Acute Care Flashcards
Explain what is meant by paradoxical breathing?
Term for a sign of respiratory distress associated with damage to the structures involved in breathing. Instead of moving out when taking a breath, the chest wall or the abdominal wall moves in. Often, the chest wall and the abdominal wall move in opposite directions with each breath.
List some simple techniques for airway management?
• Head tilt chin lift or jaw thrust (if need to protect the c spine) may be all that is required to create a patent airway
• Suction can be used to clear partial or complete obstructions cause by liquid secretions and MacGills forceps can be used to lift out more solid debris or obstructions
Explain what airway adjuncts are and when they would be used?
• Airway adjuncts are used either to improve an airway opened with a simple manoeuvre or to maintain it so that we can free our hands up and continue onto breathing
• The two primary adjuncts available are the oro and naso pharyngeal airway (In some situations supraglottic airway devices may be available but additional training is required in their use)
Describe advanced techniques for airway management and when they would be used?
• At the advanced end of the interventions available are orotracheal intubation and the surgical airway
• Orotracheal intubation is used when you need a controlled and protected airway
• The indication for a surgical airway would be where there is such complete obstruction that the patient cannot be ventilated by either simple means or intubation, and the obstruction cannot be cleared by simple means ie suction or removal with McGill’s forceps
Where do you need to check for bleeding?
On the floor and four more
- External (floor)
- Abdomen
- Pelvis
- Long bones
- Chest
What is the mainstay of treatment in shocked patients?
crystalloid IV fluid such as 0.9% Sodium Chloride or Hartmann’s solution.
Most forms of shock will respond at least initially to this fluid replacement, whilst more definitive management is planned
What is the highest and lowest GCS score?
highest = 15 and expected in a normal healthy individual
lowest = 3 and has a very high mortality rate
In relation to AVPU it is generally recognised that a response to P is equivalent to a GCS score of ______ and is relevant because ______
8
it may hint that a patient may no longer be able to protect their own airway
GCS Scoring
Eye Opening:
Spontaneous =4
Verbal command = 3
Opens to painful stimuli = 2
None = 1
Verbal Response:
Oriented = 5
Confused = 4
Inappropriate words = 3
Incomprehensible sounds = 2
None = 1
Motor Response:
Obeys = 6
Localises to pain = 5
Withdraws to pain = 4
Decorticate posturing = 3
Decerebrate posturing = 2
None = 1
Explain what decorticate posturing is?
• Decorticate posturing indicates severe brain damage to areas including the cerebrum, internal capsule and thalamus. The midbrain is generally spared. The patient has abnormal flexion of the arms, hands clenched into fists and legs extended and feet turned inwards. As the lateral corticospinal tract is disrupted the rubrospinal and reticulospinal take over.
Explain what decerebrate posturing is?
• Decerebrate posturing is more severe indicates that there is also brainstem damage, specifically at the level below the red nucleus in the midbrain. The patient presents with head arched back and both arms and legs extended. In this case both the lateral corticospinal and rubrospinal tract are damaged so the reticulospinal tract causes extension of the whole body.
Fasting rules for anaesthetic?
Food 6 hours
Milk 4 hours
Clear liquid 2 hours
Investigations on day of surgery?
• Investigations are limited on the day of surgery
• Blood results may be required if a patient has co-morbidities. All females aged
• 12-55 years must have a pregnancy test
What measures can be put in place to limit risk of hypo in diabetic patients?
have them first on list to minimise fasting
Moderate acute asthma features?
increasing symptoms, PEF > 50-75% best or predicted, no features of acute severe asthma
Severe acute asthma features ?
PEF 33-50% best or predicted, RR > or = 25/min, HR > or = 110/ min, inability to complete sentences in one breath
Life threatening acute asthma features?
PEF < 33% best or predicted, SPO2 < 92%, PaO2 < 8kPa, normal PaCO2, altered conscious level, exhaustion, arrhythmia, hypotension, cyanosis, silent chest, poor respiratory effort
Near fatal acute asthma features?
raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures
Management of acute asthma?
