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
