A-E assessment Flashcards
How to assess airway in pt cannot talk?
Look, listen, inspect
Look for signs of airway compromise:
* angioedema
* cyanosis
* see-saw breathing
* use of accessory muscles
Listen for abnormal airway noises:
* stridor
* snoring
* gurgling
inspect: look for obstructions:
* secretions
* foreign object
Seesaw motion suggests impaired gas exchange. Might need mechanical ventilation as it suggests resp failure due to diaphragmatic or respiratory muscle fatigue.
What are some causes of airway compromise?
- Inhaled foreign body
- Blood in the airway: epistaxis, haematemesis and trauma
- Vomit/secretions in the airway: alcohol intoxication, head trauma and dysphagia
- Soft tissue swelling: anaphylaxis and infection (e.g. quinsy, sub-mandibular gland swelling)
- Local mass effect: tumours and lymphadenopathy (e.g. lymphoma)
- Laryngospasm: asthma, GORD and intubation
- Depressed level of consciousness: opioid overdose, head injury and stroke
What should you do if you see airway obstruction during your A-E?
- Seek immediate expert support from anaesthetist and crash team
- Basic airway manoeuvres while you wait for senior input
What are some specific manoeuvres you could do for airway?
- Head-tilt chin-lift manoeuvre
- Jaw thrust
How to perform a head-tilt chin-lift manoeuvre?
- Place one hand on the patient’s forehead and the other under the chin.
- Tilt the forehead back whilst lifting the chin forwards to extend the neck
- Inspect the airway for obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to try and remove it.
When is a jaw thrust better than a head-tilt chin-lift?
If the patient is suspected of having suffered significant trauma with potential spinal involvement,
How do you perform a Jaw thrust?
- Identify the angle of the mandible
- Place two fingers under the angle of the mandible (on both sides) and anchor your thumbs on the patient’s cheeks
- Lift the mandible forwards
What are some airway adjuncts you could use to maintain a pts airway?
oropharyngeal airway
asopharyngeal airway
Which airway adjunct is better for a conscious pt?
NPAs are typically better tolerated in partly or fully conscious patients than oropharyngeal airways.
Specific causes of airway compromise:
Anaphylaxis :
what should be the rapid treatment?
IM adrenaline
Specific causes of airway compromise:
Blood, vomit, secretion in airway :
what should be the rapid treatment?
Suction
Pt positioned in the left lateral position
Specific causes of airway compromise:
Stridor :
what should be the rapid treatment?
sit the patient upright, urgent anaesthetic/ENT input
Specific causes of airway compromise:
Foreign body :
what should be the rapid treatment?
basic life support choking algorithm
Breathing: when you observe the patient what is a normal respiratory rate?
between 12-20 breaths per minute
What are some causes of Bradypnoea?
- sedation
- opioid toxicity
- raised intracranial pressure (ICP)
- exhaustion in airway obstruction with CO2 retention/narcosis (e.g. COPD)
What are some causes of Tachypnoea?
schema: resp vs non resp
RESP:
- airway obstruction
- asthma
- pneumonia
- PE
- pneumothorax
- pulmonary oedema
NON RESP
* heart failure
* anxiety
Breathing: you review the pts 02 sats
what are normal Sp02 ranges?
- 94-98% in healthy individuals
- 88-92% in patients with COPD at high risk of CO2 retention
Breathing: the pts oxygen sats are low: what are some causes of Hypoxaemia?
*PE
*aspiration
*COPD
*asthma
*pulmonary oedema
Breathing: General inspection - what signs might you see suggesting underlying pathology?
- Cyanosis
- Shortness of breath
- Cough
- Stridor
- Cheyne-Stokes respiration
- Kussmaul’s respiration
Breathing: Cyanosis
what is it? What might be the cause?
What?
* bluish skin discolouration due to poor circulation
Cause
* e.g. peripheral vasoconstriction secondary to hypovolaemia
* inadequate oxygenation, e.g. right-to-left cardiac shunting
Breathing: SOB
what are signs may see in SOB?
- nasal flaring
- pursed lips
- use of accessory muscles
- intercostal muscle recession
- tripod position
- The inability to speak in full sentences indicates significant shortness of breath.
Breathing: Cough
possible causes?
Productive cough:
* pneumonia
* bronchiectasis
* COPD
* cystic fibrosis.
A dry cough may suggest:
* asthma
* interstitial lung disease.
Breathing: Stridor
what is it?
what causes it?
