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CSI > Bill > Flashcards

Bill Flashcards

1
Q

What do we learn from Bill’s patient persona?

A

He has been sleeping rough for 4 years
Smoker
He has been receiving lesser coin recently

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2
Q

What do the paramedics say in the handover?

A 
Picked up from local Homeless centre 
Went to sleep and was very difficult to rouse after fire alarm at 2:30am non-verbal
Drowsy
GCS E3 V4 M6
Reactive pupils 
37.4 temperature 
HR 97
BP 89/65
Sats 90% now 94% on oxygen
14 resp rate
Mildy wheezy
Abdomen distended
Blood sugar 4.2
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3
Q

What had the paramedics done before his admission to hospital?

A 
500 ml of fluid 
Bought is systolic up to 105
Glucogel given
One cannula in the right AVF
Oxygen
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4
Q

What did the paramedic find?

A

Smoking papers
Papers with number on
Smells of alcohol

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5
Q

What do we see in Bill?

A

Altered mental state

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6
Q

How would you work our what is happening with Bill?

A

Symptom sieve

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7
Q

What is the symptom sieve used by Bill’s doctor?

A 
Primary neurological
Infection
Cardiorespiratory
Gastro-intestinal
Metabolic\Endocrine
Toxins
Psychiatric
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8
Q

What is GCS?

A

Glasgow Coma Scale

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9
Q

What are the possibilities for primary neurological symptoms?

A

Trauma

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10
Q

What Infection’s could be present?

A

COPD
Asthma
TB

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11
Q

What are possible GI issues?

A

Alcohol poisoning
Pancreatitis
Distended abdomen

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12
Q

What toxins could be present?

A

Drugs

Alcohol

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13
Q

What psychiatric problems could be present?

A

Depression

Anxiety

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14
Q

What comprises an A - E assesment?

A

Airways

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15
Q

What would an Airways assessment show in Bill

A

Verbalising intermittently
No foreign objects in mouth or excessive secretions
No snoring / stridor
No mouth or tongue swelling

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16
Q

Who could you call when examining airways?

A

An anaesthetist who are experts in airway management

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17
Q

What observations can you make about Bill’s breathing?

A 
Normal resp. rate (14 breaths per min)
Slight wheeze (stridor) when examining abdomen 
He was distressed 
90% sats but 94% on 2L oxygen  
Smoker
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18
Q

What can you exclude when assessing breathing?

A

Exclude trauma to neck
C3,C4,C5 keeps the diaphragm alive

Look at the neck muscles

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19
Q

What should you look at in regards to smoker?

A

Nicotine stained fingernails

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20
Q

What was Dr. Patel’s C assessment?

A

Blood pressure - 86/64 mm Hg
Heart rate - 110 bpm
Heart sounds - normal
12 lead ECG - sinus tachycardia nil. ischaemic changes
Peripheral capillary refil brisk bilaterally ( more than 3-4 secs)
Warm peripheries, looks flushed

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21
Q

What is most concerning about the circulation assessment?

A

Blood pressure is low
High heart rate is normal response
Worry about shock and its consequences

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22
Q

How do you conduct a capillary refill test?

A

Lift patients hand to heart level

Place pressure on the fingernail see how long it takes for colour to return

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23
Q

What are the 4 types of shock?

A

Hypovolemic
Cardiogenic
Obstructive
Distributive

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24
Q

What is the most common form of shock?

A

Hypovolemic shock

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25
Q

What causes cardiogenic shock?

A

Anything that impairs the heart generating pressure

Inadequate tissue perfusion causes shock

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26
Q

What causes obstructive shock?

A

Something physically obstructs the vessels preventing perfusion

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27
Q

What are the three types of distributive shock?

A

Septic
Anaphylactic
Neurogenic

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28
Q

How does distributive shock come about?

A

Vasodilation

TPR falls

Blood pressure falls

Inadequate perfusion

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29
Q

Disability, what is his mental state?

A 
Blood glucose - 5.7
Temperature - 38.2
Confused 
GCS E3 V4 M5
Moving four limbs normally 
PEARL - 3mm
Smells of alchol
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30
Q

What comprises the GCS?

A

Eyes
Verbal response
Motor

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31
Q

What is the exposure?

