Exam prep

Question 1

How do you evaluate pain? What should you ask the patient in relation to the pain?

Answer 1

PQRST!!!

Question 2

What are the other risk factors presenting with headache? (8)

Answer 2

1. Altered mental state (GCS below 15)
2. Fever (Meningococcal infection?)
3. Neurologic deficit
4. Age above 50 years or below 10 years
5. First headache of this kind
6. Head trauma in 3 months.
7. Continuously increasing intensity
8. Skin abnormalities (e.g. petechia) (Meningitis)

Question 3

What are the risk factors of chest pain? (10)

Answer 3

1. Abnormal vital parameters (tachycardia, bradycardia, hypotonia, tachypnea)
2. Shortness of breath – dyspnea
3. Hypoxia
4. Vegetative symptoms – sweating, nausea
5. Symptoms of perfusion problem / shock
6. Altered mental state
7. Asymmetric chest movement
8. Paradox pulse (Pericardial Tamponade)
9. BP side difference (significant) (Aortic dissection)
10. New cardiac murmur (ACS, endocarditis)

Question 4

What are the Risk factors (Red flags) of abdominal pain? (8)

Answer 4

1. Abnormal vital signs– shock signs
2. Shortness of breath- dyspnea
3. Fever
4. Abrupt onset
5. Bleeding (hematemesis, melena, hematochezia, hematuria, vaginal bleeding)
6. Testicular pain (Testicular torsion)
7. Old patient (>75 years)
8. Previous abdominal surgery

Question 5

What are the risk factors (red flags) of Low back pain? (12)

Answer 5

1. Abnormal vital signs – shock signs
2. Immunosuppressed state (chronic corticosteroid use, chemo, iv drug abuser, HIV)
3. Fever
4. History of cancer
5. Focal neurologic deficit
6. Injury / Trauma – high-risk mechanism of injury
7. Injury / Trauma – med-risk mechanism of injury but age > 50 y
8. Age > 70 years (new onset LBP)
9. Pain ongoing > 6 weeks
10. Coagulation disorder (acquired – VKA, DOAC ; or inherited)
11. Pain at rest
12. Pulsating abdominal mass

Question 6

What are the risk factors of limb pain? (7)

Answer 6

1. Abnormal vital signs – shock signs
2. Cold, pulseless limb
3. Fever
4. Immunosuppressed condition
5. Trauma – significant deformity
6. Focal neurologic deficit
7. Major tension, enlargement – compartment signs

Question 7

What are the risk factors (red flags) of fever? (6)

Answer 7

1. Abnormal vital signs – shock signs
2. Dyspnea - hypoxia
3. Immunocompromised state
4. 2 or more SIRS criteria
5. Skin abnormality – petechia
6. Altered mental state – AMS (GCS below 15)

Question 8

What are the risk factors (red flags) of AMS (Altered Mental State)? (8)

Answer 8

1. Abnormal vital signs
2. Low blood glucose (below 3 mmol/l)
3. Headache
4. Fever
5. Trauma – high-risk mechanism of injury
6. Focal neurologic deficit
7. Acquired or inherited coagulation defect
8. Unconsciousness

Question 9

What are the risk factors (red flags) of focal neurologic deficit? (7)

Answer 9

1. Abnormal vital signs – shock signs
2. Onset of symptoms (0-4,5 h or 4,5-6h or 6-24h or over 24h)
3. Altered mental state (below GCS 15)
4. Acquired or inherited coagulation defect
5. Fever
6. Blood glucose below 3 mmol/l
7. Undulating symptoms (on-off), or crescendo symptoms

Question 10

What are the risk factors of dyspnea? (8)

Answer 10

1. Abnormal vital signs – shock signs
2. Hypoxia – cyanosis
3. Altered mental status (GCS is under 15)
4. Stridor
5. Breathing work without air movement (frustrane breathing)
6. Asymmetric chest wall movement
7. Deviating trachea and or unilaterally missing breathing sounds
8. Extreme high respiratory rate (over 40/min)

Question 11

What are the risk factors (red flags) of Syncope (T-LOC)? (8)

Answer 11

1. Abnormal vital signs – shock signs
2. New onset arrhythmia/ irregular pulse or the major elevation of the frequency of an already diagnosed arrhythmia
3. The loss of consciousness did not have a prodrome
4. The loss of consciousness happened after the sensation of palpitation or chest pain
5. The lot of consciousness happened during physical activity
6. Dyspnoe - hypoxia
7. Altered mental status (GCS is under 15)
8. Fever

Question 12

What are the risk factors (red flags) of seizures (6)?

Answer 12

1. Ongoing seizure
2. Abnormal vital signs – shock signs
3. Ill detrimental status (GCS is under 15) (Altered mental status)
4. Focal neurologic deficit
5. Fever
6. Headache

Question 13

What are the 4 main vital signs?

Answer 13

1. Body Temperature
2. Blood Pressure
3. Pulse
4. Breathing

Question 14

What are the shock signs?

Answer 14

1. low blood pressure
2. nausea or vomiting , sweating
3. rapid shallow breathing
4. cold, clammy skin
5. rapid, weak pulse
6. dizziness, fainting or weakness/fatigue
7. Pale or ashen skin
8. Bluish tinge to lips or fingernails (or gray in the case of dark complexions)
9. Enlarged pupils
10. Changes in mental status or behavior, such as anxiousness or agitation

Question 15

What should be looked at in the “quick look” assessment?

