Other Flashcards
What are the 5 main steps to confirming a death?
- Confirm patient identity, 2. Check for response to stimuli, 3. Check pupillary responses, 4. Feel the carotid pulse, 5. Auscultate for heart and lung sounds
If after a fluid status examination a patient is found to be hypovolaemic, what should you do?
Initiate fluid resuscitation
What are some clinical signs of a patient being fluid overloaded?
Raised JVP, peripheral/sacral/pulmonary oedema
What should be done next if an individual’s blood glucose has been > 14mmol/L for more than 2 hours?
Check blood ketones
Excessive amounts of IV 0.9% sodium chloride can result in what metabolic abnormality?
Hyperchloraemic metabolic acidosis
How can you calculate what one unit of insulin will reduce an individual’s blood glucose by?
100 / total daily dose
In any patient with a reduced urine output (< 0.5ml/kg/hour), a fluid challenge should be given. What is meant by this?
250-500ml of 0.9% sodium chloride or Hartmann’s solution over 15 minutes
What are some further investigations you may consider doing after a fluid status examination?
Bloods (Hb, U&Es, renal function), imaging (CXR, ECHO, abdominal US)
The main advantage of 5% dextrose is being able to maintain hydration without administering an excess of electrolytes. However, if required it can be prescribed with supplementary amounts of what electrolyte?
Potassium
Describe the main components of the general examination section of a fluid status examination?
End of the bed assessment (SOB, oedema, medical equipment), hands (CRT, skin turgor), pulse and BP, neck (JVP), eyes and mouth (dry mucous membranes), legs (oedema)
How are maintenance fluids calculated for children?
100ml/kg for first 10kg, 50ml/kg for the next 10kg, 20ml/kg for any additional kg
What medication should you be aware of that increases fluid losses?
Diuretics
If after a fluid status examination a patient is found to be euvolaemic, what should you do?
Calculate maintenance fluids (if required)
How should you check for a response to stimuli when confirming death?
- Assess for a verbal response, introduce yourself and ask the patient if they can hear you, 2. Assess for a response to pain by applying supraorbital pressure
What are the 2 main reasons that somebody may become hypervolaemic?
Increased fluid intake, fluid retention (e.g. cardiac/renal failure)
How is the fluid within the extracellular space divided into compartments?
1/4 is found in the intravascular space (plasma) while 3/4 are found in the extravascular space (interstitial fluid)
What is the correction dose of insulin for people who remain hyperglycaemic (BM 10-15mmol/L) despite their normal subcutaneous insulin? (assuming they haven’t just eaten and have taken a bolus)
10% of total daily dose
What is the daily requirement of water?
25-30ml/kg/day
What should you do if a patient appears euvolaemic but has signs of shock?
Seek expert help immediately
What electrolytes are found in 1L of 0.9% sodium chloride?
154mmol of sodium and chloride
What electrolytes are found in 1L of Hartmann’s solution?
131mmol sodium, 111mmol chloride, 5mmol potassium, 2mmol calcium and 29mmol bicarbonate
If after a fluid status examination a patient is found to be hypervolaemic, what should you do?
Do not prescribe IV fluids and seek senior help
What are you hoping to achieve when giving a fluid challenge?
Increase in BP and decrease in HR
What electrolyte can be added to 0.9% sodium chloride if required?
Potassium (as 20 or 40mmol KCl)
What is the daily requirement of sodium, potassium and chloride?
1-2mmol/kg/day for sodium, 1mmol/kg/day for potassium and chloride
What is most people’s baseline rate of insulin, e.g. a sensible dose to start someone on who is first diagnosed with type 1 diabetes?
0.5 units/kg/day
How many units of insulin are in 1ml?
100 units
What is the correction dose of insulin for people who remain hyperglycaemic (BM > 15mmol/L) despite their normal subcutaneous insulin? (assuming they haven’t just eaten and have taken a bolus)
20% of total daily dose
Fluid losses from non-urine sources are termed insensible losses- these will increase in who?
Acutely unwell patients
What are the most important questions to ask yourself before prescribing any fluids?
What type of fluid prescribing is required? What is the weight and size of the patient? Are there any co-morbidities to consider? What are their most recent electrolytes?
The concentrations of which ion(s) is/are normally high in the intracellular fluid and low in the extracellular fluid?
Potassium
What type of resuscitation fluids should be used in children?
