Anaesthetics and A&E Flashcards
Initial management of acute patient
ABCDE
Airway
- Secure airway (Guedel, NP airway, LMA (i-gel), ET tube
Breathing
- Check RR
- O2, neb salbutamol/Ipratropium bromide
Circulation
- BP, HR, Cap refill, urine output
- Fluid resus, vasopressors, cathertirisation
Disability
- Do GCS, AVPU, cap glucose,
- CT, IV glucose if needed
Exposure
- Rashes, burns etc
What scoring system used to determine CT post neck injury
Canadian C spine score
Canadian C-spine indicators for Radiography
Age over 65 Dangerous mechanism Parasthesia Immediate pain, C-spine tenderness Unable to rotate 45 degrees L and R
AVPU
- What does this assess
Patient response:
Awake
to Voice
to Pain
Unresponsive
Burns:
- Who are high risk
- Initial assessment
Under 5 and over 75 yrs
ABCDE (prevent hypothermia) ± need for fluid resus
Burns rule of 9s
Head 9% Each arm 9% Torso front 18% Torsa back 18% Each leg 9%
Hand as % body surface area
1%
5 Burn thickness
1) Epidermal (superficial partial thickness)
2) Superficial dermal
3) Deep dermal
4) Full-Thickness (third degree)
5) Fourth degree
Superficial epidermal/dermal features
Pain, red, no/small blistering, brisk cap refill,
Healing 1-3 week, minimal scarring
Full thickness burn features
White/black, dry, no blistering, no cap refill, no sensation/pain
Tx: requires surgical excision and graft.
What is fourth degree burn?
Includes sub cut fat/muscle/bone.
May need Reconstruction/amputation
What is the problem with burns assessment
They are DYNAMIC. Need reassessment in 24-72hrs
Ix in burns
Bloods: Serum glucose, Crossmatch, U&E
CXR: Dysrhythmia and electrolyte disturbance
Circulation: BP may be low, monitor urine
Burn management
Stop burning (remove stimulus, chemical/clothing etc) and cool site
Minor burns - Dress, analgesia, ABX (fluclox) if infected
Major: ABC
- A: look for inhalation injury, May need ET intubation (stridor due to airway oedema in inhalation inj)
- Breathing for inhalation, CO poisoning. COHb levels
- C: Fluid loss (vasodilation = inc cap permeability)). Fluid replace 15% Body SA burns adults and 10% in children
Parkland formula for fluids in burns
4ml/kg/% body area
Hartmann’s
50% first 8 hours
50% second 16 hours
Children then also get 4/2/1 maintenance per hour
Burns when to refer
Under 5 or Over 60yrs
Site: Face, hands, perineum (risk forneirs), flexure, circumferential
Inhalaiton injury
Over 5% child under 16
Over 10% in someone over 16
Flail Chest
- Mech
- what is seen
- Assoc with
3+ ribs broken in 2 + places due to trauma and detached from rest of the chest
Paradoxical breathing - in-drawing on inspiration
Pulmonary contusions - haemothorax
Punctured lung - pneumothorax
Flail chest management
Positive pressure ventilation (note intubation may worsen tension pneumothorax)
Pain control - intercostal blocks
Reversible causes of cardiac arrest (5H’s, 4T’s)
Hypoxia Hypovolaemia Hypo/Hyperkaaemia Hypothermia H+ (acidosis)
Thrombosis (coronary/pulmonary)
Tamponade
Toxins
Tension Pneumothorax
Major haemorrhage Lethal triad (similar to what kills you in shock)
Hypothermia
Acidosis
Coagulopathy of trauma
What kills you in shock?
Hypothermia
Acidosis
Coagulopathy (e.g. DIC)
Major haemorrhage management
Stop bleeding:
- splint, pressure, haemostat agent (tranexamic acid IV), REBOA (aortic occlusion balloon)
Replace fluids lost:
- Fluids + Blood + Blood products (FFP, cryoprecipitate)
Major haemorrhage protocol:
RBC 4 units
FFP 4 units
Platelets 1 unit
GCS
- Three categories
- How many points per
Eye opening response (4)
Verbal response (5)
Motor response (6)
Max score: 15
Min score: 3
GCS - Eye opening
Spontaneously
To verbal command
To pain
None
GCS - Verbal response
Oriented Confused conversation Inappropriate words Sounds None
GCS - Motor
Obeys command Moves toward pain Withdraws from pain Spastic flexion Extensor response No motor
BUFALO
Bloods Urine (vol and culture) Fluids Abx Lactate Oxygen
Status epileptics: Drug: - No IV access - IV access - If not effective
Buccal Midaz
Lorazepam
Phenytoin
Wernickes (reversible)
Ophthalmoplegia
Encephalopathy
Ataxia
Korsakoffs
non-reversible
Aterograde/Retrograde amnesia
Confabulation
What to give in Alcoholic presenting to A&E
PAbrinex: prevent Wernickes/Korsakoffs
Delerium tremens
Coarse tremor
Confusion
Visual hallucinations (Lilliputian), formication
Seizures
Anaphylaxis
- Type of reaction
- Mech
Type 1
Antigen binds to IgE on mast cells of sensitised individuals
Mast cell degranulation (histamine, thromboxjnes PG, Leukotrienes, Pt activators - bradykinins)
Vasodilation & Inc permeability
Bronchospasm
Anaphylaxis features
Respiratory - swollen lips, tongue, pharynx, epiglottis
Lower - wheeze, chest tightness,
dyspnoea
Skin - pruritus, erythema, urticarial rash, angio-oedema
CVS - increased permeability leading to hypotension —> anaphylactic shock
GI - N&V, diarrhoea, cramps
5 Step anaphylaxis Tx
1) Remove offending agent (e.g. if infusion)
2) IV adrenaline
(500micrograms = 0.5ml 1 in 1000 )
3) Establish airway, give O2, consider Salbutamol
4) IV fluid challenge to correct hypotension
(up to 2L)
5) Chloramphenamine and hydrocortisone can reduce symptom severity and duration
Fluid maintenance:
- Adult
- Paeds
25-30 ml/kg/day of water and. approximately 1 mmol/kg/day of potassium, sodium and chloride.
