if intracranial path suspected
3. GCS <8 involve anaesthetist
4. treat - opioid tox with naloxone and hypoglyc with admin of glucogel, and DKA with fluids/insulin

E- EXPOSURE
inspect skin
review IV lines
assess calves
review catheter 
temp
interventions:
- cultures/swabs

Question 2

SBAR handover

Answer 2

Situation
- intro you and ur grade
- provide identification details of patient and where they are
- provide timing of deterioration
- detail what you think is happening and why you need help
eg - “Hello, I’m David, an FY1 calling from the A&E. Can I ask who I’m speaking to? …”

“I’m calling about a patient called Jane Doe (DOB, NHS number), a 62-year-old lady who arrived 15 minutes ago with a suspected intracerebral haemorrhage, and I’d like you to review the patient.”

Background-
basically anything about the patient thats happened before thats relevant
HPC, PMH, ix, meds, recent ops, allergies
also current management and patients clinical response so far
eg - “Mrs Doe presented with acute onset dysarthria, left-sided limb weakness and inattention. Her past medical history includes a TIA in August 2017, hypercholesterolaemia and atrial fibrillation. She is anticoagulated with warfarin and her admission INR is 4.8. A CT head demonstrates an intracerebral haemorrhage in the right hemisphere with some associated mass effect and midline shift. We are currently administering Beriplex but the patient does appear to be becoming more drowsy.”

assessment -
vitals
ABCDE
overall clinical imp - ‘septic’ or ‘neurologically deteriorating’

recommendation -
State your suspected diagnosis, what you think needs to happen and in what time frame you expect those things to happen
eg - “This lady has suffered an acute intracerebral haemorrhage and given the ongoing clinical deterioration she needs urgent review by the neurosurgical team.”
ask them -
Whether they can review the patient and in what time frame they would be able to do this.
Whether there is anything further you could do (e.g. requesting investigations, administering treatments).
Whether a transfer to another clinical environment is required (e.g. ward, theatre, ICU)

DOCUMENT THE DISCUSSION IN THE NOTES

THANK THE PERSON AT THE END

Question 3

causes of airway compromise

Answer 3

inhaled foreign body - sudden + stridor
blood in the airway - epistaxis, haematemesis, trauma
vomit/secretions - alcohol, trauma, dysphagia
soft tissue swelling - anaphylaxis + infection
local mass effect - tumours/lymphadenopathy
laryngospasm - asthma, GORD, intubation
depressed level of consciousness - opioids, head injury, stroke

Question 4

what does bronchial breathing mean

Answer 4

harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal and there is a pause between. This type of breath sound is associated with consolidation.

Question 5

what does quiet/reduced breath sounds mean

Answer 5

suggest reduced air entry into that region of the lung (e.g pleural effusion, pneumothorax)

Question 6

what does wheeze mean

Answer 6

continuous, coarse, whistling sound produced in the respiratory airways during breathing. Wheeze is often associated with asthma, COPD and bronchiectasis.

Question 7

what does stridor mean

Answer 7

a high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways. Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).

Question 8

what does coarse crackles mean

Answer 8

discontinuous, brief, popping lung sounds typically associated with pneumonia, bronchiectasis and pulmonary oedema

Question 9

what does fine end-insp crackles mean

Answer 9

often described as sounding similar to the noise generated when separating velcro. Fine end-inspiratory crackles are associated with pulmonary fibrosis.

Question 10

causes of tachycardia

Answer 10

hypovolaemia, arrythmia, infection, hypoglycaemia, thryotoxicosis, anxiety, pain, drugs (eg salbutamol)

Question 11

causes of bradycardia

Answer 11

ACS, IHD, electrolyte imbalances (hypokalaemia), drugs (BB)

Question 12

causes of hypertension +

presentation of severe hypertension

Answer 12

hypervolaemia
stroke 
conn's syndrome 
cushings 
pre-eclampsia

pres of severe:
confusion, drowsiness, breathlessness, chest pain, visual disturbance

Question 13

causes of hypotension

Answer 13

hypovolaemia, sepsis, adrenal crisis, drugs (opioids, antihypertensives, diuretics)

Question 14

what is the definition of oliguria + causes

Answer 14

0.5ml/kg/hour in adult

dehydration, hypovolaemia, low CO, AKI

Question 15

what does these findings mean on pulse:

• irregular
• slow-rising
• pounding
• thready

Answer 15

irregular - arryhythmias (AF)

slow-rising - aortic stenosis

pounding - aortic regurg , CO2 retention

thready - intravascular hypovolaemia eg sepsis

Question 16

what causes a raised JVP?