Answer 15

1. Posture
2. Skin - color, wet or dry, temperature, odema, spots and dots.
3. Smell
4. Breathing
5. Mental state

Question 16

What are the parameters of assessing pain?

Answer 16

In every sort of pain the following parameters should be assessed (PQRST):

• P = Provoke: What provokes and exacerbates, and what alleviates the pain.
• Q = Quality : what is the quality of pain (e.g. stabbing, compressing, burning, colic)
• R = Radiation: in which direction does it radiate
• S = Severity: what is the severity – assess using objective scaling like PPI or VAS. Is is a central or peripheral pain.
• T = Timing: is it acute or chronic (acute = <1 month, or >1 month but changed intensity or quality). Is it continuous or pulsating or does it come-and-go? How fast did it start (pain appeared abruptly or presented gradually)?

Question 17

When is intraosseous cannulation used?

Answer 17

Intraosseous cannulation is recommended when securing vascular access is crucial and the third attempt of a peripheral vein cannulation fails.

Question 18

What are the advantages of IO technique?

Answer 18

The IO technique is fast and safe. The IO administration can provide a faster route to the central circulation than a distal peripheral IV line.

Question 19

Where is the IO inserted?

Answer 19

The most common site recommended for (IO) insertion is the proximal tibia. Alternative sites are the distal tibia, distal femur, sternum, and humerus.

Question 20

What do you need to avoid when inserting IO cannulation in children?

Answer 20

During IO cannulation of children the growth plate should always be avoided.

Question 21

What are the contraindications of IO cannulation?

Answer 21

The contraindications are:

1. fracture
2. infection
3. burn of the chosen limb.
4. Osteoporosis also can be a relative contraindication.

After an unsuccessful attempt an alternative limb should be chosen.

Question 22

Why is local anesthesia not needed for IO cannulation?

Answer 22

Idk? Local anaesthesia is not necessary. However Lidocaine is given after the cannulation has been made due to the aspiration pain before infusion is given.

Question 23

What are the steps of installing a IO cannula?

Answer 23

Insert the IO needle through the skin and subcutaneous tissue. Upon reaching the bone start drilling the needle with constant pressure until the loss of resistance.

Question 24

What is done after the IO cannula has been placed?

Answer 24

1. You remove the inner trocar, attach a special right-angle connector to the needle and push a 5-10ml bolus of isotonic sodium chloride solution through the needle.
2. Attach a syringe and aspirate. Obtaining marrow confirms placement. If you are unable to aspirate it does not necessary means that the needle is not in position. The obtained bone marrow can be sent to the lab for initial diagnostic laboratory studies.
3. After that you should inject 20-30mg or maximum 1 mg/kg Lidocaine because administering large volumes can be painful.
4. Secure the needle with gauze pads and tape.
5. Observing the circumference of the calf is important.
6. Every IV administrable solution can be injected intraosseously.

Question 25

How long should a IO cannula be used for?

Answer 25

The IO route can be maintained up to 24 hours but should be immediately removed when it is not needed anymore.

Question 26

What is important to remember about infusion solutions? What errors can you make if your not careful?

Answer 26

During fluid therapy we can meet a lot of types of infusion solutions therefore knowing there advantages and disadvantages is important. It has been proven that solutions with high chlorine concentrations have adverse effects on the survival of the critically ill patients therefore the solutions containing sodium chloride have lost their priority. The hypochloremic metabolic acidosis was a popular topic over the past decade. Its development is clearly associated with inappropriate or exclusive use of 0.9% sodium chloride solutions. For decades we know that the excess intake of sodium or chloride is harmful for the body. For at least 50 years the so-called balanced solutions are available. With the use of them the hypernatremia and hyperchloremia is avoidable. There are general requirements that every solution must meet. They should be isotonic, isosmotic and its pH should be around neutral. The concentration of positively and and negatively charged ions should be equal. The balanced solutions are the closest to meet these criteria. If we want a solution that has the same components as the plasma than we need 140 mmol of sodium and 103-110 mmol of chloride. This solution would not be isotonic and there would be imbalance between the concentration of the positively and negatively charged ions. Therefore we need to add more cations and if we want to reduce the chlorine concentration we need to add anions as well. This process is called “the balancing” of the solution. We have a lot of cations we can easily and safely add to the solution such as sodium, potassium, calcium, magnesium. Adding anions are much harder. In the plasma the natural anions are chloride, bicarbonate and albumin. They can not be mixed into all solutions, albumin is expensive and bicarbonate is not stable in the presence of other ions. Alexis Hartmann was the one who found a solution. He realised that there are non toxic, negatively charged compounds in the human body. These compounds also can be metabolised quickly to non harmful molecules. He found out that the some components of the citric acid cycle are ideal for “balancing”. These are: lactate, acetate, maleate, citrate. Except the citrate they are non toxic molecules and they are metabolised into bicarbonate which can be useful when there is acidosis or the solution’s pH is low. Lactate was the first to use as a balancing component. In a healthy adult its serum level is under 1-1.5 mmol/l. Its level increases if the perfusion and tissue oxygenation decreases - if the metabolism became anaerobic. In a critically ill patient the rate of its increase correlates with the severity of the condition and with the mortality.