A 
No rashes
No sites of infection / track marks
No evidence of trauma to limbs or head
No evidence of external bleeding
Abdominal examination - abdomen distended, tender in left illiac fossa
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32
Q

What are Dr. Patels impressions?

A

Sepsis
Altered mental state
Likely due to sepsis however need to consider alcohol, delirium, drugs and intra-cranial pathology

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33
Q

Why do we think it is sepsis?

A 
Developing high temperature (may or may not have in sepsis)
Difficult to wake/Sleepier than normal 
Altered mental state
Oxygen to maintain above 92% sats
Low blood pressure
From shelter/streets - poor hygiene
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34
Q

What is Dr. Patel’s plan?

A

Sepsis management
Need to investigate the source of sepsis
CT head to rule out intra-cranial pathology

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35
Q

What is important about observations?

A

They are not static
Must be reviewed regularly
Compared to previous

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36
Q

How do you diagnose SIRS?

A

2 or more of

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37
Q

What is the flowchart for septic shock?

A

SIRS
Sepsis
Severe Sepsis
Septic Shock

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38
Q

What are the SEPSIS 6?

A 
Give O2 to keep sats above 94%
Take blood cultures
Give IV antibiotics
Give a fluid challenge 
Measure lactate
Measure urine output
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39
Q

What biochemical tests do Dr. Patel order?

A 
CRP
Creatinine
Urea
Na
K
ALT
ALP
GGT
Bili
Amylase
Lactate
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40
Q

What haematology test do Dr. Patel order?

A

Hb
WCC
Neut
PLT

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41
Q

What other test does Dr. Patel order?

A

Toxicology screen

Blood culture

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42
Q

What can you tell from the blood results

A 
High CRP (marker of inflammation)
High Lactate (tissue ischaemia)
High WBC and Neut (infection)
Creatinine (poor kidney function/muscle breakdown)
Blood ethanol is positive
Hyponatremic (possible dehydration)
High urea (kidney problems)
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43
Q

Which abnormal bloods are most relevant?

A 
CRP
Creatinine + Urea (kidney problems)
Lactate
WBC
Neut
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44
Q

What is Dr. Patel’s clinical update?

A 
CT head normal
Blood tests are keeping with sepsis
Blood cultures sent 
IV AB given
Patient improving clinically with AB and fluids
Less confused
Reporting severe pain in his abdomen
Patient tender in left iliac fossa
Abdomen soft to palpitation
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45
Q

What is his NEWS2 score?

A

Systolic BP 1
Pulse 1
Consciousness 3
Temperature 1

6 Medium risk, key threshold for urgent response

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46
Q

What antibiotic do you give after taking cultures?

A

Best guess antibiotics immediately after taking cultures
‘empirical antibiotics’
When culture results come in 24 hours antibiotic treatment can be fine tuned

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47
Q

What is the timescale for the Sepsis 6?

A

Should be done within an hour

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48
Q

What is Dr. Patel’s second clinical plan?

A

Analgesia
CT abdomen/pelvis
Continue intravenous fluids and antibiotics

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49
Q

What his is new NEWS 2 score?

A

Now less confused

so is now 3

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50
Q

After more information what symptom sieve categories are most likely to be causing his confusion?

A

Infection
GI
Toxins
Psychiatric

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51
Q

What organs could be causing Bill’s pain?

A

Descending and sigmoid colon

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52
Q

What are the radiologist’s observations?

A

Normally positioned liver with evidence of mild parenchymal nodularity and fatty infiltration

No portal vein enlargement

The intra- and extra-hepatic billiard ducts and gallbladder are unremarkable

The spleen is of normal size. There is no ascites.

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53
Q

What is Bill most likely to have?

A

Sigmoid diverticulitis

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54
Q

What is sigmoid diverticulitis?

A

Constant abdominal pain
Signs of systemic upset
Common cause of sepsis

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55
Q

What is diverticulitis?

A

Out-pouching with infection/inflammation

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56
Q

What is diverticulosis?

A

Out-pouching without inflammation

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57
Q

What are diverticula>

A

Abnormal out-pouching of the mucosa

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58
Q

When does it become diverticular disease?

A

Intermittent abdominal pain
Changes in bowel pain
Related to a high fat, low fibre diet

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59
Q

What is important to know about tests?

A

They are there to confirm your suspicions

In this case palpating would have given you the diagnosis and test confirmed it.

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60
Q

What is the main aim of the A-E approach?

