ABCDE Flashcards
A
call senior
protect c-spine, if ?injury
a: check patency - ?obstruction
m: establish patent airway
B
a:
resp rate, chest expansion, percuss, auscultate
m:
no resp effort - treat as arrest, intubate + ventilate
breathing compromised - hi conc O2 + manage cause (eg relieve pneumothorax)
C
a:
pulse, BP, CRT
peripheries shut down?
bleeding?
m:
if shocked - treat shock as
no cardiac output - treat as arrest
D
AVPU
pupils - size, equality, reactions
GCS if time
glucose
E
undress + cover to prevent hypothermia
post-ABCDE - history from relative
events, intoxication, suicide, trauma?
PMH - esp diabetes, asthma + COPD, alcohol + drugs, epilepsy, recent head injury or travel
DH + allergies!
acute: post ABCDE + history?
ensure ventilation + circulation are adequate
continue hx, exam, invs + mgmt
bloods - ABG, FBC, U+E, LFT, CRP, ESR, ± tox/drug screen
cultures
urinalysis
CXR, CT head
GCS - components + total score for each
EVM - 456:
eye opening - 4
best verbal response - 5
best motor response - 6
record ‘not testable’ if a component not testable eg due to trachy, swollen eyes, paralysed by drugs
GCS - best motor response
6 - obeying commands 5 - localising to pain - eg move hand to yours 4 - withdrawing to pain (normal flexion) 3 - flexor response to pain 2 - extensor response to pain 1 - no response to pain
command - stick out tongue / move hand
pain - don’t record until maximum stimulus given + 10s. try:
trapezius pinch
supraorbital
nailbed
normal flexion:
elbow bends + arm moves rapidly away from body/stimulus
abnormal pain responses (flexion + extension) help localise damage:
abnormal flexion:
decorticate posture:
elbows bend slowly + into chest, fist, legs extended
damage above red nucleus in midbrain
extension:
decerebrate posture:
extension of elbows, adduction + internal rotation of shoulder, forearm pronation / wrist flexion
midbrain damage below red nucleus
if diff in diff limbs, record best one. response of worse side may indicate focal brain damage or local injury
GCS - best verbal response
5 - orientated to time, place person (ask) 4 - not orientated 3 - inappropriate speech 2 - incomprehensible sounds 1 - none
GCS - eye opening
4 - spontaneous
3 - in response to speech
2 - in response to pain
1 - none
pain - start with pen side to finger bed + move centrally
pupils - relevance of findings (for coma but maybe transferrable?)
normal direct + consensual - intact midbrain
mid position (3-5mm), nonreactive ± irregular - midbrain lesion
unilateral dilated + fixed - 3rd nerve compression
small + reactive - opiates or pontine lesion
acute neuro exam
AVPU
resp pattern
pupils, visual fields, eye movements, fundus
spontaneous movements, tone, reflexes
relevance of acute hyperventilation
hypoxia
acidosis
sepsis - definitions (sepsis, severe sepsis, septic shock)
sepsis - systemic inflammatory response in the presence of infection with relevant signs
severe sepsis - sepsis with organ hypoperfusion (eg hypoxaemia, oliguria, lactic acidosis, altered cerebral function)
septic shock - severe sepsis with hypotension despite adequate fluid resus, or the need for vasopressors or inotropes to maintain BP
septicaemia - old term that meant multiplying bacteria in the blood. replaced with terms above.