Question 27

vein cannulas**

Answer 27

The flow rate, thus the possible administered amount of fluid, is determined by the diameter and the length of the cannula. According to Hagen-Poiseuille’s law the flow is proportional to the pressure difference (ΔP) between the ends of the pipe and the fourth power of its radius (r4) but inversely proportional to the fluid viscosity (η) and the tube length (l) [F=(ΔP x π x r4) / (8 x η x l)]. That means that doubling the radius of the cannula results in a 16 times faster fluid flow. Also, the reducing of the cannula length by half will double the flow.

Question 28

monitoring blood pressure **

Answer 28

When using a non invasive blood pressure measuring equipment the cuff size is determined by the arm circumference. Incorrect cuff size makes the measurement inaccurate or sometimes impossible. In certain cases, such as arrhythmias with changing pulse amplitude (e.g. atrial fibrillation) or the movement or tremor of the upper limb the automatic blood pressure monitor can be inaccurate or sometimes it can not measure the BP. In these cases, the auscultation method which depends on the examiner’s abilities is the only possible option. Normally, however, the automated oscillometric blood pressure measurement is more reliable and more accurate. Positioning the cuff is critical, to obtain a correct measurement the cuff’s sensor should be placed over the brachial artery. The place of the sensor is marked on the cuff. The measuring frequency is based on the patient’s complaints and his or her general status and it varies between one hour to 5 minutes or even less if it is necessary (in these cases usually invasive blood pressure monitoring is indicated). During and after every diagnostic or therapeutic intervention the BP should be measured in every 3-4 minutes until the patient can be considered stable.

Question 29

ecg monitoring **

Answer 29

The ECG monitoring of a patient with critical or potentially critical condition is obligate and indispensable. For monitoring purposes 3 or 5 electrodes are the most common. If they are positioned correctly 3 electrodes are enough for ECG monitoring and to recognise arrhythmias. Mixing up the order of the electrodes does not affect the quality. Generally, the electrodes should not be placed over bones or the breast tissue what is difficult when the patient is cachexic or thin. When placed over hairy areas the contact is reduced therefore the signal would be impaired. If the electrodes are placed too far from each other e.g. to the extremities the signal strength weakens which can also affect the quality of the monitoring. One electrode should be placed near the right shoulder (red), one near to the left shoulder(yellow) and the third one over the bottom third of the chest wall (can be placed both right or left). It is recommended to choose the lead with the best signal strength on the monitor which is usually a standard bipolar lead. Monitoring with 5 electrodes is a safe way to detect ST changes. The electrodes should be correctly placed: one electrode on the right shoulder (red), one on the left shoulder (yellow), one on the right side of the trunk (green), one on the left side of the trunk (black) and one on the V5 or central position (white). The unipolar V5 lead is the most suitable for monitoring the ST segment. If the ST segment deviation on the previous 12 lead ECG was shown in other leads than V5 then the white electrode should be placed according to that. Keep the cables organised and away from the chest wall so they will not interfere with the possible interventions.

Question 30

oxygen monitoring **

Answer 30

Judging the patient’s oxygenation in addition to our eyes (searching for cyanosis) we can use a pulse oximeter. It is a non-invasive device, it has no contraindications and it can be used for continuous monitoring. It measures what percentage of haemoglobin is binding oxygen (SpO2). The principle of its operation is the Beer-Lambert Law as it measures the absorption of red and infrared light. The pulse oximeter needs a pulsatile flow to calculate the saturation. Many things can interfere with the measurement. Some of them we can not control (e.g.: carboxyhaemoglobin, intravenous dyes, high serum bilirubin, severe anaemia, hemodilution, low perfusion), but some of them we can (strong light, movements of the device or the extremities, cold or compressed extremities, painted nails). The device is usually calibrated between 70-100% SpO2. The uncertainty of the measurements is usually about +/-2 %. The pulse oximeter can also be used for monitoring the circulation. The pulse pressure and the height of the pulse wave (with correct monitor settings) helps to detect peripheral ischemia and in some cases the changing in the peripheral circulation. The heart rate can be monitored by a pulse oximeter and it is also useful in the detection of pulse deficit but it can not be used to differentiate between arrhythmias. The target SpO2 is 95% or higher. It is important to keep in mind that the changes of the arterial saturation can only be seen on the monitor 30 to 90 seconds later.

Question 31

Humidification?**

Answer 31

Oxygen therapy without humidification can be harmful for the airways as secretion congestion, mucus plugs, airway obstruction, atelectasis occur. This is especially true for >4L/min and high-flow oxygen therapy methods. In order to maintain mucociliary clearance function and reduce heat-loss caused by ventilation, inspired gas should be warmed to body temperature and humidified. Methods for producing water vapor: A) Active a. Vaporizers: directing air flow over (pass-over vaporizer) or through (pass- through vaporizer) heated water. b. Nebulizers: convert water into tiny water droplets either by ultrasound or high- velocity gas jet B) Passive: heat-moisture exchange (HME) attachment, HME filter (with bacterial filter) The widely used bubble-through (pass-through) humidification method is inappropriate since the cold gas can be humidified much less (the absolute humidity it can reach is low) then body temperature gas, so the humidity of the inspired gas will be insufficient. Also, only vapor particles smaller then 5 μm can reach the bronchioli, which are not created during bubble- through humidification. On the top of that, the water tank is a potential source of infections. Ultrasound nebulization is the best in terms of droplet size, safety and consistency of efficacy.