• OHSHITMAN
• Oxygen
• Salbutamol nebulised
• Hydrocortisone/ steroid therapy – usually oral prednisolone
• Ipratropium bromide nebulised
• Theophylline (IV) – by senior staff
• Magnesium sulfate (IV) – considered
• And call an anaesthetist / senior help
Hypoglycaemia is glucose below?
4 mmol/l
Management of hypoglycaemia?
• Initially 10-20g of glucose by mouth, or 2 teaspoons of sugar, non diet sugary drinks
• Hypoglycaemia that is not responding should be treated with 10% glucose infusion (150-160ml)
• If it is causing unconsciousness this is an emergency – 20% IV glucose (75-80ml) through large gauge needle, alternatively glucagon IM if in community
What measurement do you use to determine the size of an oropharyngeal airway?
Incisor teeth to mandibular angle
Naso-pharyngeal airways are better tolerated than oropharyngeal airways in patients ______
are not deeply unconscious
When are nasopharyngeal airways contraindicated?
basal skull fractures
Correct order for opening obstructed airway?
• Head tilt
• Chin lift
• Jaw thrust
• Oropharyngeal airway
• Nasopharyngeal airway
• Laryngeal mask airway
Basic airway management is indicated in _______
everyone getting an anaesthetic
Surgical airways should only be used in what situation?
cant intubate, cant oxygenate (cant ventilate) situation
Explain what capnography is used for?
• This is used to determine patency of a patient’s airway
• It determines exhaled CO2 concentration
• Inadequate or absent capnography trace suggests incorrect placement etc.
• Square shaped trace should be present
Explain how to position a patient in airway management?
• Place the patient in a supine position, sit them slightly head up and support the patients head back and lift the patient’s chin into a “sniffing” position
• To check this position, looking from the side you can imagine a line taken from the patient’s tragus that should be higher than the patient’s sternum
• Additional equipment or pillows may be required to achieve this position in some patients
• You may also need to adjust the height of the bed to allow you to perform airway manoeuvres effectively
Explain what is meant by pre-oxygenation and what it is used for?
• Preoxygenation, or administration of oxygen prior to induction of anaesthesia, is an essential component of an airway management
• Preoxygenation is used to increase oxygen reserves in order to prevent hypoxemia during apnoea
Explain the difference between crossmatch and group and save and when they would both be done?
• Group and save is when the sample is processed to determine blood group and any atypical antibodies
• Group and save is done if blood loss is not anticipated but may be required if there is greater blood loss than expected
• Cross match involves physically mixing patients blood with donors blood to assess compatibility and then there is donor blood actually issued, this is done if blood loss is anticipated
• Note: you have to group and save before you crossmatch
use of cardiac medication before during and after operation?
• In general, cardiac medication should be given over the peri-operative period (most are cardioprotective)
• Exceptions include anticoagulants due to bleeding risk
• Aspirin traditionally is withheld but this is starting to be challenged
• ACE inhibitors are also withheld due to risk of renal failure and hypotension
Explain the different sizes and colours of cannulae?
• Blue – smallest, useful in those with difficult access or small veins, however limited use for infusions
• Pink – the go to size in non-emergency situations, still has limited use for fast infusions
• Green – this should be used in patients that either need or may need fast infusions, though remember it may be more painful to place
• Grey – largest size routinely used on wards, indicated in emergency situations i.e. fluid resus, be aware that without local anaesthetic it can be very painful to insert
Describe the fluid compartments of the body?
• Broadly body fluid can be intracellular (67%) or extracellular (33%)
• Extracellular fluid can be divided into Plasma (aqueous component of blood) and Interstitial Fluid (immediate aqueous environment around cells)
Describe 0.9% sodium chloride as a fluid and uses?
• Because of the electrolytes it doesn’t enter cells so only goes to ECF (the plasma and interstitial fluid)
• It is therefore good for resuscitation and maintenance
• It is cheap and widely available
• Beware large doses in a resus situation thought can cause metabolic acidosis
Describe 5% Glucose as a fluid and uses?
• Metabolised by the liver leaving water only and equilibrates with everything
• So will go to ICF and ECF
• So it is good in pure dehydration because it gives water to inside cells and outside
• It is bad however in a resus situation
Describe Hartmanns solution as a fluid and its uses?
• This is closer to normal plasma composition than sodium chloride
• Because it also contains electrolytes it equilibrates in the way sodium chloride does
• It is good for resus and maintenance
Describe colloid solutions as a fluid and their uses?
• Big molecules that stay in intravascular space for longer than simple crystalloid e.g. sodium chloride and theoretically attract water due to their oncotic pressure
• This means they can draw in water from the extracellular fluid and can be called volume expanders
• Debate over whether actually better for resus but that is there use
What are the four components of pharmacokinetics?
Absorption
Distribution
Metabolism
Excretion
Describe use of antacids in anaesthesia?
• These are important in reduction of gastric acid reflux or aspiration risk at induction of anaesthesia
• 2 groups that are commonly prescribed are PPIs (omeprazole) and H2-receptor antagonists (ranitidine)
Describe use of anxiolytics in anaesthesia?
• Midazolam as quick onset and commonly given as sedation for regional anaesthesia or procedures such as endoscopy, can also be given to relieve anxiety prior to the induction of anaesthesia
• Temazepam has slower onset of action than midazolam and can be given as pre-medication the night before or morning of surgery
• Lorazepam and diazepam are used in the immediate management of seizures, diazepam is also prescribed for anxiety disorders and muscle spasms
List some intravenous anaesthetic induction agents?
• Propofol
• Etomidate
• Ketamine
• Midazolam
Describe use and examples of volatile anaesthetic agents?
• These are mainly used for maintenance anaesthesia, however nitrous oxide and sevoflurane can be used for inhalational anaesthesia in those with difficult IV access or in children
• Modern agents are halogenated chemical compounds – sevoflurane, desflurance, nitrous oxide, isoflurane
Describe use of neuromuscular blocking agents in anaesthetics?
• These are given in anaesthesia to relax or paralyse muscle, facilitate intubation and improve surgical conditions (e.g., relax abdominal wall)
• Examples are suxamethonium, atracurium and rocuronium
Features of acute pain?
• Acute pain is usually nociceptive and in response to injury (physical or chemical), or other pathology
• Pain is usually proportionate to extent of injury
• Acute pain is usually self limiting and subsides as tissue healing occurs
Simple verbal ratings of pain?
0 = no pain at rest, none on movement
1 = no pain at rest, slight on movement
2 = intermittent at rest, moderate on movement
3 = continuous at rest, severe on movement
Describe patient controlled analgesia?
• Analgesia prescribed by doctor and administered by patient
• Used in the control of postoperative pain and also for those with severe non operative pain e.g. pancreatitis, fractured ribs
• Usual prescription is a 1mg bolus of morphine with a 5 minute lockout i.e. the patient can receive up to 12 mgs morphine per hour
Describe process of managing cardiac arrest?
• Unresponsive and not breathing normally – call resus team/ambulance – Tayside cardiac arrest team call 2222
• Start high quality CPR at 30:2 ratio
• Attach defibrillator
• Assess rhythm
• Shockable rhythms are VF and pulseless VT
• Non shockable rhythms are PEA and Asystole
• PEA: organized cardiac electrical activity in absence of a palpable pulse
• If shockable give shock, resume CPR for 2 mins and then re-assess rhythm and shock again if still shockable
• If non-shockable continue CPR then reassess rhythm after 2 mins
• Give adrenaline every 3-5 minutes
• Give amiodarone after 3 shocks
Features of high quality CPR?
• Ratio 30:2
• Site: centre of chest (lower 1/3 sternum)
• Depth: 5-6 cm
• Rate: 2 per second (100-120/ min)
• Chest recoil: shoulders directly above hands with elbows locked
• Minimal interruptions (< 5 secs)
• Switch CPR every 2 minutes to avoid fatigue
• Continuous compressions once airway secured
What are the 4Hs and 4Ts of reversible cardiac arrest?
4Hs: hypoxia, hypothermia, hypovolaemia, hyperkalaemia
4Ts: thrombin, toxins, tamponade, tension pneumothorax
Management of 4Hs in cardiac arrest?
• Hypoxia: ensure patent airway, give high flow supplemental oxygen, avoid hyperventilation
• Hypovolaemia: history, examine for internal or external haemorrhage, check surgical drains, control haemorrahge, if hypovolaemia suspected give IV fluids/ blood products
• Hypo/ hyperkalaemia and metabolic disorders: near patient testing for K+ and glucose, check latest lab results, for hyperkalaemia give calcium gluconate and insulin plus dextrose, hypokalaemia/ hypomagnaesia give electrolyte supplementation
• Hypothermia: use low reading thermometer, treat with active rewarming techniques, consider cardiopulmonary bypass machines
Management of 4Ts in cardiac arrest?
• Tension pneumothorax: check tube position if intubated, clinical signs are decreased breath sounds and hyper-resonant percussion note, tracheal deviation away from side of pneumothorax, initial treatment with needle decompression or thoracostomy
• Tamponade: difficult to diagnose without echo, consider if penetrating chest trauma or after cardiac surgery, treat with needle pericardiocentesis or resuscitative thoracotomy
• Thrombosis: if high clinical probability for PE consider fibrinolytic therapy, if fibrinolytic therapy given continue CPR for up to 60-90 mins
• Toxins: rare unless evidence of deliberate overdose, review drug chart
Management when ROSC in patient?
• Use an ABCDE approach
• Aim for SPO2 of 94-98 and normal PaCO2
• 12 lead ECG
• Identify and treat causes
• Targeted temperature management
Management of adult tachycardia?
• Assess with ABCDE approach
• Check for life threatening features: shock, syncope, myocardial ischaemia, severe heart failure
• If life threatening features present: synchronised DC shock up to 3 attempts (give sedation or anaesthesia if conscious) if unsuccessful give amiodarone 300 mg IV over 10-20 mins, repeat synchronised DC shock
• If not life threatening: is the QRS narrow or broad? Is it regular?
• If irregular and broad: could be AF with BBB – treat as narrow irregular, could be torsades de pointes give magnesium 2g over 10 minutes
• If regular and broad: likely VT give amiodarone 300 mg IV over 10-60 minutes, if ineffective synchronised DC shock up to 3 attempts (give sedation or anaesthesia if conscious)
• If regular and narrow: try vagal manoeuvres, if ineffective give adenosine 6 then 12 then 18 until works, if still ineffective try verapamil or a beta blocker
• If irregular and narrow: likely atrial fibrillation, control rate with a beta blocker, consider digoxin or amiodarone if evidence of heart failure, anticoagulated if duration > 48 hours
Management of adult bradycardia?
• Assess with ABCDE approach
• Evidence of life-threatening signs? Shock syncope, myocardial infarction, heart failure
• If yes give atropine 500 mcg IV
• If satisfactory response and no risk of asystole observe
• If unsatisfactory response or in someone without life threatening signs but risk of asystole: atropine 500 mcg IV can be repeated up until 3 mg, isoprenaline 5 mcg/ min IV, adrenaline 2-10 mcg/ min, alternative drugs or transcutaneous pacing
Describe the anti-cholinergic toxidrome?
• Due to anticholinergic drugs such as atropine, scopolamine, glycopyrrolate benztropine, trihexyphenidyl
• Or can be due to antihistamines – chlorpheniramine, hydroxyzine, doxylamine
• Increased heart rate and blood pressure, no change to resp rate, increases temperature, dilated pupils, no bowel sounds, reduced sweating
What toxidrome is being described?
Increased heart rate and blood pressure, no change to resp rate, increases temperature, dilated pupils, no bowel sounds, reduced sweating
anticholinergic
Describe the cholinergic toxidrome?
• Due to organic phosphorous compounds: carbamates, arecholine, pilocarpine, Urecholine, mushrooms
• No change in heart rate, blood pressure, resp rate or temperature
• Pinpoint pupils, increased bowel sounds, increased sweating (diaphoresis)
What toxidrome is being described?
• No change in heart rate, blood pressure, resp rate or temperature
• Pinpoint pupils, increased bowel sounds, increased sweating (diaphoresis)
cholinergic
Describe the Opioid toxidrome?
• Due to opioid drugs e.g. morphine, codeine, tramadol, heroin, meperidine, oxycodone etc.
• Decreased heart rate and blood pressure, decreased resp rate, decreased temperature, pin point pupils, no bowel sounds, reduced sweating
What toxidrome is being described?
• Decreased heart rate and blood pressure, decreased resp rate, decreased temperature, pin point pupils, no bowel sounds, reduced sweating
opioid
Describe the sympathomimetic toxidrome?
• Due to caffeine, cocaine, amphetamines, methamphetamines, Ritalin, LSD, theophylline, MDMA
• Increased heart rate and blood pressure, increased resp rate, increased temperature, dilated pupils, increased bowel sounds, increased sweating (diaphoresis)
What toxidrome is being described?
• Increased heart rate and blood pressure, increased resp rate, increased temperature, dilated pupils, increased bowel sounds, increased sweating (diaphoresis)
sympathomimetic
Describe the sedative hypnotic toxidrome?
• Due to anti-anxiety agents, muscle relaxants, antiepileptics and preanaesthetic medications, barbituates, benzodiazepines
• Decreased heart rate and blood pressure, decreased resp rate, decreased body temperature, no changes in pupils, no bowel sounds, decreased sweating
What toxidrome is being described?
• Decreased heart rate and blood pressure, decreased resp rate, decreased body temperature, no changes in pupils, no bowel sounds, decreased sweating
sedative hypnotic
What is meant by diaphoresis?
excessive, abnormal sweating in relation to your environment and activity level
Does paracetamol fall into a toxidrome? What does this mean?
• Paracetamol overdose does not have a classic toxidrome, so unfortunately patients may feel fine until their liver fails and if they don’t present to A and E early enough they will present with fulminant liver failure
What do you do when someone presents with paracetamol overdose?
• When someone presents with paracetamol overdose have to wait 4 hours post ingestion as this is when serum levels peak, can then judge them against treatment threshold curve
• Acetylcysteine is the antidote for paracetamol overdose (brand name is parvolex)
• INR level can be used to measure liver function after paracetamol overdose
Opioid overdose antidote?
naloxone
Beta blocker overdose antidote?
glucagon
Tricyclic antidepressant antidote?
sodium bicarbonate
Ethylene glycol and methanol antidote?
ethanol
Benzodiazepines overdose antidote?
flumazenil
iron salts overdose antidote?
desferrioxamine
Cyanide antidote?
hydroxycobalamin, sodium nitrate, sodium thiosulphate
ECG findings in PE?
most common is sinus tachycardia
classic finding is S1Q3T3
A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain
What is meant by ordering type specific?
when you need blood but dont have time to do full crossmatch you can ask for type specific
If GCS < 8 ______
intubate
Long term mechanical ventilation can result in _____
trachea-oesophageal fistula
- choking and coughing up things after food
Explain malignant hyperthermia?
similar to neuroleptic malignant syndrome can occur after giving an anaesthetic agent
avoid halothane and suxmethonium if think patient at high risk
Management of malignant hyperthermia?
dantrolene
Contraindication to LMA?
non fasted patients
LMA provides poor control against reflux of gastric contents
depolarising vs non depolarising muscle relaxants?
non depolarising - rocoronium and atracurium
depolarising - suxamethonium
Reversal of non-depolarising muscle relaxants post surgery?
neostigmine
Management of salicylate overdose?
iv fluids
activated charcoal if present within one hour
iv sodium bicarbonate
potassium replacement
Blood tests for osteoporosis?
Osteoporosis is commonly associated with normal blood test values (e.g. normal ALP, normal calcium, normal phosphate, normal PTH)
