Bill emergency medicine Flashcards
What is the aim of having a standardised approach for all deteriorating/ clinically ill patients?
This approach aims to keep the patient alive and achieve some clinical improvement. This will buy time for further treatment and making a diagnosis.
What steps are included in the approach to all deteriorating or critically ill patients?
- Use the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to assess and treat the patient.
- Do a complete initial assessment and re-assess regularly.
- Treat life-threatening problems before moving to the next part of assessment.
- Assess the effects of treatment, remembering it can take a few minutes for treatments to work
- Recognise when you will need extra help. Call for appropriate help early.
- Use all members of the team. This enables interventions (e.g. assessment, attaching monitors, intravenous access), to be undertaken simultaneously.
- Communicate effectively - use the Situation, Background, Assessment, Recommendation (SBAR) or Reason, Story, Vital signs, Plan (RSVP) approach.
What is the ABCDE approach?
Airway, breathing, circulation, disability, exposure
What are we assessing under A in ABCDE?
Is the patient’s airway secure (i.e. safe and patent) or is it compromised?
How do we know if a patients airway is safe?
If the patient is able to speak.
Is airway obstruction an emergency?
Yes- calls for immediate expert help
What can happen if airway obstruction is left untreated?
Untreated, it causes hypoxia and risks organ damage, cardiac arrest, and death.
What problems are associated with airway in ABCDE assessment?
- Decreased GCS (GCS ≤8 usually requires intubation)
- Excessive secretions
- Foreign body
- Airway swelling / inflammation
- Trauma
What abnormalities can we see when assessing airway in ABCDE?
- 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
What actions can be taken to treat airway obstruction under ABCDE?
- 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
What problems are associated with breathing in ABCDE assessment?
- 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)
How would we assess breathing in ABCDE?
- Obtain oxygen saturations (pulse oximeter) and count RR
- Are they able to talk in sentences? Words? Not at all?
- Look for use of respiratory muscles, central cyanosis, sweating
- Look / feel for symmetry of chest movement and for chest deformity
- Feel for the trachea – deviation to one side may indicate a tension pneumothorax or large effusion on the contralateral side, or collapse on the ipsilateral side
- Percuss the chest - hyper-resonance may suggest a pneumothorax; dullness usually indicates consolidation or pleural fluid
- Listen to the chest – for air entry and any added sounds (crackles, wheeze, stridor). Absent or reduced sounds suggest a pneumothorax or pleural fluid or lung consolidation caused by complete obstruction to that region.
- Look at the calves for any signs of DVT (which might indicate possibility of PE)
What actions can be taken to treat breathing problems under ABCDE?
- Specific treatment will depend on cause (for example adrenaline in anaphylaxis, chest drainage in pneumothorax, Naloxone in opioid overdose, bronchodilators in airway disease)
- An arterial blood gas analysis is likely to be useful
- Sit the patient up if possible and they’re short of breath
- All critically ill patients should be given oxygen. For most patients, the oxygen saturation target should be >94%*
- If the patient’s rate or depth of breathing is insufficient or absent, use bag-mask or pocket mask ventilation to improve oxygenation and ventilation, whilst calling immediately for expert help
- If breathing doesn’t improve, non-invasive ventilation or intubation and ventilation may be required.
Why may high concentrations of oxygen depress breathing in patients with COPD?
What can happen if you give high flow oxygen?
What are the possible complications of this?
Patients with COPD often have chronic hypercarbia and can start to rely upon hypoxia (rather than CO2 levels) to stimulate ventilation, known as ‘hypoxic drive’.
Giving high flow oxygen could therefore remove their driving factor for ventilation, which could result in respiratory depression and the patient becoming unwell.
Nevertheless, these patients will also sustain end-organ damage or cardiac arrest if their blood oxygen levels are allowed to remain significantly low.
How do you treat breathing in patients with COPD who breathe through hypoxic drive?
Aim for lower than normal saturations. Give oxygen via a controlled mask at 2-4L per minute and reassess. Aim for target SpO2 of 88–92% in most COPD patients but evaluate this based on the patient’s arterial blood gas measurements.
What should you consider to be primary cause of circulatory failure (shock), in almost all emergencies, till proven otherwise?
