Acute Care Flashcards
1
Q
What is the most common cause of death and disability in young people (age 1-40) in the UK?
A
Head injury
2
Q
Outline the risk factors for VTE
A
- Previous VTE/FHx
- Cancer
- Thrombophilia
- Immobility
- Pregnancy
- Long haul travel
- Recent surgery
- Obesity
- Oestrogen HRT
- Polycythaemia
- SLE
- Fracture of the pelvis, hip or long bones
3
Q
Outline the configuration of trauma services in England
A
- Pre-hospital services: ambulance services, air ambulance services, enhanced care services.
- Hospitals: major trauma centres (MTC), trauma units (TU),
- Rehabilitation services: specialist centres, local hospital services.
- Trauma care pathway: first responders —> emergency care —> acute hospital —> clinical rehab —> community rehab.
- Triage system by ambulance service to appropriate destination.
- Pre‑hospital major trauma triage tool to differentiate between patients who should be taken to a MTC and those who should be taken to a TU for definitive management.
- The optimal destination for patients with major trauma is usually a MTC.
- In some locations or circumstances intermediate care in a trauma unit might be needed for urgent treatment, in line with agreed practice within the regional trauma network.
- Spend only enough time at the scene to give immediate life‑saving interventions.
- Divert to the nearest TU if a patient with major trauma needs a life‑saving intervention, such as drug‑assisted rapid sequence induction of anaesthesia and intubation, that cannot be delivered by the pre‑hospital team.
- Spend only enough time to give life‑saving interventions at the TU before transferring patients for definitive treatment.
- MTC is the ultimate destination for definitive treatment.
- Multispecialty trauma teams are activated immediately in TU to receive patients with major trauma.
4
Q
Evaluate the possibility of fractures as an indicator of non- accidental injury including domestic violence
A
The most common physical injuries sustained from domestic violence are: contusions, abrasions, lacerations, fractures, sprains and strains with most injuries occurring on the face, neck, extremities or in multiple locations.
Fractures which are highly specific to non-accidental injury (particularly in children):
- Metaphyseal fracture (bucket handle fracture or corner fracture) - virtually pathognomonic.
- Rib fractures (especially posterior).
- Skull fractures: non-parietal skull fractures, multiple bone fractures, depressed fractures, diastatic sutures, crosses sutures.
- Scapular fractures.
- Sternal fractures.
- Outer third clavicle fractures.
- B/L fractures.
- Fractures of differing ages
5
Q
Outline the rehabilitation process and discuss the potential longer term functional, psychological and socioeconomic consequences of trauma for the patient
A
- Specialist rehabilitation (led by a consultant) is a critical component for the trauma care pathway.
- It is a process of assessment, treatment and management with ongoing evaluation by which their family are supported to achieve their maximum potential for physical, cognitive, social and psychological function, participation in society and quality of living.
- MDT co-ordinates the rehab.
- Physiotherapy: assessment and mobilisation should occur as quickly as possible (particularly hip#).
- OT, social workers, geriatricians are part of the MDT who assess needs for discharge.
Impact of Trauma:
- Alters life-trajectory.
- Take on the sick role.
- Potential social isolation during recovery.
- Require time of work.
- Concern about life-long health impacts.
- Stress.
- Family/friends may have to take on role of carer.
- Potential long-term disability.
Trauma care pathway: acute trauma care —> post-acute care —> rehabilitation (may need specialist) —> supported discharge —> community reintegration —> integrated care planning.
6
Q
Demonstrate knowledge of burns as a form of non-accidental injury
A
- Delayed presentation in seeking medical attention (may be due to effective first aid measures masking the severity of the injury).
- An unrelated adult presenting the child to healthcare services.
- Evasive or changing history.
- Trigger event e.g. soiling, enuresis or minor misbehaviour by the person.
- History inconsistent with assessed development.
- A lack of parental or carer concern.
- A lack of appropriate supervision of a vulnerable person (may indicate neglect).
- Failure to engage with healthcare appointments or health promotion programmes (may indicate neglect).
- History incompatible with examination findings.
- No splash marks in scald injuries.
- Signs of restraint on upper limbs.
- Sparing of flexion creases (suggesting child was in foetal position when burned).
- Central sparing (doughnut sign) of the buttocks - may be found is submersion injuries if a person has been forcibly held down.
- Associated unrelated injuries (bruises of varying ages).
7
Q
Outline effective approaches to health promotion with relation to burns and scalds
A
- Fire alarm testing.
- Electrical PAT registration.
- Chip pan fire awareness scheme.
- Bonfire night ad campaigns.
- Building regulations.
- Public area H&S regulations (fire extinguishers, fire exits, fire retardant materials).