Answer 16

right-sided heart failure (pulm HTN from COPD, ILD    or LHF)
tricuspid regurg (caused by infective endocarditis and rheumatic heart disease)
constrictive pericarditis (often idiopathic but RA, TB can cause)

Question 17

ejection systolic murmur

Answer 17

aortic stenosis

Question 18

early diastolic murmur

Answer 18

aortic regurg

Question 19

mid-diastolic murmur

Answer 19

mitral stenosis

Question 20

pan-systolic

Answer 20

mitral regurg

Question 21

murmur of recent onset =

Answer 21

MI or endocarditis

Question 22

pericardial rub or muffled heart sounds

Answer 22

pericarditis

Question 23

3rd heart sound?

Answer 23

congestive heart failure

Question 24

what specific blood tests would you want if you suspected:
sepsis
haemorrhage or surg emergency
ACS
arrhythmia
PE
overdose
anaphylaxis

Answer 24

sepsis
CRP, lactate, blood culture

haemorrhage or surg emergency
coag, cross-match, G&S

ACS
trop

arrhythmia
calcium, mg, phosphate, TFT, coag

PE
d-dimer if appropriate based on wells score

overdose
tox screen eg paracetamol levels

anaphylaxis
serial mast cell tryptase levels

Question 25

causes of depressed consciousness

Answer 25

``` hypovolaemia hypoxia hypercapnia metabolic disturbance - eg hypoglycaemia seizure raised ICP or neuro insult eg stroke drug overdose iatrogenic causes eg admin of opiates ```

Question 26

Major trauma assessment

Answer 26

CABCDE Primary survey C-spine - immobilise + TTBTO (turn the blood tap off) - any major haemorrhage visible press and maintain focussed pressure, not tourniquet - if cannot control -> surg A - as normal, cannot head tilt so opt for jaw thrust B - must fully expose chest to look for: tension pneumo haemothorax flail chest C - fluids/blood low threshold, if not responding to resus then consider occult bleeding into abdo cavity/long bone/pelvic fractures D - really important to focus on neuro status - GCS - pupils - limb movements/spont resp effort - glucose E - ensure on warmed bed/blankets after adequate exposure scans - CXR/ pelvic xray/ lateral C-spine, FAST (focussed assessment with sonography for trauma) Secondary survey - starts when patient has responded to ABCDE - essentially head-to-toe exam ``` History: AMPLE A - allergies M - meds current P - past illness/preg L - last meal E - events/environment related to injury ``` O/E identify serious injuries that may have been missed, review neuro exam.

Question 27

what injuries will you expect in burns

Answer 27

dehydration - fluid requirements | inhalation injury

Question 28

what mx would you expect when patient has been exposed to extreme cold

Answer 28

continue resus until warmed

Question 29

high-voltage electricity injuries

Answer 29

extensive muscle injury likely to be concealed

Question 30

name types of bleeding and explain what they mean

Answer 30

primary - during surgery secondary - withing 24hrs of op secondary - withing 7-10 days of op

Question 31

classifying haemorrhagic shock

Answer 31

``` class 1 <750mls / 15% HR <100 normal BP 14-20 RR UO - >30mL/hr ``` ``` class 2 750-1500ml 15-30% HR - 100-120 normal BP RR 20-30 UO - 20-30ml/hr ``` ``` 3 1500-2000ml 30-40% HR 120-140 BP decreased RR 30-40 UO - 5-20mls/hr ``` ``` 4 >2000ml >40% HR >140 BP decreased RR >40 UO - <5mls/hr ```

