Quizlet Flashcards
Simple airway management
Suction – remove vomit, blood, secretions. Consider turning the patient on their side (if appropriate).
Head tilt/chin lift – may be helpful to place a pillow under the patient’s shoulders if they are obese.
Jaw thrust – may be tiring to hold this position, so consider using an airway adjunct.
Simple airway adjuncts
Nasopharyngeal and oropharyngeal airways – note these are generally only tolerated in unconscious patients. Use the nasopharyngeal airway in patients with airway compromise whose mouths are difficult to open (e.g. seizing patients).
High concentration reservoir mask
Non rebreathing reservoir mask
- O2 conc. 60-80% or more
- Critical illness/trauma patients
- Effective for short-term treatment
Nasal canulae
Suitable for most patients with both types I and II resp failure.
- V unreliable with amount of O2 delivered
- 2-6L/min gives approx. 24-50% FiO2 and depends massively
- FiO2 depends on O2 flow rate and patient’s minute volume and inspiratory flow and pattern of breathing
- Much better tolerated/preferred by patients (vs a mask), comfortable, can eat and drink
- No rebreathing, low cost
Simple face masks
Alternative to nasal cannulae. Used for patients with type I resp failure.
- Delivers slightly more oxygen than nasal cannulae, 35-60%
- Low-cost product
- Flow 5-10L/min
Venturi or fixed performance masks
- aim to deliver constant oxygen concentration.
- e.g. CO2 retainers who need careful titration
Advanced oxygen delivery systems
High flow nasal oxygen (HFNO): up to 100% FiO2, humidified, up to 60L/min
CPAP: up to 100% FiO2, can be humidified, variety of interfaces
NIV: increases ventilation as well as oxygenation
Formal ventilation: ICU only, variety of modes and delivery options
Types of advanced care plans
-a last will and testament
-lasting power of attorney
-advance statement
-DNACPR
Risk factors for post op delirium
-age >65
-multiple co-morbidities
-underlying dementia
-renal impairment
-MALE
-sensory impairment
Differentials for post-op pyrexia
1st 24h
-systemic response to trauma
-pre-existing infection
24-72h
-pulmonary atelectasis
-chest infection
3-7d
-chest infection
-wound infection
-intraperitoneal sepsis
-UTI
-anastomotic leak
7-10d
-DVT
-PE
4 stages of wound healing
Hemostasis
Inflammation
Proliferation
Maturation/remodeling
Primary and secondary intention healing
Primary intention: Occurs in wounds with dermal edges which are close together. Minimal scarring
Secondary intention: occurs when the sides of the wound are not opposed, therefore healing must occur from the bottom of the wound upwards
Keloid scar
Thick raised scar caused by excess amounts of collagen
P-possum score
Estimates morbidity and mortality for general surgery patients
How is BiPAP different to CPAP
CPAP is continuous where as BiPAP is high pressure on inspiration and low on expiration
Skin prep for surgery
- Chlorhexidine
- Povidone-iodine
- Atraumatic skin closure and sterile dressing
Neutropenic sepsis
Potentially life-threatening complication of neutropenia (low neutrophil count)
Defined as temp > 38°C or any sx and/or signs of sepsis, in a person with an absolute neutrophil count of 0.5 x 10^9/L or lower.
Difficult to pick up as often atypical sx/signs of infection/sepsis
Patients most at risk are receiving chemotherapy, causes neutropenia as it kills fast growing cells in the body
Neutropenic sepsis
Potentially life-threatening complication of neutropenia (low neutrophil count)
Defined as temp > 38°C or any sx and/or signs of sepsis, in a person with an absolute neutrophil count of 0.5 x 10^9/L or lower.
Difficult to pick up as often atypical sx/signs of infection/sepsis
Patients most at risk are receiving chemotherapy, causes neutropenia as it kills fast growing cells in the body
Drugs not to stop before surgery
Epilepsy drugs
Parkinson’s drugs
Antipsychotics (except lithium)
Immunosuppressants
Drugs found on the emergency trolley
Adrenaline: 10 mL Minijet 1 mg (for cardiac arrest) - large syringe
Adrenaline: 0.5 mL Minijet 0.5 mg (for anaphylaxis) - small syringe
Atropine 600 mg Minijet (unstable bradycardia)
Amiodarone 300 mg Minijet (unstable tachyarrhythmias, shockable cardiac arrest)
Adenosine 6 mg (pharma cardioversion of SVT)
Calcium chloride 10% 10 mL (hyperkalaemia, prevent coagulopathy in massive transfusion)
Common abx used in prophylaxis
Piperacillin-Tazobactam in abdominal sepsis.