- Dedicated fire safety wardens in public places, schools etc.
- Regular fire drills.
- Fire safety training.
- Fire alarms in public places.
- Charity i.e. Red cross raising awareness on how to treat burns.
Education:
- SMART (Spend time in shade between 11-3, make sure you’re not burned, Aim to cover up, remember extra care with children, then use sun cream).
- Use fireguards for open fire.
- Do not smoke in bed.
- Close door at night to prevent fire spread.
Children:
- Keep children out of the kitchen unless supervised.
- Use back rings on the hobs.
- Keep hot objects/candles/matches out of reach of children.
- Teach older children how to boil the kettle safely.
- Do not drink hot drinks when holding/sitting next to children.
- Test bath water before putting child in.
At risk groups:
- Children < 5 years, mostly occur in the kitchen.
- Diabetic neuropathy.
- > 75s (neuropathy, visual and cognitive impairment, Polypharmacy, decreased mobility.)
8
Q
Explain the role of psychiatric assessment, assessment of suicide risk and continuing care in patients whom have taken an overdose
A
SAD PERSONS risk :
- < 6 = outpatient management
- 6-9 = urgent psych evaluation
- > 9 = inpatient
Can be used for people coming to ED due to overdose to stratify suicide risk.
RFs:
- Male
- Age <19 or >45
- Depression or hopelessness
- Previous attempts or psychiatric care
- Excessive alcohol or drugs
- Rational thinking loss
- Separated/divorced/widowed
- Organised or serious attempt
- No social supports
- Stated future
Professionals involved in psychiatric assessment:
- Registered medical practitioner (usually a doctor who knows the pt e.g. GP)
- Section 12 approved doctor (usually a psychiatrist)
- Approved mental health professional (AMHP)
See RFs for suicide and MHA (section 2, 4 & 5).
9
Q
Understand the importance of critical thinking in avoiding diagnostic error in patients at risk of deterioration
A
- Diagnostic reasoning involves the use of conscious and subconscious processes and can rely upon experience of clinician and the familiarity of the situation.
- Pt harm can result from errors of commission (wrong diagnosis made and so improper therapy given) or errors of omission (not fully appreciating the extent of a patient’s illness and failing to act quickly).
2 Types of clinical reasoning:
- Type 1 (intuitive): processes are very fast and this is used by experts most of the time, with experience clinicians can relate current patterns to previous experiences, mental templates and illness scripts of disease.
- Type 2 (rational) : processes are slower, deliberate and more reliable and focus more on hypothesis and deductive clinical reasoning (hypothetical-deductive reasoning); further histories, examinations and investigations help to exclude some diagnoses/increase the likelihood of other diagnoses - thought that with proper command of clinical evidence and its significance that diagnostict errors may be prevented.
Pitfalls with type 1:
- Overconfidence may cause one to overestimate experience and underestimate uncertainty
Not reliable reasoning tool for novices. - Intuition can be source of flawed judgement and performance.
- There is a general consensus that diagnostic errors occur from occasional faults in the use of this type of clinical reasoning.
Pitfalls with type 2:
- Results of robust models can be skewed by incorrect estimates of pre-test probability and strength of evidence.
- Not useful in stressful events.
- Accuracy is dependent upon effort and time.
- Dependent on the user’s understanding of diseases and their distinguishing features plus time to plan and reason through a diagnosis.
10
Q
Demonstrate an understanding of levels of care in hospital, ceilings of care and DNACPR decisions
A
Levels of care in hospital:
- Level 0: pts whose needs can be met through normal ward care in an acute hospital - IV treatments, NG feeding, 8:1 nursing care.
- Level 1: pts at risk of their condition deteriorating or those recently relocated from higher levels of care whose needs can be met on an acute ward with additional advice and support from the critical care team - higher level nursing care (4:1), generally no invasive monitoring, AMU.
- Level 2: pts requiring more detailed observation or interventions including support for a single failing organ system or post-operative care and those “stepping down” from higher levels of care - invasive monitoring, single organ failure, HDU, 2:1 nursing care.
- Level 3: pts requiring advanced respiratory support alone or basic respiratory support together with support of at least 2 organ systems; this level includes all complex pts requiring support for multi-organ failure - ICU, intubation and ventilation, CVVH alone, 1:1 nursing care.
Ceilings of care:
- The maximum level of care which the patient is set to receive.
- The predetermined highest level of intervention deemed appropriate by a medical team, aligning with the pt and family wishes, values and beliefs.
- Aims to improve quality of care.
- Predetermined and outlined in documents such as RESPECT forms or advanced care plans.
DNACPR:
- Used when cardiac or respiratory arrest is an expected part of the dying process of a pt and CPR will likely not be successful and so making and recording an advance decision not to attempt CPR will help to ensure that the pt dies in a dignified and peaceful manner.
