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.
2
Q
Why is the ABCDE approach important?
A
Quickly identifies the deteriorating patient.
3
Q
How would you check for signs of life in a collapsed/unresponsive patient?
A
- Palpate for central pulse.
- Check for breath sounds.
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.
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.
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).
7
Q
When is a nasopharyngeal airway contraindicated?
A
- Epistaxis.
- Basilar skull fracture.
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.
9
Q
List causes of hypotension
A
- Sepsis
- Anaphylaxis.
- Hypovolaemia: dehydration, haemorrhage.
- Arrhythmias.
- ACS.
- Acute LVF.
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.
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?
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
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).
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.
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.
16
Q
What can a raised blood glucose indicate?
A
- Raised: diabetes, severe sepsis, metabolic stress.
17
Q
Give examples of type 1 respiratory failure
A
PE, pneumonia, asthma, pulmonary oedema.
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.
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
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).
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.
22
Q
Describe the presentation of an aspirin overdose
A
- Hyperventilation
- Sweating
- Nausea & vomiting
- Epigastric pain
- Tinnitus
- Deafness
- ARDS (rare)
- Hypoglycaemia (children in particular)
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
Are venous and arterial pCO2 and pO2 comparable?
No
26
List some causes of bradypnoea
- Sedation
- Opioid toxicity
- Raised ICP
- Exhaustion in airway obstruction with CO2 retention/narcosis
27
List some causes of tachypnoea
- Airway obstruction
- Asthma
- Pneumonia
- PE
- Pneumothorax
- Pulmonary oedema
- HF
- Anxiety
28
Cause of symmetrical and asymmetrical reduced chest wall expansion
- Symmetrical: pulmonary fibrosis reduces lung elasticity, restricting overall chest expansion.
- Asymmetrical: pneumothorax, pneumonia, and pleural effusion can all cause ipsilateral reduced chest expansion.
29
What is bronchial breathing?
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
Cause of tachycardia and bradycardia?
- 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
Cause of hypertension and hypotension?
- 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
List some causes of oliguria
Dehydration, hypovolaemia, reduced cardiac output and AKI.
33
What do cool hands indicate?
Poor perfusion e.g. congestive HF, ACS.
34
What is a ‘thready pulse’ associated with?
Intravascular hypovolaemia (e.g. sepsis).
35
What does a raised JVP indicate?
- Right sided HF.
- Tricuspid regurgitation.
- Constrictive pericarditis.
36
Outline the systematic approach to interpreting CXR
- 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
Define shock
Circulatory failure resulting in inadequate tissue perfusion and insufficient delivery of oxygen.
38
What is an early sign of sepsis?
Tachypnoea
39
What is meant by antimicrobial stewardship?
- 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
Outline the role of source control in the management of sepsis
- 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
Why should you have a low threshold of suspicion for sepsis in neutropenic or immunosuppressed patients?
Because neutropenic or immunosuppressed patients may have normal observations despite being life-threateningly unwell.
42
List some sources of infection which sepsis could originate from
- Pneumonia (most common)
- UTI
- Abdomen
- Skin, soft tissues, bone and joints
- Endocarditis
- Device-reacted infection
- Meningitis
43
Which parts of the body have the heaviest bleeds?
- Head
- Chest
- Abdomen
- Pelvis
- Long bones
44
How can good perfusion be monitored?
Via lactate levels and urine output
45
A star sign on head CT angiography indicates what?
Subarachnoid haemorrhage
46
What intervention can be used in an emergency to control the bleeding from oesophageal varices?
Sengstaken-Blakemore tube
47
What can be used for the reversal of dabigatran?
Idarucizumab
48
What can be used for the reversal of rivaroxaban or apixaban?
Andexanet alfa
49
Which CXR quality is better, PA or AP?
PA
50
How can the technical quality of a CXR be assessed?
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
Outline the causes of syncope
- 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
Which antibiotic can be used in decompensated hepatic encephalopathy?
Rifaximin
53
What is the most common organism in psoas abscess?
Staphylococcus aureus
54
Back pain, fever and pain on hip extension in IVDU?
Psoas abscess
55
What is the investigation of choice for a psoas abscess?
CT abdomen
56
What is the most common site of necrotising fasciitis?
Perineum (Fournier’s gangrene)
57
What is the most common and severe type of malaria?
Plasmodium falciparum
