Acute Care Flashcards

Question

How to manage anaphylactic shock

Answer 1

Remove the trigger Administer adrenaline and antihistamines. Fluid boluses to correct hypovolaemia (Steroids?)

Answer 2

acts on adrenergic receptors in the sympathetic nervous system to reverse the systemic vasodilation, acting as a vasopressor. it also decreases vessel permeability, which helps to prevent further third-space fluid losses.

Answer 3

usually hydrocortisone likely to reduce the likelihood of a biphasic anaphylaxis (i.e. a second event), rather than having any role in correcting the current abnormalities.

Answer 4

A mixed picture – Bacterial endotoxins have an effect of: 1. Widespread vasodilatation (causing distributive shock) 2. Increasing vessel permeability (causing hypovolaemia through third-space losses).

Answer 5

Remove trigger - urgent antibiotics Fluid boluses to correct hypovolaemia In cases refractory to fluid boluses, referral to HDU or ITU for infusion of vasopressors

Answer 6

occurs when there is an injury to the central nervous system above the T6 level => total loss of sympathetic tone whilst leaving vagal stimulation unopposed. profound vasodilatation causing a distributive shock, but potentially with no tachycardia as compensation due to the loss of sympathetic stimulation

Answer 7

neurogenic shock - ?injury to the brain or spinal cord

Answer 8

Any/all of: * Fluid resuscitation * Vasopressors to reverse systemic vasodilatation * Inotropes to increase myocardial contractility * Chronotropes to correct the Bradycardia Prolonged supportive measures during recovery (~1-3 weeks)

Answer 9

vasopressin (ADH), adrenaline, noradrenaline, etc

Answer 10

dopamine, isoprenaline, adrenaline, noradrenaline, etc

Answer 11

atropine, adrenaline, dopamine, etc.

Answer 12

Increased HR may lead to myocardial ischaemia, though coronary perfusion is preferentially maintained

Answer 13

pre-renal AKI due to reduced perfusion

Answer 14

Cerebral perfusion is maintained for as long as possible Depending on degree and duration of shock - can get hypoxic brain injury

Answer 15

reduced perfusion can cause Type 1 respiratory failure acutely, even after resuscitation

Answer 16

Reduced perfusion can cause mucosal ischaemia - may lead to stress ulceration over time

Answer 17

A-E assessment (and regular reassessment) Obs repeated regularly Hourly Urine Output monitoring – Insert urinary catheter Blood gas - for lactate, and for acid-base/respiratory status Bloods ECG

Answer 18

Admission to HDU (Level 2)/ITU (Level 3) Advanced monitoring: - Central Venous Pressure monitoring via Central Venous Catheter (CVC/Central Line) - Invasive Blood Pressure monitoring via Arterial Line (A-Line) - Continuous cardiac monitoring

Answer 19

High-flow (15L) oxygen via a non-rebreathe mask Establish IV access early IV fluid resuscitation (unless obvious Cardiogenic shock) Treat the Cause - Vasopressors (if SVR impaired) - Inotropes (if Contractility impaired) - Chronotropes (if HR impaired) - Cardioversion (if arrhythmias present) – chemical or DC Don’t forget to reassess and escalate if needed.

Answer 20

``` Ketones >6 pH <7.1 HCO3 <5 / anion gap >16 K+ <3.5 GCS <12 SpO2 <92% SBP <90 Pulse >100 or <60 ``` HDU/ITU must be contacted

Answer 21

Potassium levels can fluctuate severely during DKA => osmotic diuresis (due to glucosuria) leads to a total body K+ (and phosphate) depletion. => Life threatening hypokalaemia can occur with insulin infusion. BUT Serum potassium levels may not mirror this and may be low/normal/high. So continuous monitoring of potassium is essential and replacement may be required.

Answer 22

if rate >20 mmol/hour

Answer 23

1. IV Fluid replacement – to replace loss caused by the hyperglycaemia 2. IV insulin – to bring the blood glucose level down. => but often very sensitive to insulin and require much lower doses than in DKA. = > Aim is to reduce glucose levels slowly. 3. Treat any underlying cause, if known 4. Refer to diabetes specialist nurse – education for prevention of further emergencies.

Answer 24

glucose <4.0 mmol/L

Answer 25

Delayed/missed meals Low carbohydrate content in meals Unplanned or strenuous exercise Taking too much insulin

Answer 26

``` Fatigue, Sweating, Pallor, Headache Tachycardia ```

Answer 27

If conscious and able to swallow: 1. 15–20 g of fast-acting carbohydrate 2. Repeat treatment after 10–15 minutes, up to a maximum of 3 treatments in total. 3. Once glucose >4mmol/L, long-acting carbohydrate should be given to prevent blood glucose from falling again.