- In cases where CPR might be successful it may still not be seen as clinically appropriate because of the likely outcomes.
- Any discussions with a pt or those close to them about whether to attempt CPR and any decisions made with decisions made with regard to that topic should be documented in the pt’s notes or ACP.
- DNACPR decision only applies to CPR and does not imply that any other treatments will be withdrawn/withheld.
- Should not override your clinical judgement about CPR if the pt experiences a cardiac or respiratory arrest from a reversible cause.
RESPECT forms:
- Recommended summary plan for emergency care and treatment form.
- Can be found at the front of pt notes along with DNACPR forms.
- Creates a summary of personalised recommendations for a person’s clinical care in a future emergency in which they may not have capacity to make or express their choices.
- Contains a feature based upon whether or not CPR should be attempted if a pt were to enter into cardiac arrest.
- Created through conversations between a person and one or more of the HCP’s involved in their care.
- Should stay with the pt and be immediately available to health care professionals faced with making immediate decisions in an emergency.
11
Q
Evaluate a patient’s fitness for surgery; understand the principles of individualised risk assessment, communicating this risk in an understandable way, lifestyle modification, shared decision making and promoting recovery following surgery
A
Risk scores:
- American Society of Anaesthesiology (ASA) physical status score categorises pts into 6 subgroups using subjective pre-operative measures of physical fitness.
- Correlates with outcome in a number of different clinical settings.
- High ASA score is predictive of increased post-operative complications and mortality after non-cardiac surgery.
- Significant inter-operator variability but still remained useful in conveying risks of anaesthesia and surgery.
- Lee’s revised cardiac risk index is the most commonly used score for the development of cardiac complications after major non-cardiac operations.
Risk Prediction Models:
- POSSOM or P-POSSOM use 12 physiological variables and 6 surgical variables to calculate 30 day mortality after surgery.
- Physiological variables: age, cardiac signs, CXR, BP, HR, GCS, Hb, WCC, urea, sodium, potassium, ECG.
- Operative variables: operative severity, multiple procedures, total blood loss, peritoneal soiling, presence of malignancy, urgency of surgery.
Fasting guidelines:
- 2 hours before - clear fluids only.
- 6 hours before - food.
- Diabetics: first on the list, only miss one meal.
Perioperative care - medications:
- Continue beta blockers.
- Stop: COCP (4w), hypoglycaemics, warfarin (5d), clopidogrel (7d), ACEi (on the day).
- Don’t routinely offer CXR, echo or ABG.
Postoperative recovery and discharge:
- Ensure no need for airway support, breathing spontaneously, monitor pulse ox, ECG, BP.
- Discharge if awake and responsive, analgesia, stable CV, normal RR, temperature acceptable, records up to date.
12
Q
Demonstrate an understanding of the different options and indications for anaesthesia (general anaesthesia, regional anaesthesia, sedation, local anaesthesia)
A
- GA: state of controlled unconsciousness, no pain, asleep.
- Regional: epidural, spinal or nerve blocks.
- Sedation: relaxation during awake procedures.
- LA: numbing an area of the body for minor procedures. Prophylaxis of pain after surgery.
13
Q
Explain the cognitive science behind checklists, briefings and debriefings and their role in patient safety
A
- Checklists e.g. WHO surgical safety checklist, reduces occurrence of adverse events or never events such as wrong site surgery.
- WHO surgical safety checklist has been shown to reduce surgical complications.
- They encourage communication between all parties involved.
- Briefing and debriefing take place before and after the surgical checklist is implemented- some elements of the checklist are more effective if incorporated into a briefing before the list starts.
- Briefing is an opportunity to make a plan for the list, amongst all the team members to anticipate and plan for any problems that can foreseen.
- Any team member can lead the briefing, ensuring that everyone has introduced themselves and clarified their role and responsibilities for the list.
- An overview is taken of the list, highlighting any changes, equipment considerations, special requirements or safety concerns.
- All theatre team should be present for the briefing and debriefing.
- The debriefing naturally occurs at the end of the list before any team members have left the theatre or department.
- Purpose of debrief is to reflect on the list and share perspective on the tasks that went well and those that did not - may include discussion of teamwork, the theatre atmosphere, errors and near misses and a retrospective look at the briefing and use of the surgical safety checklist throughout the day.
- It is important to register success, learning points, areas that require change or escalation and for this to be conducted in a non-threatening, open environment.
14
Q
What is the leading cause of death in children and young adults?
A
TBI
15
Q
What are the RFs for TBI?
A
- M>F (2:1)
- Lower SES
- Sports & dangerous occupations
- Previous TBI