Flucloxacillin in vascular and dermatological
Co-Amoxiclav in many laporascopic, and orthopaedic surgeries.
Gentamicin IV + Metronidazole In open GIT surgeries
Also cefazolin, vancomycin
Surgical procedures that usually require antibiotic prophylaxis
Clean surgery involving a prosthesis or implant
Clean-contaminated surgery – thus incision of respiratory, GIT or GU tract.
Contaminated surgery – Incision causing break in sterility or gross GIT spillage, or surgery where acute inflammation is present. Trauma too.
Dirty or infected surgery – Where pus and active inflammation is found, such as in faecal peritonitis, or traumatic wounds after a day, etc.
FRAT score
Falls risk assessment tool
-recent falls
-meds (e.g. anti-depressants, sedatives, Parkinson’s drugs, diuretics, anti-hypertensives)
-psychological
-cognitive status
-behavior
-mobility
-ADLs
-nutrition
-environment
-continence
-vision
ITU (intensive care unit) vs HDU (high dependency unit)
Usually an ICU (aka ITU) patient requires one to one nursing care, while a high-dependency patient requires one nurse to every two patients.
- In contrast, on a normal ward 2 nurses often care for up to 30 patients between them.
HDU also tends to be single organ support vs. ITU with multi-organ support or anyone requiring advanced respiratory support.
Finally some hospitals have an integrated ICCU (ITU and HDU together)
What is the colour coded classification for triage
RED = immediate. Casualties in need of life-saving interventions immediately.
YELLOW = urgent. Unwell but with a degree of stability. Unable to walk but have comparatively normal physiology. Will require interventions within 2-4h.
GREEN = delayed. Sometimes referred to as walking wounded, and are able to ambulate to a treatment area and are deemed safe to have a treatment delay of 4h or more.
BLUE = expectant. Such severe injuries they are unlikely to survive with the resources available and their treatment would divert effort away from patients with a greater chance of survival, so lowest priority for management.
What are the normal triage levels used in emergency services 1-3
1 = life-threatening requiring immediate treatment e.g. cardiac arrest, trauma, anaphylaxis, unresponsive, limb amputations, catastrophic haemorrhage
2 = emergency with 15 min wait time e.g. confused, lethargic, severe pain, chest pain, stroke, suicidal, homicidal, amputations, overdose
3 = urgent with 30 min wait time e.g. danger zone vitals, head injury but conscious, breathing difficulties
What are the normal triage levels used in emergency services 4-5
4 = less urgent with 60 min wait time e.g. ankle sprain, strep throat, UTI, migraine, simple lacerations
5 = non-urgent with 120 minute wait time e.g. cut not requiring stitches, med refill, illness requiring a prescription, common cold
Goals of patient positioning
- Maintain patient’s airway and circulation throughout the procedure
- Prevent nerve damage
- Allow surgeon accessibility to the surgical side as well as for anaesthetic administration
- Provide comfort and safety to the patient
- Prevent soft tissue or musculoskeletal and other patient injury
Type of patient positions for sugery: Supine and Trendelenburg
Supine - most patients. May cause reduce ventilation and ulnar neuropathies.
Trendelenburg - head down to 20 deg, supine. Ideal for some abdo, laparoscopic, gynae surgeries. Also possibly in hypotension. May cause increase ICP, vomiting risk, lung movement restriction due to pressure on diaphragm, facial + eye swelling. Non slip mattress!
Type of patient position for surgery: reverse trendelenburg and Lihotomy
Reverse trendelenburg - head up 15-20 deg. Ideal for head/neck surgery or upper GI or in obese patients to give good laryngeal exposure.
Lithotomy - urology, gynaecology or AP excision rectum or proctology. Can cause compartment syndrome, nerve injury, obstruction to venous drainage (DVT), increased central venous return on leg elevation and hypotension after 2 hours mainly.