anaphylaxis - A-E
A + B: secure airway 100% O2 intubate if resp obstruction imminent remove cause + raise legs
C:
adrenaline (0.5mg IM (0.5ml 1:1000) ± repeat 5-minly)
IV access → chlorphenamine 10mg + hydrocortisone 200mg
saline - 500ml 0.9% bolus in 10 mins (may need 2L, titrate against BP)
D:
wheeze - treat for asthma
consider ventilation
still hypotensive - ICU ± IV adrenaline ± aminophylline + salbutamol nebs
acute MI - A-E
call senior immediate ECG + IV access + take cardiac + routine bloods quick hx - PMH, RFs, CIs to pci obs incl bilateral BP, glucose, gas then A-E:
A + B:
low flow O2 if <94%
resp - auscultate, expansion, percussion
C:
radial pulses, JVP, scars, heart sounds, peripheral oedema
D + E: aspirin + clopi 300 morphine 5mg IV metoclopramide 10mg PCI if available in 2h
acute HF - A-E
brief hx
alert ICU + sit pt up
get obs, glucose, ECG
A+B:
a: resp - auscultate, expansion, percussion
m: 100% oxygen if no lung dx
C:
a: cardio - pulses, JVP, HS, oedema
m: IVa - gas, routines, troponins, BNP
D: a: CXR ± echo m: treat cause eg AF, sepsis IV furosemide 40-80mg IV GTN if sBP > 90 IV opiate
E:
?CPAP + ITU
acute asthma - A-E
call senior ± ICU
IV access, obs + ECG monitor
A:
assess severity - PEF, speech, RR, HR, sats
auscultate, expansion, percuss
ABG + glucose
B:
salbutamol 5mg nebd with O2
hydrocortisone 100mg IV ± pred 50mg po
O2 if <92
C:
heart sounds
monitor for arrhythmias
D - if life-threatening:
salbutamol nebs every 15m
ipratropium 0.5mg: add to nebs
MgSO4 1.2-2g IV over 20m
reassess PEF + ABG
E - improving: salbutamol nebs every 4h monitor PEF + sats ± O2 - sats 94-98 oral pred - 40mg, 5-7d
not improving:
ICU - ?ventilatation, aminophylline, IV salbutamol
acute asthma: concerning signs that indicate ICU referral
deteriorating PEF
hypoxia persistent, hypercapnia, acidosis
exhaustion, altered LOC
acute COPD: A-E
call senior ± ICU
obs + glucose
A:
auscultate, expansion, percuss
pulses, heart sounds, JVP, oedema
B:
salbutamol 5mg/4h neb
ipratropium 500mcg/6h
ABG + CXR
C:
IV access + ECG monitor
D:
if <88 - 28% oxygen (aim 88-92 / 94-98 if no hypercapnia on abg. adjust re abg + aim for PaO2 > 8)
E: hydrocortisone 200mg IV pred 30mg po (continue 1-2wk) abx - amoxicillin/clarithro/doxy APLGs physio to aid sputum expectoration
no improvement:
?IV aminophylline
?NIV
don’t forget sepsis!
PE - A-E
call senior
ask nurse to set up obs + ECG
A + B: a: resp exam + ABG m: oxygen if hypoxic - 10-15L/m morphine 5mg IV antiemetic if pain/distress
C:
a: CRT, pulses, HS, JVP, oedema, calves
m:
IVa - routines, clotting, lipids, glucose
D:
CXR
well’s score ± d-dimer/CTPA/VQ (CKD)
E - PE confirmed:
start LMWH
sBP<90 - ring ICU
sBP>90 - start warfarin loading regimen eg 5mg po
shock from upper GI bleed - A-E
call senior/surgical reg + keep NBM
ask nurse to set up obs, BM + ECG
brief hx
A + B:
protect airway
brief resp
oxygen?
C:
brief cardio + assess for shock (pulses, CRT, JVP, HS)
2 large bore cannulae ACF (14-16G) - urgent routines, glucose, clotting, crossmatch 6 units
fluids eg saline challenge or rapid crystalloid IV infusion - up to 1L
D:
brief abdo
use rockall scoring system to determine next steps eg transfusion or just crystalloid
correct clotting abnormalities eg PCC
E:
?ICU + surgeons
catheterise + monitor UO
urgent endoscopy in 4h if variceal bleed or 12-24h if unstable
avoid saline in decompensated liver disease (ascites, peripheral oedema) - worsens ascites
bacterial meningitis - A-E
call senior + ICU
get obs + ECG
?sepsis - sepsis six
A:
brief resp
B:
100% oxygen
ABG
C:
brief cardio + get IVa
in - ceftriaxone + vanc, dex, fluids (cautiously if ICP)
out - cultures + PCRm, lactate, clotting, routines, glucose, serology
D:
brief abdo
catheterise
throat + rectal swabs (v + b)
E:
brief neuro + CNs + fundus
CXR when stable
consult senior re LP - ci if icp, rash, septicaemic sx eg hypoperfusion
inform PHE
cipro for contacts
change abx as per cultures
status epilepticus - A-E
senior, ICU, obs, ECG
A: open + maintain airway + lay in recovery position remove false teeth insert oral/nasal airway intubate if necessary
B:
100% oxygen ± suction
ausc chest
C:
IVa - lorazepam 2-4mg slow IV bolus OR buccal midazolam
routine, glucose, calcium, anticonvulsant levels ± tox screen
ABG
ausc HS
D:
check pupils
no response in 10min - repeat
E:
