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)