Question 32

types of shock

Answer 32

distributive - hypovolaemia eg sepsis, anaphylaxis, neurogenic hypovolaemia - haemorrhage, burns, substantial fluid loss cardiogenic - relative or absolute reduction in cardiac output due to a primary cardiac disorder - also have raised JVP or arryhthmias - causes MI, HR, arryhtmias - mx aim is increasing CO, improving cardiac perfusion, decreasing cardiac workload obstructive shock - when physical impedence to blood flow - causes saddle PE, cardiac tamponade - aim of mx remove obstruction quick (eg pericardiocentesis/anticoag)

Question 33

what manoeuvre can you perform when someone is in shock and you dont have access to fluids

Answer 33

passive leg raise

Question 34

what score can you use to determine whether to CT scan post neck injury and when is it applicable

Answer 34

canadian c spine score applicable if patient is alert and stable following trauma

Question 35

what is a burn | what is a scald

Answer 35

Injury by thermal, chemical, electrical or radiation energy Contact with hot liquid or steam

Question 36

initial assessment of burns

Answer 36

ABCDE (prevent hypothermia) ± need for fluid resuscitation look in nostrils for inhalation injury

Question 37

assessing area of burns

Answer 37

``` rule of 9's!!!! Arm 9% Head 9% each Leg 18% Torso (front) 18% Torso (back) 18% ```

Question 38

5 depths of burns

Answer 38

1. Epidermal/superficial partial thickness (description) Pain, red, glistening, NO blisters, brisk capillary refill. Heal in one week no scarring 2. Superficial dermal Pale pink/mottled, swelling, SMALL blisters ± weeping, brisk capillary refill. Heal 3 weeks minimal scarring 3. Deep dermal Cherry red, blistering, dry, blotchy, no blanching, no capillary refill, reduced sensation. 3-8 weeks healing with scarring ± surgical treatment 4. Full-thickness (third degree) White/black, dry, no blisters, np capillary refill, no sensation. Requires surgical repair/graft 5. Fourth-degree Includes subcut fat, muscle + bone. Reconstruction ± amputation

Question 39

ix for burns

Answer 39

Bloods - FBC, crossmatch, carboxyhaemogobin, serum glucose, U+E, ABG CXR Cardiac monitoring - Dysrhythmia for hypoxia and electrolyte disturbances *Circulation - BP may be difficult and unreliable - Monitor urine hourly therefore urinary catheter

Question 40

first aid mgmt of burns

Answer 40

1. Stop the burning + cool - Remove clothing, if stuck cool with water - Brush chemical powders away - Rinse in tap water (cold tap not ice - vasoconstriction) 20 minutes n.b. can cause hypothermia - Remove constricting clothing and cover with clean/dry linens for hypothermia 2. Minor burn (dress + analgesia) - Clean with soap and water - Leave blisters < 1cm intact (reduce infection), aspirate large blisters - Non adhesive gauze dressings (re-examine at 48 hours) - If infection occurs - daily wound inspection + dressing change + 7 days flucloxacillin - Give analgesia + check tetanus prophylaxis

Question 41

major burn worries

Answer 41

Direct thermal injury -> airway oedema/obstruction Carbon monoxide poisoning Inhalation of smoke -> pneumonia + oedema

Question 42

mgmt of major burns

Answer 42

Airway Look for indications of inhalation injury (heat) -> hoarseness, singed nostril hairs, face/neck burns ET intubation and ventilation (stridor) + transfer to burn centre Breathing ABG (note PaO2 not good with CO poisoning) 100% O2 + COHB levels Elevated head and chest 25 degrees to reduce oedema Circulation* IV access and fluid replacement if > 15% (total s.a.) adults and 10% children Replacement in first 24 hours FROM time of injury Aim for 0.5-1ml/kg urine adults and 1-2ml/kg children Adults - partial/full thickness burns/inhalation injury = Parkland formula 4ml / kg / %total body area of Hartmann’s/Ringer’s lactate = 4 x weight x % Half in first 8 hours, half in following 16 hours ``` Children also receive maintenance calculated as expected 4/2/1 Pain relief (strong opioids) + prevent hypothermia ```

Question 43

burns comps

Answer 43

Fluid loss, infection, scarring (minimised by graft in under 3 weeks)

Question 44

when to refer to specialist burns unit

Answer 44

<5 or >60 Site: face, hands, perineum, flexure e.g. armpit Inhalation injury Suspected NAI Large area: >5% if under 16, >10% if over 16

Question 45

flail chest what is it can cause O/E mgmt

Answer 45

This is a life threatening injury that occurs when a segment of the rib cage (3 or more ribs) breaks due to trauma and becomes detached from the rest of the chest wall (i.e. unable to contribute to rib expansion) Indicative of pulmonary contusion. May puncture lung and cause pneumothorax O/E: paradoxical movement i.e. indrawing on inspiration Management involves ventilation PPV (n.b. Intubation and ventilation will exacerbate a pneumothorax or tension pneumothorax) + pain control (intercostal blocks) + pulmonary toilet

Question 46

reversible causes of cardiac arrest

Answer 46

5Hs + 4ts ``` Hypoxia Hypovolaemia Hypo/hyperkalaemia Hypothermia H+ ions - acidosis ``` Thrombosis (coronary or pulmonary) Tamponade (cardiac) Toxins Tension pneumothorax

Question 47

major haem lethal triad

Answer 47

Hypothermia, acidosis, acute coagulopathy of trauma*

Question 48

major haemorrhage protocol

Answer 48

Blood on the floor and 4 more… chest, pelvis, abdomen/retroperitoneum, thigh For chest/abdo/pelvis may use REBOA - resuscitative balloon occlusion of the aorta 1. stop the bleeding - Splint, pressure, haemostatic agents (tranexamic acid IV), REBOA 2. replace the fluid - Fluids + blood + blood products (FFP, cryoprecipitate) - RBC - 4 units, FFP - 4 units, Platelets - 1 unit

Question 49

explain acute coagulopathy of trauma

Answer 49

Caused by shock and hypoperfusion not hypothermia, haemodilution or acidosis It occurs early in trauma

Question 50

what are patients at risk of during surgery

Answer 50

