A-E Station Flashcards
What should you do to assess airway?
talk to the patient
if the patient cannot talk to you:
look in the mouth for obstruction / visible secretions
suction any visible secretions - don’t suction what you can’t see!
perform a head-tilt chin lift
insert a nasopharyngeal airway / oropharyngeal airway (ask about basal skulls fractures before)
What should you do to assess breathing?
Assess oxygen sats
Resp rate (normal is 12-20)
Tracheal deviation and chest expansion
Percussion and ausculation
What should you do to assess circulation?
assess temperature of extremities
assess capillary refill (less than 2 seconds is normal)
assess pulse
assess blood pressure
look for JVP
attach an ECG monitor
listen to heart sounds
What should you do to assess disability?
verbally assess their AVPU
Assess temperature
Assess pupillary reactions using a pen torch
Take capillary blood glucose
Consider urine dip and monitoring urine output
What should you do in exposure?
Assess the patient from head to toe
move their hair to the side if needed
expose genitalia
assess any lines
What interventions can you do in ‘breathing’?
15L oxygen via a non rebreathe if hypoxic
PEFR and asthma medications if indicated
ABG if hypoxic
Consider CXR
What interventions can you do in ‘circulation’?
get IV access (14 G cannula), take bloods and blood cultures if indicated
if hypotensive - give 500ml 0.9% NaCl stat
monitor urine output
Define altered conciousness
New onset confusion, decrease in GCS of > 2 points or repeated or prolonged seizures
How should you approach an A-E of a patient with altered conciousness?
Verbally assess AVPU
Check Airway:
If evidence of obstruction - call anaesthetics/ICU and apply airway manouevres
If airway unprotected turn patient to lateral position
Check Breathing
If breathing inadequate - call anaesthetics/ICU
Low sats = apply 15L of oxygen via non-rebreathe
If saturations do not improve on oxygen call for bag-valve-mask
If respiratory rate < 8 and recent opioid use - NALOXONE PEN
Take ABG
Check Circulation and give fluids if hypotensive
Check Disability using either ACVPU –or– GCS
Check pupils for size, equality, and reaction to light
Check blood glucose
Check Exposure
How should you react to change in glucose?
If hypoglycaemia - give dextrose (50ml 10% dextrose IV up to a total of 250ml)
If hyperglycaemia - check ketones and start fixed-rate insulin
infusion
Define anaphylaxis
Anaphylaxis is a life-threatening hypersensitivity reaction featuring rapidly developing hypotension and tachycardia, and potentially life-threating airway obstruction or bronchospasm
How should you approach an A-E for a patient with anaphylaxis?
Check airway
If airway involvement: call anaesthetics/ICU
Give oxygen
If respiratory distress: sit the patient upright
If hypotension: lie the patient flat –and– elevate the legs
Treat anaphylaxis:
500 micrograms IM adrenlaline, repeat at 5 minute intervals if no improvement
Give a rapid bolus of IV crystalloid
Check for and remove any suspected causative agent(s)
How should you approach an asthma A-E?
In breathing consider doing PEFR and ABG
Give 15L oxygen
If severe or life-threatening features - call anaesthetics/ICU urgently
Start nebulised bronchodilators:
* Give nebulised salbutamol once (continuously if severe or life-threatening)
* Give nebulised ipratropium once
Start steroid therapy - oral prednisolone or IV hydrocortisone
Consider cardiac monitoring and IV magneisum sulphate
Define choking
Foreign body airway obstruction, with an ineffective cough in a patient who is conscious
How would you approach an A-E for a patient who is choking?
check for visible obstruction that you can easily remove
position the patient upright
give 5 back blows, stop to check if airway has cleared, then 5 abdominal thrusts
If patient conscious but no improvement - call anaesthetics and ENT, may need to remove obstruction in theatre
Define hyperkalaemia
Serum potassium greater than 6.5 mmol, with or without ECG changes.
ECG changes may include:
flattened/absent P-waves
tall T- waves
broad QRS complexes
ST-segment changes
How should you manage hyperkalaemia if you pick it up during an A-E?
apply continuous cardiac monitoring
if ECG changes - bloods to check their serum potassium
give 30 mL IV 10% calcium gluconate over 2-5mins
give nebulised salbutamol
check bms, then start insulin / dextrose infusion
repeat blood glucose and serum potassium afterwards
How would you manage major haemorrhage if you pick it up during an A-E?
call for help and say that you would like to activate major haemorrhage protocol
call 2222
get IV access and insert 2 large bore cannulae
Take blood for FBC, clotting, fibrinogen, and cross-matching
give up to 2L warmed crystalloid bolus (pressure bag)
Give tranexamic acid and reverse any anticoagulants
Give blood
if visible bleeding - elevate site and apply pressure
How would you manage PPH?
escalate to senior staff members immediately
STABILISE:
two peripheral cannulae (14G), bloods including group and save
lie the woman flat
commence warmed crystalloid infusion
MECHANICAL:
palpate the uterine fundus and rub it to stimulate contractions
catheterisation to prevent bladder distension and monitor urine output
MEDICAL:
IV oxytocin (slow IV injection followed by an IV infusion) , ergometrine , carboprost IM (unless there is a history of asthma) , misoprostol sublingual
SURGICAL:
intrauterine balloon tamponade where uterine atony main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
hysterectomy is sometimes performed as a life-saving procedure
How would you expect a PE to present in an A-E?
chest pain, SOB, signs of DVT
sinus tachycardia
How would you manage a patient with a PE?