Hypovolemia
Give an example of a breathing problem that can compromise a patients circulation?
Tension pneumothorax (should have been treated earlier)
General treatment of cardiovascular collapse
The specific treatment of cardiovascular collapse depends on the cause, but should be directed at fluid replacement, haemorrhage control and restoration of tissue perfusion. Look for signs of life-threatening conditions (e.g. cardiac tamponade, massive haemorrhage, septic shock), and treat them urgently.
Circulatory problems
- Hypovolaemia (bleeding, burns, diarrhoea / vomiting, dehydration)
- Pump failure
o Cardiogenic eg heart failure, myocardial infarction, arrhythmia
o Non-cardiogenic eg cardiac tamponade, tension pneumothorax, PE - Vasodilation (sepsis, anaphylaxis)
Circulatory assessment
- 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). 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).
- 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). An elevated JVP may indicate heart failure or fluid overload
- Palpate peripheral and central pulses, assessing for rate, quality, regularity and equality. Barely palpable central pulses suggest poor cardiac output. A bounding pulse may indicate sepsis.
- Measure the blood pressure. Even in circulatory failure (shock), the blood pressure may be normal, because compensatory mechanisms increase peripheral resistance in response to reduced cardiac output.
- 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
Action taken for cardiovascular treatment
- Insert one or more large intravenous cannulae - Take blood from the cannula for routine haematological, biochemical, coagulation and microbiological investigations, and cross-matching. A lactate level can give an indication as to tissue perfusion.
- If the BP is low, give a fluid challenge – this may be 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
- If the patient is bleeding, replace blood with blood (rather than Crystalloid).
- 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
What does disability look for in ABCDE?
Level of consciousness and neurological functioning.
Problems associated with disability
- Profound hypoxia or hypercapnoea
- Drugs – sedatives, opioids, toxins, poisons
- Cerebral hypoperfusion (eg from profound hypotension)
- Raised intracranial pressure
- CVA
- Metabolic dysfunction eg hypoglycaemia
Disability assessment
- Think ABC-DEFG – Don’t Ever Forget Glucose! Check the BM
- Take the temperature
- Assess the neurological status
o Rapid assessment - ACVPU (Alert – confused – respond to voice – respond to pain – unresponsive)
o Formal assessment - GCS - 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
Disability actions
- 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
Important consideration for E of ABCDE
To examine the patient properly full exposure of the body may be necessary. Respect the patient’s dignity and minimise heat loss.
What is carried out in E portion of ABCDE
- Examine 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
- 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.
What is a symptoms sieve?
Symptom sieve is used to get broad categories explaining pathological processes behind a condition
How does the GCS score work?
3 is lowest and means you are not doing anything or saying anything - 1 in each category
Eye- Spontaneous, to sound, to pressure, none (4-1)
Verbal response- Orientated, confused, words, sounds, none (5-1)
Motor response- Obey commands, localising, normal flexion, abnormal flexion, extension, none (6-1)
What is PEARL and what is measured here?
Pupils Equal And Reactive to Light
Measure pupil diameter
What is the most concerning part of the patients ‘circulation’ assessment and what can be done?
Systolic is less than 90 and so this should be intervened with by giving IV fluids to increase blood pressure
This also tells us if the BP is low due to hypovolemia (if responds)
If not treated, this could lead to hypovolemic shock
What is meant by circulatory shock?
Circulatory shock - used when inadequate blood flow results to damage to body tissues
What are the 4 types of circulatory shock and explain briefly what causes each of them?
Hypovolemic - loss of blood volume
Obstructive - physical obstruction to blood flow
Cardiogenic - due to ventricular failure
Distributive - due to vasodilation
Due to sepsis, anaphylaxis (allergic reaction), neurogenic
Why is altered mental state considered a sign of sepsis?
Decreased cerebral perfusion due to histamine and cytokine release leading to vasodilation and this can cause altered mental state
The decreased cerebral perfusion can be due to circulatory shock initiated by sepsis
What is a renal sign of hypoperfusion
Low urine output as kidneys are not receiving enough blood
What are 2 other signs of hypoperfusion (non-renal)
Mottled skin and tachycardia also shows hypoperfusion
What is the diagnosis criteria for SIRS?