``` Surgery - damage to structures - blood loss - complications Effect of anaesthesia Pre-existing disease ```

Question 51

pre-op prep

Answer 51

``` Optimise medical conditions Adjust medication Check investigations Check weight EXPLAIN AND CONSENT ```

Question 52

pre op assessment: ASA grade

Answer 52

1. Healthy individual 0.05% mortality 2. Mild systemic disease not limiting activity 0.5% 3. Severe systemic limiting activity, not incapacitating 5% 4. Incapacitating systemic disease, life threatening 25% 5. Expected survival <24 hours without surgery 50% 6. Brain stem dead - organ retrieval

Question 53

pre-op assessment: anaesthetics

Answer 53

relevant anaesthetic history - any problems, including nausea and vom? problems with family with anaesthetic? allergies - eggs? (propofol) DH - and stopped approp ones? ACEi, ARB, warf, clopido, aspirin, steroid? (continue, IV in surg) pmh - CV HTN, pacemaker, resp OSA, asthma + NSAIDs, exercise tolerance, GI - reflux, DM, thyroid, DVT/PE, rheum, smoking, alc, other drugs (increase tolerance) O/E heart +lungs teeth - expensive? missing? loose? explain might catch neck flexibility - >90 degrees is good airway assess - RA, anky spon, obese, small neck, downs, small mouth, large tongue, beard ``` mallampati - oropharynx: Class 4: soft palate not visible Class 3: soft palate only Class 2: uvula tip masked Class 1: pillars, soft palate, uvula ``` thyromental test: length from tip of chin to adams apple in extension >6.5cm

Question 54

anaesthetic triad

Answer 54

anaesthesia analgesia muscle relaxation

Question 55

3 phases and 2 routes of anaesthetic

Answer 55

PHASES Induction - secure airway, pre- oxygenate Maintenance Reversal 2 ROUTES IV - propofol Inhaled (iso/sevo/desfluorane) @young children/ needle phobics

Question 56

induction agents

Answer 56

Propofol - painful on injection Sevofluorane - minimal vasodilation, almost zero metabolism (taken up by and excreted via lungs), irritant, taken up in fat tissue -> prolonged drowsiness Nitrous oxide - analgesic properties, low solubility -> rapid onset and offset can use opioids but may cause resp depression: 1. Remifentanil Tiny doses, breaks down spontaneously in 10-15s, used in TIVA 2. Alfentanyl Potent, rapid onset, duration 2-3 mins 3. Fentanyl Onset 1-2 mins, duration 10-15 mins 4. Morphine More histamine release - PONV, slow onset (10-15 mins), causes constipation

Question 57

maintenance agents

Answer 57

GASEOUS Volatile N20/02 isofluorane, desfluorane, sevofluorane TIVA Propofol infusion + remifentanil infusion

Question 58

if use muscle relaxant what do you need to consider

Answer 58

MUST BE VENTILATED

Question 59

what GCS requires airway adjunts?

Answer 59

<8

Question 60

how to ensure correct placement of endotrachael tube?

Answer 60

1 - chest movement 2 - misting of mask 3- trace on capnography

Question 61

mechanism of LA

Answer 61

Unionised LA enters cell LA becomes ionised Blocks Na channel

Question 62

where can LA be used for anaesthetic

Answer 62

Nerve block (peripheral) Plexus block Epidural block Spinal block (good at respiratory compromise)

Question 63

compare lidocaine and bupivocaine

Answer 63

