A-E assessments (SMART) Flashcards
You were called by a staff nurse on a general surgical ward to see an unwell 75 year old lady, 5 days post-Hartmann’s for diverticulitis-related bowel obstruction.
a) Perform an A-E assessment on them, picking out all relevant components.
b) Give some differentials for acute deterioration in the post-operative patient
Airway.
- patent? (talking = yes)
- abnormal sounds/ cyanosis/ see-saw breathing, etc.
- Obvious obstructions (eg. vomit for suctioning)
- Simple manouevres + adjuncts as necessary
- If these fail, put out 2222
- Once happy with airway, move onto breathing
Breathing.
- High-flow oxygen (15L/min) via non-rebreathe mask (unless KNOWN retainer* - 4L/min via Venturi 24-28%, aiming for SpO2 88-92%)
- Obs: RR? SpO2? (are they on air or oxygen?)
- Attach a sats probe on if not on already
- Resp exam: tracheal deviation, chest expansion, percussion, auscultation (?pneumonia, pneumothorax, etc.)
- If patient is hypoventilating, provide ventilation via a BVM at a rate of ~ 12/min (every 5 seconds)
- Once happy with breathing, move on to circulation
- Note: only 10% of COPD patients are chronic retainers. Also, hypoxia will kill before hypercapnia; make sure sats are at least up to 88-92%, before worrying about CO2 retention
Circulation.
- Assess fluid status: colour, warmth, clamminess, CRT, pulse and BP, mucous membranes, urine output, signs of dehydration/ overload?
- Catheterise if not already (check catheter- cloudy?)
- Auscultate heart sounds
- 12-lead ECG, then heart monitoring
- Temperature
- 2x wide-bore cannulae in ACF, take bloods (FBC, CRP, UEs/creatinine, clotting, group/save, X-match, lactate, glucose BM, +/- cultures)
- IV fluid bolus if appropriate: 250 - 500 ml 0.9% NaCl
- Monitor for response to bolus (HR and BP every 5 min), repeat as necessary up to 2L before escalating
- Auscultate for crackles after every bolus, especially if worried about overload
- (IV ABx)
- Temperature technically in ‘Exposure’, but will inform need to take blood cultures, so appropriate to put in ‘Circulation’
Disability.
- AVPU or GCS? (if GCS 8 or less, need airway support)
- Glucose? - BM (if peri-arrest, BM not reliable so do a VBG/ ABG) - if hypoglycaemic - treat with 50 ml 10% dextrose
- Pupils? (pinpoint = ?opiate overdose)
- Check drug card for any possible contributing drugs to the reduced consciousness (eg. opiates/ benzos) and give a reversal agent (eg. naloxone/ flumazenil)
- Place in lateral (recovery) position if airway is supported
Exposure.
- Temperature (if not done already)
- Any overt bleeding? (check bed, check catheter bag)
- Wound site (vital in post-surgical patients)
- Pressure sores
- Calves - DVT? / overload, etc.
Decision.
- Level of care: ward, HDU, ITU
- Further management/ fluids/ drugs to prescribe
- Record in notes
- Monitor and review
b) Differentials.
- Most likely chest sepsis (poor breathing and coughing post-op due to pain)
- Other infection: wound site, peritonitis, UTI, etc.
- Hypovolaemia: haemorrhage, dehydration
- Other shock: cardiogenic, anaphylaxis, etc.
You reviewed an unwell 75 year old lady on a general surgical ward, 5 days post-Hartmann’s for bowel obstruction. She was able to talk to you, but appeared confused. Her obs were: SpO2 91%, RR 26, HR 120, BP 92/50, Temp 38.1. She had crackles at the right base, no other focal signs.
- After your initial management her obs are: SpO2 93%, RR 25, HR 110, BP 96/55, Temp 38.0
a) What management would you have initiated?
b) Following this management, she does not improve. Give an SBAR handover to the medical registrar
a) - Airway - patent, no management required
- Breathing - given 15L/min via a non-rebreathe mask
- Circulation - 2L of 0.9% NaCL (in 250 - 500ml IV boluses over < 15 mins); IV ABx (eg. tazocin); sepsis 6 commenced
Situation.
- (Introduction, patient details, ward, HEADLINE, e.g. anaphylaxis/ septic)
- Hi, I’m the F1 on surgical ward 9. I’ve got a septic patient (name, gender, age, hospital number) that I’m concerned about.
Background.
- (relevant admission details, relevant PMHx)
- She is 5 days post-Hartmann’s for bowel obstruction, secondary to diverticulitis. Before coming in, fit and well
Assessment.
- (A - E assessment, give observations, management)
- Airway was patent
- Breathing - SpO2 was 91% on air, and she had some crackles at the right base. Sats improved to 93% on 15L via a non-rebreathe mask
- Circulation - HR was 120 and BP 92/50; I gave her 2L NaCl, no signs of overload. BP 96/55 and HR 110. Also started sepsis 6, and started her on IV tazocin (no penicillin allergy), put a catheter in
- Disability - she’s confused, glucose is 7 (not diabetic), pupils are normal and no focal neurology
- Exposure - temp was 38.1, now 38.0. Wound looks ok, abdomen SNT, calves SNT, no rashes, no overt bleeding
Recommendation.
( - review, transfer, etc.)
- Can you please come and review her?