Answer 28

1. Glucagon or glucose 10% (or 20%) infusion. 2. Long-acting carbohydrate should be given as soon as possible. (Patients who have received glucagon require a larger portion of long-acting carbohydrate to replenish glycogen stores)

Answer 29

self-poisoning or self-injury, irrespective of the apparent purpose of the act. => it's not an illness itself but is more or less dangerous behaviour that should alert us to an underlying problem, difficulty or disorder.

Answer 30

= an intentional self-inflicted act that results in death

Answer 31

~10 deaths per 100,000 in the UK 1/3rd of all suicides in the UK are men in their 40s and 50s ~90% are suffering from a psychiatric disorder at the time of death

Answer 32

F:M = 1.5 : 1 Increased incidence in some ethnic groups Previous self-harm (40% of people who present have a history of self-harm) Diagnosis of personality disorder Alcohol / drug misuse Lower socioeconomic status, social isolation Hopelessness, impulsivity, poor problem-solving ability Sexual abuse, traumatic life events Recent significant life events

Answer 33

Statement of intent and access to means Psychiatric illness – depressive illness, early schizophrenia, comorbidity, recent discharge from hospital History of previous self-harm, History of violence Family history of self-harm and suicide Social isolation, unemployed, lower social class, single, Significant life events e.g. bereavement Painful physical illness Impulsive personality traits Male Older age Factors associated with HIGH Risk: - Recurrent and persistent suicidal ideation, - Hopelessness, Agitation, Intoxication, - Delusions of control, poverty, guilt, - Impulsive personality traits, poor engagement with services

Answer 34

women presenting in the post-partum period. Deaths in post-partum period are more likely to be by violent means Postpartum psychosis is associated with 70x risk

Answer 35

History Assessment of Mental State

Answer 36

involves a Bio-psychosocial approach to minimise risk to self and others is discharge safe or is admission needed?

Answer 37

a life-threatening organ dysfunction due to a dysregulated host response to infection

Answer 38

= a subset of sepsis where particularly profound circulatory, cellular and metabolic abnormalities substantially increase mortality

Answer 39

Previously, the SIRS criteria were used (with sepsis being SIRS + evidence of infection) Now, NEWS2 scores are used NEWS2 score of 5+ should trigger a sepsis screen if one of the risk factors is present, or if a HCP is concerned.

Answer 40

- Extremes of age (<1 or >75) - Impaired immune system (chemotherapy, comorbidities, long-term steroids). - Recent invasive procedure (e.g. surgery, trauma, etc.) - Broken skin (indwelling lines, IVDU, cuts/burns/blisters) Also some more specific risk factors in pregnancy and neonates.

Answer 41

1. Pneumonia 2. UTI 3. Abdominal infection 4. Skin, soft tissue, bone/joint infections 5. Other infections – endocarditis, device-related, meningitis, etc.

Answer 42

Suggestive diagnostic results Clinical suspicion Signs of infection – e.g. fever, high/low temperature, sweating, flushing; but with no suggestion of source.

Answer 43

SOFA Score - the “Official” diagnostic criterion for diagnosis of organ dysfunction (and therefore Sepsis) Can only really be used in critical care situations Therefore, "red flag" sepsis criteria used more frequently

Answer 44

* Objective evidence of new or altered mental state * Systolic BP ≤90 mmHg, or a drop of >40 mmHg from the patient’s normal * Heart rate ≥130 beats per minute * Respiratory rate ≥25 breaths per minute * Requirement for Oxygen supplementation to maintain saturations of 92% or above (or 88% in COPD) * Skin signs – such as a non-blanching rash, mottled or ashen appearance, or cyanosis * A Lactate level of 2 or higher * Recent chemotherapy * Anuria for 18 hours, or <0.5ml/kg/hr if catheterised If any one of these is present, START SEPSIS SIX.

