The Acutely Unwell Patient Flashcards
describe the ABCDE assessment?
focussed examination to detect life threatening problems in a sequential fashion. It allows for abnormalities to be addressed before moving on with the assessment. Re-assessment is needed.
why is ABCDE assessment important?
- allows us to identify the deteriorating patient and treat abnormal physiology and perform life threatening interventions whilst buying time for deciding on further investigations and treatment.
- ABCDE should be structured with clear communication with colleagues in stressful situations.
- Decreases cognitive overload with framework to fall back on
when should an ABCDE assessment be carried out?
anyone who looks unwell, has altered conscious level, sudden deterioration or high NEWS score
what are the components of the ABCDE assessment?
Airway Breathing Circulation Disability Exposure
AIRWAY
- what signifies a patent airway?
- what are the consequences of obstructed airway
- patient alert/talking
2. can become fatal if not treated ASAP due to poor perfusion to organs
what are some of the causes of airway obstruction?
- reduced conscious level so loss of soft tissue tone
- foreign body (aspirated food, blood, vomit)
- oedema (swelling and narrowing eg infection, burns, anaphalaxis)
- tumour or abscess.
AIRWAY?
1. what are the signs of partial airway obstruction?
- what are the compensatory features of partial airway obstruction?
- what are the signs of complete airway obstruction?
- – snoring, gurgling (liquid), stridor (inspiration, obstruction at level of pharynx)
- Sitting up, leaning forwards (tripod position), reluctant to speak or cough, Nasal flaring, Accessory muscle use, Pursed lips, Paradoxical chest movements
- silent, ‘see-saw’ movement of chest and abdomen
what are the steps involved in airway support?
- Manoeuvres: Head tilt and chin lift, Suction (if liquid in airway)
- Airway adjuncts – nasopharyngeal, oropharyngeal airways
- Anaesthetist for advanced airway
- Apply oxygen
- Re-assess
how can breathing be assessed as part of the ABCDE assessment?
look
feel
listen
BREATHING
1. what would you LOOK for to assess breathing?
- what would you FEEL for to assess breathing?
- what would you LISTEN for to assess breathing?
- colour of patient, resp rate (12-20), oxygen saturations, inspired oxygen
- tracheal deviation, chest wall movement, percuss
- equal air entry, absent breath sounds, added sounds
what are some of the causes of acute shortness of breath?
pneumothorax pneumonia anaphylaxis asthma exacerbation COPD PE acute pulmonary oedema trauma anaemia sepsis metabolic overdose poisoning mental health conditions
what are the steps involved in management of breathing?
- Oxygen 15L/min via mask with reservoir bag
- Target sats 94-98%
- All criticaly ill patients should be given oxygen
- Aim for 88-92% in patients with COPD at risk of hypercarbic respiratory failure
- ABG and CXR if indicated
- Re-assess
what would you look for when assessing circulation as part of a ABCDE assessment?
- Colour and temperature of hands
- Peripheral and central pulse rate, rhythm, quality (weak, difficult to find = hypotension / bounding pulse = sepsis)
- Capillary refill time (<2 seconds)
- BP (systolic >100mmHg)
- JVP
- Heart sounds
- what is the equation for mean arterial pressure?
2. what are the causes of hypotension?
- MAP = CO X SVR
- pump (arrythmias, ACS, acute LVF)
pipes (sepsis, anaphalaxis)
fluid (hypovolaemia eg dehydration, haemorrhage)
what steps would be taking in management of circulation?
- IV action
- Take bloods
- 12 lead ECG
- Measure urine output (0.5ml/kg/h)
- Commonest cause: hypovolaemia: 500ml fluid bolus (caution in cardiac, renal failure)
- Tachy/bradyarrhymias – resus council guidelines
- ACS: follow guidelines
- Acute haemorrhage: stop the bleeding (pressure, contact surgeon), replace like with like – give packed red blood cells
- Re-assess
what are the important things to consider when assessing disability as part of an ABCDE assessment?
conscious level
pupil size and reactivity
glucose
DISABILITY
1. what is the common scale used when assessing consciousness?
- what are the causes of loss of consciousness?
