ABCDE Flashcards
A : why is it the most important ?
Can cause hypoxia (state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis) and damage vital organs.
A : what do you look for ?
Foreign object in the mouth, audible breath sounds, movement of air through mouth and nose.
A : what happen if the patient is completely unresponsive ?
They won’t realise the airway is blocked.
A : How do you manual open the airway ?
Chin lift or jaw thrust (if there is a cervical spine problem suspected).
A : What tool can you use to open the airway ?
An oropharyngeal or nasopharyngeal airway then a tracheal or endotracheal intubation.
Use an airway suction to remove foreign object.
A : what do you do after opening the airway ?
Provide high concentration oxygen with an hand bag mask ventilation.
B : What are the vital signs to check ?
Oxygen saturation, distress, respiratory rate
B : What do you also look for and what do the findings means ?
Central cyanosis ==> inadequate ventilation / perfusion
Asymmetrical chest ==> pneumothorax, hemothorax, tension pneumothorax
Chest breathing ==> use of accessory muscle
Deviation of the trachea ==> pneumothorax, lung fibrosis
Rib fracture
Emphysema (conditions causing shortness of breath)
B : What abnormal sound can you auscultate and what does it means ?
Bronchial breathing ==> lungs consolidation
Reduced sounds ==> pneumothorax, pleural fluids, lungs consolidation
B : What abnormal percussion can you hear ?
Hyper-resonance ==> pneumothorax and tension pneumothorax (side of the collapse lung)
Dullness ==> consolidation or pleural fluids
B : What are the solution to those respiratory problem ?
Give oxygen via bag-mask or pocket mask ventilation.
Nebulise medicine (turn them into a mist patient can breath)
B : What additional analysis can you make ?
Perform an arterial blood gas test to measure oxygen, pH and CO2 level.
C : Where do you check for bleeding ?
If there blood on the floor check 4 places more :
Thorax
Abdomen
Pelvis
Femur
C : check vital signs
Heart rate, blood pressure, CVP, urine production, capillary refill.
C : What do you look for ?
Skin color, temperature.
State of the veins : hypovolaemia, distended
Peripheral and central pulse : presence, rate, regularity.
Heart murmur
C : What does the pulse can tell you ?
If its barely palpable the cardiac output is poor
If the pulse is bounding there is sepsis.
C : What are the solutions ?
Get IV access and fluid replacement. Prepare restoration of tissue perfusion.
C : What additional test can you make ?
Make an ECG to check for further signs.
D : What are you looking for ?
Any signs of neurological complication
D : What are the score of consciousness ?
PEARL : pupils equal and reactive to light
EMV
AVUP
D : What is anisocoria ?
Unequal pupils size.
D : What do you check additionally ?
The lateralisation, the neck for cervical injury, the glucose level
E : What are you searching for ?
Skin disorder, haematomas, haemorrhage, swelling, oedema, wounds, signs of inflammation, needlestick injury
What kind of fluid do you inject by intravenous perfusion ?
Crystalloid solution : containing small dissolved molecules that can easily pass from bloodstream into tissue and cells
What are the 8 reversible cause of cardiac arrest ?
4 Hs :
- Hypoxia
- hypovolumia
- hyper/hypokalaemia, hypoglycemia, hypocalcaemia, acidosis and other metabolic causes
- hypo/hyperthermia
4Ts :
- Thrombosis
- Tamponade
- Toxins
- Tension pneumothorax
A : during CPR
If advanced airway is required only for high success rate professional.
- once airway inserted ventilate lungs at 10/min and continue CPR without interruption
Give highest feasible oxygen and give each breath 1s to achieve rising.
What drugs do you inject during CPR ?
Adrenaline 1mg IV asap for non shockable rhythm
- or after the 3rd shock for shockable rhythm
- repeat every 3-5 min while ALS continue
Amiodarone 300 mg IV after 3rd shock for VF and pVT
- give another 150mg after 5 shock
- use lidocaine 100mg if amiodarone cannot be used
Thrombolytic drugs when pulmonary embolism is suspected
Fluids only in hypovolumia
What are the life threatening features in unstable patient ? (Send me a SMS)
Shock : hypotension and reduced cerebral blood flow
Syncope : consequences of reduced cerebral blood flow
Severe heart failure : pulmonary edema, raised jugular pressure
Myocardial ischemia : chest pain or isolated findings on ECG
B : how to use a non rebreather mask ?