Answer 45

*mostly* match up with the red flag criteria, with a lower threshold for each * Concern from relatives about the patient’s mental status * An acute deterioration in the patient’s functional ability (“off legs”) * Immunosuppressed * Trauma/Surgery/Procedure in the last 8 weeks * Respiratory rate between 21 and 24 * Systolic BP between 91-100 * Heart rate between 91-130, or any new abnormal heart rhythm * Temperature <36°C * Clinical signs of wound infection If any one of these are present, FURTHER REVIEW REQUIRED.

Answer 46

``` Sepsis AND (following fluid resuscitation) Hypotensive (SBP <90 mmHg) AND Lactate >2 mmol/L ``` As a trigger to call Critical Care

Answer 47

BUFALO: Blood – IV access – cultures, coag, glucose, lactate FBC, U&E, CRP (culture all other potential sources – e.g. sputum, urine) Urgent Review – escalate for senior review (ST3+) Fluids – fluid bolus of 500ml and monitor urine output. Antibiotics – high dose broad spectrum BUT remember allergies! Lactate – identifies patients at risk Oxygen – give if required (aim for 94-98% or 88-92% in hypercapnic failure)

Answer 48

= a time-critical and potentially fatal condition occurring in immunocompromised patients. It is a medical emergency requiring immediate investigation and treatment in hospital. these patients tend to deteriorate more rapidly than those without neutropaenia.

Answer 49

= Neutrophil count: < 0.5 × 10^9/L The risk of sepsis increases with severity (how low) and duration of neutropaenia. Maintain a high level of suspicion

Answer 50

1. Rapid A-E assessment 2. Escalation onto Sepsis 6 pathway => CRITICAL: Commence antibiotics within 1 hour 3. Treat on suspicion - DO NOT DELAY whilst awaiting confirmation of neutropaenia via bloods 4. Consider potential for atypical infections

Answer 51

further deterioration is often experienced before they are recognised as being septic.

Answer 52

Depends on the substance in question, quantities ingested and the timeline of presentation. Often there are no signs or symptoms early on.

Answer 53

nausea and vomiting, Loin pain/haematuria – renal failure RUQ pain/jaundice – hepatic necrosis

Answer 54

CNS depression, ataxia, slurred speech, respiratory depression

Answer 55

respiratory depression, pin-point pupils, coma

Answer 56

dependent on the amount of alcohol consumed (i.e. dose dependent) - Euphoria, social disinhibition, joyousness - Extraversion, decreased reasoning - Ataxia, nausea and vomiting - Anterograde amnesia - CNS depression

Answer 57

* Observations * Physical examination (especially neurological) * ABG/VBG * ECG * Baseline bloods (especially renal and hepatic function) * Serum levels of substance in question

Answer 58

Alcohol is metabolised through zero-order metabolism – the rate of reaction is independent of concentration. The enzymes become saturated, so the body can’t keep pace with the rising concentration

Answer 59

If needed, treatment is supportive – e.g. recovery position, monitoring vital signs, sometimes IV fluids.

Answer 60

seen in alcohol dependent states (usually >20 units/day) typical symptoms include sweating, tremor, anxiety, nausea and vomiting. More serious symptoms: - Confusion, - Hallucinations - Very high temperature - Seizures

Answer 61

= rapid onset of confusion usually caused by withdrawal from alcohol

Answer 62

formication (a type of tactile hallucination) – the feeling of imaginary insects/spiders on the skin.

Answer 63

Medically assisted withdrawal is the treatment of choice. Benzodiazepine (e.g. chlordiazepoxide) + Pabrinex (vitamins B&C) Either symptom-triggered or fixed-dose reducing regimen

Answer 64

Exhaustion of vitamin B1 (thiamine) leads to biochemical lesions in the CNS.

Answer 65

Often diet deficient in thiamine, but also alcohol prevents absorption of thiamine.

Answer 66

Typically present with a triad of: 1. Ataxia 2. Ophthalmoplegia 3. Confusion (new onset)

Answer 67

high-dose parenteral thiamine (e.g. Pabrinex) often leads to full resolution of symptoms, if given quickly. IV or IM

Answer 68

= Irreversible brain damage, typically due to chronic alcohol misuse. Often there have been previous instances of acute Wernicke’s encephalopathy. Typically presents with dense anterograde amnesia, confabulation and personality change. - Often have similar needs to someone with dementia. - Can believe made up things with a delusional intensity.

Answer 69

Serum paracetamol levels => Only valid after 4 hours post-ingestion. Baseline bloods to assess renal and liver function (includes INR) ABG/VBG to assess acid/base status Weight - will guide treatment later on

Answer 70

Patients on/above the treatment line for paracetamol overdose will be treated with acetylcysteine. If overdose is staggered, paracetamol levels are difficult to interpret – treat with acetylcysteine Acetylcysteine is given in a 21-hour infusion, based on the weight of the patient. Psychiatric assessment after patient is stable.

Answer 71

Vomiting of bright red blood indicates an acute upper GI bleed

Answer 72

Peptic Ulcer Disease Variceal Bleeding Oesophagitis Mallory-weiss tear Upper GI malignancy Rare causes (<5%) - aorta-enteric fistula, AV malformation, etc.

Answer 73

Vomiting of black material = blood altered by gastric acid

Answer 74

Black, tarry stools = blood digested by intestinal enzymes. Usually upper GI bleed, but can be small bowel or right side of colon.

Answer 75

Fresh, red blood per rectum. = Usually colonic/rectal bleeding Sometimes profuse upper GI bleeding, which stimulates peristalsis and results in rapid transit of blood (~10% of haematochezia)

Answer 76

A-E assessment => may be pale, tachycardia, hypotensive Abdominal exam PR exam Bloods - FBC, U&E, LFT, coag, XM, VBG Imaging - OGD, (CT contrast), (erect CXR)

Answer 77

Callculated pre-endoscopy. Evaluating the likelihood of need for intervention. Scores range from 0 – 23, => Score = 0 – patient may be suitable for outpatient care. => Score >0 – consider admission for endoscopy => Score = 6+ – indicates 50% chance of intervention being required (transfusion/OGD/surgery)

Answer 78

Used to predict the risk of re-bleeding and death. Requires both pre- and post-endoscopy findings. If the total Rockall score is 3+, this indicates a significant risk of re-bleeding.

Answer 79

blood loss occurring from a site distal to the ligament of Treitz (duodenal-jejunal junction).

Answer 80

No visible blood Iron deficiency anaemia +ve FOB or FIT

Answer 81

Rectal bleeding or melaena | Haemodynamically stable

Answer 82

Large amounts of rectal bleeding Postural hypotension +/- Significant drop in haematocrit Haemodynamically unstable Persistent bleeding/rebleeding Requires multiple blood transfusions

Answer 83