- AVPU - alert, verbal stimulation, pain, unresponsive
- : collapse secondary to CVD, hypoxaemia, shock, diabetic emergencies, endocrine emergencies, hypothermia, hepatic encephalopathy, uraemic encephalopathy, poisoning and overdose, seizures, epilepsy, head injury, acute stroke, cerebral tumour or infection, intracranial bleeds, alcohol or substance misuse, mental health problems
DISABILITY
whilst undertaking an ABCDE a patient has pin point pupils. what does this suggest and what would be the management?
overdose
antidote ie naloxone
DISABILITY
whilst undertaking an ABCDE a patient has unequal pupils. what does this suggest and what would be the next steps?
intracranial event
head CT
DISABILITY
whilst undertaking an ABCDE a patient is found to have glucose of 3mmol/L. what does this suggest and what would be the next steps?
hypoglycaemic (<4mmol/L)
100mL 20% dextrose IV
DISABILITY
what are the possible consequences of reduced conscious level and how can this be prevented?
risk of airway obstruction and aspiration, left lateral position, protect airway if GCS <8)
EXPOSURE
describe assessment of exposure as part of ABCDE assessment?
- Focused examination of rest of patient, screen for other abnormal findings
- Temperature, rash, calf swelling, bleeding, palpation
- Collateral history, full examination
- Re-assess
iSBAR
what is I?
identify self - name, position, location and who you are talking to
identify patient - name, age, sex, location
iSBAR
what is S?
SITUATION
state purpose “the reason I am calling is…”
if urgent say so
iSBAR
what is B?
BACKGROUND
tell the story
current problem
relevant history, examination, test results
management
if urgent give relevant vital signs, current management
iSBAR
what is A?
ASSESSMENT
state what you think is going on
“the patient is febrile and I can’t find the source of infection”
iSBAR
what is R?
REQUEST
eg “i’d like your opinion on…” or “i need help urgently, are you able to come”
how can causes of acute airway failure be classified?
extramural
mural
intraluminal
give examples of extramural causes of acute airway failure?
trauma burns to face, head or neck oedema neck haematoma thyroid cartilage fat abscess
give examples of mural causes of acute airway failure?
angioedema
burns to mouth
infection
neoplasm
give examples of intraluminal causes of acute airway failure?
foreign body
laryngospasm
tongue obstruction
bilateral recurrent laryngeal nerve palsy
- define sepsis
2. define septic shock
- life threatening organ dysfunction due to a dysregulated host immune response to infection
- sepsis unresponsive to adequate fluid resuscitation (remain hypotensive)
give examples of infections leading to sepsis?
common to less common
- Pneumonia (streptococcus pneumoniae)
- UTI (e. coli)
- Intra-abdominal infections (gram negatives/ anaerobes)
- Skin and soft tissue (staphylococcus aureus)
how would you identify a patient with sepsis?
- NEWS score >5 (or 3 in one parameter / gut feeling)
- Could this be due to infection?
- Red flags?
what is the role of the sepsis red flags?
- Signs to detect high risk patient
- Bedside indication of organ dysfunction
- Patient at high risk of severe illness and death
- Prompts initiation of the sepsis 6
what are the sepsis red flags?
- New or altered mental state/ confusion
- Respiratory rate >25
- Systolic BP <90 (20% less than normal)
- O2 sats <94% (not copd) or supplemental O2 >40% to maintain sats
- Oliguria/anuria or AKI
- Lactate >2mmol/L
- Coagulopathy/purpuric rash/ mottled/ashen /cyanotic
- Heart rate >130bpm
- Recent chemotherapy (2-3 weeks)
what are the sepsis 6?
- Give oxygen
- Give IV antibiotics
- Give IV fluids
- Take blood
- Check lactate
- Monitor urine output
SEPSIS 6
describe the role of giving oxygen?
maintain >94% sats Reduced supply (Hypovolaemia, leaky capillaries, tissue oedema, microthrombi) and increased demand (higher metabolic requirements) -> low oxygen saturation / high respiratory rate
SEPSIS 6
describe the role of taking blood cultures?
ideally take 2
allows for targeted antibiotic therapy
SEPSIS 6
describe the process of giving IV antibiotics?
- Every hour delay in giving antibiotics increases mortality
- Stat dose on front of drug chart
- Where possible target antibiotics
- Antibiotic guidelines differ from trust to trust
SEPSIS 6
describe the role of giving IV fluids?
