Clinical skills Flashcards
Shockable rhythm & interventions
Pulseless ventricular tachycardia
Ventricular fibrillation
Interventions:
CPR-rhythm-defibrillation cycles x3 then 1mg IV adrenaline 1:10,000 and 300mg IV amiodarone
Repeat CPR-rhythm-defibrillation cycle with alternating cycle of IV adrenaline administration
Important to secure airway (intubation/SGA), IV/IO access, waveform capnography
Non-shockable rhythm & interventions
Pulseless electrical activity
Asystole
Interventions:
CPR 2mins with 1mg IV adrenaline 1:10,000 & rhythm analysis
Then CPR-rhythm cycle repeated, with alternating cycle IV adrenaline administration
Important to secure airway (intubation/SGA), IV/IO access, waveform capnography
4Hs of cardiac arrest
Hypoxia
Hypovolaemia
Hypo/hyperkalaemia
Hypothermia
4Ts of cardiac arrest
Tension pneumothorax
Cardiac tamponade
Toxins
Thrombosis
DR ABCDE
D - danger
R - response –> AVPU assessment
A - airways --> head tilt-chin lift & jaw thrust manoeuvres B - breathing --> chest rise and fall C - circulation --> carotid pulse D - disability E - exposure/everything else
Post-resuscitation care
A - new ABG B - repeat bloods C - request CXR D - destination e.g. ITU E - 12-lead ECG F - inform family G - gratitude for team
Aim for: 94-98% spO2 32-36 degrees temperature normal paCO2 mean arterial pressure > 65mmHg
CPR
Cardiopulmonary resuscitation used for cardiac arrest
30 chest compressions of 5-6cm depth (1/3 of chest) and at a rate of 100-120 compressions per minute
2 breaths via bag-valve mask or pocket mask with 500-700ml of air given
Asynchronous ventilation requires 10 breaths per min
Devices used for airway obstruction
Yankeur suction
Magill’s forceps
Suction catheter = flexible, long tube used to remove respiratory secretions from the airway, typically used in pts on tracheostomy
SBARR
Introduce self
- Situation - pt demographics, and reason for call
- Background - reason for admission/concern
- Assessment - what has been done so far e.g. bloods, examinations, etc.
- Recommendation - further investigations, tx, specialist input
- Response - confirm how soon pt will be reviewed
Breath sounds associated with partial obstruction
Inspiratory stridor - pharynx or above obstructed
Expiratory wheeze - lower airways obstructed
Gurgling - fluid/semi-solid material in main airway
Crowing - laryngeal spasm
Snoring - tongue obstructing pharynx
Complete airway obstruction
See-saw/paradoxical movement of chest and abdomen seen
Absence of breath sounds aka silent chest
Battle’s sign
Seen with skull base fracture
Bruising of the scalp overlying the mastoid process (mastoid ecchymosis)
Indicates a petrous temporal bone fracture
Airway adjuncts
Pocket mask Nasopharyngeal airway Oropharyngeal airway (Guedel) Bag-valve-mask Yankeur suction Magill's forceps
Variable oxygen devices
Hudson mask (simple face mask) = FiO2 of 40-60% at 5-10L/min
Nasal cannula = FiO2 of 24-40% at a flow rate of 1-6L/min
Fixed oxygen devices
Venturi mask FiO2 of 24-60% depending on colour with flow rates of 2-15L/min
B24, W28, O31, Y35, R40, G60
Non-rebreathe mask (high conc. reservoir mask) = FiO2 of 85% at a flow rate of 12-15L/min
Contraindicated in pt with pre-existing airway disease due to high risk of carbon dioxide retention
NEWS2 score
National early warning score used to monitor adult patients in the acute hospital setting
6 physiological parameters used to assess pt: HR, sBP, RR, temp., consciousness, spO2
2 extra points given if pt on supplemental oxygen
Indication for nasopharyngeal airway
Reducing Glasgow Coma Score
Patients who cannot tolerate an oropharyngeal airway e.g., during a seizure
Contraindication for nasopharyngeal airway
Skull base fracture signs/suspicion
Calculating alcohol units
Alcohol units = volume (ml) * ABV / 1,000
1 unit = 10ml of pure ethanol
Erb’s point (cardiology)
3rd intercostal space L sternal edge
S2 heard best
Mental state examination
ABSMAT PCI
Appearance, Attitude, Behaviour - fidgety, agitated, avoiding eye contact
Speech (rate/tone/volume) - pressured speech, monotonous, low volume, fast rate
Mood (pt description) & Affect (examiner’s observation)
Thoughts (form, content, possession) - speed, flow and coherence, delusions, obsessions, compulsions, suicidal thoughts, homicidal/violent thoughts, thought insertion/withdrawal/broadcasting
Perception - derealisation, depersonalisation, hallucinations, illusions, pseudo-hallucinations
Cognition - concentration, attention, memory, orientation
Insight - illness, interventions, impact
Judgement - considered decision
Glasgow Coma Score
3-15 points
Motor response - out of 6 (highest score for any limb)
- Obeys commands
- Localises to pain
- Withdraws from pain
- Abnormal flexion to pain (decorticate posture = severe CNS damage)
- Extending to pain
- None
Verbal response - out of 5
- Orientated
- Confused
- Words
- Sounds
- None
Eye opening - out of 4
- Spontaneous
- To speech
- To pain
- None
AMTS
Abbreviated mental state test
Used to determine any mental/cognitive impairment in elderly patients, max score is 10, score <8 indicates impairment
Questions asked: age time --> ask pt to repeat "42 west register street" then keep in mind year location identify 2 people nearby DOB year of 1st/2nd world war name of current monarch count back from 20 recall address given earlier
Limitations: language barrier, pt may not normally be able to recall dates of world wars/current monarch
Motivational interviewing
Definition: patient-centred interpersonal discussion to address pt uncertainty and increase motivation to change problematic behaviours
- agenda setting - prioritise pt’s needs/concerns
- demonstrate empathy - OARS (open-ended qs; affirmation of strength, efforts, past success; reflect by repeating/rephrasing what pt has told you to draw more info; summarise to check understanding)
- importance and confidence scale 0-10 to evoke motivation for change
- value and goals - what pt wants to achieve in life
- action plan
- support services available
Purple blood tube
Used for haematology: FBC and HbA1c
Yellow/Gold blood tube
Used for biochemistry U&Es LFTs CRP TFTs Bone profile Cardiac enzymes Iron studies Magnesium Lipid profile Endocrinology Tumour markers Toxicology Drug level tests Microbiology Virology Immunology
Blue blood tube
Coagulation screen
D-dimer
INR
Grey blood tube
Glucose & lactate
Pink blood tube
Group & save
Crossmatch
Labelled by hand
Blood culture bottles
Aerobic (blue) and anaerobic bottles (red)
Aerobic blood culture collected first as air in needle can be pushed into the aerobic bottle
Auscultatory gap
Transient disappearance of the Korotkoff sounds between systolic and diastolic pressures during cuff deflation
Causes underestimation of sBP or overestimation of dBP
Korotkoff sounds
K1 = systolic pressure K4 = 1st diastolic pressure (only used for pregnant women or pt with increased circulation when measuring manual BP) K5 = 2nd diastolic pressure