≥2 of
Temp >38 or <36 (elderly)
Heart rate >90bpm
Resp rate >20
First sign of deterioration is tachypneoa
WBC Count >12x10^9 or <4x10^9/L
Other than meeting criteria for SIRS, what else is required for a sepsis diagnosis?
Meets SIRS criteria and evidence of infection
Blood cultures
What is needed to diagnose a patient with severe sepsis?
Sepsis with evidence of organ dysfunction, hypotension or hypoperfusion
Lactate, Urine output
When would someone be considered to be in septic shock?
Severe sepsis with hypotension despite adequate fluid resuscitation
If you suspect sepsis, you are supposed to do the Sepsis 6, what are these?
Give Oxygen to keep stats above 94%
Take blood cultures - sign of sepsis
Give IV Abx - if you suspect sepsis then give Abx within an hour
Give a fluid challenge - give a bit of fluid fast 250-500ml of crystalline solution within 15 mins (stat)
Measure lactate - sign of hypoperfusion
Measure urine output - sign of hypoperfusion
After seeing the patient has increased CRP, Lactate and WBC/Neutrophilia, why are these each suggestive of sepsis?
CRP - inflammation
Produced by liver and produced when we have an inflammatory response
Lactate - anaerobic respiration
Part of sepsis 6
Vasodilation meaning hypoperfusion which means there is no oxygen and so anaerobic respiration occurs and this leads to increased lactate
WBC and neutrophila - sign of infection
Neutrophil is suggestive of bacterial infection
Why is abnormal urea not suggestive of sepsis?
Not Urea - too many causes for renal injury therefore not specific for sepsis
Why is raised GGT in this case not used to suggest sepsis diagnosis?
Not GGT due to chronic elevated levels of ethanol - history of alcohol abuse
NEWS thresholds and triggers
Clinical response to NEWS trigger thresholds
If patient has COPD, what sats should be aimed for and why is this different to if they didn’t have COPD?
If they have COPD, instead of aiming for sats of 98 you aim for sats of 94 as they have emphysema and large alveoli and a lot of dead space which does not help with tissue perfusion so there is V:Q mismatch
Is high BP an issue in NEWS2 scoring?
No- unless over 220 (then score of 3)
Specifically in women, what could be the cause of left iliac fossa pain?
Violent torsion, infection in reproductive system in women could be a cause of left iliac fossa pain
What organ is most likely to be affected if there is left iliac fossa pain?
Issue with sigmoid colon as it is in the left iliac fossa
What is meant by a diverticulum
Where in the digestive tract are they most common
Diverticulum is singular out-pouching due to weakness within the wall
Most common in Large colon - Rectum as this is where stool are becoming more solid
What is meant by a diverticulum
Diverticulum is singular out-pouching due to weakness within the wall
What group of people are diverticuli most common in and why?
Common in older people
Lack of fibre therefore colon does not have a lot of help to excrete faeces and be motile so has to contract more and so it gets weaker and weaker which leads to outpouching
Bowel movements over time progress to diverticuli formation
Can be present in younger people as well
Can diverticuli present with PR bleeding?
Yes
Diverticulosis vs diverticulitis
Diverticulosis - several diverticuli
Diverticulitis - inflammation of diverticuli (lots of faeces= inflammation more likely)
What can airway obstruction cause if untreated?
Hypoxia
Risks cardiac arrest, organ damage and death
What does a GCS≤8 require?
Intubation
Is central cyanosis a late or early sign in the airway assessment?
Late
What would you give if a patient had anaphylactic shock?
Adrenaline
If the patient’s depth or rate of breathing is insufficient or absent, what should be done?
Use bag-mask or pocket mask ventilation to improve oxygenation and ventilation whilst calling immediately for expert help
If breathing does not improve, what may be required?
Non-invasive ventilation or intubation and ventilation
What is a normal capillary refill time?
Less than 2 seconds
What might a long CRT be due to?
Poor peripheral perfusion
Can also be due to cold surroundings and old age
What might an elevated JVP indicate?
Heart failure or fluid overload
In cardiac tamponade are are the heart sounds difficult to hear?
Yes
If the patient is bleeding, what would you replace the blood with instead of crystalloid fluid?