Question 32

Fix Performance Systems**

Answer 32

These systems deliver 30-60 L/min oxygen flow which is more then the patient’s Peak Inspiratory Flow (PIF). Thus the patient always gets the FiO2 we set. Two major forms are: - Venturi mask: works on the principle of jet mixing. There are different (color-coded) Venturi masks for different FiO2 targets. Also, there are adjustable Venturi masks where you can set distinct FiO2 values. In general, 0.24-0.6 FiO2 can be reached. - CPAP-systems: Oxygen flow can be even higher, up to 120 L/min. High flow is delivered by a device where FiO2 can be set between 0.21 and 1.0. A well-shaped, well-sealing mask is put on the patient’s face. The mask has a PEEP-valve which maintains a constant 2 – 10 cmH2O positive pressure in the mask.

Question 33

Variable Performance systems**

Answer 33

These systems work by increasing the functional residual capacity of the patient to 100%, which will increase FiO2 during inspiration. The major drawback of these systems is that in case of elevated minute ventilation or peak inspiratory flow, performance drops because atmospheric air is inhaled besides the ventilation gas, so FiO2 will fall. - Nasal cannula: FiO2 can be 0.3 if oxygen flow is 3-5 L/min and the patient is breathing normally. Higher oxygen flow will not increase FiO2 significantly, but will be very uncomfortable. - Normal mask: Reachable FiO2 is 0.3–0.5. Oxygen flow should be 6-10 L/min. The mask increases the dead space around the face, which is filled with oxygen during the expiratory pause. The drawback is that humidification is difficult and the higher oxygen flow dries the airways. The mask can cause emotional stress (feeling of choking). - Non-rebreathing mask: A reservoir balloon is attached to the mask where the patient exclusively breaths from. The reservoir is completely filled with oxygen during the expiratory pause. The oxygen flow must be set that the reservoir never empties out completely during inspiration but only 30-40%. With 12-15 L/min flow, maximum FiO2~0.8 can be reached (theoretically 1.0 but there is always room air leaking in the system around the imperfect sealing of the mask)

Question 34

There are two main groups of oxygen delivery systems:**

Answer 34

A) Fix Performance Systems deliver the entire ventilation requirement by providing 40-50 L/min gas through the mask, which is usually enough to meet the total respiratory demand of the patient (gas flow always exceeds peak inspiratory flow). Thus, FiO2 will be constant and not affected by breathing. B) Variable Performance systems deliver only a proportion of the ventilation requirement. They provide slower gas flow, so the patient’s inspiratory flow can exceed the available gas flow, in which case environmental air is inspired to meet the respiratory demand. FiO2 is hence dependent of the breathing pattern of the patient (peak inspiratory flow, minute ventilation [respiratory rate, tidal volume]). The method of oxygen delivery should be decided by the breathing pattern of the patient and the target FiO2. Target FiO2 is decided by the current state of the patient. Oxygen therapy should be guided by continuous monitoring of SpO2 and intermittent blood gas measurements.

Question 35

oxygen therapy **

Answer 35

There are three phases of breathing: 1) inspiration, 2) expiration, 3) expiratory pause. Expiratory pause has a crucial importance regarding the efficacy of different oxygen therapy methods.

Question 36

Managing airways **

Answer 36

The first step of oxygen therapy is always airway management. Oxygen has to reach the lungs at first in order to supply the tissues via the blood flow. If the patient has compromised airway, even a properly selected O2-supply method will fail to help. The mental state/consciousness of the patient can give a clue about what airway to expect. Note that a conscious patient can also have compromised airway, so speech, breathing pattern and sounds must be evaluated. Clear auscultation and a speaking patient is a proof of patent airways. You should always expect a compromised airway in a patient in altered mental state. Assess the following: inspect breathing movements (effectivity), listen and auscultate breathing sounds (wheezing, stridor), note increased work of breathing.

Question 37

??

Answer 37

Airway managing manoeuvres and devices can cause distress and pain to the patient, inappropriate use of them might also cause smaller injuries. The first-line manoeuvre is the one that you can safely secure the airway with. A) Head tilt – Chin lift It’s best to stand aside the patient’s head. Place one hand on the forehead, and the fingers of the other hand below the jaw. Slowly tilt the head backwards with both hands, while lifting the chin upwards with your fingers. If the airway opened, lifting the chin without holding the forehead might be enough to maintain it. If the airway closes again, go back to neutral position and start the manoeuvre again. B) Jaw-thrust manoeuvre It’s best to stand behind the patient’s head. Place your thumbs on the tip of the chin, and your remaining fingers under the angle of the jaw. With these fingers, you can subluxate the jaw, hence you can move the root of the tongue away from the pharyngeal wall. At the same time, you can open the mouth with your thumbs on the chin. You need both hands to maintain this airway. Manoeuvres are temporary solutions, but are important to secure breathing and oxygenation. The maintenance of these airways require one person’s continuous presence, so he/she cannot help in other procedures.

Question 38

??

Answer 38

Next level of airway management is the use of simple airways. When using oropharyngeal or nasopharyngeal devices, choosing the right size of device is crucial. The point is to measure the distance between the angle of the jaw and the tooth line / nostrils. An inappropriately sized device might cause more problems then help. A smaller then needed device might not open and secure the airway, while a bigger might go too deep and irritate the pharynx, larynx, causing cough, vomiting or even laryngospasm that might be life-threatening. A) Oropharyngeal Airway (OPA) is easy to use. The airway is inserted in the patient’s mouth upside down. You keep pushing the airway in until you feel soft resistance or reach the end. Once it reaches the back of the throat, the airway is rotated 180 degrees. B) Nasopharyngeal Airway (NPA) is inserted until the flared end rests against the nostril.

