Critically ill patient

Question 1

Purpose of NEWS?

Answer 1

Track deterioration and trigger of any needed escalation responses

Question 2

Parameters monitored on news?

Answer 2

RR
O2 sats
any inspired oxygen
BP
HR
AVPU
Glucose

Question 3

If they are on inspired oxygen how many more points do they score?

Answer 3

2

Question 4

What parameters change in MI or angina?

Answer 4

They dont change till patient starts to decline

Question 5

Why is RR and O2 not always a good representation of respiratory disease?

Answer 5

Doesn’t account for chronic respiratory disease or depth of breath

Question 6

What RR gets 2 points? 3 points?

Answer 6

you want RR to be 12-20
RR 9-11 get 1 point
RR 21-24 gets 2 points
RR 8 and below or 25 and above gets 3 points

Question 7

What Oxygen saturation gets 2 points? 3 points?

Answer 7

want it 96 or above
94-95 get 1 point
92-93 get 2 points
91 or below get 3 points

Question 8

What temperature do you get 1 point? 2 points? 3 point?

Answer 8

Want temperature at 37
If temperature is between 38 and 39 or between 36 and 35 then 1 point
If temperature is 39 or above its 2 points
If temperature is below 35 then its 3 points

Question 9

On a NEWS chart, what BP gets 1 point? 2 points? 3 points?

Answer 9

Blood pressure below 90 systolic is 3 points or above 220 systolic
Blood pressure between 90-100 systolic gets 2 points
Blood pressure between 100-110 systolic gets 1 point

Question 10

What Heart rate warrants 1 point on NEWS score? 2 points? 3 points?

Answer 10

1 point between 90 and 110 and between 40 and 50
2 points between 110 and 130
3 points either over 130 or below 40

Question 11

What conditions does HR on a NEWS chart not account for?

Answer 11

Rhythm problems or bradycardia caused by drugs like beta blockers

Question 12

What are the main changes seen on a NEWS2 chart?

Answer 12

identify those likely to have sepsis
score over 5 needs urgent response
New recording for those with hypercapnic respiratory failure
AVPU changed to ACVPU for confusion, delirium

Question 13

Why is colour scheme of NEWS2 different

Answer 13

Take into account for red green colour blindness

Question 14

In ABCDE approach what is the A before airways?

Answer 14

Approach

Question 15

What are you initially looking for in the approach to a patient?

Answer 15

End of bed inspection, patient cyanosed, breathing, comfortable, on oxygen, clammy, vomiting, do they have venous access, losing blood, UO, catheter, Conscious? speak to them

Question 16

If a patient is unresponsive on approach what do you do?

Answer 16

Feel for a pulse - if none then CPR

Question 17

How do you assess the airways?

Answer 17

Look, listen, feel
Look - any see saw movements, accessory muscles
Listen - stridor, wheeze, snore, cough, gurgling
Feel - air flow

Question 18

If a patient has stridor or upper airway obstruction how are they managed? if they have c-spine injury?

Answer 18

Call for help
Head tilt chin lift
C-spine injury = jaw thrust

Question 19

After calling for help for airway obstruction what is the next action you take to support the patient?

Answer 19

Suction oropharynx to prevent aspiration and laryngospasm, you can then suction nasopharyngeal as long as there is no risk of base of skull fracture

Question 20

After suction to prevent aspiration what is the next stage you take in securing a patient presenting with stridor or upper airway obstruction? How does management change at this stage if they are in cardiac or respiratory arrest?

Answer 20

Oropharyngeal airway or LMA mask if they are cardiac or respiratory arrest

Question 21

What sats are you aiming for in someone presenting with respiratory or cardiac arrest? in severe COPD?

Answer 21

above 94

COPD aim for 88-92

Question 22

What are you looking for in breathing of ABCDE?

Answer 22

Any emergency signs - Acute severe asthma, tension pneumothorax, haemorrhage, pulmonary oedema

Question 23

Why is adequate oxygen saturations not the only essential aspect of respiratory failure to get under control?

Answer 23

Need adequate rate and depth of breathing as can still be hypercapnic

Question 24

How do you assess the breathing?

Answer 24

look, listen, feel
Look - breathing, tachypnoea, distress signs, cyanosis, accessory muscles, abdominal muscles, depth of breathing, symmetrical chest movement, chest drains, any deformities
Listen - wheeze, silent chest
Feel - respiratory exam, percussion note, central trachea, subcutaneous emphysema

Question 25

How do you initially act to treat a patients breathing in the ABCDE approach?

Answer 25

Sit them up 30 degrees Call for help if the cause is trauma, blocked drains or there is no breathing Give high flow oxygen to achieve sats of above 94 or between 88-92 in severe COPD

Question 26

How does your breathing management adapt if they have bronchospasm? if they have copd exacerbation? if they have atelectasis/sputum retention?

Answer 26

Bronchospasm = bronchodilators COPD exacerbation = NIV Atelectasis or sputum retention = physio

Question 27

What tests can you order at B in ABCDE?

Answer 27

ABG and CXR

Question 28

If a patient is hypovolaemic what is it important to ascertain before giving big fluid bolus? What can happen? how can you do this from simple assessment? When can you nor do this quick assessment?

Answer 28

ensure they are not in cardiac failure it could cause a flash pulmonary oedema so give a smaller bolus of 250mls for example Assess by raising legs on pillows and tilting head then reassessing BP, HR and respiratory distress for oedema (do not do in spinal injury or rasied ICP

Question 29

What do you assess in C of ABCDE?

Answer 29

CRT, BP, HR, warmth of peripheries Auscultate - murmurs, tachycardia, arrythmias Is there any abdominal distension

Question 30

When do you need to act immediately in C of ABCDE?

Answer 30

Sepsis Cardiac tamponade Haemorrhage

Question 31

If someone presents with sepsis, cardiac tamponade or haemorrhage what is your immediate management aligned with C? what monitoring is done both continuously and standard?

Answer 31

IV access large bore cannula Take bloods for cultures and crossmatch Give IV bolus of Haartmans or 0.9% saline 250-500mls over 15 mins recheck BP every 5 minutes for systolic above 100 12 lead ECG - arrhythmia get cardiologist

Question 32

During reassessment of a patients circulation, what are you looking for? What would mean they need to go to ICU?

Answer 32

Seeing if their systolic has gone above 100, HR and perfusion if it hasn't or they are hypotensive - ICU

Question 33

What neurological factors should you take into consideration for D in ABCDE?

Answer 33

``` Sepsis Hypoxia Hypercapnia CNS infection Renal failure Hepatic encephalopathy Drugs/alcohol Stroke Seizures Intracranial or intracerebral bleed Hypo or hyperglycaemia Malignant hypertension ```

Question 34

What things do you assess for in D of ABCDE?

Answer 34

``` Glucose Pupil reflexes Seizure signs Ammonia levels if hepatic failure Any photophobia, neck stiffness Medications ```

Question 35

What imaging is performed at D stage?

Answer 35

CT head

Question 36

When is naloxone given in opioid overdose? Why is naloxone treatment reassessed after an hour?

Answer 36

RR at 8 or below | reassessed as half life is 30-60 minutes which is shorter than the opioids

Question 37

If alcohol is thought to be the cause of the acutely unwell patient, what is given?

Answer 37

Pabrinex