A

Buy time for further treatment and making a diagnosis

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61
Q

What is the SBAR approach?

A

Situation
Background
Assessment Recommendation

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62
Q

What is the homelessness iceberg?

A

Most obvious is homelessness on the street increased from 2000 in 2010 to 4800 in 2018

People in tents/carparks

On the edge of homelessness e.g. living with a friend

People in hostels

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63
Q

Why does homelessness cause a public health issue?

A

Those sleeping rough have average age of death of 47

High drug use

The effects of being in rentery’s is equivalent to becoming redundant

Affects skin, breathing, mental health

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64
Q

What is RSVP approach?

A

Reason
Story
Vital signs
Plan

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65
Q

What causes homelessness?

A

Eviction from private tenancies

You can evict someone with only 8 week notice in UK

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66
Q

How many children live in houses where they can be evicted?

A

1/3

67
Q

Why is there now a lot of housing that is not being used?

A

More people are buying houses to rent

Makes housing market inefficient

E.g. a 2 bed maisonette would usually house a 4 people family

Now a private landlord will rent it out to a single working professional

68
Q

What might airway obstruction cause if untreated?

A

Hypoxia
Risks organ damage
Cardiac arrest
Death

69
Q

Where is homelessness less prevalent?

A

Scotland e.g. Edinburgh and Glasgow

70
Q

Give examples of airway problems

A
  • Decreased GCS (GCS ≤8 usually requires intubation)
  • Excessive secretions
  • Foreign body
  • Airway swelling / inflammation
  • Trauma
71
Q

How can airway obstruction present?

A
  • There may be paradoxical chest and abdominal movements
  • There may be use of accessory muscles
  • In partial obstruction there may be noisy breathing (snoring, stridor, wheeze) with diminished air entry
  • In total obstruction there will be no breath sounds at the nose or mouth
  • Central cyanosis is a late sign
72
Q

What actions can you take to treat an airway obstruction?

A

Airway opening manoeuvres - head tilt and chin lift, or jaw thrust

  • Suction to remove debris (don’t ever use your fingers!)
  • Simple airway adjuncts – nasopharyngeal airway, oropharyngeal airway (aka Guedel)
  • Supraglottic airway (eg iGel)
  • Advanced airway interventions – intubation, emergency surgical airway
  • Then give oxygen at high concentration
73
Q

Give some examples of respiratory pathologies the can cause problems with breathing

A
  • Reduced GCS
  • Acute severe asthma or COPD
  • Pneumonia or lung infection
  • Pulmonary oedema
  • Pneumothorax or tension pneumothorax
  • Pulmonary embolism
  • Haemothorax (blood in the pleural cavity, often secondary to trauma)
  • Respiratory depression (e.g. secondary to drug toxicity)
74
Q

How do you assess someone’s breathing?

A
  • Oxygen sats
  • Can they talk?
  • Use of respiratory muscles, central cyanosis, sweating?
  • Look / feel for symmetry of chest movement and for chest deformity
  • Feel for the trachea deviation
  • Percuss the chest - hyper-resonance
  • Listen to the chest – for air entry and any added sounds (crackles, wheeze, stridor)
  • Look at the calves for any signs of DVT
75
Q

What may tracheal deviation indicate?

A

to one side may indicate a tension pneumothorax or large effusion on the
contralateral side

or collapse on the ipsilateral side

76
Q

What might hyper-resonance suggest?

A

pneumothorax; dullness usually indicates consolidation or

pleural fluid

77
Q

What might absent or reduced breath sounds suggest?

A

a pneumothorax or pleural fluid or lung consolidation caused by complete obstruction to that region.

78
Q

What would DVT possibly indicate?

A

possibility of PE

79
Q

What action do you take when someone’s breathing is compromised?

A

Specific treatment depends on cause

Sit the patient up if possible

Give oxygen to meet sat target of >94%

80
Q

What would you give to treat breathing in anaphylaxis?

A

Adrenaline

81
Q

What would you do to treat breathing in a pneumothorax?

A

Chest drainage

82
Q

What do you give to treat breathing due to an opioid overdose?

A

Naloxone

83
Q

What do you used to treat breathing in airway disease?

A

Bronchodialtors

84
Q

What do you do if the patient’s rate or depth of breathing is insufficient or absent?

