PBL - emergency treatment and triage Flashcards
What is a NEWS2 score?
track and trigger system used to identify adult patients at risk of clinical deterioration
what makes up the NEWS2 score?
respiratory rate oxygen saturation temperature systolic BP heart rate level of consciousness
NEWS2 scoring
score of 0-3 is allocated to each physiological parameter
the magnitude of score reflects how extreme the parameter varies from norm
additional 2 points given for those requiring oxygen
total = 0-20
not diagnostic
oxygen saturation
scale 1 and scale 2
scale 1 oxygen saturation
target sats >96% and used for most patients
scale 2 oxygen saturation
target sats 88-92%
used for patients at risk of hypercapnic respiratory failure
e.g. COPD
interpreting NEWS score
aggregate score 0-4 = low risk, ward-based response
red score - score of 3 in any individual parameter = low-medium risk, urgent ward-based response
aggregate score 5-6 = medium risk, key threshold for urgent response
aggregate score 7 or more = high, urgent/emergency response
what causes hyperglycaemia?
type 1 or 2 diabetes stress flu and other illnesses similar type lack of exercise missing diabetic medication overtreatment of hypoglycaemia steroids diabetic ketoacidosis hyperosmolar hyperglycaemic state cushing's syndrome pancreatitis pancreatic cancer CF diuretics gestational diabetes surgery trauma
raised glucose in pneumonia
may help predict death
Raised lactate
type a, b1 or b2 or b3
type A raised lactate
inadequate oxygen delivery
anaerobic muscular activity
tissue hypoperfusion
reduced tissue oxygen delivery
type B raised lactate
no evidence of inadequate tissue oxygen delivery
B1 raised lactate
leukaemia lymphoma thiamine deficiency infection pancreatitis short bowel syndrome hepatic failure renal failure diabetic failure
B2 raised lactate
phenformin cyanide beta-agonists methanol adrenaline salicylates nitroprusside infusion ethanol intoxication in chronic alcoholics anti-retroviral drugs paracetamol salbutamol biguanides fructose sorbitol xylitol isoniazid lactate-based dialysate in RRT congenital forms with various enzyme defects
B3 raised lactate
associated with inborn errors of metabolism
causes of raised lactate
- increased in any condition that decreases the amount of oxygen available to body tissues
- any disease increasing lactate production
- any disease decreasing lactate removal – impaired hepatic metabolism
- strenuous exercise
- shock
- infections
- inherited metabolic disorders
- mitochondrial disorders
- certain medicines = metformin and isoniazid (TB)
- greater increase in lactate the greater severity of condition
- not diagnostic
- meningitis – suggests bacterial if raised
- sepsis
- heart attack
- congestive heart failure
- severe lung disease
- respiratory failure
- fluid build-up on lungs – pulmonary oedema
- severe anaemia
- liver disease
- kidney disease
- uncontrolled diabetes
- leukaemia
- AIDs
- deficiency in vitamin B1
initial triage measurements
temperature RR HR BP capillary refill time O2 saturations
normal RR
12-16
normal capillary refill
<2 seconds
normal O2 sats
95-100%
Airway
patency ability to vocalise dyspnoea secretions foreign body trauma
breathing
adequacy of breathing and gas exchange breathing rate chest wall movements use of accessory muscles breath sounds cyanosis tachycardia BP
circulation
function of CVS pulse quality and rate capillary refill time adequate blood volume skin colour temperature
disability
assess neurological system level of consciousness - GCS AVPU pupils physical or psychological problems identified assess pain
AVPU
patient is alert
patient responds to voice
patient responds to pain
patient is unresponsive
primary survey
ABCD
secondary survey
EFGH
EFGH
exposure
full vital signs
give comfort measures
head-to-toe assessment
full vital sounds
temperature HR and rhythm pulse quality RR oxygen saturation BP ECG scans - MRI, CT, CAT, X-rays urinalysis blood lab studies blood glucose levels comprehensive neuro evaluation neurovascular function height weight BMI sensory perception skin assessment mental health assessment pain assessment
give comfort measures
NSAIDs IV opioids analgesics imagery distraction repositioning breathing techniques heat packs
what is GCS
glasgow coma scale
GCS
consistent evaluation of consciousness used in head trauma identifies early signs of deterioration 3 aspects score the highest response the patient elicits
highest GCS score
15 - fully conscious
lowest GCS score
3 - coma/dead
what are the aspects of GCS?
motor responsiveness
verbal performance
eye opening
eye opening
4 points = eye opening spontaneously
3 = eye opening to sound
2 = eye opening to pain
1 = no response NT = not testable
Verbal response
ask patient: - name - where they are right now - today's date 5 = orientated 4 = confused conversation 3 = inappropriate words 2 = incomprehensible sounds 1 = no response NT = not testable
motor response
scoring based on highest scoring response patient elicits in any single limb ask patient to perform a 2-part request 6 = obeys command 5 = localises to pain 4 = withdraws to pain 3 = flexion decorticate posture 2 = abnormal extension decerebrate posture 1 = no response NT = not testable
overall GCS
add all scores and calculate GCS
document results
what is flexion decorticate posture?
abnormal flexion response to pain
adduction of arm, internal rotation of shoulder
pronation of forearm
wrist flexion
indicates damage to cerebral hemispheres, internal capsule and thalamus
what is decerebrate posture ?
abnormal extension response to pain head extension arms and legs extended internal rotation of limbs rigid patient teeth clenched indicates brainstem damage, exhibited with lesions or compression of midbrain and cerebellar lesions
what is coning?
progression from decorticate posturing to decerebrate posturing
uncar/tonsillar brain herniation
When is ABG needed over VBG?
accurately determine PaCO2 in severe shock
determine PaCO2 if hypercapnic - >45mmHg
accurately determine arterial lactate >2mM
determining PaO2
acute respiratory distress syndrome
