RRAPID Scenarios Flashcards
Give brief history taking structure at beginning of RRAPID station
SAMPLE
- Signs & symptoms
- Allergies
- Medications
- PMH
- Last wee/last meal
- Events leading up
General overview of what you would do to assess patient’s airway
See if patient was talking to me → if yes, airway patent
General overview of what you would do to assess patient’s breathing
- Respiratory rate
- O2 sats
- Chest expansion
- Trachea position
- Percussion
- Auscultation
General overview of what investigations you would do to assess patient’s breathing
- CXR
- ABG
General overview of some interventions you may need to do in ‘breathing’
Low O2 sats → oxygen (15L non rebreathe - check if COPD)
General overview of what you would do to assess patient’s circulation
- Temperature of hands
- CRT
- Radial pulse (rate, rhythm character)
- BP
- JVP
- Apex beat
- Auscultation of heart valves
General overview of what investigations you would do to assess patient’s circulation
- Bloods e.g. FBC, U&Es, LFTs, CRP, troponin, blood cultures, VBG
- 12-lead ECG
General overview of some interventions you may need to do in ‘circulation’
- Insert 2x wide bore cannulae, one in each antecubital fossa
- Give fluid if hypotensive → 500ml 0.9% sodium chloride over 15 minutes (250ml in HF)
- Catheterise patient - monitor fluid output
General overview of what you would do to assess patient’s disability level
- Conscious level - ACVPU
- Blood glucose
- Temperature
- Pupils
General overview of what you would do to assess ‘everything else’
- Abdominal exam
- Check skin for bleeding, rashes
- Check legs - DVT, cellulitis?
What PMH specifically should you ask about in ACS patients? Why?
Ask about history of diabetes as these patients are at higher risk of a silent MI.
Signs seen in ACS?
- Dyspnoea
- Pale
- Raised JVP
- Hypotensive
- Tachycardic
RRAPID response to a STEMI?
- Morphine
- Oxygen
- Nitrates (GTN)
- Antiplatelets - 300mg aspirin & ticagrelor 180mg
- PCI - if presents within 12 hours of onset of pain
Also - give fluids if hypotensive
What should you always do in a RRAPID scenario if concerned about patient?
Call for senior help
What should you always do before giving any medications in a RRAPID scenario?
Ask for trust guidelines
RRAPID response to an NSTEMI?
- Inform senior immediately
- Morphine (IV bolus)
- Oxygen
- Nitrates (GTN spray)
- Aspirin 300mg & ticagrelor 180mg
- LMWH as per local guidelines
Future pharmacological management of ACS?
- Beta blocker (bisoprolol)
- Statin (atorvastatin)
- Dual antiplatelet therapy (aspirin & ticagrelor)
- ACEi (ramipril)
Give some signs seen in CHF with pulmonary oedema
- Tachypnoea
- Low O2 sats
- Use of accessory muscles
- Dullness to percussion at lung bases
- Wheeze (cardiac asthma)
- Inspiratory crackles
- Reduced air entry at lung bases
- Pale
- Hypotension
- Tachycardia
- Raised JVP
- Triple/gallop rhythm
What signs may you seen on a CXR in CHF with pulmonary oedema?
- Cardiomegaly
- Fluffy bilateral shadowing with peripheral sparing (‘bat wings’)
- Kerley B lines
- Pleural effusions
What specific blood would you want in ACS?
Troponin
What specific blood would you want in CHF with pulmonary oedema?
troponin and brain natriuretic peptide (BNP)
What is the pharmacological response to CHF with pulmonary oedmea?
- Morphine
- Nitrates
- Furosemide (IV)
- Oxygen
What is the future management for CHF with pulmonary oedema?
- Beta blocker
- ACEi
- Furosemide
- Aldosterone-antagonist (spironolactone)
Signs of an acute exacerbation of COPD?
- Tachypnoea
- Low O2 sats
- Cyanosis
- Use of accessory muscles
- Pale
- Tachycardia
- Hypotensive
- Decreased breath sounds
- Expiratory wheeze
- Coarse crackles
- Hyper resonant (2ary pneumothorax)
How should O2 be delivered in COPD patients?
If patient at risk of hypercapnic respiratory failure due to conditions such as COPD à give O2 via a venturi mask with target sats 88-92%
What is the pharmacological response to acute exacerbation of COPD?
Oxygen
Bronchodilators:
- Salbutamol 5mg nebulised - as required
- Ipratropium bromide 500mg nebulised - given 4-6 hourly
Corticosteroids:
- Oral prednisolone 30mg
- IV hydrocortisone 100mg IV
Antibiotics:
- If evidence of infection
- Sepsis 6 if indicated (low BP, low O2 sats, tachycardia, high temp)
Signs seen in AKI?
- SOB from pulmonary oedema
- Cyanosis
- Prolonged CRT
- Reduced skin turgor
- Dry mucous membranes
- Hypotensive
- Tachycardia
- Decreased urine output
- Peripheral oedema
What is the RRAPID response to AKI?