Question 39

??

Answer 39

The highest level of simple airway devices is the supraglottic devices (SGDs) (LMA, LT, Combitube, etc.) Laryngeal Mask (LMA) and iGEL are simple and secure devices to maintain airway with. Choosing the right size of LMA (iGEL) is based on ideal body weight. Inserting is simple: the mouth is opened with one hand, then the device is inserted until soft resistance occurs. There is a line on the mask that marks where the dental line should be. If it is not reached, the device is not in the right position yet. After inserting, the cuff of the LMA must be inflated (iGEL has no cuff to inflate). Then, ventilation can be started. If there is air leaking, but there is chest raise, decision must be made about repositioning based on adequate patient oxygenation (not ventilation!). Using a SGD means that you have to assist the breathing of the patient (ventilation!). SGD does not protect the patient from aspiration.

Question 40

What could be potentially lethal pathologies in the background of chest pain?

Answer 40

1. ACS
2. tPTX
3. PE
4. cardiac tamponade
5. Aorta Dissection
6. esophageal rupture
7. bilateral pneumonia

Question 41

What could be the possible disorders or distrubances behind dyspnea?

Answer 41

Shortness of breath is a difficult symptom as it could be because of ventilatory, diffusion or perfusion disturbances as well as metabolic disorders.

Question 42

What could be in the background of an acute neurologic deficit?

Answer 42

Acute neurologic deficit is most often caused by cerebrovascular disease, but can also be a symptom or consequence of other high-risk conditions. If cerebrovascular catastrophe is an option, it is of utmost importance to determine the onset of symptoms (or the time of last seen well) accurately.

Question 43

What should be examined in a patient with AMS (Altered Mental State)?

Answer 43

1. Mental state should be examined in the following axes: alertness, orientation, attention, memory, visuospatial functioning, language functions and executive functions.
2. It should be determined whether AMS is novel or chronic (mostly dementia). Acute onset AMS is obviously alarming, but a demented patient can also present with acute changes.

Question 44

What is the second most frequent cause of ED visits?

Answer 44

Fever

Question 45

What is the most frequent cause of ED visits?

Answer 45

Pain

Question 46

What are potential causes of a fever?

Answer 46

In most cases, fever is a sign of uncomplicated infections, but often it is a significant sign of life-threatening condition, such as sepsis.

Question 47

What are some red flags regarding headaches?

Answer 47

1. Wake-up headache, or headache described as „the worst headache ever felt”.
2. In case of a patient who frequently has headaches, but this time the quality or the severity of pain is different.
3. Continuously increasing headache, or novel headache in HIV or oncology patient.

Question 48

What are the different types of categories of urgency given to patients in the emergency department by the attending physicians?

Answer 48

The decision making process in emergency should categorize patients in order of urgency, either:

1. the patient is at risk
2. potentially at risk
3. probably stable

Question 49

Something about the SBAR structure?** (idk)

Answer 49

how to ask / call for help – incl. how to communicate effectively (SBAR structure)

Question 50

What can the posture of the patient tell us in the quick look evaluation of a patient in the ED?

Answer 50

1. In many cases the posture of the patient will clearly tell about pain – it’s location and severity. A visually obvious severe pain must warn you and means a high-risk patient or patient in critically ill condition.
2. The patient presenting with continuous rhythmic movement probably because of pain, is considered at risk.
3. When the pain is of musculo-skeletal origin, the posture is often typical, called antalgic, to avoid painful movement and posture.
4. Abdominal, peritoneal pain: to reduce peritoneal tension, the patient pulls up the legs, flexes hips and knees, maybe lays on the side.

Question 51

What can the skin color of a patient tell us in the quick look evaluation?

Answer 51

1. Pale skin is not always pathologic, but in many cases will mark a critical condition, or anemia which means extra risk because of reduced oxygen transport capacity.
2. Pale-grey skin color can mark critical condition. But it is also a sign of chronic kidney failure.
3. Cyanosis always marks oxygen-insufficient state, which can be acute or chronic. It is always a warning sign, since balanced chronic hypoxia can at any time change to oxygen supply-demand imbalance if something acute happens.
4. Jaundice (yellow skin) marks impairment in the bilirubin metabolism. On it’s own doesn’t mark a critical condition. However, most probably protein synthesis is also impaired, including coagulation factors – that is important. Also, changes in oncotic pressure environment is an additional risk in the case of critical condition.

Question 52

What can wet or dry skin of a patient tell us in the quick look evaluation in the ED?

Answer 52

1. Normally, dry skin is normal. However, dry skin is alarming in some conditions (extremely warm environment, increased body temperature)
2. Dry skin accompanied with altered mental state often marks severe dehydration, exsiccosis(loss of fluids), which is alarming.
3. Cold and damp/Wet skin marks obviously critical condition.
4. Warm & damp/Wet skin marks potentially critical condition.

Question 53

What can the patients skin temperature tell us in the quick look evaluation in the ED?

Answer 53

1. Abnormal temperature should be alarming, but is not always pathologic.
2. Cold skin can simply be a sign of cold environment. Cold skin which is sweating / wet marks critical condition.
3. Warm skin also be a result of warm environment. Warm and wet skin without warm environment means increased core temperature, which is a warning sign.