For deteriorating sick patient : need to give 15L non rebreather
- apply the end of the oxygen mask to the oxygen port
- fill the bag with oxygen then let the air escape to verify its working
- put the band around the face and tighten the mask
A : applying a mayo tube
Indication : unresponsive patient with absent gag reflex
- simple non invasive and easy to place method
- risk of pushing the tongue back and make obstruction worse, no protection against vomiting
Check size by putting the oropharyngeal airway next to the mouth and look at jaw angle.
Check for foreign body
Invert it and insert it in the mouth against the hard palate. Rotate it and locate it in the oropharynx.
What are peri-arrest arrhythmias ?
Arrhythmias that occur after initial resuscitation from cardiac arrest.
Can be tachycardias or bradycardias.
How do you treat peri-arrest tachycardias ?
Use electrical cardio version in life threatened patient : conscious patient require anesthesia or sedation.
- to convert atrial/ventricular tachyarrhythmia, shock must be synchronised to occur with R wave of ECG
If patient is stable and not deteriorating, pharmacological treatment may be possible
What to do if cardio version fails to restore sinus rhythm, patient unstable with tachyarrhythmia.
- give 300 mg amiodarone IV over 10-20 min then re-attempt
- can follow with infusion of 900 mg over 24h
How to treat peri-arrest bradyarrhythmias ?
Accompanied by life threatening sign :
- give atropine 500 mcg IV
- repeat every 3-5 min to total 3 mg
If ineffective consider
- isoprenaline 5 mcg
- adrenaline 2-10 mcg
If caused by inferior MI, cardiac transplant, spinal cord injury
- give aminophylline 100-200 mg slow IV
If beta blocker / calcium channel blocker are the cause
- give glucagon
D : what type of body odor do you need to be aware of ?
Acetone : presence of ketone bodies
- diabetic ketoacidosis
Alcohol : doesn’t tell you how much they drank
- do not fixate on this and be alert for other cause
Ammonia : fish odor
- disturbance in breakdown of waste product : excessive amount of ammonia and methylamine
- severe hepatic failure
D : what type of breathing can be significant ? (5)
Hyper ventilation : fever, sepsis, hypoxia, stress
Hypo ventilation : intoxication, injury
Gasping : rapid short inspiratory movement with long expiratory
- circulatory arrest, deep anorexia, injury to brainstem
Kussmaul respiration : very deep rapid breathing, expelling lots of CO2
- compensate for metabolic acidosis
Cheyne-Stokes respiration : cyclic increasing and decreasing respiration depth alternated with apnea period
- cardiac failure, brainstem dysfunction
Ataxic respiration : irregular patterns with varying depth and frequency
- injury to the brainstem
D : what should you inspect on the head ?
Injury, hematoma, swelling
Blood or CSF bleeding out
- fracture to skull
Bile to tongue
- result of convulsion
D : what are the different brainstem reflexes test ?
Ocular alignment
Pupils, fundoscopy
Oculocephalic reflex (Vestibulo ocular reflex): doll’s eye
Corneal reflex
Eye movement
D : what clinical significant sign can you see in ocular alignment ?
Hemiparesis with gaze palsy : look in the direction of the affected hemisphere
- brainstem injury likely
Involuntary deviation of both eyes : loss of frontal visual center, both eyes turn to the lesion side
Deviation away from lesion
- cortical hyperactivity : epileptic seizure
- brainstem lesion : loss of pontine reticular formation
Lowered consciousness : eyes slightly divergent
D : what clinical significance signs arise from the examination of the pupils ?