- Reduces organ dysfunction and multi organ failure
- Optimise tissue organ delivery
- Increases organ perfusion
- Give even if BP not fallen
- If hypotensive/lactate >2mmol/L give up to 30mls/kg of fluid stat
SEPSIS 6
describe the role of checking lactate?
- Venous or arterial sample
- Increased tissue hypoxia
- Anaerobic metabolism
- Sepsis is not the only cause of raised lactate
- High lactate indicates poor prognosis
- Lactate should improve with treatment
SEPSIS 6
describe the role of monitoring urine output?
- Patient doesn’t have to have catheter
- Need 0.5mls urine/kg/hr
- Urine output reflects cardiac output
- Measure BP but not CO on ward
- A fall in urine output may be first indication that CO is falling even if BP is normal
SEPSIS PHYSIOLOGY
the heart?
inflammatory response to infection -> vasodilation and capillary leak -> decreased circulatory blood volume and decreased SVR ->drop in BP and decreased tissue perfusion
heart rate increases to try and compensate for drop in BP and in response to stress hormones
SEPSIS PHYSIOLOGY
the adrenal glands?
stress response -> release of adrenaline, noradrenaline and cortisol
SEPSIS PHYSIOLOGY
the kidneys?
decreased perfusion from low BP -> reduced urine output and AKI
SEPSIS PHYSIOLOGY
the skin?
reduced circulation to peripheries -> mottled discoloured skin and abnormal clotting -> purpuric rash
SEPSIS PHYSIOLOGY
the brain?
reduced blood flow to brain -> confusion, drowsiness, slurred speech, agitation, anxiety or altered conscious level
hypothalamus responds to infection with high or sometimes low body temp
SEPSIS PHYSIOLOGY
lungs?
fluid leaks into alveoli -> decreased gas exchange
tissue hypoxia -> acidosis->RR
SEPSIS PHYSIOLOGY
liver?
stress response alters gluconeogenesis and can lead to high or low blood sugars
SEPSIS PHYSIOLOGY
lactate?
tissue hypoperfusion and decreased clearance-> increased plasma lactate
describe how to review and escalate a patient with sepsis?
- Once diagnosed you need to do sepsis 6 and done within hour of diagnosis
- All patients with sepsis need to be reviewed by consultant or registrar ASAP
- Review the patient
- If no improvement with initial treatment refer to critical care
what are some of the complications of sepsis?
- Death
- Loss of fingers, toes, limbs
- Impact on life and ability to work
what are the symptoms of post sepsis syndrome?
- Sadness
- Difficulty swallowing
- Muscle weakness
- Clouded thinking
- Difficulty sleeping
- Poor memory
- Difficulty concentrating
- Fatigue
- Anxiety
define anaphylaxis?
a severe, life threatening, generalised or systemic hypersensitivity reaction. Characterised by rapidly developing, life threatening airway and/or breathing and/or circulation problems usually with skin and or mucosal changes
what is biphasic anaphylaxis?
after complete recovery of anaphylaxis, a recurrence of symptoms within 72 hours with no further exposure to the allergen
give examples of common triggers for anaphylaxis?
insect venom food (nuts) latex drugs (antibiotics, anaesthetic drugs,NSAIDs, contrast media) idiopathic
describe the IgE mediated allergic mechanism of anaphylaxis?
- mature B cells produce specific IgE antibodies to the allergen
- IgE antibodies bind to mast cells and basophils receptors
- this initial phase of sensitisation is clinically silent
- on re-exposure, the allergen cross links the 2 specific IgE receptors creating a bridge and resulting in mast cell degranulation
- release of histamine, tryptase etc, followed by newly formed mediators eg prostoglandin D2, leukotrienes, thromboxane A2 results in clinical manifestation of IgE mediated anaphylaxis
describe non allergic mechanisms of anaphylaxis?
MAST CELL ACTIVATION
- direct non specific activation - histamine releasing agents
- calcium and phospholipase dependent mechanism eg vancomycin and red man syndrome
- MRGPRX2 activation
- mastocytosis
MAST CELL INDEPENDENT MECHANISM
- COX-1 inhibition - NSAIDs (bronchospasm, angioedema)
what cofactors may modulate the onset of allergic and non allergic immediate hypersensitivity?
stress infection dose of allergen rate of drug infection chemical property and molecular weight of drugs host factors