Question 54

What can edema tell us about the patients condition in the quick look evaluation at the ED?

Answer 54

1. Odema on the face /neck is alarming as it can mark airway compromise. In this case odema must be judged together with breathing. Consider it rather alarming, than underestimate the risk.
2. Limb odema and odema at other location are not alarming on its own, but should raise attention. Can be the sign of cardiac failure or venous insufficience, which can be a risk factor in acute condition.

Question 55

What can spots and dots of the skin tell us about the patient in the quick look evaluation at the ED?

Answer 55

1. Look for signs of contagious infections (tick, flea, louse, scabies). It is important to protect not only the patient but also the medical care providers.
2. Presence of petechia always mark a critical condition in emergency care (knowing however that usually it marks thrombocyte number of function defect-Thrombocytopenia).

Question 56

What can smell tell us about the patient from the quick look evaluation?

Answer 56

1. During quick look you often smell typical or pathognomic odours.
2. Smell due to low hygienic level is not an alarming sign on its own but should raise your attention regarding co-morbidities. In acute conditions, lack of hygiene is a risk factor.
3. Bacterial infections can have typical smell and they can be easily recognized if the source of infection is on the skin.
4. Breath can contain acetone or alcohol you can smell. This with other signs (e.g. breathing pattern) can suggest clearly critical condition (e.g. acetonic breath + Kussmaul breathing = DKA)

Question 57

What can the breathing (work of breath) tell us about the patients condition in the quick look evaluation?

Answer 57

1. First thing to assess is the respiratory rate. RR below 8 or above 20 must be alarming.
2. Work of breathing can be quickly assessed. The excessive use of breathing muscles and the use of accessory muscles is always pathologic and alarming.
3. Large airway noise during breathing (stridor, snoring) should prompt the assessment of breathing work, as it would be alarming and potentially mean loss of airway.
4. Abnormal breathing patterns (e.g. Kussmaul, Cheyne-Stokes) should be recognized as it is always pathologic.

Question 58

What can the mental state tell us about the patients condition in the quick look?

Answer 58

1. Acute altered mental state is always a critical condition in emergency medicine.
2. Abnormality in any axis of mental state (alertness, cognition, attention, etc.) is alarming.
3. The role of mental state assessment during quick look is not differentiate between different types of altered mental state (AMS), but to raise suspicion that the patient is in AMS.

Question 59

What should be done after quick look of the patients in the emergency department?

Answer 59

Taking the history of the patient. You should explore the „chief complaint” or „chief symptom” which can help categorize the patient into one of the boxes of groups of symptoms. This would help in focusing the subsequent questions to reveal risk factors and alarming signs, also called red flags.

Question 60

What are the different symptoms that can raise red flags about the patients condition? (7)

Answer 60

1. Pain syndromes
2. Fever syndrome
3. Altered mental state
4. Neurologic deficit
5. Dyspnoe
6. Transient Loss of Consciousness
7. Seizure

Question 61

List the pain syndromes. (5)

Answer 61

1. Headache
2. Chest pain
3. Abdominal pain
4. Lower back pain
5. Limb pain

Question 62

How do you assess the level of Pain?

Answer 62

1. To assess the level of pain we use the Visual Analogue Scale (VAS) (10).
2. In case of pain we have to distinguish between acute and chronic pain as well as peripheral and central pain. Central pain is originating from body cavity (Head, chest, abdomen, throat, testicles). Peripheral pain originates from the musculo-skeletal system (chest wall, abdominal wall, extremities, bones) and from the ear nose and mouth.
3. If the pain is severe (8-10/10), central and acute we always have to suspect an emergency behind it until it is proven otherwise.
4. We should give higher attention to the moderate, central, acute pain (4-7/10) as well.
5. The peripheral pain is usually not caused by a life- threatening illness but if it is severe it is a warning sign.
6. If the area of pain is caused by life threatening injury it should be treated as a central pain.
7. Chronic central pain by itself it is only just a warning sign however if the intensity or a quality changed it is alarming.

Question 63

Why do we use the GCS?

Answer 63

The Glasgow Coma Scale is a useful tool to assess and monitor the consciousness (not only for the trauma patient).

Question 64

Who created the GSC?

Answer 64

Teasdal and jennet in 1947.

Question 65

How do you measure the Respiratory rate?

Answer 65

To measure the respiratory rate we only have to count how many times does outpatient take a breath in a minute.

Question 66

How do we measure Body temperature?

Answer 66

There are numerous methods to measure temperature.

1. We can measure the surface temperature at the forehead, armpit or we can measure core temperature at the mouth, rectum or tympanic membrane.
2. There is no relevant difference between the places but the site should be chosen according to the situation.
3. In the case of severe hypothermia use off the surface temperature is not recommended as it could result in major errors.
4. The use of the classic thermometers are not recommended due to the long equilibrating time and hygienic issues. Before the use of these they have to be “shaken down”. They are able to measure between 34 to 41°C.
5. There are several options to measure core temperature and it is still unclear which one is the best. They usually require electronic thermometers which have an equilibration time of about 1 minute.
6. The rectal temperature has a good correlation with the core temperature but it is not recommended for monitoring as there could be a major delay compared to core due to its position and blood supply.
7. If we choose this site the probe should be inserted 4 cm high. The oral (sublingual) temperature has a good correlation with the core temperature but the mouth has to be closed to get a good measurement.
8. The tympanic thermometer uses infrared light but its use is controversial because it requires a proper technique to get a correct measurement (otherwise one could measure the temperature of the ear canal and not the tympanic membrane). The temperature of the tympanic membrane has a good correlation with the core temperature.