``` Haemorrhoids Anal fissure IBD Colorectal cancer Diverticular disease Angiodysplasia UGI bleed Haemorrhagic infective gastroenteritis ```

Answer 84

Acquired submucosal AV malformations Most commonly located in caecum and ascending colon. Most commonly presents with iron deficiency anaemia and occult bleeding Typical presentation is of painless, fresh, PR bleed in elderly patients Can be difficult to differentiate from diverticular bleeding.

Answer 85

A-E assessment if severe Abdominal exam PR exam Stool cultures Faecal calprotectin Bloods - FBC, U&E, LFT, coagulation, G&S, XM, ferritin/iron studies, VBG

Answer 86

the gradient of negative pleural pressure increases from the lung base to the apex => alveoli at the lung apex in tall individuals are subject to significantly greater distending pressure than those at the base of the lung predispose to the development of apical subpleural blebs.

Answer 87

No underlying lung disease | Rupture of a pleural bleb

Answer 88

Due to underlying lung disease: COPD, asthma, severe pulmonary fibrosis, etc.

Answer 89

Primary - young, tall (and thin?) males. Secondary - older patients (>40), usually smokers

Answer 90

Primary - symptoms can be minimal - low index of suspicion is required. Secondary - symptoms more likely to be severe, even with a small PTX

Answer 91

Sudden onset pleuritic chest pain Potentially pallor and tachycardia (tension???) If small, potentially no symptoms.