Fluid resus: 500ml crystaloid in 15 min
Fluid maintenance:
- Adult
- Paeds
25-30 ml/kg/day of water and. approximately 1 mmol/kg/day of potassium, sodium and chloride.
Fluid resus: 500ml crystaloid in 15 min
Paeds hourly = 0-10kg 4 ml per kg, 10-20 2ml/kg/hr after that its 1ml/kg/hour
Drugs to stop Pre-op
ACEi/ARB: Anaesthetic will drop BP so stop 24 hr before
Warfarin: if Af use LMWH bridging protocol
Clopidogrel: stop 5d before
For Insulin dependant diabetics pre-surgery
Don’t starve
Give variable rate insulin infusion
What makes up a difficult airway
Anatomically: small mouth, small chin, big neck, beard
Mechanical: mouth opening, neck mobility
Dentition: dentures
Pre-op prediction of difficult airway
Mallampati
Thyromental distance (under 6.5cm = difficult)
Upper cervical spine extension
The anaesthetic triad
Unconsciousness
Analgesia (local or systemic)
Muscle relaxation
3 Phases of anaesthesia
Induction (normally IV)
Maintenance (IV e.g. propofol and remifentanil infusion or inhaled e.g. volatiles)
Reversal
Opioids used in anaesthesia
Remifentanil
Alfentanyl
Fentanyl
Morphine (nausea)
All risk respiratory depression
What GCs needs airway control
8
Airway manoeuvres
Airways
Head tilt, Chin lift, Jaw thrust
Guedel (Oropharyngeal), Nasopharyngeal (Beware skull base fracture), Supraglottic (LMA), ET tube
When is Muscle relaxant needed
Intubation: relax tracheal opening
Relax skeletal muscles for surgery
Local anaesthetic action
Unionised LA enters cell
LA becomes ionised and blocks Na channel
Types of use for NA
Local wound/area
Peripheral nerve block
Plexus block
Spidural/Spinal block
Lidocaine Vs Bupivocaine
Onset
Duration
Use
Onset:
L - immediate
B - 10 mins
Duration:
L - 15 mins
B - 12 hrs analgesia
Use:
L - small procedures, lacerations, chest drain
B - Regional blocks
Advantages of regional anaesthesia
Avoid GA
Can stake awake
Avoid airway issues
Less N&V
Spinal Vs Epidural
Spinal through ligaments and dura. Local anaesthetic bolus lasts 2 hours
Epidural - through ligaments, sit on top of dura. Catheter and infusion of LA
Both block from below highest nerve root affected
Types of muscle relaxants
Depolarising
- Suxamethonium (depolarises and blocks depolarisation)
Non-depolarising
- Atracruium, rocurnium
- Competitive inhibition of ACh at nicotinic receptors
Reversal of muscle relaxants
Neostigmine (inc Each by blocking ACh esterase)
BP formula
CO X systemic vascular resistance
CO = HR X SV
Why older have faster HR
Lower vagal tone.
Vagus is PSNS
Drugs to inc HR in surgery
Block ACh (Atropine)
Stimulate Beta-adrenoreceptors (Dobutamine) = inc HR and contractility
Drugs to give if BP too low
Stim alpha adrenoreceptors
Ephidrine and adrenaline
- added befit of also inc HR
Alpha nd beta stimulation
WHO pain ladder
- Step 1
- Step 2
- Step 3
1) aspirin, para, NSAIDs
2) Codeine ±non-opioid
3) Morphine ± non-opioid
Paracetamol caution and reversal
Liver failure in OD (Glutathione depletion)
N-acetyl-cysteine
NSAIDs mechanism
COX inhibitors (irreversible)
COX usually converts Arachidonic acid into PGs = inflammation, rubor, dolor
SE of NSAIDs
Peptic ulcers (prostaglandins key in mucus secretion)
AKI: Pre-renal and infrarenal (nephrotoxic)
Bleeding
Opioids SE
CNS: sedation, Miosis (constriction)
CVS: Bradycardia, Hypotension
Resp: Bradypnoea, apnoea
GI: N&V, constipation
Urinary retention
Opioids mechanism
Pre and post synaptic modulation via MU receptors
Weak opioid and strong opioid examples
Weak:
- Codeine (PO/IM) = prodrug connected to morphine
- Tramadol
Strong:
- Morphine, oxycodone, Methadone, Buprenorphine
Calories per Kg needed
20
Crystaloids Vs colloids
Crystaloids have ions or small molecules which dissolve in water
Colloids have large insoluble molecules retained within plasma. Can be natural (blood albumin) or synthetic (starch, gelatin)
O2 sats aims
94-98%
If T2RF 88-92% (don’t want to remove hypoxic drive)
E.G of non-invasive ventilation
CPAP (T1RF)
BiPAP (T2RF - keeps airways open on expiration to allow CO2 clearance)
Venturi mask
Invasive ventilation E.G
ET tube, Tracheostomy
Complications invasive ventilation
Ventilator assoc pneumonia
Vent assoc lung injury
Oxygen toxicity
Indications for intubation
Paralysis
Long surgery
Surgery with: Lung disease, Obese
Low GCS