Airway: causes of obstruction
- Reduced consciousness
- Aspiration: Teeth, Food debris, Vomit, Blood, Foreign bodies (e.g. pen tops)
- Thick sputum
- Bronchospasm/ laryngospasm
- Infection causing swelling (eg. epiglottitis)
- Allergic reaction (anaphylaxis)
- Direct trauma to face/throat (eg. injury, burns)
- Obstructing mass (eg. airway tumour)
Airway: inspection (LOOK)
- Condensation of the mask
- Visible object/blood/vomit obstructing the airway
- See-saw breathing typical of UA obstruction
- Palpation: feel, listen and look down chest
Airway: auscultation (LISTEN)
- Normal patent airway: speech is normal • Gurgling • Stridor, Wheeze • Snoring - SILENT CHEST
Airway: management
- Secretions: suctioning
- Removal of any foreign bodies
- Simple manouevres: head tilt, jaw thrust
- Airway adjuncts: OPA (if tolerated), NPA if not, then more complex adjuncts if required
- Oxygen!!
- Position: recovery, lie flat/sit up
Airway adjuncts.
a) In conscious patient - 1st line. - Sizing?
- Contraindications?
b) Next choice? - Sizing?
c) Then you might try a…?
d) Finally - you may need to…?
a) Nasopharyngeal airway (NPA) - sized from tragus to tip of nose? - CI: suspected basilar skull # / nasal damage (eg. nasal septum haematoma)
b) Oropharyngeal airway (OP/ Guedel) - sized from tragus to corner of the mouth.
c) Laryngeal mask airway (LMA/ iGel)
d) Call the anaesthetist (2222 - airway management) and intubate with an endotracheal tube (ETT)
Breathing: causes of SOB/ resp failure a) Acute life-threatening causes that must be diagnosed and treated immediately (4) Other: b) Respiratory c) Cardiac d) Metabolic e) Other
a) Acute severe asthma, pulmonary oedema, tension pneumothorax, and massive haemothorax
b) Asthma, COPD, pneumonia, TB, pleural effusion, pneumothorax, Lung Ca, PE
d) MI, arrhythmias, heart failure (pulmonary oedema usually)
d) DKA (Kussmaul), sepsis, anaemia, poisoning/toxins
e) - Neuromuscular - GBS, MG, MS, MND, etc. Also cervical cord injury
- Rib fractures
- Anxiety, pain, fear
Breathing: inspection (LOOK) / palpation (FEEL)
Look.
- RR and character (depth, pattern, etc.)
- SpO2 (are they on oxygen?)
- Colour (cyanosed)
- Respiratory effort, accessory muscles
- Alert and orientated/ confused
- Chest drains/other paraphernalia?
Feel.
- JVP- raised (?pneumothorax)
- Trachea- central? (?pneumothorax)
- Chest expansion - symmetrical? (?pneumothorax)
- Percussion? - hyper-resonance (pneumothorax), dullness (consolidation - collapse, pneumonia, effusion)
Breathing: auscultation (LISTEN)
- Air entry (good air entry?, equal?)
- Wheeze (asthma, COPD, anaphylaxis), stridor (UA obstruction, anaphylaxis)
- Crackles/ rattles (indicate secretions - pneumonia)
Breathing: management
- oxygen* (note: in COPD, hypoxia will kill before hypercapnia; make sure sats are at least up to 88-92%, before worrying about CO2 retention)
- wheeze: bronchodilator nebs/inhalers
- hypoventilating? - need to ventilate - via BVM (aim for 12 breaths per minute: one every 5 seconds)
Do an ABG in anyone at risk of hypoxia or hypercapnia. Titrate oxygen accordingly, repeating ABG if necessary
Oxygen masks.
- Give the types, from most intensive to least intensive oxygen delivery
- For each, give the flow and approximate FiO2
- What rough formula can be used for converting flow (L/min) to delivery (FiO2)?
- Non-rebreathe (resevoir) mask - 15L/min acute situation (deliver around 80%)
- Face mask - deliver 5-10L/min flow
- Venturi masks - regulate concentration (24 - 60%); in COPD retainers, use 24-28% devices (4L/min)
- Nasal cannulae: 1-4L/min (24-40%)
Formula:
- 1L/min = approx 24% FiO2
- Add 4% for each litre above 1L
- Hence: 2L/min = 28%, 3L/min = 32%, 4L/min = 36%… etc.
Circulation: fluid balance
a) Urine output - monitored how often in acutely unwell patient?
b) Minimum urine output should be…?
c) Fluid balance monitoring should involve…?
a) Hourly
b) 0.5ml/kg/hr (so 35ml in 70kg male)
c) Record readings accurately on a Fluid Balance Chart • Hourly Urine Output measurements
• Check the patency of the catheter
• Ensure optimum circulation
• Do not give drugs which will damage the kidneys
Circulation: inspection (LOOK)
- Skin colour - blue / pale / flushed?
- Skin appearance - mottled / clammy?
- Dry mucous membranes, sunken eyes, etc.
- Bleeding/surgical drains, etc.
- JVP raised? (tension pneumothorax, heart failure, tamponade)
- Veins collapsed - may indicate hypovolaemia
Circulation: palpation (FEEL)/ auscultation (LISTEN)
- CRT (note: may be rapid in hyperdynamic state e.g. sepsis)
- Pulse - weak + thready (hypovolaemia), bounding (vasodilation - anaphylaxis, sepsis)
- Temperature - cool, clammy
- Blood pressure
- Auscultate the heart - murmurs, muffled/quiet sounds (tamponade), pericardial rub (pericarditis)
- Calves - pitting oedema, tenderness (?DVT)
