A&E + anaesthetics Flashcards
A-E assessment
- things to remember
- the assessment - what you physically would do
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
SBAR handover
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
causes of airway compromise
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
what does bronchial breathing mean
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.
what does quiet/reduced breath sounds mean
suggest reduced air entry into that region of the lung (e.g pleural effusion, pneumothorax)
what does wheeze mean
continuous, coarse, whistling sound produced in the respiratory airways during breathing. Wheeze is often associated with asthma, COPD and bronchiectasis.
what does stridor mean
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).
what does coarse crackles mean
discontinuous, brief, popping lung sounds typically associated with pneumonia, bronchiectasis and pulmonary oedema
what does fine end-insp crackles mean
often described as sounding similar to the noise generated when separating velcro. Fine end-inspiratory crackles are associated with pulmonary fibrosis.
causes of tachycardia
hypovolaemia, arrythmia, infection, hypoglycaemia, thryotoxicosis, anxiety, pain, drugs (eg salbutamol)
causes of bradycardia
ACS, IHD, electrolyte imbalances (hypokalaemia), drugs (BB)
causes of hypertension +
presentation of severe hypertension
hypervolaemia stroke conn's syndrome cushings pre-eclampsia
pres of severe:
confusion, drowsiness, breathlessness, chest pain, visual disturbance
causes of hypotension
hypovolaemia, sepsis, adrenal crisis, drugs (opioids, antihypertensives, diuretics)
what is the definition of oliguria + causes
0.5ml/kg/hour in adult
dehydration, hypovolaemia, low CO, AKI
what does these findings mean on pulse:
- irregular
- slow-rising
- pounding
- thready
irregular - arryhythmias (AF)
slow-rising - aortic stenosis
pounding - aortic regurg , CO2 retention
thready - intravascular hypovolaemia eg sepsis
what causes a raised JVP?
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)
ejection systolic murmur
aortic stenosis
early diastolic murmur
aortic regurg
mid-diastolic murmur
mitral stenosis
pan-systolic
mitral regurg
murmur of recent onset =
MI or endocarditis
pericardial rub or muffled heart sounds
pericarditis
3rd heart sound?
congestive heart failure
what specific blood tests would you want if you suspected: sepsis haemorrhage or surg emergency ACS arrhythmia PE overdose anaphylaxis
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
causes of depressed consciousness
hypovolaemia hypoxia hypercapnia metabolic disturbance - eg hypoglycaemia seizure raised ICP or neuro insult eg stroke drug overdose iatrogenic causes eg admin of opiates
Major trauma assessment
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.
what injuries will you expect in burns
dehydration - fluid requirements
inhalation injury
what mx would you expect when patient has been exposed to extreme cold
continue resus until warmed
high-voltage electricity injuries
extensive muscle injury likely to be concealed
name types of bleeding and explain what they mean
primary - during surgery
secondary - withing 24hrs of op
secondary - withing 7-10 days of op
classifying haemorrhagic shock
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
types of shock
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)
what manoeuvre can you perform when someone is in shock and you dont have access to fluids
passive leg raise
what score can you use to determine whether to CT scan post neck injury and when is it applicable
canadian c spine score
applicable if patient is alert and stable following trauma
what is a burn
what is a scald
Injury by thermal, chemical, electrical or radiation energy
Contact with hot liquid or steam
initial assessment of burns
ABCDE (prevent hypothermia) ± need for fluid resuscitation
look in nostrils for inhalation injury
assessing area of burns
rule of 9's!!!! Arm 9% Head 9% each Leg 18% Torso (front) 18% Torso (back) 18%
5 depths of burns
- Epidermal/superficial partial thickness (description)
Pain, red, glistening, NO blisters, brisk capillary refill. Heal in one week no scarring - Superficial dermal
Pale pink/mottled, swelling, SMALL blisters ± weeping, brisk capillary refill. Heal 3 weeks minimal scarring - Deep dermal
Cherry red, blistering, dry, blotchy, no blanching, no capillary refill, reduced sensation. 3-8 weeks healing with scarring ± surgical treatment - Full-thickness (third degree)
White/black, dry, no blisters, np capillary refill, no sensation. Requires surgical repair/graft - Fourth-degree
Includes subcut fat, muscle + bone. Reconstruction ± amputation
ix for burns
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
first aid mgmt of burns