``` lidocaine Immediate 15 minutes Small procedure Laceration Chest drain ``` bupivocaine 10 minutes 2 hours anaesthesia, 12 hours analgesia Regional blocks

Question 64

advantages of regional anaesthetics

Answer 64

``` Avoids GA Can be awake Avoid airway problems Less nausea and vomiting Better peri-operative pain control ```

Question 65

dermatomes

Answer 65

``` Shoulder - C5 Thumb - C6 Middle finger - C7 Little finger - C8 Nipples - T4 Umbilicus - T10 Knee - L4 Little toe - S1 ```

Question 66

spinal vs epidural

Answer 66

``` spinal through ligaments and dura (deeper) LA as bolus duration - 2 hours comp - CSF leak headache ``` epidural - goes between ligaments and dura uses LA via catheter as infusion

Question 67

muscle relaxants 3 purposes 2 types

Answer 67

Relax opening to trachea (glottis) Relax muscles for surgery Patients do not fight ventilators 2 types depolarising - suxamethonium, onset 30seconds, emergencies non-depolarising - atracurium, rocuronium onset 2-3mins,routine ops

Question 68

muscle relaxant reversal

Answer 68

neostigmine

Question 69

how to work out BP(equation)

Answer 69

PVR X CO CO = SV X HR

Question 70

heart too slow?

Answer 70

Inhibit vagus (PSNS) PSNS uses ACh as an NT Use anticholinergics to increase HR atropine glycopyrrolate hyoscine or dobutamine - stimulate myocardium

Question 71

BP too low?

Answer 71

adrenaline | epinephrine

Question 72

BP low and HR slow

Answer 72

Stimulate 𝜶 and β adrenoreceptors with combined 𝜶 and β agonist e.g. ephedrine or adrenaline (very potent therefore only @arrest/ITU)

Question 73

how does NSAIDs work

Answer 73

inhibit cyclo-oxygenase

Question 74

how does CPAP work and problems

Answer 74

increase intrathoracic pressure improves FRC and oxygenation ``` cons discomfort non-compliance gastric distention aspiration no impact on CO2 ```

Question 75

how does BiPaP aka NPPV work and cons

Answer 75

increases tidal volume better co2 clearance, reverses resp acid ``` cons discomfort gastic distention aspiration failure ```

Question 76

which NIV is indicated in T1RF

Answer 76

CPAP maintains minimum airway pressure alveolus held open fluid forced from lung

Question 77

which NIV is indicated in T2RF

Answer 77

BiPAP insp it adds insp pressure - IPAP which further expands lungs and increases ventilation exp - adds EPAP, holds open collapsing airway

Question 78

resp failure differentials

Answer 78

Pneumonia Atelectasis (collapsed units), pneumothorax Pulmonary oedema Thromboembolic disease Bronchospasm/obstruction, pre-existing, ARDS, increased metabolic demand Central respiratory depression