ABCDE Approach

Question 1

How can the ‘airway’ be assessed?

Answer 1

Get patient to confirm their name & DOB - a normal response confirms a patent airway (move on to B)

Question 2

What is the most common cause of an airway obstruction in adults?

Answer 2

A reduced conscious level - tongue, soft palate & epiglottis can occlude the upper airway.

Question 3

If the patient is not verbally responsive, how can you assess the airway?

Answer 3

• Look for chest movements - ensure your head is on the horizontal plane of chest
• Listen for breath sounds
• Feel for air movement on your cheek
• Check for foreign bodies or secretions

Question 4

What signs may indicate a patient has an obstructed airway?

Answer 4

• Not able to talk in full sentences
• Visibly SOB
• Use of accessory muscles
• Cyanosis
• Angioedema (tongue/lip swelling)

Question 5

What should you feel for when assessing the airway?

Answer 5

Tracheal position

Question 6

What would angioedema indicate?

Answer 6

Anaphylaxis

Question 7

What would a ‘gurgling’ sound indicate?

Answer 7

secretions

Question 8

What would ‘snoring’ sounds indicate?

Answer 8

soft palate or tongue partially obstructing pharynx

Question 9

what would a stridor indicate?

Answer 9

foreign body

Question 10

How would a fully obstructed airway sound?

Answer 10

Silent

Question 11

What manoeuvres can be done if the patient is unconscious with an obstructed airway?

Answer 11

1. Head tilt chin lift
2. Jaw thrust

Question 12

When would the jaw thrust be used over the head tilt chin lift?

Answer 12

If suspected C-spine injury

Question 13

What airway adjuncts can be used in unconscious patients with an obstructed airway?

Answer 13

1. Oropharyngeal
2. Nasopharyngeal

Question 14

Which airway adjunct would be preferred in a patient who was not deeply unconscious?

Answer 14

Nasopharyngeal (better tolerated)

Question 15

Which airway adjunct would be preferred in a patient who had a suspected base of skull fracture?

Answer 15

Oropharyngeal

Question 16

How can the correct size of oropharyngeal adjunct be measured?

Answer 16

Measure from angle of mouth to edge of mandible

Question 17

If patient not breathing/hypoxic, ventilate using bag and mask (2 person technique). What rate should you squeeze the bag at?

Answer 17

10-12 per minute

Question 18

What is paradoxical breathing a sign of?

Answer 18

Sign of respiratory distress that occurs with increasing partial airway obstruction.

Question 19

Describe paradoxical breathing

Answer 19

• Chest contracts during inspiration and expands during exhalation (opposite of normal)
  
  • Vertical rib cage movement
• The abdomen moves outwards as the diaphragm moves downwards, but the negative pressure generated against the obstructed airway draws the chest inwards
  
  • Abdominal hollowing, no distension

Question 20

Define ventilation

Answer 20

The amount of air the reaches the alveoli

Question 21

Define perfusion

Answer 21

The amount of blood that reaches the alveoli

Question 22

Define a V/Q mismatch

Answer 22

Mismatch between alveolar ventilation and alveolar blood flow

Question 23

What PaO2 defines respiratory failure?

Answer 23

PaO2 < 8 kPa

Question 24

What response should always be done in any patient presenting SOB?

Answer 24

Sit patient up

Give 15L oxygen on a non-rebreathe mask

Question 25

What 2 observations should **always** be done during ‘breathing’?

Answer 25

1. O2 saturations (put on probe) 2. Respiratory rate

Question 26

What observation should be done during ‘breathing’ if concerned about an asthma attack?

Answer 26

Peak flow (PEFR)

Question 27

What response should be taken if the SpO2 is low?

Answer 27

15L oxygen via a non-rebreathe mask

Question 28

Describe some potential steps for the ‘look’, ‘listen’ and ‘feel’ aspect of ‘breathing’

Answer 28

**Look**: * Symmetrical chest expansion & depth * Breathing effort **Listen**: * Auscultation of lung lobes **Feel:** * Percussion * Chest expansion

Question 29

What condition would **reduced breath sounds** with **coarse crepitations** and **bronchial breathing** over a certain area indicate?

Answer 29

Pneumonia

Question 30

Describe the percussion in pneumonia

Answer 30

Dull over the affected zone

Question 31

Describe the vocal resonance in pneumonia

Answer 31

Increased over the affected zone

Question 32

Give the percussion sounds in a pleural effusion

Answer 32

Stony, dull

Question 33

How can a pleural effusion affect trachea position?

Answer 33

Central or **shifted away** from the affected side if large

Question 34

Describe breath sounds in a pleural effusion

Answer 34

Reduced/absent

Question 35

What condition would **fine inspiratory crepitations** ranging from the lung bases to throughout the lungs indicate?

Answer 35

Pulmonary oedema

Question 36

What condition would a high pitched expiratory wheeze indicate?

Answer 36

Severe asthma exacerbation

Question 37

What condition would a bilateral expiratory wheeze and crepitations indicate?

Answer 37

COPD exacerbation

Question 38

What investigations would you do in ‘breathing’?

Answer 38

* ABG * Portable chest XR

Question 39

What would you give in a suspected asthma exacerbation?

Answer 39

1. Sit patient up and give oxygen 2. Salbutamol 5mg nebulised 3. Ipratropium bromide 4. Hydrocortisone or prednisolone

Question 40

What would you give in a suspected COPD exacerbation?