Non reactive dilated pupil : transtentorial herniation, brainstem lesion
Symmetrically non reactive pupil : diffuse cerebral swellings
Symmetrically constricted pupil : opioids overdose
Papilloedema : intracranial hypertension and pre-retinal haemorrhage due to subarachnoid haemorrhage
D : technique of the oculocephalic reflex ?
Hold patient head and lift eyelids
Rotate head L/R and observe movement
Flex and extend head and observe movement
Result :
- intact : eye movement are symmetrical and move in opposite direction, motor fixation function in the eye is used
- asymmetry : focal lesion at brainstem cranial nerve palsy or functional disorder
- absent : severe brainstem injury
D : what other test can you use for the oculocephalic reflex ?
Caloric reflex test : provoke eye movement by spraying cold water against the tympanic membrane
- eye should move in the direction of the side stimulated
- can be used with cervical injury and to confirm brain death
D : what are the clinical signs of corneal reflex ?
Unilateral absence : acute lesion in contralateral hemisphere or ispilateral lesion in brainstem
Bilateral dysfunction : deeper coma and brainstem injury
D : what do you assess in motor function ?
Muscle tone, symmetry of response to pain
- may appear asymmetrical because of hypotonia
Hemiparesis : affected side is hypotonic in acute phase
Response asymmetry : apply painful stimulus
- face : apply retromandibular painful stimulus behind jaw angle
- arms/legs : firmly roll pen over nail bed
D : what do you assess in reflex ?
Hemiparesis : hyporeflexion on affected side in acute phase with Babinski sign
D : what are the meningeal irritation test ?
Contraindicated in suspected cervical lesion or injury until cervical fracture is exclude
- Nuchal rigidity : flexion of neck
— infection or presence of blood can cause hypertonic in paravertebral muscle
— present in the acute phase but can also develop later
- Brudzinski’s signs 1 and 2
- Kernig’s sign
D : technique of nuchal rigidity ?
Patient lie supine, both hands under their head
- turn patient head to L/R a few times
- if no local disorder and rigidity the movement should be unrestricted and painless
- flex patient head : movement should be smooth
D : technique of Brudzinski signs ?
Sign 1 :
- does patient raise their knee and has a painful neck when placing chin on the chest
Sign 2 :
- hold ankle with one hand the other above the knee of the same leg
- bring hip in maximal flexion but keep knee extended
- is there flexion at the knee/hip of other leg while bringing the first in hip flexion
D : technique of Kernig’s sign ?
Hold heel and lift extended leg
Is there flexion in the knee joint of the raised leg, is there increased head/neck pain
Is the patient unable to sit upright with knee extended
D : what can produce false positive and negative for meningeal irritation test
False positive : pneumonia, sepsis, mastoiditis, viral infection with high fever, cervical osteomyelitis, peritonsillar/cervical abscess, brain tumor
False negative : nuchal rigidity may absent in comatose patient with meningitis
E : what are indications to do a scan in case of high trauma ?
Blood thinner medication
Alcohol/being drunk
Symptoms : headache, confusion, behavior problem, amnesia, neurological symptoms
E : what is compartment syndrome ?
Muscles in the body are separated into compartments. When there’s a bleeding in a closed compartment it is going to increase the pressure in the compartment.
It leads to ischemia and can cause to lose the nerve and the entire muscle
- blood thinner may cause it to bleed slower and retard the start of symptoms
E : What are the 2 type of ankle fractures to know ?
Maisonneuve injury : proximal fibula fracture with syndesmosis and deltoid ligament injury
- unstable
- if knee isn’t examined proximal fibula fracture may be missed
Pilon : fracture of distal tibia including articular surface
- due to fall from height
E : what are signs and symptoms of fractures ?
Pain
- palpation and movement
- unable to bear weight
Reduced range of motion
Swelling
Bruising / discoloration
Obvious deformities
Neurovascular compromise
- cold pale pulseless extremity
- sensory/motor disturbances.
E : what are signs of Maisonneuve fracture on X-ray ?
Fracture is normally indicated by a disturbance in the cortical outline of the bone
You consider Maisonneuve if there’s a clear space disturbance without fracture
E : what are treatments of a fracture ?