Blood
If BP does not improve after IV fluid resuscitation, what might they need instead?
Specific drug infusions
At what stage of A-E assessment should glucose be checked?
D - Disability
What is in the right upper quadrant and what is pain in this area usually associate with?
Right portion of the liver, the gallbladder, right kidney, a small portion of the stomach, the duodenum, the head of the pancreas, portions of the ascending and transverse colon, and parts of small intestine. Pain in this region is associated with infection and inflammation in the gallbladder and liver or peptic ulcers in the stomach.
What is in the left upper quadrant and what is pain in this area usually associated with?
Left portion of the liver, part of the stomach, the pancreas, left kidney, spleen, portions of the transverse and descending colon, and parts of the small intestine. Pain in this region is associated with malrotation of the intestine and colon.
What is in the right lower quadrant and what is pain in this area usually associated with?
Caecum, appendix, part of the small intestines, the right half of the female reproductive system, and the right ureter. Pain in this region is most commonly associated with appendicitis.
What is in the left lower quadrant and what is pain in this area usually associated with?
Majority of the small intestine, some of the large intestine, the left half of the female reproductive system, and the left ureter. Pain in this region is generally associated with colitis (inflammation of the large intestine) as well as pelvic inflammatory disease and ovarian cysts in females
What is sometimes considered to be a tenth abdominal division?
Perineum - area beneath the hypogastric region at the bottom of the pelvic cavity
What is in each of the 9 abdominal regions?
- Right hypochondriac
Right portion of liver, gallbladder, right kidney, parts of small intestine - Epigastric (pushed out when diaphragm contracts during bleeding)
Majority of stomach, part of liver, part of pancreas, part of duodenum, part of spleen, adrenal glands - Left hypochondriac
Spleen, left kidney, part of stomach, pancreas, parts of colon - Right lumbar
Gallbladder, the right kidney, part of the liver, and the ascending colon - Umbilical
Umbilicus (navel), and many parts of the small intestine, such as part of the duodenum, the jejunum, and the illeum. It also contains the transverse colon (the section between the ascending and descending colons) and the bottom portions of both the left and right kidney - Left lumbar
Descending colon, the left kidney, and part of the spleen - Right iliac
Caecum, and the right iliac fossa. It is also commonly referred to as the right inguinal region. Pain in this area is generally associated with appendicitis - Hypogastric
Contains the organs around the pubic bone. These include bladder, part of the sigmoid colon, the anus, and many organs of the reproductive system, such as the uterus and ovaries in females and the prostate in males - Left iliac
Part of the descending colon, the sigmoid colon, and the left illiac fossa. It is also commonly called the left inguinal region
In most cases is treatment of diverticulitis needed?
No - commonly cause no symptoms
A diet high in what is recommended to prevent complications of diverticulitis?
Fibre
About half of people in UK have diverticula by the time they are how old?
50 years old
What causes diverticula?
Lack of fibre means stool is drier and smaller and more difficult to move along
Muscles work harder and this creates high pressure in parts of your gut when squeezing hard stools
High pressure pushes inner lining of small area of gut through muscle wall which has been weakenes and this forms a small diverticulum
What are some of the common symptoms of diverticula?
Intermittent, crampy lower abdominal pain or bloating without swelling (inflammation) or infection
Constipation or diarrhoea or mucus in stool
What may ease the pain from diverticula?
Going to the toilet to pass stools
Symptoms of diverticula that develop in a young adult are more likley to be due to what condition?
IBS
The symptoms of diverticular disease in older people can also be similar to what other condition?
Early bowel cancer
How can you make a diagnosis of diverticular disease?
Confirming presence of diverticula - colonoscopy or sigmoid colonoscopy
Ruling out other causes of symptoms
Why might diverticulitis occur?
Faceses gets trapped and stagnate in diverticulum
Germs in trapped faeces may then multiply and cause infection
What are 5 symptoms of diverticulitis?
A constant pain in the abdomen. It is most commonly in the lower left side of the abdomen, but can occur in any part of the abdomen. Indeed, in people of Asian origin, it sometimes occurs on the right side
High temperature (fever)
Constipation or diarrhoea
Some blood mixed with your stools
Feeling sick (nauseated) or being sick (vomiting)
What are 4 possible complications of diverticulitis?
