A to E and SBARR

Question 1

Opening statement
Rules
A

Answer 1

Ensure the patency of the airway, effective breathing and adequate tissue perfusion, assessing and treating as I go along.

Seek another team member to aid - practice nurse for observations, simple tasks
Regular re-assessment
Delegate tasks where appropriate
Continuous monitoring if necessary
Call for help early - SBAR handover 
Prescribe fluids/medication
Review results
Follow guidelines
Document afterwards

A:
Assessment:
Talking:
Y - patent airway
N - open mouth, inspect airway, cyanosis?
Intervention:
1. Call for anaesthetist
2. Maintain airway:
- If no C-spine injury, head tilt, chin lift (sniff morning air in children)
- Jaw thrust
- Airway adjunct - OPA if unconscious, NPA (better tolerated if partially conscious)

Question 2

What are possible causes of airway compromise?

Answer 2

Foreign body inhalation - stridor, sudden onset
Secretions, blood, vomit aspiration - gurgling
Soft tissue swelling - anaphylaxis, infection - quinsy
Mass in surrounding tissue
Laryngospasm
Depressed consciousness - head injury, opioid overdose

Question 3

B

Answer 3

B:
Assessment:
Obs:
RR 12-20
- tachypnoea - airway obstruction, asthma, pneumonia, PE, pneumothorax, pulmonary oedema, heart failure, anxiety - resp alkalosis
- Bradypnoea - sedation, opioid toxicity, RICP, exhaustion in airway obstruction - reps acidosis
SaO2 (94%-98%, or 88-92% in COPD)
- Hypoxaemia in PE, aspiration, COPD, asthma, pulmonary oedema

Examination:
Inspect:
JVP
Resp distress signs - sweating, accessory muscles, abdominal breathing, recessions, tracheal tug
Rhythm and depth of inspiration:
Kussmaul’s respiration - deep sighing, metabolic acidosis in DKA
Cheyne-stokes respiration - irregular respriation in RICP

Feel:
Trachea - mediastinal shift (tension pneumothorax)
Chest expansion

Percuss:
Hyperresonance - pneumothorax
Dullness - consolidation/pleural effusion

Auscultate
Bronchial breathing - pneumonia
Reduced breath sounds - pneumothorax, pleural fluid, consolidation
Unilateral crackles - consolidation
Bibasilar crackles - pulmonary oedema, bronchitis

Investigations:
ABG
CXR - portable

Intervention
Sit patient up if SOB
O2: 15L high flow O2 via non-rebreathe mask targetting SaO2 >94%
In COPD 88-92 with Venturi 24%
NIV in acute exacerbation of COPD
Nebulisers
Steroids
Treat pneumothorax/PE/pneumonia

Reassess after intervention

Question 4

C

Answer 4

Assessment:
Observations:
Heart rate (60-90)
- Tachycardia - Hypovolaemia, arrythmia, infection, hypoglycaemia, thyrotoxicosis, PE
- Bradycardia 
BP
- Hypertension - fluid overload, endocrine, pre-eclampsia -visual disturbance/confusion/chest pain?
- Hypotension - shock
Temperature (36-37.5)
- Pyrexia - infection - neutropenia?
- Hypothermia - warming (Bair hugger)

Examination:
Inspect:
- Capillary refill > 2s - shock/dehydration
- JVP - overload/dehydration
Feel:
- Radial pulse - bounding? AF? Weak
- Carotid pulse
- Oedema - heart failure
Auscultate
- Heart sounds
- Pericaridal rub/muffled heart sounds - pericarditis
- Gallop rhythm? HF
- New murmur -  endocarditis

Investigations:
Cannulation:
- Wide bore IV (14G/16G)

Bloods/Culture

• CRP, lactate, cultures
• Coagulation, XM
• Troponins
• Calcium, Mg, PO4, TFT
• D-dimer
• Toxicology screen
• Baseline: FBC, U&E, LFT

ECG

• 12 lead ECG if cardiac signs
• Continuous ECG monitoring

Bladder scan
- Retention or obstruction

Pregnancy test

Cultures/Swabs

Fluid output/Catheterisation
- Fluid balance chart

Intervention:
Fluid challange:
1. Lay supine, raise legs
2. 500ml STAT bolus of 0.9% NaCl over 15 mins (250ml in HF, check for crackles)
3. Repeat up to 4 times, monitoring response
4. Stop/seek help if overload
5. ICU for inotropic support if not responding

Question 5

D

Answer 5

Assessment:
GAPPS

Glucose (4-11)

• Cap glucose
• Check for ketones if BM >15) - urine dip

AVPU/GCS: Alert, Verbal stimuli, Pain stimuli, Unresponsive

Pupils - size, symmetry, reaction to light

• Pinpoint - opioid overdose
• Dilated - TCA overdose, intracerebral pathology

Pain

Seizures

Question 6

Exposure

Answer 6

While maintaining dignity and conserving heat, I shall expose the patient to make a full assessment

Inspection:
Rashes - widespread, blanching?
Bruising
Bleeding - total blood loss? Shock? Major haemorrhage protocol
Calves - red, swollen, tender 
Lines in - phlebitis
Catheter output
Surgical wounds - bleeding, infection
Drains - output, content - blood, pus?

Investigations:
Cultures/swabs

Interventions
Blood products
Sepsis
DVT

Question 7

Call for help

Answer 7

Critical care team
Anaesthetist on call
Crash team
Medical registrar

Airway:
Anaesthetist on call

Breathing:
Medical registrar on call
Critical care team for NIV/intubation

Circulation:
Medical registrar on call
Microbiologist on call
Surgical registrar on call
Gynae
Gastro

Question 8

SBARR

Answer 8

Situation
Background
Assessment
Recommendations
Review/Response

Situation:
Who - you, them, patient
Where - location
When - timing
What/why - headline

Background:
PC
Diagnosis
PMH/PSH
Medications
Allergies
Investigations
Interventions tried

Assessment:
Obs/vital signs
Clinical examination findings
Clinical impression

Recommendation
What you think should hapen
Ask for their review, suggestions in meantime, transfer

Response
Clarify expectation of response
Document discussion in patient notes
Thank

Question 9

After a to e

Answer 9

i) review drug and fluid charts
ii) Document asessment in the notes
iii) Who has been contacted
iv) Current management plan and when review time is (put this on jobs list)
v) Put re-assessment frequency in the notes too (doctors and nurses) Every fifteen minutes if acute and advise to bleep if NEWS score shanges