Question 67

What are the NIBP measuring techniques/options?

Answer 67

There there are two options to measure non-invasive blood pressure:

1. Manual BP measurement listening to the korotkoff sounds.
2. Automatic BP measurement.

Question 68

How do we measure the pulse rate?

Answer 68

1. We could measure the pulse rate by a pulse-oximeter but for the quality of the pulse we have to use our fingers.
2. If we cannot feel peripheral pulses (radial, cubital) or they are weak using boarding to check the central pulses as well (carotid, femoral). We have to specify the frequency (counted for 30 seconds at least), the regularity or irregularity and its quality. (To diagnose arrhythmias you need to obtain a 12 lead ECG).
3. The pulse rate can only help us raise suspicion of an underlying condition.

Question 69

For the SpO2, how do we judge or measure a patients oxygenation status?

Answer 69

To judge the patient’s oxygenation we can use our eyes (looking for cyanosis) and we can use a pulse-oximeter. There is no contraindication, and it can be used for continuous non- invasive monitoring.

Question 70

What is the normal value of RR and when is it alarming?

Answer 70

1. Normally it is 12-20.
2. If it is under 8 or over 25 it is an alarming sign and requires attention.

Question 71

What are alarming breathing signs.

Answer 71

Besides counting the rate we also have two give attention for the mechanics in patterns of the breathing. If the breathing work it does not result in airflow (frustrane breathing) it is a life-threatening situation.

Question 72

What is the normal vs. abnormal breathing patterns?

Answer 72

Question 73

List all the different breathing patterns.

Answer 73

Question 74

How do you measure the BP manually?

Answer 74

1. This is the traditional method using a stethoscope and an analogue manometer.
2. We measure the systolic and diastolic blood pressure by listening to the Korotkoff. The mean arterial pressure (MAP) could be calculated from these values.

Question 75

What is the mechanism of measuring BP automatically?

Answer 75

1. Every automatic blood pressure monitor is based on oscillometry.
2. The machine measures that mean arterial pressure and it calculates the systolic and diastolic BP.

Question 76

What is the normal value of BP?

Answer 76

1. Normal values of the BP is hard to quantify/specify due to great personal variabilities.
2. Perhaps around 120/80 should be considered normal BP?

Question 77

What is abnormal BP?

Answer 77

In general we could say:

1. If the systolic blood pressure is higher than 220 mmHg or the diastolic blood pressure is higher than 130 mmHg it could be treated as abnormal even if the patient doesn’t have any symptoms (dizziness headache, chest pain, shortness of breath)
2. If the SBP is between 200 and 220 mmHg and or the DBP is between 110 in 130 mmHg and the patient has relevant symptoms (symptoms that could be caused by the elevated BP or high blood pressure can make them worse) we treat it as a risk factor
3. It’s even harder to specify low BP but in general we could say that if the SBP is under 80 mmHg it is always alarming
4. If the SBP is under 100 mmHg and the patient has symptoms (dizziness, weakness transient loss of consciousness, weak and thready pulse) it Is also alarming.

Question 78

What can be the problems/errors to be aware of when measuring BP?

Answer 78

1. The circumference of the patient’s arm specifies the size of the cuff. In case of an incorrectly sized cuff the measurement will be either impossible or inaccurate.
2. The manual blood pressure monitor is greatly user dependent but in some cases the automatic device cannot be used accurately. These conditions are the arrhythmias with variable pulse amplitude (such as AF), shivering or other movement of the extremities. In these situations the use of a manual BP meter is necessary however the automatic devices are more accurate and reliable and they should be used whenever it’s possible.
3. The positioning of the cuff is another important aspect for an accurate measurement – the cuff’s bladder should be over the brachial (artery).

Question 79

How frequent should we measure the BP of patients in the ED?

Answer 79

The frequency of BP measurement is based on the patient’s condition, signs and symptoms

1. In general if the patient is at the observation unit it should be measured q1 hours.
2. In a critically ill patient the frequency should be q5 minutes or even less (but this could indicate invasive blood pressure monitoring).
3. With every patient who is undergoing intervention we should measure q15 minutes until we are sure the patient is stable.

Question 80

What is triage?

Answer 80

Triage is the assignement of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties. Priority is give to more sick patients.

Question 81

What are the alarming values of body temperature?

Answer 81

Temperature below 35°C and over 39°C are both alarming and require attention.

Question 82

What is the normal pulse rate vs. alarming pulse rate?

Answer 82

1. The normal pulse rate is different from person to person.
2. If it’s under 40 even if there is no relevant complain or sign we should treated as abnormal and it should raise suspicion.
3. It’s even harder to specify a critically high pulse rate.
4. Over 90 it should raise suspicion but if it’s over 140 it’s for sure abnormal.

Question 83

In case of both low and high blood pressure what are the relevant signs and symptoms that we should look for?

Answer 83

1. Syncope
2. Chest pain
3. Shortness of breath
4. Altered mental status
5. Signs of shock

Question 84

How is the SpO2 measured with a pulsoximeter?