STOP AKI
- Sepsis → sepsis 6 if indicated
- Toxins → stop nephrotoxins e.g. gentamicin/NSAIDs/IV contrast
- Optimise BP & volume status
- Prevent harm → treat complications (acidosis, pulmonary oedema, hyperkalaemia)
Identify cause!
Give some signs seen in acute severe asthma
- RR >/= 25
- HR >/= 110
- Inability to complete sentences in one breath
- PEFR 33-55% of best or predicted
Give some signs seen in life threatening asthma
- O2 sats <92% on air
- PaO2 <8 kPa
- PaCo2 normal (4.6-6.0 kPa)
- Silent chest
- Cyanosis
- Poor respiratory effort
- Arrhythmia
- Hypotension
- Exhaustion
- Altered conscious level
- PEFR <33% of best or predicted
Give some signs seen in near fatal asthma
- Raised PaCO2
- Requiring mechanical ventilation with raised inflation pressures
What is the pharmacological response to an acute severe asthma attack?
Bronchodilators:
- Salbutamol 5mg nebulised - when required
- Ipratropium bromide - 4-6 hourly
Corticosteroids:
- Oral prednisolone 30mg
- IV hydrocortisone
Pharmacological response for anaphylactic shock?
Follow resus guidelines:
- IM adrenaline 500 micrograms
- Chlorphenamine IV
- Hydrocortisone IV
- IV challenge if hypotensive
General:
- Call for help if airway compromised
- Assess face for swelling
- Once anaphylaxis is recognised – give immediate management and remove antigen if identified
Blood glucose diagnostic criteria for DKA?
Raised blood glucose >11mmol/L (or known diabetes)
Capillary & ketones diagnostic criteria for DKA?
Capillary ketones <3mmol/L (or ketones >/= 2 in urine)
Venous pH diagnostic criteria for DKA?
Venous pH <7.3 or venous bicarbonate <15 mmol/L
Give some symptoms of DKA
- Blurred vision
- Increased thirst
- Increased urine production
- Infective symptoms
- N&V
Give some signs of DKA
- Tachypnoea
- Acetone smell on breath
- Delayed CRT
- Reduced skin turgor
- Dry mucous membranes
- Hypotensive
- Tachycardia
- Tender abdomen
- Confusion
- Reduced GCS
Extra investigations needed in RRAPID DKA?
- Blood/urine ketones
- Consider sepsis 6 if indicated
- Urinalysis
Response to DKA?
F → Fluids (0.9% saline)
I → Insulin fixed rate (0.1 units/kg/hr)
G → Glucose (monitor levels and give 10% dextrose if needed)
P → Potassium (monitor levels and give extra if needed as insulin causes hypokalaemia)
I → Infection (may be underlying trigger of DKA)
C → Chart fluid balance
K → Ketones (monitor - want <0.6mmol/l)
Causes of an upper GI bleed?
- Peptic ulcer
- Oesophageal varices
- Oesophagitis
- Mallory-Weiss tear
- Coagulopathies
- Tumours
Causes of a lower GI bleed?
- Diverticular disease
- Ischaemic colitis
- Crohn’s disease
- Ulcerative colitis
- Cancer
- Internal haemorrhoids
- Anal fissure
- Polyps
Symptoms of upper vs lower GI bleed
Signs seen in GI bleed?
- Tachypnoea
- Delayed CRT
- Reduced skin turgor
- Hypotensive
- Tachycardia
- Decreased urine output
- Signs of liver disease if associated with live failure:
- Palmar erythema
- Liver flap
- Telangiectasia
- Ascites
- Gynaecomastia
What 2 scales are used to grade the severity of an upper GI bleed?
- Glasgow Blatchford score
- Rockall score
Which scoring system estimates the risk of a patient with an upper GI bleed requiring intervention, such as transfusion or endoscopy?
Glasgow Blatchford Score
Which scoring system estimates the risk of rebleeding or death in patients with upper GI bleed?
Rockall
What scales is used to grade the severity of a lower GI bleed?
Oakland score
What does the Oakland score predict?
This is used to predict whether it is safe to discharge a patient with a lower GI bleed.
If a massive haemorrhage is suspected in a RRAPID station, what should you do?
- Initiate the massive haemorrhage protocol
- 12-lead ECG
- Keep patient nil by mouth
- Withhold precipitant factors after considered risk-benefit ratio e.g. anticoagulants, antiplatelets
What criteria can be used to determine if an oesophago-gastro-duodenoscopy (OGD) is required in an upper GI bleed?
- Ongoing bleeding
- Suspected variceal bleed
- Unstable episode requiring transfusion
- Lost >/= 30% blood volume
Investigations in lower GI Bleed?
- Colonoscopy
- Likely to require OGD to rule out upper GI bleed