- 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 - 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
major burn worries
Direct thermal injury -> airway oedema/obstruction
Carbon monoxide poisoning
Inhalation of smoke -> pneumonia + oedema
mgmt of major burns
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
burns comps
Fluid loss, infection, scarring (minimised by graft in under 3 weeks)
when to refer to specialist burns unit
<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
flail chest what is it
can cause
O/E
mgmt
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
reversible causes of cardiac arrest
5Hs + 4ts
Hypoxia Hypovolaemia Hypo/hyperkalaemia Hypothermia H+ ions - acidosis
Thrombosis (coronary or pulmonary)
Tamponade (cardiac)
Toxins
Tension pneumothorax
major haem lethal triad
Hypothermia, acidosis, acute coagulopathy of trauma*
major haemorrhage protocol
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
- stop the bleeding - Splint, pressure, haemostatic agents (tranexamic acid IV), REBOA
- replace the fluid - Fluids + blood + blood products (FFP, cryoprecipitate) - RBC - 4 units, FFP - 4 units, Platelets - 1 unit
explain acute coagulopathy of trauma
Caused by shock and hypoperfusion not hypothermia, haemodilution or acidosis
It occurs early in trauma
what are patients at risk of during surgery
Surgery - damage to structures - blood loss - complications Effect of anaesthesia Pre-existing disease
pre-op prep
Optimise medical conditions Adjust medication Check investigations Check weight EXPLAIN AND CONSENT
pre op assessment: ASA grade
- Healthy individual 0.05% mortality
- Mild systemic disease not limiting activity 0.5%
- Severe systemic limiting activity, not incapacitating 5%
- Incapacitating systemic disease, life threatening 25%
- Expected survival <24 hours without surgery 50%
- Brain stem dead - organ retrieval
pre-op assessment: anaesthetics
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
anaesthetic triad
anaesthesia
analgesia
muscle relaxation
3 phases and 2 routes of anaesthetic
PHASES
Induction - secure airway, pre- oxygenate
Maintenance
Reversal
2 ROUTES
IV - propofol
Inhaled (iso/sevo/desfluorane) @young children/ needle phobics
induction agents
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
maintenance agents
GASEOUS
Volatile
N20/02
isofluorane, desfluorane, sevofluorane
TIVA
Propofol infusion + remifentanil infusion
if use muscle relaxant what do you need to consider
MUST BE VENTILATED
what GCS requires airway adjunts?
<8
how to ensure correct placement of endotrachael tube?
1 - chest movement
2 - misting of mask
3- trace on capnography
mechanism of LA
Unionised LA enters cell
LA becomes ionised
Blocks Na channel
where can LA be used for anaesthetic
Nerve block (peripheral)
Plexus block
Epidural block
Spinal block (good at respiratory compromise)
compare lidocaine and bupivocaine
lidocaine Immediate 15 minutes Small procedure Laceration Chest drain
bupivocaine
10 minutes
2 hours anaesthesia, 12 hours analgesia
Regional blocks
advantages of regional anaesthetics
Avoids GA Can be awake Avoid airway problems Less nausea and vomiting Better peri-operative pain control
dermatomes
Shoulder - C5 Thumb - C6 Middle finger - C7 Little finger - C8 Nipples - T4 Umbilicus - T10 Knee - L4 Little toe - S1
spinal vs epidural
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
muscle relaxants
3 purposes
2 types
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
muscle relaxant reversal
neostigmine
how to work out BP(equation)
PVR X CO
CO = SV X HR
heart too slow?
Inhibit vagus (PSNS)
PSNS uses ACh as an NT
Use anticholinergics to increase HR
atropine
glycopyrrolate
hyoscine
or dobutamine - stimulate myocardium
BP too low?
adrenaline
epinephrine
BP low and HR slow
Stimulate 𝜶 and β adrenoreceptors with combined 𝜶 and β agonist
e.g. ephedrine or adrenaline (very potent therefore only @arrest/ITU)
how does NSAIDs work
inhibit cyclo-oxygenase
how does CPAP work and problems
increase intrathoracic pressure
improves FRC and oxygenation
cons discomfort non-compliance gastric distention aspiration no impact on CO2
how does BiPaP aka NPPV work and cons
increases tidal volume
better co2 clearance, reverses resp acid
cons discomfort gastic distention aspiration failure
which NIV is indicated in T1RF
CPAP
maintains minimum airway pressure
alveolus held open
fluid forced from lung
which NIV is indicated in T2RF
BiPAP
insp it adds insp pressure - IPAP which further expands lungs and increases ventilation
exp - adds EPAP, holds open collapsing airway
resp failure differentials
Pneumonia
Atelectasis (collapsed units), pneumothorax
Pulmonary oedema
Thromboembolic disease
Bronchospasm/obstruction, pre-existing, ARDS,
increased metabolic demand
Central respiratory depression
