RRAPID Scenarios Flashcards
1
Q
Give brief history taking structure at beginning of RRAPID station
A
SAMPLE
- Signs & symptoms
- Allergies
- Medications
- PMH
- Last wee/last meal
- Events leading up
2
Q
General overview of what you would do to assess patient’s airway
A
See if patient was talking to me → if yes, airway patent
3
Q
General overview of what you would do to assess patient’s breathing
A
- Respiratory rate
- O2 sats
- Chest expansion
- Trachea position
- Percussion
- Auscultation
4
Q
General overview of what investigations you would do to assess patient’s breathing
A
- CXR
- ABG
5
Q
General overview of some interventions you may need to do in ‘breathing’
A
Low O2 sats → oxygen (15L non rebreathe - check if COPD)
6
Q
General overview of what you would do to assess patient’s circulation
A
- Temperature of hands
- CRT
- Radial pulse (rate, rhythm character)
- BP
- JVP
- Apex beat
- Auscultation of heart valves
7
Q
General overview of what investigations you would do to assess patient’s circulation
A
- Bloods e.g. FBC, U&Es, LFTs, CRP, troponin, blood cultures, VBG
- 12-lead ECG
8
Q
General overview of some interventions you may need to do in ‘circulation’
A
- 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
9
Q
General overview of what you would do to assess patient’s disability level
A
- Conscious level - ACVPU
- Blood glucose
- Temperature
- Pupils
10
Q
General overview of what you would do to assess ‘everything else’
A
- Abdominal exam
- Check skin for bleeding, rashes
- Check legs - DVT, cellulitis?
11
Q
What PMH specifically should you ask about in ACS patients? Why?
A
Ask about history of diabetes as these patients are at higher risk of a silent MI.
12
Q
Signs seen in ACS?
A
- Dyspnoea
- Pale
- Raised JVP
- Hypotensive
- Tachycardic
13
Q
RRAPID response to a STEMI?
A
- Morphine
- Oxygen
- Nitrates (GTN)
- Antiplatelets - 300mg aspirin & ticagrelor 180mg
- PCI - if presents within 12 hours of onset of pain
Also - give fluids if hypotensive
14
Q
What should you always do in a RRAPID scenario if concerned about patient?
A
Call for senior help
15
Q
What should you always do before giving any medications in a RRAPID scenario?
A
Ask for trust guidelines
16
Q
RRAPID response to an NSTEMI?
A
- Inform senior immediately
- Morphine (IV bolus)
- Oxygen
- Nitrates (GTN spray)
- Aspirin 300mg & ticagrelor 180mg
- LMWH as per local guidelines
17
Q
Future pharmacological management of ACS?
A
- Beta blocker (bisoprolol)
- Statin (atorvastatin)
- Dual antiplatelet therapy (aspirin & ticagrelor)
- ACEi (ramipril)
18
Q
Give some signs seen in CHF with pulmonary oedema
A
- 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
19
Q
What signs may you seen on a CXR in CHF with pulmonary oedema?
A
- Cardiomegaly
- Fluffy bilateral shadowing with peripheral sparing (‘bat wings’)
- Kerley B lines
- Pleural effusions
20
Q
What specific blood would you want in ACS?
A
Troponin
21
Q
What specific blood would you want in CHF with pulmonary oedema?
A
troponin and brain natriuretic peptide (BNP)
22
Q
What is the pharmacological response to CHF with pulmonary oedmea?
A
- Morphine
- Nitrates
- Furosemide (IV)
- Oxygen
23
Q
What is the future management for CHF with pulmonary oedema?
A
- Beta blocker
- ACEi
- Furosemide
- Aldosterone-antagonist (spironolactone)
24
Q
Signs of an acute exacerbation of COPD?
A
- Tachypnoea
- Low O2 sats
- Cyanosis
- Use of accessory muscles
- Pale
- Tachycardia
- Hypotensive
- Decreased breath sounds
- Expiratory wheeze
- Coarse crackles
- Hyper resonant (2ary pneumothorax)
25
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%
26
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)
27
Signs seen in AKI?
* SOB from pulmonary oedema
* Cyanosis
* Prolonged CRT
* Reduced skin turgor
* Dry mucous membranes
* Hypotensive
* Tachycardia
* Decreased urine output
* Peripheral oedema
28
What is the RRAPID response to AKI?
STOP AKI
* **S**epsis → sepsis 6 if indicated
* **T**oxins → stop nephrotoxins e.g. gentamicin/NSAIDs/IV contrast
* **O**ptimise BP & volume status
* **P**revent harm → treat complications (acidosis, pulmonary oedema, hyperkalaemia)
Identify cause!
29
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
30
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
31
Give some signs seen in near fatal asthma
* Raised PaCO2
* Requiring mechanical ventilation with raised inflation pressures
32
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
33
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
34
Blood glucose diagnostic criteria for DKA?
Raised blood glucose \>11mmol/L (or known diabetes)
35
Capillary & ketones diagnostic criteria for DKA?
Capillary ketones \<3mmol/L (or ketones \>/= 2 in urine)
36
Venous pH diagnostic criteria for DKA?
Venous pH \<7.3 or venous bicarbonate \<15 mmol/L
37
Give some symptoms of DKA
* Blurred vision
* Increased thirst
* Increased urine production
* Infective symptoms
* N&V
38
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
39
Extra investigations needed in RRAPID DKA?
* Blood/urine ketones
* Consider sepsis 6 if indicated
* Urinalysis
40
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)
41
Causes of an **upper** GI bleed?
* Peptic ulcer
* Oesophageal varices
* Oesophagitis
* Mallory-Weiss tear
* Coagulopathies
* Tumours
42
Causes of a **lower** GI bleed?
* Diverticular disease
* Ischaemic colitis
* Crohn’s disease
* Ulcerative colitis
* Cancer
* Internal haemorrhoids
* Anal fissure
* Polyps
43
Symptoms of upper vs lower GI bleed
44
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
45
What 2 scales are used to grade the severity of an **upper** GI bleed?
* Glasgow Blatchford score
* Rockall score
46
Which scoring system estimates the _risk of a patient with an upper GI bleed requiring_ **_intervention_**, such as transfusion or endoscopy?
Glasgow Blatchford Score
47
Which scoring system estimates the _risk of_ **_rebleeding_** _or_ **_death_** in patients with upper GI bleed?
Rockall
48
What scales is used to grade the severity of a **lower** GI bleed?
Oakland score
49
What does the Oakland score predict?
This is used to predict whether it is _safe to discharge a patient with a lower GI bleed_.
50
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
51
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
52
Investigations in lower GI Bleed?
* Colonoscopy
* Likely to require OGD to rule out upper GI bleed