Answer 92

Reduced chest expansion Hyper-resonance on percussion Diminished breath sounds on auscultation

Answer 93

``` Trachial deviation (away from affected side) Cyanosis Severe tachypnoea Tachycardia Hypotension ```

Answer 94

one-way valve system at the site of the breach in the pleural membrane allows air to enter the pleural cavity during inspiration but preventing release of air during expiration. This increases the intrapleural pressure so that it exceeds atmospheric pressure. This results in impaired venous return and reduced cardiac output results in the typical features of hypoxaemia and haemodynamic compromise.

Answer 95

``` Ventilated patients on ITU Trauma patients Resuscitated patients (CPR) Lung disease: acute asthma or COPD Blocked or clamped chest drains Patients on non-invasive ventilation Hyperbaric oxygen treatment (very small patient group) ```

Answer 96

1. call for help immediately. 2. Oxygen therapy 3. Needle decompression with a cannula => 2nd intercostal space, midclavicular line with a 14g (orange) cannula. => If initial treatment at 2nd ICS fails, then try 4th/5th ICS. 4. After decompression, patient will require rapid insertion of a chest drain.

Answer 97

The general rule is that a 2cm interpleural distance at the level of the hilum equates to a pneumothorax of 50% of the volume of the lung. <2cm is a small pneumothorax and patient may not need treatment

Answer 98

1. Fluid resuscitation 2. Fluid maintenance 3. Fluid replacement

Answer 99

intracellular (ICF) and extracellular (ECF). ECF => interstitial compartment => intravascular compartment

Answer 100

~65% in ICF ~35% in ECF => 75% is interstitial => 25% is intravascular

Answer 101

fluid movement due to filtration across the wall of a capillary is dependent on the balance between the hydrostatic pressure gradient and the oncotic pressure gradient across the capillary.

Answer 102

high potassium concentration. low sodium concentration. Intracellular solute concentrations remain more or less constant

Answer 103

high sodium concentration. low potassium concentration.

Answer 104

large molecular weight particles such as proteins in the intravascular compartment create a pressure gradient drawing water towards it.

Answer 105

affected by circulatory pressures and other pressures in tissues such as oedema, and mechanical restriction such as with infection, plaster casts or bandaging.

Answer 106

1. Oral fluids. 2. Parenteral fluids. 3. Water released from metabolism (about 400 ml per day, but not normally included in fluid balance calculations).

Answer 107

Urine GI losses Insensible losses (skin/breathing/etc). Others - e.g. drains, burns, bleeding.

Answer 108

Depends, but usually ~1.5-2L aim for a minimum urine output of 0.5mL/kg/day

Answer 109

Normally minor (approximately 100 ml/day lost via the faeces) Can be substantial in someone with diarrhoea, vomiting, biliary drains and high stoma output.

Answer 110

500 – 800 ml per day can increase significantly (e.g. if patient is sweating, febrile, tachypnoeic, or undergoing open cavity surgery).

Answer 111

25-30 ml/kg/day of water Approximately 1 mmol/kg/day each of sodium, chloride and potassium 50 - 100 g/day of glucose to limit starvation ketosis

Answer 112

older adults and/or frail, renal/cardiac failure, malnourished and at risk of refeeding syndrome

Answer 113

Sodium 1 mmol/kg/day Chloride 1 mmol/kg/day Potassium 1 mmol/kg/day

Answer 114

sodium, potassium and bicarbonate

Answer 115

potassium, chloride and hydrogen ions

Answer 116

none - essentially pure water loss

Answer 117

1. Crystalloids - solutions of mineral salts. | 2. Colloids - contain larger water-insoluble molecules such as complex branched carbohydrates or gelatins

Answer 118

Cheap and effective solutions. Do not cause adverse immunological reactions. Can be used as maintenance and replacement fluid. Depending on their solute concentration, they are classified as hypo-, hyper- or isotonic solutions.

Answer 119

e.g. sodium chloride 0.9% stays almost entirely within the extracellular compartment

Answer 120

e.g. sodium chloride 3%, mannitol increase plasma tonicity and draw fluid out of cells

Answer 121

e.g. sodium chloride 0.45% lower serum osmolarity and are not commonly used

Answer 122

initially when they are rapidly infused, they do cause a transient expansion of the plasma volume. In emergency - do not wait till the ideal fluid becomes available, give whatever is available to maintain haemodynamic stability.

