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Acute Care > Approach to the acutely unwell > Flashcards

Approach to the acutely unwell Flashcards

1
Q

What is the ABCDE approach?

A
  • Focussed examination.
  • Detects life threatening problems in a sequential fashion.
  • Abnormalities addressed/treated before moving on with the assessment.
  • Re-assessment after every intervention.
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2
Q

Why is the ABCDE approach important?

A

Quickly identifies the deteriorating patient.

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3
Q

How would you check for signs of life in a collapsed/unresponsive patient?

A
  • Palpate for central pulse.
  • Check for breath sounds.
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4
Q

Outline the ABCDE approach

A

AIRWAY

  • Is the airway patent (yes - if they’re talking to you)?
  • Action: head tilt & chin lift, suction what you can see, airway adjuncts (oropharyngeal and nasopharyngeal airways), advanced airway management, apply high flow oxygen, re-assess.

BREATHING

  • Look: colour, RR and pattern, O2 sats.
  • Feel: tracheal deviation, symmetry of chest wall movement, percussion.
  • Listen: equal air entry, absent breath sounds, added sounds.
  • Action: oxygen 15L/min via mask with reservoir bag, target sats 94-98% (88-92% in COPD patients at risk of hypercapnic respiratory failure), any specific treatments, request ABG and CXR if indicated, re-assess.

CIRCULATION

  • Look: colour of hands (pale, blue, mottled).
  • Feel: temperature of hands, peripheral and central pulse rate, rhythm and quality.
  • Meausre: CRT, BP, JVP.
  • Listen: heart sounds.
  • Action: obtain IV access (or interosseous if IV can’t be achieved), bloods, ECG, measure urine output (0.5ml/kg/hour), 500ml fluid bolus (caution in cardiac/renal failure, call for help if 2L fluid given and no improvement - vasopressors may be required), treat underlying cause (e.g. packed red cells for acute haemorrhage), re-assess (BP improved and tachycardia settled).

DISABILITY

  • Conscious level - AVPU (alert, responds to verbal stimulation, responds to pain e.g. supraorbital pressure, unresponsive), GCS (eye response, verbal response, motor response).
  • Pupil size and reactivity.
  • Glucose.
  • Action: pinpoint pupils (opioid overdose - naloxone), unequal pupils (head CT), hypoglycaemia < 4mmol/L (100ml 20% IV dextrose), reduced consciousness (risk of airway obstruction and aspiration - left lateral position, airway protected if GCS < 8), re-assess.

EXPOSURE

  • Focussed examination, tailored to the clinical picture.
  • Temperature.
  • Rash.
  • Calf swelling/tenderness (VTE).
  • Bleeding.
  • Abdominal palpation.
  • Relevant systems examination.
  • Collateral history.
  • Re-assess.
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5
Q

List causes of acute airway obstruction

A
  • Reduced consciousness (due to loss of soft tissue tone in upper airway e.g. soft palate).
  • Foreign body inhalation (e.g. aspiration of food/vomit/blood, inhaled objects in children).
  • Oedema of upper airway (caused by infection, burns or anaphylaxis).
  • Tumour or abscess in airway.
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6
Q

List the signs of an obstructed airway

A
  • Partial: snoring (loss of soft palate tone), gurgling (liquid), stridor (obstruction at level of larynx).
  • Complete: silent - ‘see-saw’ movement of chest and abdomen (paradoxical breathing).
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7
Q

When is a nasopharyngeal airway contraindicated?

A
  • Epistaxis.
  • Basilar skull fracture.
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8
Q

List causes of acute SOB

A
  • Pneumothorax.
  • Anaphylaxis.
  • Acute pulmonary oedema.
  • Trauma.
  • Anaemia.
  • Sepsis.
  • Metabolic.
  • Overdosing/poisoning.
  • Asthma/COPD exacerbation.
  • PE.
  • Pneumonia.
  • Mental health.
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9
Q

List causes of hypotension

A
  • Sepsis
  • Anaphylaxis.
  • Hypovolaemia: dehydration, haemorrhage.
  • Arrhythmias.
  • ACS.
  • Acute LVF.
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10
Q

Outline causes of altered conscious level

A
  • Mental health conditions e.g. delirium, dementia.
  • Epilepsy/seizures.
  • Meningitis or encephalitis.
  • Diabetic emergencies: hypoglycaemia, DKA, HHS.
  • Collapse secondary to CVD.
  • Hypoxaemia or hypercapnia.
  • Shock (sepsis, hypovolaemia, anaphylaxis).
  • Endocrine emergencies.
  • Hypothermia.
  • Hepatic/uraemic encephalopathy.
  • Poisoning/overdose.
  • Head injuries/TBI.
  • Acute stroke.
  • Cerebral tumour.
  • Intracranial bleeds.
  • Alcohol or substance misuse.
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11
Q

How would you structure a clinical handover?

