Acute Care Flashcards
When should you consider making a DNACPR decision
Cardiac/respiratory arrest likely to be part of dying process and CPR will not be successful > advanced decision.
Last hours/ days spent in their preferred place of care
CPR may be successful, clinical outcomes may still be bad – consider risk/benefit
of treatment.
May want CPR even if unlikely to be successful
Issues with capacity surrounding CPR
If they have capacity, they can refuse CPR
If not, can be judged that CPR would not be overall beneficial to them.
Judgements about CPR should be made as early as possible.
If lack capacity, inform legal proxy or others close to patient about DNACPR decision and reasons for it
What do you do about CPR in the acute situation
no time for assessment, if no DNACPR in place/ find out their view, CPR should be attempted, unless certain there is sufficient information about patient to judge that it will not be successful
What are the 3 levels of critical care
0: Hospitalisation on the ward (IV therapy, observation 4hr)
1: Recently discharged from high level care/additional monitoring and interventions (4 hrly observation, continuous O2, IV fluid, analgesia)
2: 1 nurse to 2 pts, step down from level 3 (basic resp, CV, renal and neuro support)
3: Advanced resp support, min 2 organs supported, 1:1 care
Fasting guidelines for anaesthesia
Clear liquid (water, fruit juices, clear tea, black coffee) – 2 hours
Breast milk – 4 hours
Infant formula/ nonhuman – 6h
Light meals – 6h
In diabetes: minimize number of meals missed to 1, guidance on meds.
ASA Grades
- 1: normal healthy patient
- 2: mild systemic disease
- 3: severe systemic disease
- 4: severe systemic disease with constant threat to life
Which drugs should you stop before anaesthesia
OCP (4w)
Hypoglycemics, Warfarin (5d)
Clopidogrel (7d)
ACEI (on the day) (exaggerate hypotension), other antihypertensives can be continued
Recovery and discharge after anaesthesia
Ensure no need for airway support, breathing spontaneously; monitor pulse ox, ECG, BP
Discharge if awake, responsive; analgesia; stable CV; normal resp; temp acceptable; records up to date
Assessment for soft palate
LEMON: look, evaluate mouth opening, mallampati score I: can see soft palate II: can see uvula III: only base of uvula IV: soft palate not visible at all
What is a major trauma centre and the 3 types
all the services available to receive and manage seriously injured adults and/or children.
3 types: those that treat adults, children, and both
What are the 5 levels of the triage system
1 immediate (red): immediately seen by doctor 2 very urgent (orange): within 5-10 minutes 3 urgent (yellow): within 1 hour 4 standard (green): within 2h 5 non-urgent (blue): within 4h
Who initially triages
Local ambulance service to the appropriate destination
What are major trauma centres linked to
MTCs linked to local trauma units working with local emergency hospitals, specialist rehabilitation providers and local general rehabilitation services
Key points from the NHS clinical advisory group trauma report
Each region has one hospital which is MTC, supported by LTUs.
All major trauma/ <45 minutes away > MTC
If > 45 minutes then stabilize in ambulance > LTU.
Acute hemorrhage control needs to be in operating room/intervention in 1h
Aims for MTCs
System based pathway of care from pre-hospital > rehab
Reduce avoidable deaths
Reduce injuries through prevention program
Improve quality of life/ functionality
Monitored system and subjected to continuous quality improvement
Trauma care pathway
first responders > emergency care > acute hospital > clinical rehab > community/ general rehab
What is the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS)
Anatomic global scoring system that classified injures in every body region.
Looks at 9 regions (head, face, neck, thorax, abdomen, spine, upper extremity, lower extremity, external and other) and bases on a scale of 1-6 (minor, moderate, serious, severe, critical, maximal)
How do you calculate the ISS?
Body into six parts (head/neck, face, chest, abdomen/pelvic content, extremities/pelvic girdle, external)
Use the scale of 1-6, then square it for each body part; finally add the top 3 squared scores together for ISS.
- ISS score > 15 have major trauma
- 9-15 is moderate-severe trauma (needs rehab)
- > 8 treat in MTC
3 consequences of major trauma
- impairment on physical health
- impairment on mental health
- employment affected
Team members in rehabilitation
consultant in rehab medicine, OT, physio, specialist nurses
Well’s Score meaning
Use 2 level Wells score
- > /=2 then DVT likely Doppler Ultrasound + D-dimer
- If D-dimer +ve but US -ve repeat in a week
- If
6 indications for DVT
previous DVT, swollen, 3cm larger, paralysis/paresis, cancer, immobility
9 RF for DVT
cancer, immobility, high BMI, age > 60, FHx, comorbidities, oestrogen therapy.
- surgery with total anaesthetic > 90 mins or 60 mins of lower limbs
- pregnancy
How can you assess suicide risk
SAD PERSONS assessment scale
What is the sad persons scale
- SAD PERSONS: < 6 outpatient; 6-9 emergency psych evaluation; > 9 inpatient
- sex (male) (1)
- age (<19, > 45) (1)
- depression (1)
- previous attempts (1)
- excessive alcohol or drug use (1)
- rational thinking loss (2)
- single/ divorced (1)
- organized or serious suicidal attempt (2)
- no social support (1)
- stated future intent (2)
6 things to assess
assess reasons for self-poisoning, suicidal intent, difficulties, psychiatric disorders, risk assessment in future, social support
What do you do with an under 16 year old who has self-poisoned
Admit to paeds ward