Type of patient position for surgery: Lloyd davies and prone
Lloyd Davies - // lithotomy but head down. Useful for pelvic and rectal surgery.
Prone - Intracranial, spinal and achilles tendon repair. Issues include AW access difficulty, nerve and vessel injury, decreased ventilation and venous access is difficult.
Why is it important to know if a patient has diabetes before a CT scan
You can’t have metformin on the day of your CT scan (risk of renal toxicity) and depending on the trust up to 48 hours beforehand, and then not until serum creatinine is back to a normal level
Indications for non contrast Ct
Basically, trauma and fracture
- Brain – Trauma, headache, bleeding, shunt check, mental status change
- Sinuses – Pain, congestion, sinusitis
- Orbits – Trauma, fracture, foreign body
- Facial Bones – Trauma, pain
- Chest – Nodule, cough, pain
- Abdomen and Pelvis – Hematuria with pain, renal stone
- Spine – Pain, trauma, fracture
- Extremities – Fracture, fusion, malunion
- Pelvis – Trauma, fracture, pain
Indications for a contrast CT
Basically, ?cancer and soft tissues
Orbits – Infection, mass
Neck – Mass, adenopathy
Chest – Mass, cancer/metastatic workup, lymphoma, sarcoid
Abdomen and Pelvis – Pain, colitis, Crohn’s, appendicitis, tumor, cancer, mass
What 5 drugs would you prescribe to manage an acute infective exacerbation of COPD
- NEB salbutamol
- IV hydrocortisone -> PO prednisolone when well enough
- NEB ipratropium
- IV co-amoxiclav
- IV clarithromycin
Insulin prescribing adjustments:
- what range is generally targeted for BM?
- how would you adjust the next insulin dose for hyperglycaemia/hypoglycaemia?
4-15 is usually okay
+10% or -20%
Haemoglobin targets
80 – CV disease
70 – other
1 unit of blood
Raises Hb by bout 10 units
Volume: 300-330ml
Given over 90min to 3h, more slowly if fluid overloaded
What do you need to do when giving blood to someone who is fluid overloaded
Give furosemide
National guidelines for triage
1 - Immediate: Red - see immediately
2 - Very urgent: Orange - see in 5-10 mins
3 - Urgent: Yellow - within 1 hour
4 - Standard: Green - within 2 hours
5 - Non-urgent: Blue - within 4 hours
What are the 5 moments of hand hygiene
BARFS:
1) Before patient contact
2) Aseptic techniques
3) Right after patient contact
4) Fluid (bodily) contact
5) Surroundings (patient area) contact
MRSA/CPE screening for inpatientes
MRSA – All screened on admission. Chlorhexidine if on skin, ABX of Tetracycline etc.
CPE – Checked for if stays in foreign hospitals, certain flare ups, and past colonisation
Major signs a patient might be approaching end of life
Decline in functional ability
Dependence
Major co-morbidities
Permanently decreased GCS
Deterioration
Poor response to management
Weight loss >10% in 6 months
Clinical judgement including the acuteness of the administration
What are the 2 ways to diagnose death
Cardiorespiratory death- apnoea, no circulation, unconsciousness. Lack of pulse and heart sounds. After 5 minutes confirm brainstem activity with no pupil response, corneal reflex or lack of response to supraorbital pressure
Brainstem death- 2 doctors need to diagnose each registered for >5 years
CAM score
Confusion Assessment Method [AIDA]
- Acute onset and fluctuating course (determined in collateral hx)
- Inattention (count down from 20-1)
- Disorganized thinking
- Altered consciousness
Considered positive for delirium if 1 + 2 + one of 3 or 4
Most sensitive UTI marker
Nitrites
urine dip results: nitrites, leukocytes, blood
Nitrofurantoin contraindications
eGFR must be >45
Hartmanns cant be given with what antibiotic
Ceftriaxone
There is evidence for benefit of Hartmann’s over 0.9% saline in what situation?
Hyperchloraemic metabolic acidosis
Complications with a risk higher than what % should eb discussed with patients during the consent process?
1%
NEWS of 5-6 requires what?
NEWS of 7+ requires what?
5-6: urgent review by medical team
7+: urgent review by a clinician with critical care competencies
1-4 may need increased frequency of obs or escalation to medical team