Closed reduction : skin isn’t opened
- for stable fracture
- for patient unfit for surgery
- poor soft tissue condition
Open reduction : ORIF
- for open fracture
- for unimalleolar fracture with talar shift or bi/tri malleolar fracture
- for Maisonneuve or Pilon
E : what are type of complication in a fracture ?
Malunion/nonunion
Stiffness
Post traumatic arthritis
Ulceration from the cast
Venous thromboembolism
Poor wound healing / infection
- diabetic patient
Nerve injury
- superficial peroneal nerve injured in 15% of cases
E : what are the risk factors and complications for a hip fracture ?
Increasing age and osteoporosis. Female.
Mortality for 30 days 5-10%.
Which is why they are prioritised on the surgery list. Operated generally within 48h.
E : What are the 2 category of hip fracture ?
Intracapsular fracture : break of the femoral neck within the capsule
- can damage the retrograde blood supply to the femoral neck and cause necrosis
- next to the intertrochanteric line
- use the Garden classification
Extracapsular fractures : can be either
- intertrochanteric fracture between the greater and lesser trochanter
- subtrochanteric fracture : distal to the lesser trochanter but within 5 cm
E : how is intracapsular femoral fracture treated ?
Total hip replacement : replace both the hip and and acetabulum
- for patient who can walk independently and fit for surgery
Hemiarthroplasty : replacing the head but leave the acetabulum in place
- cement is used to hold the stem of the prosthesis in the shaft of the femur
- offered to patient with limited mobility or significant comorbidity
E : how do you treat intertrochanteric fracture ?
Dynamic hip screw that goes through the neck and into the head
- a plate with barrel that hold the screw is placed on the outside of the femoral head
- allow some controlled compression while maintaining alignment to improve healing
E : how do you treat subtrochanteric fracture ?
Treated with intramedullary nail metal pole inserted through the greater trochanter into the central cavity of the femur
E : what is the Garden classification ?
1 : incomplete fracture and not displaced
2 : complete fracture but not displaced
- blood supply may be intact => could maybe preserve femoral head
- internal fixation
3 : partial displacement, angle formed by trabeculae
- femoral head need to be replaced
4 full displacement and trabeculae parallel
- femoral head need to be replaced
E : what is a classic presentation of a patient with hip fracture ?
Older than 60 that has fallen.
Shorted abducted and externally rotated leg
Pain in the groin or hip that may radiate to the knee
Not able to weight.
E : what could be reasons for an older person to fall ?
Anemia, electrolytes imbalance, arrhythmia, heart failure, MI, stroke, urinary or chest infection
Mechanical fall : tripping or pushed over
Social contribution : dehydratation, incorrect eyewear/footwear, obstacles
E : what is Shenton’s line ?
Imaginary curved line along the inferior border of the superior pubic.
- disruption of Shelton line is a key factor to identify fracture
D : Of what is composed the ABCDE of an unconscious patient ?
GCS
Pupil examination
Signs of lateralisation : tone and reflex
Signs of meningeal irritation
Signs of convulsion
- epileptic seizure
- status epilepticus : convulsion for more then 5 min
Glucose measurement
What are the symptoms of a high trauma ?
Headache that does not improve.
Confusion
Behavioral problem
Amnesia
Neurological symptoms
What is the CPR method for a child ?
Ratio : 15:2
Depth : goes to 1/3 of the child chest represent around 4-5 cm in young children
Rate : 100-120 bpm
Release all pressure on the chest between compression to allow for complete chest recoil.
Location : over half the sternum, avoid compression of the abdomen try above xyphoid process
Why is the ratio of CPR for a child different than for an adult ?
Because the cause of pediatric cardiac arrest is more likely to be asphyxia therefore breath are more important than in adult where the cause is more likely to be cardiac.
What is the BLS sequence for a child ? (Before cardiac arrest is declared)
Check :
- safety
- response : pinch or flick but never shake an infant
- shout for help
Airway : open airway
Breathing : during the first few minutes the child may take infrequent gasp
Circulation :
- infant : brachial/femoral pulse
- child : carotid/femoral pulse
Cardiac arrest is declared if there are no signs of life or the pulse is less than 60 bpm.