A

use bag-mask or pocket mask ventilation to
improve oxygenation and ventilation

whilst calling immediately for expert help

85
Q

What do you do if breathing still has not improved after intervention?

A

Non-invasive ventilation

OR

Intubation and ventilation may be required

86
Q

In those with COPD what can high conc/ of O2 do?

A

May depress breathing

87
Q

What do patients with COPD often have?

A

Chronic hypercarbia

88
Q

What does chronic hypercarbia mean they do?

A

Start to rely upon hypoxia (rather than CO2 levels) to stimulate ventilation

‘hypoxic drive’

high flow oxygen care remove their driving factor for respiration

89
Q

Why can you not let patients with COPD have a low sats rate?

A

They might sustain end-organ damage or cardiac arrest

90
Q

What do you aim for when treating the breathing of COPD patients?

A

target SpO2 of 88–92% in
most COPD patients

evaluate this based on the patient’s arterial blood gas measurements

91
Q

In almost all emergencies what should you consider to be the primary cause of circulatory failure?

A

Hypovolaemia

92
Q

What are the basic aims of treating cardiovascular collapse?

A

Fluid replacement

Haemorrhage control

Restoration of tissue perfusion

93
Q

What life threatening conditions must you look for when assessing circulation?

A

Cardiac tamponade

Massive haemorrhage

Septic Shock

94
Q

What could be causing problems in circulation?

A

Hypovolaemia (bleeding, burns, diarrhoea / vomiting, dehydration)

  • Pump failure
    • Cardiogenic eg heart failure, myocardial infarction, arrhythmia
    • Non-cardiogenic eg cardiac tamponade, tension pneumothorax, PE
  • Vasodilation (sepsis, anaphylaxis)
95
Q

How do you assess circulation?

A

Look at the colour of the hands and digits: are they blue, pink, pale or mottled?

  • Assess the limb temperature by feeling the patient’s hands: are they cool or warm?
  • Measure the capillary refill time (CRT).
  • Take the heart rate
  • Apply 3-lead cardiac monitoring (you should also ask for a 12-lead ECG).
  • Look at the neck for the height of the jugular venous pressure (JVP).
  • Palpate peripheral and central pulses, assessing for rate, quality, regularity and equality.
  • Measure the blood pressure.
  • Auscultate the heart. Is there a murmur? Are the heart sounds difficult to hear (such as may be seen in cardiac
    tamponade) ?
  • Look thoroughly for evidence of bleeding
96
Q

How to you measure CRT?

A

Apply cutaneous pressure for 5 seconds on a fingertip held at heart
level to cause blanching. Time how long it takes for the skin to return to its previous colour after releasing. A
normal CRT is < 2 s. A prolonged CRT suggests poor peripheral perfusion (but can also be due to cold
surroundings and old age).

97
Q

What can elevated jugular venous pressure indicate?

A

An elevated JVP may indicate heart failure

or fluid overload

98
Q

What might differences in use indicate?

A

Barely palpable
central pulses suggest poor cardiac output

A bounding pulse may indicate sepsis.

99
Q

Why might blood pressure in circulatory shock be normal?

A

Even in circulatory failure (shock), the blood pressure may be normal, because
compensatory mechanisms increase peripheral resistance in response to reduced cardiac output.

100
Q

What actions do you take to treat circulatory issues?

A
  • Insert one or more large intravenous cannulae
  • Take blood from the cannula for routine checks
  • If the BP is low, give a fluid challenge
  • If the patient is bleeding, replace blood with blood
101
Q

What investigations are carried out with blood sample?

A

haematological
biochemical
coagulation
cross-matching

102
Q

What can lactate level indicate?

A

A lactate level can give an indication as to tissue perfusion.

103
Q

How do you conduct a fluid challenge?

A

250ml up to 1000ml of Crystalloid fluid

depending on the
patient and the situation (use less if the patient is elderly or known to have heart failure)

Monitor the heart
rate and BP in response to the fluid

104
Q

What might the patient benefit from if BP does not improve despite fluid resuscitation?

A

If BP does not improve despite IV fluid resuscitation, the patient may benefit from specific drug infusions on
intensive care to improve the function of their heart or to stimulate vasoconstriction

105
Q

What does disability look at?

A

Level of consciousness and neurological functioning

106
Q

What problems would cause disability?