Answer 40

1. Salbutamol 5mg nebulised 2. Ipratropium bromide nebulised

Question 41

What is ‘shock’?

Answer 41

Acute **circulatory** **failure** leading to **inadequate** **perfusion** causing **cellular** **hypoxia** which leads to cellular disorder and failure of multiple organs.

Question 42

What are the 4 types of shock?

Answer 42

1. Hypovolaemic 2. Cardiogenic 3. Vasodilatory/distributive 4. Obstructive

Question 43

What type of shock does sepsis cause?

Answer 43

Vasodilatory/distributive

Question 44

What type of shock does anaphylaxis cause?

Answer 44

Vasodilatory/distributive

Question 45

What type of shock does a tension pneumothorax cause?

Answer 45

Obstructive

Question 46

What 4 observations should be done in ‘circulation’?

Answer 46

* Pulse (rate, rhythm and character) → attach vital signs machine * Blood pressure → attach blood pressure cuff * Capillary refill time * Temperature

Question 47

What response in ‘circulation’ should almost always be done in an acutely unwell patient?

Answer 47

Insert 2x large bore cannulae (14G or 16G)

Question 48

Why is it important to measure the patient's urine output?

Answer 48

One of the most sensitive organs to reduced perfusion is the kidney → risk of AKI (especially in sepsis)

Question 49

How can the urine output be measured?

Answer 49

Catheterise the patient (ideally in ‘circulation’)

Question 50

Describe some potential steps for the ‘look’, ‘listen’ and ‘feel’ aspect of ‘circulation’

Answer 50

Look: * JVP - raised? * Mucous membranes - dry? * Urine output Listen: * Auscultation of heart valves * Auscultation of lungs Feel: * Peripheries - cool and clammy? Warm?

Question 51

In hypotensive patients (i.e. low BP), what intervention should be given?

Answer 51

Fluid bolus - 500ml 0.9% saline over 15 minutes

Question 52

What can be done at the same time as inserting the cannula?

Answer 52

Take blood tests & cultures

Question 53

What blood tests might be useful to take?

Answer 53

* VBG → for lactate * FBC * U&Es * Clotting * CRP * LFTs * Troponin (if cardiac concern) * Blood cultures (if infection/sepsis concern)

Question 54

If red flags for sepsis are identified, what treatment should be done?

Answer 54

SEPSIS 6 → BUFALO **B**lood cultures **U**rine output **F**luids (IV) **A**ntibiotics - broad spectrum IV **L**actate (VBG) **O**xygen

Question 55

If the patient presents with tachycardia, what investigation should be ordered?

Answer 55

12-lead ECG

Question 56

What 3 main aspect should you assess in ‘disability’?

Answer 56

1. Conscious level 2. Pupils 3. Blood glucose

Question 57

How can you quickly assess the patients consciousness level?

Answer 57

ACVPU

Question 58

What aspects of the pupils are you assessing in ‘disability’?

Answer 58

Size, symmetry, direct & consensual pupillary responses

Question 59

What would pin point pupils indicate?

Answer 59

Opioid overdose

Question 60

How can the blood glucose be checked in ‘disability’?

Answer 60

Rapid finger prink test → capillary blood glucose

Question 61

If blood glucose levels are **raised**, what other test should you do? Why?

Answer 61

Blood **ketones** → DKA

Question 62

What investigation would you order if there were concerns about head trauma?

Answer 62

CT head

Question 63

What would a single **fixed dilated** pupil indicate?

Answer 63

Herniation of the temporal through the temporal hiatus (coning) as a result of 3rd cranial nerve compression

Question 64

What would miosis indicate?

Answer 64

Horner's syndrome

Question 65

What would **bilateral fixed dilated** pupils indicate?

Answer 65

Brain death but can also occur in deep unconsciousness e.g. drugs/hypothermia

Question 66

Give some causes of hypoglycaemia

Answer 66

* Excessive administration of insulin * Oral hypoglycaemics e.g. gliclazide * Alcohol * Liver failure

Question 67

If the patients was presenting with severe hypoglycaemia, what would your response be?

Answer 67

IV dextrose Glucagon

Question 68

What would you be inspecting for in the ‘exposure’ aspect?

Answer 68

This may require exposing the patient - ensure to remain dignity & warmth. Inspection for: * Trauma * Bleeding * Rashes * Jaundice * Abdominal distension * Melaena * Cannula site infection * Catheter site infection INSPECT FRONT AND BACK

Question 69

What other aspects may be involved in the ‘exposure’ aspect?

Answer 69

* Abdominal examination → signs of urinary retention? * Drug chart * Bedside: medication, vomit bowls etc * Patient history * Fluid levels * Escalate → SBARR

Question 70

Before giving an antibiotics (or any medication), what should **always** be done?

Answer 70

ALLERGIES - red penicillin wristband?

Question 71

What does the SBARR tool stand for?

Answer 71

Situation Background Assessment Recommendation Read back/review

Question 72

What is NEWS2?

Answer 72

A scoring system used to **aid the recognition of acutely ill patients** or **patients who are deteriorating**. An **increasing score** triggers a call for assessment.

Question 73

What 7 aspects does NEWS2 involve?

Answer 73

1. Blood pressure 2. Respiratory rate 3. Respiratory support 4. O2 sats 5. Heart rate 6. Conscious level (ACVPU) 7. Temperature

Question 74

What is a **high risk** NEWS2?

Answer 74

7 or over