Approach to the acutely unwell patient

Question 1

an ABG comes back as pH 7.26, with HCO3- of 10mmol/L and PaCO2 of 4.0kPa. Give 4 main causes of metabolic acidosis? If the PaCO2 was 6.6kPa, what other ABG result would help define if resp or metabolic cause?

Answer 1

ketoacidosis
lactic acidosis
poisoning
advanced acute or chronic kidney disease

base excess, normal: -2 to +2

Question 2

when considering circulation of a patient, what factors influence the patient’s mean arterial BP?

Answer 2

BP=COxTPR
CO=HRxSV
SV-influenced by preload, myocardial contractility and afterload

Question 3

5 categories of shock?

Answer 3

hypovolaemic
cardiogenic
mechanical/obstructive
distributive e.g. septic, anaphylactic
neurogenic-effects afterload on heart-there is loss of peripheral vasc tone due to loss of sympathetic outflow as result of SC transection or brainstem injury, causing severe hypotension with a relative bradycardia.

Question 4

how does a tension pneumothorax lead to obstructive shock?

Answer 4

increased intrathroacic pressure impedes venous return to heart so heart unable to fill adequately for CO sufficient to meet metabolic demands of the body.

Question 5

how does cardiogenic shock differ on pt assessment from hypovolaemic shock?

Answer 5

raised JVP in cardiogenic shock

Question 6

triad of features seen with cardiac tamponade (cause of mechanical shock)?

Answer 6

raised JVP
hypotension
muffled heart sounds
=Beck’s triad

Question 7

in what type of shock can fluid resuscitation be prolematic?

Answer 7

cardiogenic shock-likely CO will be unable to be increased, so fluids will cause pulmonary oedema

Question 8

features indicating patient with an arrhythmia is unstable and requires cardioversion?

Answer 8

shock-low BP
syncope
myocardial ischaemia
heart failure-raised JVP, basal crackles, sacral/pedal oedema, gallop rhythm

Question 9

types of shock and their causes that may be associated with the post op patient?

Answer 9

• hypovolaemic-dehydration, increased fluid loss, blood loss
• septic-wound infection, cannula infection, surgical site infection, pneumonia
• cardiogenic-MI
• mechanical-PE

Question 10

what does a GCS of less than 8 indicate?

Answer 10

risk of unprotected airway, need to contact anaesthetist for intubation with ETT

Question 11

advantages of BP monitoring with an arterial line?

Answer 11

allows frequent ABG analysis and continuous beat by beat BP monitoring, so no delay in obtaining BP recordings as with non-invasive BP monitoring
allows accurate BP monitoring even when patient profoundly hypotensive
other info from arterial trace e.g. arterial swing-indicator of myocardial contractility..

Question 12

define sepsis

Answer 12

SIRS with presumed or documented infection source.
severe sepsis-sepsis with evidence of organ hypoperfusion or dysfunction-low BP, lactic acidosis, or reduced urine output.
septic shock-persistently low BP, failed to respond to IV fluids.

Question 13

what ward observation of a pt would be the 1st thing to change on their EWS chart when becoming unwell e.g. sepsis development?

Answer 13

resp rate

Question 14

what do we want to note in particular on E assessment of pt with suspected sepsis?

Answer 14

mottled or ashen appearance
cyanosis-peripheral, central-under tongue
non-blanching skin rash
breaks in skin integrity-cuts, burns, skin infections
or other rash indicating potential infection
any lines or catheters that may be source of infection

Question 15

symptoms and signs indicating high risk of severe illness or death from sepsis?

Answer 15

objective evidence of new altered mental state
RR 25 or above, or new need for 40% O2 or more to maintain sats above 92% or above 88% in COPD pt
HR 130 or more
systolic BP 90 or less, or more than 40 below normal
not passed urine in last 18hrs
mottled or ashen appearance
cyanosis
non-blanching rash of skin

Question 16

which groups of people with sepsis may not develop a raised temp?

Answer 16

elderly or very frail
people receiving anti-cancer treatment
young infants or children
people severely ill with sepsis

Question 17

what is the worry with difficult to measure SpO2 in patients with suspected sepsis?

Answer 17

SHOCK causing poor peripheral circulation

Question 18

blood tests required in suspected sepsis pt with 1 or more high risk criteria?

Answer 18

FBC
U+Es, and creatinine
CRP
VBG for lactate and glucose
blood culture
clotting studies (DIC?)

Question 19

indications for O2 therapy in sepsis?

Answer 19

give high flow O2 therapy to maintain sats 94-98%, or 88-92% if at risk of hypercapnic resp failure.

Question 20

maximum GCS score possible in a patient who is intubated?

Answer 20

10
as pt will be unable to talk, but may be fully communicative with full motor movement and spontaneous eye opening e.g. following stopping of their sedation.
*counteracting low BP as result of sedation, need to reverse vasodilation-so need a vasopressor e.g. NA-alpha 1 adrenergic agonist (mainly).

Question 21

what diagnosis should not be missed as cause of resp distress in pt presenting with acute severe asthma attack?

Answer 21

pneumothorax-specifically TENSION

Question 22

which special groups of patients will require surgical treatment for pneumothorax?

Answer 22

pregnant women-elective surgery following birth
catamenial pneumothorax-due to endometriosis
HIV patients-require early intercostal drainage, and tment for HIV and P.jirovecii-co-trimoxazole
CF

Question 23

what may be mistaken for a pneumothorax on a CXR?

Answer 23

a large bulla

Question 24

importance of reducing a patient’s temperature if presents pyrexial?

Answer 24

reduce patient’s fluid loss that could cause them to become shocked!

Question 25

what airway adjunct may be more suitable and why for a patient having a seizure?

Answer 25

NP rather than an OP, as difficulty opening the mouth of a pt having a seizure

Question 26

what management will be necessary if a pt has a GCS of 8 or less, or GCS rapidly falling?

Answer 26

definitive airway protection with ET intubation, must call for anaesthetic help