A

Profound hypoxia or hypercapnoea

  • Drugs – sedatives, opioids, toxins, poisons
  • Cerebral hypoperfusion (eg from profound hypotension)
  • Raised intracranial pressure
  • CVA
  • Metabolic dysfunction eg hypoglycaemia
107
Q

How do you assess disability?

A

Check the Glucose

  • Take the temperature
  • Assess the neurological status
  • Check the pupils for size, equality and reactivity to light
  • Assess for pain
  • Check the drug chart for possible culprits / reversible causes of depressed consciousness
108
Q

How do you conduct a rapid neurological assessment?

A

ACVPU (Alert – confused – respond to voice – respond to pain – unresponsive)

109
Q

How do you conduct a formal neurological assessment?

A

GCS

110
Q

What actions do you take against disability?

A
  • Provide oral or parenteral glucose if needed (follow local protocols)
  • Provide analgesia for pain
  • Specific action for specific problems eg treat seizures, treat opioid toxicity with Naloxone, seek specialist input
    if raised intracranial pressure
111
Q

What does exposure mean?

A

To examine the patient properly full exposure of the body may be necessary. Respect the patient’s dignity and
minimise heat loss.

112
Q

What do you examine in the exposure stage?

A

head to toe, front and back. Look for bleeding, swellings, rashes, sores, wounds, catheters etc

Perform a focused exam of any relevant systems eg the abdomen

113
Q

What steps should you take during the exposure assessment?

A

Take a full clinical history from the patient, any relatives or friends, and other staff.

  • Review the patient’s notes and charts
  • Review the results of laboratory or radiological investigations
114
Q

What does a NEWS2 score of 0-4 indicate?

A

Low clinical risk

Ward based response

115
Q

What does a NEWS2 score of 5-6 indicate?

A

Medium clinical risk

Key threshold for urgent response

116
Q

What does a score of three in any individual parameter mean?

A

Low-medium clinical risk

Urgent ward-based response

117
Q

What does a NEWS2 score of 7 or more indicate?

A

High clinical risk

Urgent or emergency response

118
Q

What is the clinical response for a NEWS of 0?

A

Minimum 12 hourly

Continue routine NEWS monitoring

119
Q

What is the clinical response for a NEWS of 1-4?

A

Minimum 4-6 hourly
Inform registered nurse who must assess the patient
Nurse decides whether increased frequency of monitoring or escalation of care in required

120
Q

What is the clinical response for a NEWS of 3 in a single parameter?

A

Minimum 1 hourly

Registered nurse to inform medical team who will review and decide whether escalation of care in necessary

121
Q

What is the clinical response for a NEWS of 5 or more?

A

Minimum 1 hourly
Registered nurse inform medical team immediately
Nurse to request urgent assessment by clinician or team with acute core competencies
Care to be provided in an environments with monitoring facilities

122
Q

What is the clinical response for a NEWS of 7 or more?

A

Registered nurse immediately inform someone of specialist registrar level or above

Emergency assessment by a team with critical care competencies

Consider transfer of care to level 2/3 clinical care facility e.g. ICU

Clinical care with monitoring facilities

123
Q

What can the abdominopelvic cavity be divided into?

A

4 quadrants

9 areas

124
Q

What are the 4 quadrants?

A

Right upper
Right lower
Left upper
Left lower

125
Q

What are the 9 areas?

A 
right hypochondriac
right lumbar
right illiac
epigastric
umbilical
hypogastric/pubic
left hypochondriac
left lumbar
left illiac
126
Q

What is considered to be the 10th division?

A

Perineum

127
Q

What is in the left upper quadrant?

A 
Left portion of liver
Larger portion of stomach
Pancreas
Left kidney
Spleen
Bits of transverse and descending colon
Bits of small intestine
128
Q

What is in the right upper quadrant?

A 
Right portion of the liver
Gallbladder
Right kidney
Small portion of stomach
Bits of ascending and transverse colon
Bits of small intestine
129
Q

What is in the left lower quadrant?

A

Majority of small intestine
Some of the large intestine
Left female reproductive organs
Left ureter

130
Q

What is in the right lower quadrant?

A 
Cecum
Appendix
Parts of small intestine
Right female reproductive organs 
Right ureter
131
Q

What is pain in the right upper quadrant associated with?