A

iSBAR

  • Introduction: name, role, where are you and why are you communicating.
  • Situation: what is happening at the moment?
  • Background: what are the issues that led up to this situation?
  • Assessment: what do you believe the problem is?
  • Recommendation: what should be done to correct this situation?
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12
Q

What are the components of the NEWS2 score?

A
  • Respiration rate
  • Oxygen saturation
  • Systolic blood pressure
  • Pulse rate
  • Level of consciousness or new confusion
  • Temperature
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13
Q

What is a concerning/urgent response threshold (medium-level alert) for NEWS2 score?

A
  • 3 in a single parameter or total > 5.
  • > 7 requires an emergency response threshold (high alert).
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14
Q

What is the base excess in an ABG result?

A
  • This is the amount of strong acid which would need to be added or subtracted from a substance in order to return the pH to normal (7.40).
  • A value outside of the normal range (-2 to +2 mEq/L) suggests a metabolic cause for the acidosis or alkalosis.
  • A base excess more than +2 mEq/L indicates a metabolic alkalosis.
  • A base excess less than -2 mEq/L indicates a metabolic acidosis.
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15
Q

What is lactate and what does a raised lactate indicate?

A
  • Lactate is produced as a by-product of anaerobic respiration.
  • A raised lactate can be caused by any process which causes tissue to use anaerobic respiration. It is a good indicator of poor tissue perfusion.
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16
Q

What can a raised blood glucose indicate?

A
  • Raised: diabetes, severe sepsis, metabolic stress.
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17
Q

Give examples of type 1 respiratory failure

A

PE, pneumonia, asthma, pulmonary oedema.

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18
Q

Give some examples of type 2 respiratory failure

A
  • Pulmonary problems: COPD, pulmonary oedema, pneumonia.
  • Mechanical problems: chest wall trauma, muscular dystrophy, motor neurone disease, myasthenia gravis.
  • Central problems: opiate overdose, acute CNS disease.
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19
Q

What are the causes of a raised anion gap?

A

MUDPILES:

  • Methanol
  • Uraemia
  • Diabetic ketoacidosis (and alcoholic/starvation ketoacidosis)
  • Propylene glycol
  • Isoniazid
  • Lactate
  • Ethylene glycol
  • Salicylates
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20
Q

What are the differentials for a metabolic acidosis with normal, or decreased anion gap?

A

Loss of bicarbonate: from GI tract (diarrhoea, high-output stoma), from kidneys (renal tubular acidosis).

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21
Q

Differentials for metabolic alkalosis?

A
  • Persistent vomiting e.g. gastric outlet obstruction (the classic example is pyloric stenosis in a baby).
  • Hyperaldosteronaemia.
  • Diuretic use.
  • Milk alkali syndrome.
  • Massive transfusion.
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22
Q

Describe the presentation of an aspirin overdose

A
  • Hyperventilation
  • Sweating
  • Nausea & vomiting
  • Epigastric pain
  • Tinnitus
  • Deafness
  • ARDS (rare)
  • Hypoglycaemia (children in particular)
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23
Q

Describe the ABG findings in an aspirin overdose

A
  • There is an initial respiratory alkalosis due to central respiratory centre stimulation causing increased respiratory drive.
  • In the later stages a metabolic acidosis develops along side the respiratory alkalosis as a result of direct effect of the metabolite salicylic acid and more complex disruption of normal cellular metabolism.
24
Q

Contraindications to an ABG

A
  • Local infection
  • Distorted anatomy
  • Presence of arterio-venous fistulas
  • Peripheral vascular disease of the limb to be sampled
  • Severe coagulopathy or recent thrombolysis
25
Q

Are venous and arterial pCO2 and pO2 comparable?

A

No

26
Q

List some causes of bradypnoea

A
  • Sedation
  • Opioid toxicity
  • Raised ICP
  • Exhaustion in airway obstruction with CO2 retention/narcosis
27
Q

List some causes of tachypnoea

A
  • Airway obstruction
  • Asthma
  • Pneumonia
  • PE
  • Pneumothorax
  • Pulmonary oedema
  • HF
  • Anxiety
28
Q

Cause of symmetrical and asymmetrical reduced chest wall expansion

A
  • Symmetrical: pulmonary fibrosis reduces lung elasticity, restricting overall chest expansion.
  • Asymmetrical: pneumothorax, pneumonia, and pleural effusion can all cause ipsilateral reduced chest expansion.
29
Q

What is bronchial breathing?

A

Harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal, and there is a pause between. This type of breath sound is associated with consolidation.

30
Q

Cause of tachycardia and bradycardia?

A
  • Tachycardia: hypovolaemia, arrhythmia, infection, hypoglycaemia, thyrotoxicosis, anxiety, pain and drugs (e.g. salbutamol).
  • Bradycardia: acute coronary syndrome (ACS), ischaemic heart disease, electrolyte abnormalities (e.g. hypokalaemia) and drugs (e.g. beta-blockers).
31
Q

Cause of hypertension and hypotension?