What is the BLS sequence for a child ? (After the cardiac arrest has been declared)
Give 5 rescue breath
- use bag/pocket mask asap
- note gag or cough as a response
See if you detect any signs of life.
- If not : start good quality chest compression.
- if yes : continue rescue breath until the child breath on its own
Technique of rescue breath for an infant ?
Ensure neutral head position : gentle extension
Take a breath then cover their nose and mouth with yours. Blow steadily for 1s.
Maintain head position and chin lift.
Technique of rescue breath for a child ?
Ensure head tilt / chin lift.
Pinch nose closed with index and thumb.
Open their mouth.
Take a breath and place your lips around their mouth trying to have a good seal. Blow steadily for 1s enough to have the chest rise.
Child : what to do if difficulty of achieving effective breath ?
The airway may be obstructed.
- Open child’s mouth and remove visible obstruction.
- Ensure adequate head tilt/chin lift
— try jaw thrust if it doesn’t work
- up to 5 attempts to achieve effective breath : if still unsuccessful move on to compression
Child : when do you call for assistance ?
ASAP when the child collapse.
If there are more than one rescuer, one of them should either call EMS when recognition of unconsciousness or go call for assistance.
If there is only one rescuer, call for help after rescue breath. If no phone available : undertake resuscitation for 1 min then go find assistance
Left lateral recovery position for a child / infant ?
Kneel next to child, place arm nearest to you at right angle with the palm uppermost.
Bring far away arm across the chest, against the child’s cheek.
Flex the far leg at the knee and roll the child on their side.
Tilt head back to keep airway open.
For an infant : cradle the baby in your arms with head tilted downward
Technique of chest compression for an infant ?
Encircling technique :
- both thumbs flat, side by side on lower half of sternum with the tips pointing towards the infant head
- spread rest of fingers to encircle lower part of rib cage
- press down on lower sternum with 2 thumbs at least 4 cm
2 finger technique :
- compress lower sternum with the tips of 2 fingers by at least 4 cm
Technique of chest compression for a child ?
Place heel of one hand over the lower sternum. Position yourself vertically above with arms straight and compress the sternum by around 5 cm.
In larger children you can use both hands.
Signs of choking for a child ?
Witnessed episodes
Coughing or choking sounds
Sudden onset
Recent history of playing with or eating small object
Child : Ineffective vs effective coughing in choking events
Ineffective :
- unable to vocalise
- quiet or silent cough
- unable to breath
- cyanosis
- decreased level of consciousness
Effective :
- crying or verbal response to questions
- loud cough
- able to take a breath before coughing
- fully responsive
Choking infant/child sequence ?
As long as effective coughing encourage.
If cough becomes ineffective ask for help and start intervention.
-Back blow
- if back blow do not relieve it and child is still conscious do chest/abdominal thrust
Following this reassess : if object still not expelled continue and child conscious continue sequence. If child becomes unconscious move on to BLS AED.
Technique of back blow for an infant ?
Support their head downwards with prone position to enable gravity to help. Support the head with a thumb placed at the angle of the lower jaw. But do not compress the soft tissue under.
Rescuer seated or kneeling to support infant on their lap.
Deliver 5 sharp back blow with the heel of one hand between the shoulder blade.
Try to relieve obstruction with each blow.
Technique of back blow for children ?
Child head down.
Support child in a forward leaning and deliver back blow from behind.
Technique of chest thrust for infant ?
Turn infant head downward supine position. Place free arm along their back and encircle the occipital with hand.
Identify xiphoid process then deliver 5 chest thrust (similar to CPR but sharper with slower pace)
Technique of abdominal thrust for children ?
Stand/kneel behind the child place your arms under theirs and encircle their torso.
Clench fist and place it between umbilicus and xiphoid process. Grasp fist with other hand and pull sharply inward 5 times.
Ensure that the pressure isn’t applied to the lower rib cage as it could cause abdominal trauma.