A

infection and inflammation in the gallbladder and liver

peptic ulcers in the stomach

132
Q

What is pain in the left upper quadrant associated with?

A

malrotation of the intestine and colon

133
Q

What is pain in the left lower quadrant associated with?

A

colitis (inflammation of the large intestine)

pelvic inflammatory disease

ovarian cysts in females

134
Q

What is pain in the right lower quadrant associated with?

A

Appendicitis

135
Q

What does the right hypochondriac contain?

A

right portion of the liver

the gallbladder

the right kidney

parts of the small intestine

136
Q

What does the left hypochondriac contain?

A

spleen

left kidney

part of the stomach

the pancreas

parts of the colon

137
Q

What does the epigastric contain?

A

majority of the stomach

part of the liver

part of the pancreas

part of the duodenum

part of the spleen

adrenal glands

138
Q

What does the right lumbar region contain?

A

gallbladder

the left kidney

part of the liver

ascending colon

139
Q

What does the left lumbar region contain?

A

descending colon

left kidney

part of the spleen

140
Q

What does the umbilical region contain?

A

Umbilicus

Many parts of small intestine (duodenum, jejunum and illeum)

Transverse colon

Bottom portions of both left and right kidneys

141
Q

What does the right iliac contain?

A

appendix, cecum, and the right iliac fossa

142
Q

What is pain in the right iliac region associated with?

A

Appendicitis

143
Q

What does the left iliac contain?

A

descending colon

the sigmoid colon

the left illiac fossa

144
Q

What does the hypogastric region contain?

A

organs around the pubic bone

bladder

part of the sigmoid colon

the anus

many organs of the reproductive system

145
Q

What are diverticula?

A

a small pouch with a narrow neck that sticks out from (protrudes from) the wall of the gut

146
Q

Where do diverticula most commonly develop?

A

Section of colon leading to the rectum

147
Q

When in life do diverticula become more common?

A

Increasing age

148
Q

What causes diverticula?

A

Not enough fibre

Gut muscles have to work harder

High pressure develops when it squeezes hard stools

Increased pressure may push the inner lining small area of your gut through the muscle wall

149
Q

What does diverticulosis mean?

A

Diverticula are present but no symptoms

3 in 4

150
Q

What is diverticular disease?

A

diverticula cause intermittent, lower tummy (abdominal) pain or bloating

crampy and tends to come and go

pain in the lower left part of abdomen

pain and bloating may ease by passing faeces

some people develop diarrhoea or constipation or pass mucus with stools

151
Q

What are the symptoms of diverticular disease similar to?

A

IBS but this affects younger people

Early bowel cancer (colonoscopy may be needed)

152
Q

How do you diagnose diverticular disease?

A

confirm presence of diverticula

rule out all other causes

153
Q

What is diverticulitis?

A

One or more diverticula become inflamed and infected

154
Q

What can cause diverticulitis?

A

Faeces stagnates

Bacteria multiply causing infection

155
Q

What are symptoms of diverticulitis?

A

Constant pain in the abdomen

High temp

Constipation/diarrhoea

Blood in stools

Nausea and vomiting

156
Q

What are potential complications of diverticulitis?

A

Blockage of colon

Abscess in abdomen (diagnosed by CT)

Fistula may form to other organs

Perforation in the wall of the bowel which can lead to peritonitis

157
Q

What causes rectal bleeding?

A

burst blood vessel that sometimes occurs in the wall of a diverticulum

158
Q

What is the treatment for diverticulosis?

A

Advice high fibre diet
18 - 30g of fibre a day

Stop smoking

Exercise

Lose weight

159
Q

Give examples of high fibre foods?

A

Whole grains, fruit, veg
Wholemeal/Brown versions
Beans, pulses and legumes

160
Q

When might fibre supplements be advised?

A

When a high fibre diet does not ease symptoms

e.g. psyllium, methylcellulose or polycarbophil

161
Q

What is the treatment for diverticular disease?

A

High fibre diet

Plenty of fluids

Paracetamol

Antispasmodics

162
Q

What is the treatments for diverticulitis?

A

Course of antibiotics

May be admitted to hospital

Painkillers

Surgery for complications

Emergency blood transfusion for bleeding diverticula

163
Q

What scans can be used to diagnose diverticulosis?

A

Sigmoidoscopy
Colonoscopy
CT scan
Barium X-rays

CSI (17 decks)

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