oxford clinical emergency Flashcards
when a patient comes to you what is the FUNDAMENTAL Preliminary assessment ?
A TO E
What is A-E?
introduce yourself
A - airway
Can the patient talk?
Yes: if the patient can talk, their airway is patent
No:
Look for signs of airway compromise
Open the mouth and inspect for air way compromise
immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘crash team’)
Head-tilt chin-lift manoeuvre
Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to remove it
suffered significant trauma with potential spinal involvement, perform a jaw-thrust
Oropharyngeal airway (Guedel) only be inserted in unconscious patients should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.
NPA
who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR
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B - breathing
normal 12-20 breaths per min
Bradypnoea
Tachypnoea
.
Review the patient’s oxygen saturation (SpO2):
A normal SpO2 range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO2 retention.
check for Hypoxaemia
Inspect the patient from the end of the bed whilst at rest: cyanosis SOB cough stridor - Cheyne-Stokes respiration: Kussmaul’s respiration:
Tracheal position
trachea deviates away from tension pneumothorax and large pleural effusions.
check bilateral chest movement
Symmetrical:
Asymmetrical:
respiratory effort
percuss
Dullness: consolidation, tumour, lobar collapse , edema.
Stony dullness: typically caused by pleural effusion.
Hyper-resonance: the opposite of dullness, suggestive of decreased tissue density (e.g. pneumothorax)
auscultate
pulseoximetry
ABG - if low sp02
chest x ray
If the patient is short of breath, they should be sat upright in the bed if possible to aid inspiration.
hypoxemia= a non-rebreather mask with an oxygen flow rate of up to 15L. 85-90 percent oxygen
In COPD, target SpO2 levels accordingly (88-92%)
Venturi mask: 24% (4L) or 28% (4L). Consider discussing non-invasive ventilation (NIV) with a senior in acute exacerbations of COPD
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C - circulation
pulse - 60-99 per min
tachycardia (HR>99)
bradycardia (HR<60)
blood pressure - range is between 90/60mmHg and 140/90mmHg
capillary refill - less than 2 sec
look for hemorrhages
A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure
radial and brachial pulse to assess rate, rhythm, volume and character:
Auscultate the patient’s precordium to assess heart sounds:
Palpation
Place the dorsal aspect of your hand onto the patient’s to assess temperature:
In healthy individuals, the hands should be symmetrically warm, indicating adequate perfusion.
Cool hands indicate poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome).
Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.
cathetrise -urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult.
two large IV cannula
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D - disability level of consciousness AVPU score check pupil size - reactions GLASGOW COMA SCALE if there's time Blood glucose and ketones
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Exposure - undress patient - but cover to avoid hypothermia
NEWS
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Request FBC, U&Es and LFTs
Sepsis: CRP, lactate and blood cultures
Haemorrhage or surgical emergency: coagulation and cross-match
Acute coronary syndrome: troponin
Pulmonary embolism: D-dimer (if appropriate based on Well’s score)
Overdose: toxicology screen (e.g. paracetamol levels)
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12-lead ECG
what are the signs of airway compromise?
these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
what are the common causes for airway compromise ?
Inhaled foreign body:
sudden onset shortness of breath stridor.
Blood in the airway: epistaxis, haematemesis and trauma.
Vomit/secretions in the airway: alcohol intoxication, head trauma and dysphagia.
Soft tissue swelling: causes include anaphylaxis and infection (e.g. quinsy, necrotising fasciitis)
Local mass effect: causes include tumours and lymphadenopathy (e.g. lymphoma).
Laryngospasm: causes include asthma, gastro-oesophageal reflux disease (GORD) and intubation.)
how do you insert the Ororpharyngeal airway ?
Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180°
Advance the airway until it lies within the pharynx
how do you insert an NPA?
Lubricate the NPA.
Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.
If any obstruction is encountered, remove the tube and try the left nostril.
what causes bradypnea ?
may be due to sedation, opioid toxicity, raised intracranial pressure (ICP) or exhaustion in airway obstruction (e.g. COPD).
what causes tachypnea ?
may be due to airway obstruction, asthma, pneumonia, pulmonary embolism (PE), pneumothorax, pulmonary oedema, heart failure, or anxiety
when is hypoxemia seen ?
may be seen in PE, aspiration, COPD, asthma and pulmonary oedema.
at Inspect the patient from the end of the bed whilst at rest what causes stridor ?
foreign body inhalation (acute) and subglottic stenosis (chronic)
at Inspect the patient from the end of the bed whilst at rest what causes cheyne stokes breathing ?
cyclical apnoeas, with varying depth of inspiration and rate of breathing. May be caused by stroke, raised intracranial pressure, pulmonary oedema, opioid toxicity, hyponatraemia or carbon monoxide poisoning
at Inspect the patient from the end of the bed whilst at rest what causes kaussmal breathing ?
deep, sighing respiration associated with metabolic acidosis (e.g. diabetic ketoacidosis)
when checking bilateral chest movement what causes it be symmterical ?
pulmonary fibrosis reduces lung elasticity, restricting overall chest expansion.
when checking bilateral chest movement what causes it be asymmterical ?
pneumothorax, pneumonia and pleural effusion
when you auscultate someone what arfe the different breath sound that you can hear and what conclusion can be drawn from it ?
Bronchial breathing: harsh-sounding. inspiration and expiration are equal and there is a pause between. This type of breath sound is associated with consolidation
Quiet/reduced breath sounds: suggest reduced air entry into that region of the lung (e.g pleural effusion, pneumothorax)
wheeze - asthma copd bronchiectasis - obstruction of the airway
coarse crackles - pneumonia, bronchiectasis and pulmonary oedema.
Fine end-inspiratory crackles - pulmonary fibrosis
C , Causes of tachycardia (HR>99)
include hypovolaemia, arrhythmia, infection, hypoglycaemia, thyrotoxicosis, anxiety, pain and drugs (e.g. salbutamol)