Answer 84

1. The Saturation gives us the oxy-haemoglobin/ all haemoglobin ratio within the arteriolas.
2. To be able to distinguish the noise from the signal the measurement requires pulsatile bloodflow.
3. The measurement is based on light extinction where the oxy- haemoglobin absorbs more red and the deoxy-haemoglobin absorbes more infrared light.
4. The equipments are usually calibrated between 75 to 99% of SpO2. The maximum error is usually +/- 2%.
5. Besides monitoring the patient oxygenation the pulse-oxymeter can also gives us information about the circulation by displaying the pulse-waves.
6. Decrease in the height of the waves could be a sign of peripheral ischaemia.
7. It can also be used to monitor pulse rate but with that we cannot monitor arrhythmias only pulse deficit.

Question 85

What is the goal value of spO2?

Answer 85

The goal is to keep the saturation over 90%. The decrease in the saturation is a late sign of arterial hypoxia.

Question 86

What can cause error reading of the SpO2 by the pulsoximeter?

Answer 86

Everything what disturbs the light absorption, the pulsatility or their measurement will result in an error:

1. Strong ambient light
2. Movement
3. Cold extremities
4. Painted or plastic fingernails, onychomycosis
5. LVAD
6. There are situations when the problem is not with a measurement but with the patient. If the patient has a high COHb level than the pulse-oximeter will show a falsely high saturation because the COHb has the same light absorption as the OxyHb, but doesn’t have any red light absorption so it is seen by the machine as an OxyHb molecule resulting in a falsely high saturation.
7. In severe anaemia because the machine doesn’t measure the absolute haemoglobin level there could be global hypoxia even when the saturation remains high.

Question 87

What are the different modalities and scoring values of the GCS?

Answer 87

1. We measure three modalities: eye, verbal and motoric responses.
2. We give a maxium of 4-5-6 for these respectively.The minimum point for each modality is 1. So the GCS is between 3 and 15 points.
3. 14 means mild, 10-13 means moderate, 9 or less means severe altered mental status. A severe altered mental status is always a medical emergency.

Question 88

How is the eye response assessed in the GCS?

Answer 88

1. To assess eye response, initially observe the patient for spontaneous eye-opening. If the patient is opening their eyes spontaneously, your assessment of this behaviour is complete, with the patient scoring 4 points.
2. If the patient doesn’t open their eyes spontaneously, you need to speak to the patient “Hey Miss Smith, are you ok?” If the patient’s eyes open in response to the sound of your voice, they would score 3 points.
3. If the patient doesn’t open their eyes in response to sound, you need to move on to assessing eye-opening to pain by applying pressure to the patient’s supraorbital notch. If the patient’s eyes open in response to a painful stimulus, they would score 2 points.
4. If the patient does not open their eyes to a painful stimulus, they score 1 point.
5. If the patient cannot open their eyes due to oedema, trauma, dressing etc, you should document that eye response could not be assessed/not testable (NT).

Mneumonic: ESPN (E-eyes spontaneously opening, S-opening to speech, P- opening to pain, N - not opening)

Question 89

How do you assess the verbal response of a patient with the GCS?

Answer 89

1. If the patient is able to answer your questions appropriately, the assessment of verbal response is complete, with the patient scoring 5 points.
2. If the patient is able to reply, but their responses don’t seem quite right (e.g. they don’t know where they are, or what the date is), this would be classed as confused conversation and they would score 4 points. Sometimes confusion can be quite subtle, so pay close attention to their responses.
3. If the patient responds with seemingly random words that are completely unrelated to the question you asked, this would be classed as inappropriate words and they would score 3 points.
4. If the patient is making sounds, rather than speaking words (e.g. groans) then this would be classed as incomprehensible sounds, with the patient scoring 2 points.
5. No response (1 point). If the patient has no response to your questions, they would score 1 point.
6. If the patient is intubated or has other factors interfering with their ability to communicate verbally, their response cannot be tested, and for this, you would write NT (not testable).

Mneumonic: FIVE (five points and v for verbal in fiVe.

and “our country WIN”

Question 90

How do you assess the motoric responses of a patient in the GCS?

Answer 90

1. If the patient moves spontaneously and consciously they would score 6 points and the assessment would be over.
2. If the patient makes attempts to reach towards the site at which you are applying a painful stimulus (supraorbital notch) and brings their hand above their clavicle, and reaches your finger this would be classed as localising to pain, with the patient scoring 5 points.
3. This is another possible response to a painful stimulus, which involves the patient trying to withdraw from the pain (e.g. the patient tries to pull their arm away from you when applying a painful stimulus to their fingertip, or lifts his hand above the clavicle in case of a pain stimulus applied to the supraorbital notch). It differs from the “abnormal flexion response to pain” due to the absence of the other features mentioned (e.g. internal rotation of the shoulder, pronation of forearm, wrist flexion).Withdrawal to pain scores 4 points on the Glasgow Coma Scale.
4. Abnormal flexion to a painful stimulus typically involves adduction of arm, internal rotation of the shoulder, pronation of forearm and wrist flexion (known as decorticate posturing) – 3 points.
5. Abnormal extension to a painful stimulus is also known as decerebrate posturing. In decerebrate posturing, the head is extended, with the arms and legs also extended and internally rotated – 2 points.
6. The complete absence of a motor response to a painful stimulus scores 1 point.
7. If the patient is unable to provide a motor response (e.g. paralysis), this should be documented as not testable (NT).

Mneumonic: (cant live without my fans)