Answer 123

isotonic - stays in ECF 25% to intravascular (250ml) 75% to interstitial (750ml)

Answer 124

include: Blood, Dextrans, Gelatin (e.g. gelofusine), Human albumin solution, Hydroxyethyl starch (HES) exert an osmotic force across the capillary membrane drawing fluid in from the interstitial to the intravascular compartment - Higher cost. - Small, but well-established risk of anaphylactoid reactions and anaphylaxis

Answer 125

500 ml of a crystalloid containing sodium in the range 130-154 mmol/litre (e.g. sodium chloride 0.9%) administered over less than 15 minutes. Human albumin solution 4-5% can be considered for fluid resuscitation only in patients with severe sepsis

Answer 126

it is hyperoncotic => rapid administration can lead to rapid volume expansion and cardiac failure

Answer 127

mean arterial pressure, urine output other clinical measures (e.g. capillary refill).

Answer 128

mimics the administration of a fluid bolus by redirecting blood from the lower limbs to the heart (i.e. increased pre-load) Used to predict which patients are most likely to respond to administration of a fluid bolus

Answer 129

1. Dilutional hyponatraemia | 2. Pulmonary oedema

Answer 130

Stop IV fluids Restrict oral fluids Furosemide Nitrates - reduce preload

Answer 131

``` A - Airway B - Breathing C - Circulation D - Disability E - Exposure ```

Answer 132

Can the patient talk? If no: Look for signs of airway compromise – e.g. cyanosis, see-saw breathing, use of accessory muscles, diminished/added breath sounds. Open the mouth and inspect – ?obstruction with secretions/foreign object. Any added noises – snoring, crowing, gurgling, stridor.

Answer 133

Inhaled foreign body Blood/vomit/secretions in the airway Soft tissue swelling Local mass effect Laryngospasm Depressed level of consciousness

Answer 134

Seek immediate support from anaesthetist and crash team. Airway manoeuvres: => Head tilt chin lift => Jaw thrust Airway adjuncts: => Oro/nasopharyngeal airway

Answer 135

Is the patient speaking in full sentences? Is the patient orientated or confused? Respiratory Rate => Normal (12-20)/ bradypnoea/ tachypnoea O2 Sats => 94-98% in healthy individuals => 88-92% in patients with COPD Tracheal position – any deviation? Chest expansion – symmetrical? any reduced movement? Percussion and Auscultation ABG CXR

Answer 136

Position of patient. Continuous saturation monitoring. Oxygen therapy (+ nebuliser therapy?)

Answer 137

Pulse => Rate – Normal/bradycardia/tachycardia? => Rhythm, character and volume MANUAL Blood Pressure => Normal/hypotension/hypertension Obvious signs of dehydration? Pallor? Oedema? Measure capillary refill time (may need to assess central CRT) => Should be <2 seconds. Auscultate Heart Sounds

Answer 138

* Sepsis * Dehydration * Blood loss * Drugs * Electrolyte abnormalities * Ischaemia * MI

Answer 139

IV access with cannula FBC, U&Es, LFTs routinely, and consider additional bloods (lactate, ABG, etc). 12-lead ECG if appropriate. Hypovolaemia requires IV fluid resuscitation to avoid cardiac arrest.

Answer 140

Assess consciousness - AVPU (if a more detailed assessment is required, then GCS) Pupils => Inspect the size and symmetry of the patient’s pupils => Assess direct and consensual light reflex. Drug chart review => Any drugs which may alter consciousness? (e.g. opioids, sedatives, etc). Blood glucose => Normal 4.0 – 11.0 mmol/L => If elevated, check ketones (?DKA) CT head if intracranial pathology suspected

Answer 141

Alert: the patient is fully alert, although not necessarily orientated. (New) Confusion Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt). Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure). Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.

Answer 142

Eye Opening Verbal Response Motor Response

Answer 143

``` Spontaneous – E4 To sound – E3 To pressure – E2 None – E1 (NT) ```

Answer 144

``` Orientated – V5 Confused – V4 Words – V3 Sounds – V2 None – V1 (NT) ```

Answer 145

``` Obey commands – M6 Localising – M5 Normal flexion – M4 Abnormal flexion – M3 Extension – M2 None – M1 (NT) ```

Answer 146

Maintain airway if GCS 8 or below. Naloxone if ?opioid toxicity. Management of DKA/HHS or Hypoglycaemia.

Answer 147

Head-to-toe examination of the patient, front and back. Aim to maintain dignity and control temperature. Skin => Rashes, bruising, signs of infection? IV lines => Redness/discharge? Abdominal distension Calves => Erythema, swelling, tenderness? Surgical wounds => Signs of infection? Evidence of haemorrhage Evidence of infection Review output from catheter/drains Review body temperature.