A
  • Hypertension (>140/90 mmHg): hypervolaemia, stroke, Conn’s syndrome, Cushing’s syndrome and pre-eclampsia (in pregnant females). Severe hypertension (systolic BP > 180 mmHg or diastolic BP > 100 mmHg) may present with confusion, drowsiness, breathlessness, chest pain and visual disturbances.
  • Hypotension (<90/60 mmHg): hypovolaemia, sepsis, adrenal crisis and drugs (e.g. opioids, antihypertensives, diuretics).
32
Q

List some causes of oliguria

A

Dehydration, hypovolaemia, reduced cardiac output and AKI.

33
Q

What do cool hands indicate?

A

Poor perfusion e.g. congestive HF, ACS.

34
Q

What is a ‘thready pulse’ associated with?

A

Intravascular hypovolaemia (e.g. sepsis).

35
Q

What does a raised JVP indicate?

A
  • Right sided HF.
  • Tricuspid regurgitation.
  • Constrictive pericarditis.
36
Q

Outline the systematic approach to interpreting CXR

A
  • A: airway.
  • B: bones (and soft tissues).
  • C: cardiac silhouette (and mediastinum).
  • D: diaphragm (and gastric bubble).
  • E: effusions (pleural).
  • F: fields (lung).

(Also lines, tubes, devices and surgeries)

37
Q

Define shock

A

Circulatory failure resulting in inadequate tissue perfusion and insufficient delivery of oxygen.

38
Q

What is an early sign of sepsis?

A

Tachypnoea

39
Q

What is meant by antimicrobial stewardship?

A
  • An organisational or healthcare system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness. Addressing antimicrobial resistance through improving stewardship is a national medicines optimisation priority.
  • The systematic effort to educate and persuade prescribers of antimicrobials to follow evidence-based prescribing, in order to stem antimicrobial overuse, and thus antimicrobial resistance.
  • 5 components: commitment, prevention, detection, optimising use and surveillance.
40
Q

Outline the role of source control in the management of sepsis

A
  • The goal of source control is to eliminate the source of infection, control ongoing contamination, and restore premorbid anatomy and function.
  • Strategies used to achieve source control include drainage of purulent collections, removal of the infected and/or necrotic tissue (debridement), creation of diverting ‘ostomies’, and removing obstruction, among others.
  • Not all goals may be required for every infection, and strategies can be applied selectively, based on the type of infection.
41
Q

Why should you have a low threshold of suspicion for sepsis in neutropenic or immunosuppressed patients?

A

Because neutropenic or immunosuppressed patients may have normal observations despite being life-threateningly unwell.

42
Q

List some sources of infection which sepsis could originate from

A
  • Pneumonia (most common)
  • UTI
  • Abdomen
  • Skin, soft tissues, bone and joints
  • Endocarditis
  • Device-reacted infection
  • Meningitis
43
Q

Which parts of the body have the heaviest bleeds?

A
  • Head
  • Chest
  • Abdomen
  • Pelvis
  • Long bones
44
Q

How can good perfusion be monitored?

A

Via lactate levels and urine output

45
Q

A star sign on head CT angiography indicates what?

A

Subarachnoid haemorrhage

46
Q

What intervention can be used in an emergency to control the bleeding from oesophageal varices?

A

Sengstaken-Blakemore tube

47
Q

What can be used for the reversal of dabigatran?

A

Idarucizumab

48
Q

What can be used for the reversal of rivaroxaban or apixaban?

A

Andexanet alfa

49
Q

Which CXR quality is better, PA or AP?

A

PA

50
Q

How can the technical quality of a CXR be assessed?

A

RIPE

  • Rotation - spinous process equidistant from both clavicles and lung apices visible above the clavicles.
  • Inspiration - 9-10 posterior ribs or 6-7 anterior ribs visible, indicates adequate inspiration.
  • Penetration/Exposure - are the vertebrae visible behind the heart?
51
Q

Outline the causes of syncope

A
  • Hypoglycaemia.
  • Postural hypotension.
  • Anaemia.
  • Cardiac: arrhythmias, ACS, vasovagal syncope.
  • Polypharmacy.
  • Neuro: stroke, TIA, seizures, hemiplegic migraine.
  • Mechanical (e.g. fall).
  • Organic causes e.g. SOL.
  • Pseudoseizures (non-epileptic seizures).
52
Q

Which antibiotic can be used in decompensated hepatic encephalopathy?

A

Rifaximin

53
Q

What is the most common organism in psoas abscess?

A

Staphylococcus aureus

54
Q

Back pain, fever and pain on hip extension in IVDU?

A

Psoas abscess

55
Q

What is the investigation of choice for a psoas abscess?

A

CT abdomen

Acute Care (7 decks)

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