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
What would the investigation and treatment of an abscess involve?
CT to diagnose the abscess
Hospital stay and IV Abx
Drainage of abscess
