Assessment of the critically ill patient Flashcards
Airway interventions (beginner)
Head tilt chin lift, jaw thrust, suction, oral airways, nasal airways
GET HELP/2222
Airway interventions (advanced)
Nebulised adrenaline for stridor, Supraglottic airways (iGel/LMA), Intubation, Front of neck access (cricothyroidotomy)
Once airways open
15 litres of oxygen via non rebreathe mask (even in COPD patients but always re assess)
Breathing interventions
Position changes
Consider assisted inhalation with self inflating back if resp rate below 10
Circulation assessment
Colour, examine peripheries, (pulse, bp, cap refill), hypotension (later sign if young), decreased urine output, lactate
What can cause inadequate tissue perfusion
Loss of volume- hypokalaemia
Pump failure - eg MI
Vasodilation - sepsis, anaphylaxis, neurogenic
Lactate is a marker
Clinical features of lactate
Lactate builds up in anaerobic metabolism. Not always reliable though as lactate could be normal if area of dying tissue is so far gone that it cannot re enter circulation due to complete infarction
BP =
HR x SV x SVR
Disability assessment
AVPU, pupil size/response, posture, BM, pain relief, temperature
Causes of disability
Inadequate perfusion of the brain, sedative side effects, decreased BM, toxins and poisons, CVA (strokes), increased ICP
Warming the patient is good except for
Cardiac arrest
Triad of death in trauma
Hypoxia, hypothermia, and acidosis
Coagulopathic, clot in the wrong place
Acute severe asthma presentation
PEF 33-50% best or predicted
RR > 24
HR >110
Inability to complete sentences in 1 breath
Management for severe asthma
Nebulised salbutamol (5mg) O2 driven, repeat as needed
Nebulised ipratropium (500mcg) O2 driven
Hydrocortisone 100mg IV or Prednisolone 50-60mg po
MgSO4 IV 1.2-2g (seek guidance)
What may happen when you give salbutamol
Lactate and HR will be high with appropriate amounts of salbutamol
Nebulised therapy in severe asthma needs to be
Back to back
Dont give magnesium when
If very septic or old
Life threatening asthma
Severe asthma plus one of the following
PEF <33%, SPO2 <92%, PaO2 <8kpa, normal PaCO2
silent chest, cyanosis, poor respiratory effort, arrhythmias, exhaustion/low GCS
What is a pre terminal sign in asthma
Increased PaCO2
Sepsis
Life threatening organ dysfunction caused by a dysregulated host response to infection
Septic shock
Subset of sepsis where particularly profound circulatory cellular an metabolic abnormalities substantially increased mortality
When to start sepsis screen
Has NEWS score of 5 or above
Looks unwell
Has had recent chemo
Has lactate 2mmol/L or above
Causes of hypovolaemia
Haemorrhagic (external, drains, GI tract, abdomen), fluid loss (D and V, polyuria, pancreatitis), iatrogenic (diuretics, inadequate fluid prescription), trauma (chest, abdo, pelvic, long bones)
Bradycardia management
Atropine 500mcg IV, repeat to a max total dose of 3mg, external cardiac pacing
Adverse signs of bradycardia
Low BP, HR <40, heart failure, ventricular arrhythmias compromising BP
Bradycardia poor indications
Recent asystole, mobitz II Av block, QRS pauses >3 secs, 3rd degree HB with increased QRS
tachyarrythmia
Sedate and synchronised cardioversion if unstable
Stable VT - amiodarone 300mg 20-60min
Stable SVT
Vagal manoeuvres, adenosine 6mg 12mg 12mg
Stable tachy AF
Amiodarone 300mg 20-60 min if onset <48 hours, B blocker IV or digoxin IV
What to watch out for AAA
Be careful giving blood thinners in suspected MI to rule out presence of AAA
Additions to MONA IV
Second antiplatelet, monitor for hyperglycaemia
Gold standard for STEMI
PPCI - door to balloon 120mins
Intra abdominal pathology
Obstruction, perforation, collection
