O2, PSA, RSA, Pain relief

Question 1

What are you assessing when looking to put o2 on your patient?

Answer 1

• Acute vs chronic
• RSA
• continuous spo2
• Consider causes of hypoxaemia
• Bleomycin and paraquat= tx as per special notes

Question 2

What are the ranges for adequate spo2?

Answer 2

> 92%

Question 3

What are the ranges for Mild- Moderate Hypoxaemia?

And How are we treating it?

Answer 3

85-91%
Titrate to 92-96%
- NP 2-6L

Question 4

What are the ranges and treatment for Severe hypoxaemia OR Critical Illness?

Answer 4

<85% spo2 OR Critical Illness

• Cardiac arrest/resus
• severe sepsis
• shock
• Anaphalaxis
• Major trauma/head injury
• Status Epilepticus
• ketamine sedation

Initial Mx:
-Non rebreather 10-15L/min
- Consider BVM/IPPV/LMA (ETT MICA) as req’d

Once haemodynamically stable titrate spo2 to 92-96%

Question 5

What conditions come under chronic hypoxaemia and what is the treatment.

Answer 5

• COPD
• CF (Cystic Fibrosis)
• Bronchiectasis
• Obesity
• Neuromuscular disorders
• Severe kyphoscoliosis

Titrate spo2 to 88-92% with NP
Treat as per severe if deterioration or spo2 <85%

Question 6

What is the stop point in chronic hypoxaemia?

Answer 6

High flow 02 in the COPD pt can cause hypercapnia respiratory failure.

Question 7

What comes under Regardless of spo2? Treatment of these conditions.

Answer 7

• toxic inhalation exposure
• decompression illness
• PPH
• cord prolapse
• Cluster headache

O2 via NRB 10-15L/min

Question 8

RSA criteria

Answer 8

Appearance 
Speech 
Sounds 
Rate 
Rhythm 
Effort 
Pulse 
Skin 
Conscious state

Question 9

PSA criteria

Answer 9

Skin
BP
HR
Conscious state

Question 10

RSA categories

Answer 10

Appearance 
Normal- calm, quiet
Mild- Calm, or anxious 
Mod- Distressed, anxious 
Severe- Exhausted, fighting for breathe 

Speech 
Normal- Clear, steady
Mild- Full sentences
Mod- Short sentences
Severe- Words or none 

Sounds
Normal- Quiet
Mild- Cough, mild wheeze or basal crackles.
Mod- Cough, ins/exp wheeze, mid zone crackles
Severe- No cough, ins/exh wheeze, full field crackles, stridor or no breathe sounds

Rate 
Normal- 12-16
Mild- 16-20
Mod- >20
Severe- >20 or <8

Rhythm 
Normal- Regular
Mild- Prolonged expiratory phase 
Mod- Prolonged expiratory phase 
Severe- Prolonged expiratory phase 

Effort 
Normal- Normal
Mild- Slight
Mod- Marked
Severe- Marked  

Pulse 
Normal- 60-100
Mild- 60-100
Mod- 100-120
Severe- >120 or <60 (late stage)

Skin 
Normal- Normal
Mild- Normal
Mod- Pale, sweaty
Severe- Pale, sweaty, +/- cyanotic 

Conscious state 
Normal- Alert 
Mild- Alert
Mod- Alert, or altered
Severe- Altered or unconscious

Question 11

Borderline perfusion criteria

Answer 11

Skin: cool, pale, clammy
Pulse: 50-100
SBP 80-100
CS: Alert, orientated

Question 12

Inadequate perfusion

Answer 12

Skin: cool, pale, clammy
Pulse: <50 or >100
SBP: 60-80
CS: Alert or altered

Question 13

Extremely poor perfusion

Answer 13

Skin: cool, pale, clammy
Pulse: <50 or >110
SBP: <60
CS: Alerted or unconscious

Question 14

No perfusion

Answer 14

Skin: cool, pale, clammy
Pulse: nil palpable
SBP: Unrecordable
CS: Unconsious

Question 15

What perfusion would this pt be? 
Cool, pale and clammy 
HR 120 
BP 60 
Alerted conscious state

Answer 15

Inad-> extremely poor

Question 16

What perfusion would this pt be?
Skin: cool, pale, clammy 
Pulse: 55
SBP 82 
CS: Alert

Answer 16

Borderline

Question 17

What RSA would this pt be? 
Anxious appearance 
speaking short sentences 
mid zone crackles 
able to cough 
RR 24 
Prolonged exp phase 
Moderate WOB 
Pulse 110 
Skin- pale
CS alert

Answer 17

Moderate

Question 18

Adult pain relief - what are you first assessing?

Answer 18

Reported level of pain (pain scale) 
Physical signs of discomfort (and document) 
Acute vs chronic 
Analgesia already taken 
Opioid tolerance 
Co morbidities

Question 19

Headache proticol

Answer 19

If suspected intracranial haemorrhage tx as per Stroke

Paracetamol 1g or 500mg for frail/elderly/malnourished/;liver dx

+/- Prochlorperizine 12.5mg IM >21 year

If after 15/60 pain remains the same and hospital >15/60 away manage as per Severe headache

Question 20

Severe Headache

Answer 20

IV or IN or IM (if IN not available) Fentanyl (as per pain relief)
Aim to get pain <7

Question 21

What are the three Pain relief categories?

Answer 21

Mild, moderate and severe

Question 22

What do you do for mild pain?

Answer 22

Paracetamol 1g (500mg if frail, elderly, malnourished, liver)

Question 23

Moderate pain tx?

Answer 23

First line:
If IV access available:
- IV Morphine or Fentanyl IV (if specifically indicated)

Dose:
Morphine upto 5mg 5/60 MAX 20mg
Fentanyl upto 50mcg 5/60 MAX 200mcg as per severe

IV access not required, delayed or unsuccessful
- Fentanyl IN (preferred for adolescents/elderly)
OR
- Ketamine IN (if minimal response to opioids)

All pt’s unless C/I
- Paracetamol oral

Second line:
- Ketamine IN
- Morphine IM 10mg repeat 5,g 15/60 ONCE ONLY
If frail 0.1mg per kg

Third line or MILD/Moderate PROCEDURAL PAIN
- Methoxyflurane

** Ketamine should not be used to treat chest pain in suspected ACS

Question 24

What is the first line treatment for severe pain if IV access available.

Answer 24

• IV Morphine OR IV Fentanyl IV

Morphine: upto 5mg 5/60 MAX 20mg
Fentanyl upto 50mcg 5/60 MAX 200mcg

AND

Ketamine IN- consult for IV if pain remains severe following 2-3 doses

Question 25

2nd Line tx for Severe pain?

Answer 25

Fentanyl IN and/or
Ketamine IN and/or
Methoxy and/or
Morphine IM (if opined not already administered)