What?
* a high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways.
Causes?
* foreign body inhalation (acute)
* subglottic stenosis (chronic
Breathing: Cheyne-Stokes respiration
what is it? what causes it?
What?
* Cyclical apnoeas, with varying depth of inspiration and rate of breathing.
Cause:
* stroke
* raised ICP
* pulmonary oedema
* opioid toxicity
* hyponatraemia
* carbon monoxide poisoning.
Breathing: Kussmaul’s respiration
what is it? what causes it?
What?
* deep, sighing respiration
Cause:
* associated with metabolic acidosis (e.g. diabetic ketoacidosis).
Breathing: Tracheal position
What conditons cause the trachea to deviate AWAY from it?
- tension pneumothorax
- large pleural effusions
Breathing: Tracheal position
What conditons cause the trachea to deviate TOWARDS it?
- towards lobar collapse
- pneumonectomy
Breathing: chest expansion to look for reduced chest wall movement.
What could symmetrical reduced chest expansion indicate?
- pulmonary fibrosis
reduces lung elasticity, restricting overall chest expansion
Breathing: chest expansion to look for reduced chest wall movement.
What could ASYMMETRICAL chest expansion indicate?
- pneumothorax
- pneumonia
- pleural effusion
Breathing: Percussion of the chest
what finding would be ‘normal’?
should be resonant in healthy individuals
Breathing: Percussion of the chest
what are some abnormal findings and what would they indicate?
- Dullness: suggests increased tissue density (e.g. cardiac dullness, consolidation, tumour, lobar collapse)
- Stony dullness: an underlying pleural effusion
- Hyper-resonance: the opposite of dullness, suggestive of decreased tissue density (e.g. pneumothorax)
Breathing:
You auscultate the chest
what are some abnormalities you can find?
- Bronchial breathing
- Quiet/reduced breath sounds
- Wheeze
- Coarse crackles
- Fine end-inspiratory crackles
Breathing: Auscultate
Bronchial breathing
What is it? What could it indicate?
What?
* harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal, and there is a pause between.
Indicate:
* associated with consolidation
Breathing: Auscultate
Quiet/reduced breath sounds:
What is it? What could it indicate?
suggest reduced air entry into that lung region (e.g. pleural effusion, pneumothorax).
Breathing: Auscultate
Wheeze
What is it? What could it indicate?
What?
* a continuous, coarse, whistling sound produced in the respiratory airways during breathing (expiration).
Indicate:
* Wheeze is often associated with asthma, COPD and bronchiectasis.
Breathing: Auscultate
Coarse crackles:
What is it? What could it indicate?
What?
* discontinuous, brief, popping lung sounds
Indicate:
* typically pneumonia, bronchiectasis and pulmonary oedema.
Breathing: Auscultate
Fine end-inspiratory crackles:
What is it? What could it indicate?
What?
* often described as sounding similar to the noise generated when separating velcro.
Indicate:
* Fine end-inspiratory crackles are associated with pulmonary fibrosis.
What are some investigations you might order while assessing breathing? why?
ABG
* asses hypoxia severity and look for underlying causes
CXR
* Portable xray
* suspect pneumonia, pneumothorax, pulmonary oedema
What are some interventions you might implement in Breathing?
Patient position
* upright - help with oxygenation
O2
* non-rebreathe mask with an oxygen flow rate of 15L.
* trial titrating oxygen levels downwards after your initial assessment.
Breathing: Interventions if your pt has COPD?
- target SpO2 levels accordingly (88-92%)
- consider using a venturi mask: 24% (4L) or 28% (4L)
- Consider discussing non-invasive ventilation (NIV) with a senior in acute exacerbations of COPD if evidence of type 2 respiratory failure.
Breathing: specific interventions in case of acute asthma?
- nebulised bronchodilators (salbutamol/ipratropium),
- orticosteroids and other agents (e.g. magnesium sulphate, aminophylline)
- oxygen 2. salbutamol nebs and pred 3. ipratropium. 4. mag sulph IV 5. escalate
Breathing: specific interventions in case of Exacerbation of COPD?
- bronchodilators (salbutamol/ipratropium),
- corticosteroids, antibiotics (if evidence of infection)
Circulation: Observation heart rate
what is a normal HR ?
A normal resting heart rate can range between 60-99 beats per minute
Circulation: What are some causes of tachycardia?