0.9% sodium chloride
Approximately what proportion of prescribed 0.9% sodium chloride remains within the intravascular space?
25%
Describe the main components of the chest examination section of a fluid status examination?
Respiratory rate, central CRT, auscultate heart and breath sounds, palpate for sacral oedema
If you are going to confirm a death and the patient’s family or friends are present, what should you do?
Explain who you are and offer your condolences. Explain what you are there to do and offer them the opportunity to stay or leave
You should call for help from intensive care when a patient hasn’t responded to what volume of fluid challenge?
2000ml
What are the 3 main reasons that somebody may become hypovolaemic?
Inadequate fluid intake, increased fluid losses, third space fluid loss
What is the target urine output for patients?
> 0.5ml/kg/hour
How are resuscitation fluids calculated for children?
Bolus of 20mg/kg over < 10 minutes
Describe the main components of the abdominal examination section of a fluid status examination?
Inspect for distension and wounds/drains, assess for shifting dullness
Potassium should not be given at a rate greater than what?
10mmol per hour
Which crystalloid fluid has no role in resuscitation scenarios?
5% dextrose
NG feeding/enteral feeding is preferred when maintenance IV fluid have been given for how long?
3 days
Unless an urgent ABCDE approach is required, what should you look at before doing a fluid status examination?
NEWS chart, fluid charts, medication chart, stool chart
What electrolytes are found in 1L of 5% dextrose?
None- just 50g of glucose
What questions should you ask at the beginning of a fluid status assessment?
Have they been eating/drinking? Do they have any signs/symptoms of dehydration e.g. thirst, dizziness? Do they have any signs/symptoms of fluid overload e.g. SOB, PND, orthopnoea, oedema? Do they have any ongoing losses e.g. vomiting/diarrhoea, wounds/drains, bleeding? Do they have cardiac or renal failure?
How should you document a confirmation of death?
Document each of the steps you have gone through and what the response was, state the date and time at which death was confirmed, sign and print your full name along with your grade, GMC number and contact number
What is the main indication for the use of human albumin solution?
Decompensating liver disease
What should you do after confirmation of a death if not done already?
Discuss the death with the consultant to clarify the cause to write on the death certificate
How long should you auscultate for heart and lung sounds when confirming a death?
Listen for heart sounds for at least 2 minutes and breath sounds for at least 3 minutes
What are some clinical signs of a patient being fluid deplete?
Dry mucous membranes and reduced skin turgor, decreasing urine output, orthostatic hypotension
What type of maintenance fluids should be used in children?
0.9% sodium chloride and 5% glucose
Other than electrolytes, what additional metabolic product is contained within Hartmann’s solution?
Lactate
Hartmann’s solution should not be used in individuals with what electrolyte abnormality?
Hyperkalaemia
How is total daily insulin divided in a basal bolus regimen?
50% basal, 50% bolus (divided into three meals)
What three things should you use to guide your fluid management?
Clinical assessment, fluid charts and U&Es
What is the daily requirement of glucose?
50-100g/day
The concentrations of which ion(s) is/are normally high in the extracellular fluid and low in the intracellular fluid?
Sodium, calcium and chloride
How should the pupils look after death?
Fixed and dilated
What proportion of total body weight is water? Of this weight, what proportion is intracellular and extracellular?
2/3rds of total body weight is water: 2/3rds of this water is intracellular, 1/3rd is extracellular
What are some drugs that can cause hyperkalaemia?
Potassium sparing diuretics
ACE inhibitors/ARBs
Heparin
Ciclosporin
What are some drugs that can cause hypokalaemia?
Thiazide and loop diuretics
What are some drugs that can cause hyponatraemia?
Thiazide and loop diuretics
SSRIs
What are some drugs that can cause hypercalcaemia?
Thiazide diuretics
How do you calculate a breakthrough dose of morphine?
1/6th of total daily dose
How is the dose of oral codeine/tramadol converted to oral morphine?
Divide dose by 10
How is the dose of oral morphine converted to subcutaneous or intravenous morphine?
Divide dose by 2
What must you always prescribe alongside an opioid?
A laxative
What type of opiate medication is best to use in patients with mild-moderate renal impairment?
Oxycodone
What types of opiate medication are best to use in patients with severe renal failure?
Alfentanil/fentanyl
Buprenorphine
