M101 Initial Assessment

Question 1

What is the order of the A – E Assessment of an acutely unwell patient?

Answer 1

Airway 
Breathing
Circulation
Disability 
Exposure

Question 2

When is the A – E Assessment of an acutely unwell patient carried out in a different order?

Answer 2

military - patient usually bleeding out

Question 3

What does a nasal cannulae provide?

Answer 3

small and unpredictable increase in inspired oxygen

Question 4

Why is the oxygen supply from a nasal cannulae unpredictable?

Answer 4

mixed in with the air in the room

Question 5

What is the maximum capacity of oxygen delivered per minute from a nasal cannulae?

Answer 5

5 litres per minute (L/min)—delivering an oxygen concentration of

Question 6

What is the percentage of oxygen in the air delivered from a nasal cannulae?

Answer 6

28–44%

Question 7

What is the percentage of oxygen in the air delivered from a Hudson Mask?

Answer 7

around 40%

Question 8

What is the maximum capacity of oxygen delivered per minute from a non-rebreather mask?

Answer 8

flow rate of about 10 to 15 liters/minute (L/min)

Question 9

What is the oxygen supply from a non-rebreather mask?

Answer 9

60 percent to 80 percent oxygen

Question 10

Reservoir mask

Answer 10

Well fitting face mask
Reservoir bag to collect oxygen while patient is breathing out
One way valves to ensure inspiration draws oxygen from reservoir bag and expired breath is directed out of the sides of the mask
Can deliver 80-85% oxygen
Used widely in acutely unwell patients

Question 11

Controlled oxygen administration

Answer 11

Accurate oxygen delivery achieved by high flow of gas, which exceeds patient’s peak inspiratory flow rate
Used for patients who are sensitive to oxygen eg those with severe COPD

Question 12

pulse oximeter

Answer 12

can be blocked from nail varnish

Question 13

What will circulatory compromise look like in a patient?

Answer 13

pale
peripheral capillary refill will be slow
might not be conscious due to lack of blood flow to the brain
increased inspiratory rate

Question 14

What will circulatory compromise look like in a patient?

Answer 14

pale
peripheral capillary refill will be slow
might not be conscious due to lack of blood flow to the brain
increased inspiratory rate

Question 15

physiology of shock

Answer 15

Cardiac Output = Stroke Volume x Heart Rate
If stroke volume is reduced (eg by bleeding) then tachycardia can partially compensate for this.
This is mediated by the sympathetic nervous system which also causes pallor, sweating and diversion of cardiac output towards vital organ systems
Intravenous volume replacement is vital in this situation. It’s also important to stop ongoing losses

Question 16

What will circulatory compromise look like in a patient?

Answer 16

pale
peripheral capillary refill will be slow
might not be conscious due to lack of blood flow to the brain
increased inspiratory rate
cold peripherals

Question 17

Starling curve

Answer 17

Explanation of preload improving cardiac output

Need to be cautious with fluid volume resuscitation in the context of poor cardiac function

Question 18

Myocardial Contractility

Answer 18

Stroke volume requires good myocardial contractility.  Contractility is impaired by sepsis and cardiac ischaemia amongst other things
Improving contractility needs identification of the cause but treating hypoxia is important.  Cautious intravenous fluid boluses usually help.
Inotropic agents (eg adrenaline) may then be needed
This requires central venous access and intensive care

Question 19

Myocardial Contractility

Answer 19

Stroke volume requires good myocardial contractility.  Contractility is impaired by sepsis and cardiac ischaemia amongst other things
Improving contractility needs identification of the cause but treating hypoxia is important.  Cautious intravenous fluid boluses usually help.
Inotropic agents (eg adrenaline) may then be needed
This requires central venous access and intensive care

Question 20

Systemic Vascular Resistance

Answer 20

Blood pressure = cardiac output x systemic vascular resistance (V=IR)
A drop in SVR means that there is less resistance to ejection of blood. Even with a normal or high cardiac output, a low SVR (as seen in sepsis and anaphylaxis) will result in a low blood pressure
Intravenous fluid may help in situations of low SVR, but vasopressors may also be needed (eg noradrenaline) which also require central access and intensive care

Question 21

Categories/Causes of Shock

Answer 21

Hypovolaemic
Distributive
Obstructive
Cardiogenic
Patients may be suffering from more than one kind of shock

Question 22

Hypovolaemic Shock

Answer 22

Haemorrhagic (trauma/GI Bleeding/aortic aneurysm)
Non-haemorrhagic (burns/pancreatitis/GI losses)
Reduced circulating volume reduces ventricular filling, stroke volume and cardiac output

Question 23

Distributive Shock

Answer 23

Severe Peripheral Vasodilatation
Septic Shock
Neurogenic Shock
Anaphylactic Shock
These cause hypotension via a reduction in systemic vascular resistance

Question 24

Obstructive Shock

Answer 24

Pulmonary Embolism
Tension Pneumothorax
Cardiac Tamponade
These impair ventricular filling which reduces stroke volume and therefore cardiac output. Intravenous fluids may help but other specific treatment may also be necessary

Question 25

Cardiogenic Shock

Answer 25

Cardiomyopathies
Cardiac Ischaemia/Infarction
Severe Arrhythmias
Acute heart valve failure
These reduce myocardial contractility and/or cardiac output

Question 26

Cardiogenic Shock

Answer 26

Cardiomyopathies
Cardiac Ischaemia/Infarction
Severe Arrhythmias
Acute heart valve failure
These reduce myocardial contractility and/or cardiac output

Question 27

Why is a hypovolaemic patient tachycardic?
Why does an intravenous fluid bolus help in this situation?
What will you look for when reassessing the patient to see if your fluid bolus has improved their circulation?

Answer 27

fluid rentention

Question 28

What happens if you overdo it with the IV?

Answer 28

oedema

Question 29

Intraosseous access

Answer 29

drilling into a bone

usually done in children or babies as a last resort for IV