HR>99
* hypovolaemia
* arrhythmia
* infection
* hypoglycaemia
* thyrotoxicosis
* anxiety
* pain
* drugs (e.g. salbutamol)
Circulation: What are some causes of bradycardia?
(HR<60)
* acute coronary syndrome (ACS)
* ischaemic heart disease
* electrolyte abnormalities (e.g. hypokalaemia)
* drugs (e.g. beta-blockers)
Circulation: BP
what is a normal range?
What should you do when assessing a pts BP?
Normal range: 90/60mmHg and 140/90mmHg,
- Review previous readings to gauge the patient’s usual baseline BP
Circulation: BP what are some causes of hypertension
- hypervolaemia
- stroke
- Conn’s syndrome
- Cushing’s syndrome
- pre-eclampsia
Severe hypertension (systolic BP > 180 mmHg or diastolic BP > 100 mmHg)
may present with
* confusion
* drowsiness
* breathlessness
* chest pain
* visual disturbances.
Circulation: some causes of Hypotension
- hypovolaemia
- sepsis
- adrenal crisis
- drugs (e.g. opioids, antihypertensives, diuretics).
Circulation: Fluid balance assessement : how to
- Calculate using the pts fluid balance chart (e.g. oral fluids, IV fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts
Circulation: how is reduced urine output (oliguria) defined? WHat are some causes?
Defined as:
* less than 0.5ml/kg/hour in an adult
Causes:
* dehydration
* hypovolaemia
* reduced cardiac output
* acute kidney injury
Circulation: General inspection, what can Pallor suggest?
suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure)
Circulation: general observation: what can oedema suggest?
typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (ascites) and may indicate underlying heart failure
Circulation : you assess the patients temp by placing the dorsal aspect of your hand on the pts.
What would cool hands indicate?
What would cool and sweaty hands indicate?
Cool hands
* poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome)
Cool AND sweaty/clammy hands
* poor peripheral perfusion and autonomic dysfunction (e.g. acute coronary syndrome
Circulation: Capillary refill time
where to check?
Abnormal findings and why?
Check
* centrally on the sternum and compare to peripheral CRT on fingertip
- peripheral CRT > 2 seconds suggests poor peripheral perfusione e.g. hypovolaemia, congestive heart failure) and the need to assess central CRT
Circulation: When assessing radial and brachial pusle what are you assessing?
Rate, rhythm, volume and character
Circulation: pulse
An irregular pulse is associated with …
arrhythmias such as atrial fibrillation
Circulation: pulse
A slow-rising pulse is associated with…
Aortic stenosis
Circulation: pulse
A pounding pulse is associated with …
Aortic regurgitation as well as CO2 retention
Circulation: pulse
Circulation: pulse
A thready pulse is associated with…
intravascular hypovolaemia (e.g. sepsis).
Circulation: JVP
what are causes of a raised JVP?
Right HF
* caused by Left HF (e.g. secondary to fluid overload).
* Pulmonary HTN due to COPD, ILD
Tricuspid regurgitation:
* infective endocarditis and rheumatic heart disease.
Constrictive pericarditis:
* idiopathic
* RA, TB underlying causes.
Circulation: Auscultation of the heart
what are some acute cardiovascular conditions you could find?
- pericardial rub or muffled heart sounds —–> underlying pericarditis or cardiac tamponade
- A third heart sound —> congestive heart failure
- A new / recent murmur —-> recent MI (e.g. papillary muscle rupture) or endocarditis
Circulation: Ankles and sacrum what checking and cause?
Assess for evidence of oedema,
typically associated with heart failure.
Circulation: What are some interventions could do here?
(headings for now)
- Cannula
wide-bore 14G or 16G - Blood tests FBC, U&E, LFT and cultures
- ECG
- Bladder scan - retention / obstruction
- Urine pregnancy test
- Cultures / swabs e.g. sputum, urine, line
- Fluid output / Catheterisation
- Fluid resuscitation
- Blood transfusion
Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you conisder if you suspect:
sepsis?
CRP, lactate and blood cultures
Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:
Haemorrhage or surgical emergency?
coagulation and cross-match
Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:
Acute coronary syndrome?
troponin
Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:
Arrhythmia?
Calcium, magnesium, phosphate, thyroid function tests, coagulation
Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:
Pulmonary embolism?