Obstruction of colon
Abscess in abdomen
Fistula forming to other organs such as the bladder
Perforation in wall of bowel leading to peritonitis
What is usually needed to treat these serious but uncommon complications of diverticulitis?
Surgery
How would you describe the bleeding in diverticular disease?
Abrupt and painless
What is the bleeding a result of in diverticular disease?
Burst blood vessel that sometimes occurs in the wall of a diverticulum and so amount of blood loss can be heavy
- What would a very large bleed in diverticulitis require?
Emergency blood transfusion
Sometimes an operation is needed to stop bleeding
Bleeding stops on its own in 3 of 4 cases
What more serious condition could be causing the rectal bleeding?
Bowel cancer
What is the treatment for diverticulosis?
Requires no treatment as there are no symptoms but a high-fibre diet can reduce risks of complications and diverticulitis in the future
What else would reduce risk of developing symptoms of diverticulitis?
Stop smoking
Exercise
Lose weight if you are overweight or obese
- How much fibre is needed each day?
18g
If you suddenly increase the amount of fibre you eat, what might happen?
You have symptoms of wind and bloating
Any increase should be gradual to prevent this and allow gut to be used to extra fibre
Examples of high fibre foods.
Whole grains, fruit and vegetables
Wholemeal or wholewheat bread and flour (for baking)
Wholegrain breakfast cereals such as All-Bran®, Weetabix®, muesli, etc
Brown rice and wholewheat pasta
Wheat bran
Beans, pulses and legumes
Why might soluble fibre be preferred over insoluble fibre?
Insoluble fibre, found in cereals, wheat bran and nuts, may cause more wind and bloating. Eating a lot of bran-based foods or taking bran supplements can particularly aggravate symptoms in some people.
Therefore, it may be helpful to have moresoluble fibre (the type of fibre that can be dissolved in water), found mostly in fruit and vegetables. However, many foods contain both types of fibre, so when introducing a new high-fibre food, monitor your symptoms and adjust your diet accordingly
Give examples of dietary sources of souble and insoluble fibre
Dietary sources of soluble fibre include oats, ispaghula (psyllium), nuts, flax seeds, lentils, beans, fruit and vegetables. A fibre supplement called ispaghula powder is also available from pharmacies and health food shops.
Insoluble fibre is chiefly found in corn (maize) bran, wheat bran, nuts and some fruit and vegetables.
Are fluids recommended in a high fibre diet?
Yes 2L a day
What are the 2 classes of drugs given in diverticular disease?
Paracetamol - ease pain if high fibre diet or supplements do not help to ease pain
Antispasmodics - mebervine if you have persistent abdominal spasms
What drugs should be avoided in diverticular disease?
NSAIDs and opioid medicines - can cause perforation
When symptoms are not too severe, what is the treatment for diverticulitis?
Course of Abx - if patient feels unwell
Follow diverticulosis diet recommendations unless advised otherwise
Strong painkillers for a while
If a patient needs to be taken into hospital with diverticulitis, what is the treatment?
May be given fluids directly into vein via drip
Abx required in tablet form or IV
Painkilling injections
In what parts of the world is diverticulosis uncommon?
Asia and Africa
What is the difference between a sigmoidoscopy and a colonoscopy?
Sigmoidoscopy uses a short tube to examine only the rectum and lower part of the colon
Clonoscopy uses a longer tube to examine the entire colon
What other imaging tests show diverticulosis?
CT or Barium X-Rays
Give three examples of fibre supplements?
Psyllium, Methylcellulose, Polycarbophil
Does diverticulosis lead to cancer?
No
- What investigation can confirm a diagnosis of diverticulitis?
CT
What would the investigation and treatment of an abscess involve?
CT to diagnose the abscess
Hospital stay and IV Abx
Drainage of abscess
Repeated attacks of diverticulitis may require what?
Surgery to remove affected portion of colon
What is the most common cause of major colonic bleeding in patients over 40?
Diverticular bleeding
If bleeding does not stop on its own, what must be done for evaluation?
Colonoscopy
What must be done if there is an intestinal blockage in the colon from repeated attacks of diverticulitis?
Surgery to remove the involved area of the colon