Wells score- over 4 = likely PE
Do an ECG - sinus tachy commonest finding in PE (S1Q3T3 characteristic but rare)
Do a CTPA (or VQ scan)
Strong suspicion of PE but delay in the scan - start tx dose anticoagulant and monitor closely in the meantime
If CTPA +ve proceed with treatment (thrombolyse or give DOAC)
If CTPA -ve but DVT strongly suspected then consider a proximal leg vein ultrasound scan
How should you manage a patient with massive PE and hypotension?
thrombolyse immediately
What bloods should you do in a patient with suspected sepsis?
Venous blood gas (including lactate)
Blood culture
FBC, U&Es, CRP, clotting, glucose
also state would monitor urine output
What should you give in sepsis?
fluid bolus
15 L oxygen via non-rebreathe
Meropenem 1g IV
How should patients be monitored during blood transfusion?
The patient’s baseline obs (including blood pressure, pulse, resp rate and temperature) should be checked at 0, 15 and 30 minutes from the onset of the transfusion.
Observations can then be performed on an hourly basis and again when the transfusion has finished.
Regular observations allow early detection of transfusion reactions
What is the blood transfusion threshold and Hb target?
Without ACS:
threshold = 70 g/L
target = 70-90g /L
With ACS
threshold = 80 g/ L
target = 80-100 g/ L
How is TRALI differentiated from TACO?
hypotension in TRALI vs hypertension in TACO
Which blood product is most likely to cause an iatrogenic septicaemia with a Gram-positive organism?
Platelets - stored at room temperature
The first step in management of any suspected transfusion reaction is what?
stop the transfusion!!!
Fever, abdominal pain, hypotension during a blood transfusion →
acute haemolytic reaction
due to RBC destruction by IgM-type antibodies
Hypotension, dyspnoea, wheezing, angioedema during a blood transfusion →
anaphylaxis
Outline the UHL massive haemorrhage protocol
Alert senior staff member that you are activating massive haemorrhage protocol
Give warmed IV crystalloid bolus
Transfuse 4 units red cells if indicated (can use O- blood if required but inform Blood Bank if emergency supplies used)
Attempt to control bleeding
Consider tranexamic acid
Reverse any anticoagulation
Arrange cell salvage where available
How do patients with low clotting factors versus low platelets present differently?
low clotting factors = bruises or bleeding into joint spaces
low platelets = petechial rash (pinprick), gum bleeding, oral blisters
What is the threshold for platelet transfusion?
<10 - wait till as low as possible because patients quickly make antibodies to platelets and become refractory to tx
Non-haemolytic febrile reaction is thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage.
How does it present?
How can it be managed?
Fever, chills, more common following platelet transfusion
Mx:
Slow or stop the transfusion
Paracetamol
Monitor
Minor allergic reactions to blood products are thought to be caused by foreign plasma proteins.
How may they present?
How should they be managed?
Pruritus, urticaria
Mx:
Temporarily stop the transfusion
Antihistamine
Monitor
Acute haemolytic reaction occurs when a patient is given ABO-incompatible blood e.g. secondary to human error.
How does it present?
How should it be managed?
Fever, abdominal pain, hypotension
Mx:
Stop transfusion
Confirm diagnosis : check the identity of patient/name on blood product, send blood for direct Coombs test, repeat typing and cross-matching
Supportive care (fluid resuscitation)
Transfusion-associated circulatory overload (TACO) occurs due to excessive rate of transfusion or pre-existing heart failure.
How does it present?
How should it be managed?
Pulmonary oedema, hypertension
Slow or stop transfusion
Consider intravenous loop diuretic (e.g. furosemide) and oxygen
How does TRALI present?
Hypoxia, pulmonary infiltrates on chest x-ray, fever, hypotension
How should TRALI be managed?
Titrate oxygen, give IV fluids and consider escalation of care
What symptoms may someone present with if they have DKA?
abdominal pain
polyuria, polydipsia, dehydration
Kussmaul respiration (deep hyperventilation)
Acetone-smelling breath
What is the diagnostic criteria for DKA?
glucose > 11 mmol/l or known diabetes mellitus
pH < 7.3
ketones > 3 mmol/l or urine ketones ++ on dipstick
How should you manage a patient with suspected DKA?
Fluid replacement: 1L 0.9% sodium chloride
fixed rate insulin infusion at 0.1 unit/kg/hour
once blood glucose is < 14 mmol/l an infusion of 10% dextrose should be started
What are the potential complications of DKA that you should screen for?
cerebral oedema due to shift in osmolality - usually occurs after 4-12 hours of tx, look out for headaches and altered mental status
Arrythmias
AKI
VTE
What should you do if someone starts seizing in your A-E?
note the start time
cushion their head
once recovered check their airway and place them in the recovery position
check oxygen and glucose
If status:
IV lorazepam (x2)
IV phenytoin
Then escalate care and consider GA