D-dimer (if appropriate based on Well’s score)
Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:
Overdose?
toxicology screen (e.g. paracetamol levels)
Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:
Anaphylaxis?
consider serial mast cell tryptase levels
Circulation: You have recorded a 12 lead ECG, in what pts would you consider continuous cardiac monitoring?
critically unwell patients (e.g. MI, severe electrolyte abnormalities requiring replacement).
Disability: How to asess a pts Consciousness?
ACVPU scale:
* Alert: fully alert
* Confusion: new onset / worse confusion
* Verbal: response when you talk to them (e.g. words, grunt)
* Pain: responds to a painful stimulus (e.g. supraorbital pressure)
* Unresponsive: no evidence of any eye, voice or motor responses to pain
for a more detailed assessment of the patient’s level of consciousness, use the Glasgow Coma Scale (GCS).
What are causes of depressed consciousness?
- Hypovolaemia
- Hypoxia
- Hypercapnia
- Metabolic disturbance (e.g. hypoglycaemia)
- Seizure
- Raised intracranial pressure or other neurological insults (e.g. stroke)
- Drug overdose
- Iatrogenic causes (e.g. administration of opiates)
Disability: Pupils
what inspect / Asess?
Inspect:
* size and symmetry of the patient’s pupils
Assess
* direct and consensual pupillary responses which may reveal evidence of intracranial pathology (e.g. stroke).
Disability: Pupils
what might:
* pinpoint
* Dilated
* Asymetrical
pupils indicate?
pinpoint pupils
* opioid overdose
dilated pupils
* tricyclic antidepressant overdose)
Asymmetrical pupillary size
* intracerebral pathology (e.g. stroke, space-occupying lesion, raised intracranial pressure).
Disability: brief neuro assessment
Perform a brief neurological assessment by asking the patient to move their limbs.
If a patient cannot move one or all of their limbs, this may be a sign of focal neurological impairment, which requires a more detailed assessment.
Disability: why might a quick drug chart review be helpful?
Review the patient’s drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives, anxiolytics).
Disability : investigations
- Blood glucose and ketones
- CT head if intracranial pathology is suspected after discussion with a senior.
Disability: Investigations
Blood glucose:
normal fasting plasma glucose?
Hypoglycaemia def in hospitalised pt?
The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.
Hypoglycaemia if plasma glucose less than 3.0 mmol/l.
In hospitalised patients, treat a blood glucose ≤4.0 mmol/L if symptomatic.
Disability: Interventions …
- Maintain airway if concerned about pt conscious level
- GCS or 8 or lower
- P or U on ACVPU scale
- urgent expect help
- Correct hypoglycaemia
Disability: what are specific interventions for
* Opioid overdose
* DKA
* Seizures
* Hypercapnia
Opioid overdose:
* ventilation, naloxone
DKA
* intravenous fluids and insulin
Seizures
* maintain airway, benzodiazepines
Hypercapnia
* urgent senior clinician review for consideration of ventilation
Exposure: …..
- ask if in pain
Inspect:
* rashes (men sepsis)
* Bruising (coag, trauma, surgery)
* signs of infection (cellulitis)
Review:
* insitu IV line for erythema / discharge
Expose:
* Abdomen for distention / hernia
* calves for erythema / swelling (DVT)
* Surgical woulds for Haematoma, bleeding, infeciton (purulent discharge)
* Output of pts catheter / surgical drains for blood, fluid loss and pus
Exposure: Palpate…
Briefly palpate the abdomen for signs of peritonism or other life-threatening pathology (e.g. abdominal aortic aneurysm).
Palpate the calves for tenderness which may suggest a deep vein thrombosis.
Exposure : temp
What is normal?
causes of high temp?
Causes of a low temp?
A normal body temperature range is between 36°c – 37.9°c
- > 38°c is most commonly caused by infection (e.g. sepsis)
- <36°c may also be caused by sepsis or cold exposure (e.g. drowning, inadequate clothing outside)
Exposure: investigations
- Cultures / swabs for infeciton source e.g. line tip
Exposure: interventions
Control bleeding
* active: stop loss, estimate total blood loss and rate of blood loss
* re-assess for signs of hypovolaemia shock e.g. hypotension, tachy, pre-syncope)
Warm patient
* blankets
* active warming e.g. Bair Hugger or warmed fluids
Treat infection
* e.g surgical wound leaking pus - reassess for signs of sepsis and start sepsis 6 if appropriate
After you have done your A-E what next?
Re-assess using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.
Any clinical deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
Escalating to other teams using an SBAR handover…..
What teams that might be approproate to call based on where in the A-E the problem is?
