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YEAR 5 ED > A-E assessment > Flashcards

A-E assessment Flashcards

1
Q

How to assess airway in pt cannot talk?

Look, listen, inspect

A

Look for signs of airway compromise:
* angioedema
* cyanosis
* see-saw breathing
* use of accessory muscles

Listen for abnormal airway noises:
* stridor
* snoring
* gurgling

inspect: look for obstructions:
* secretions
* foreign object

Seesaw motion suggests impaired gas exchange. Might need mechanical ventilation as it suggests resp failure due to diaphragmatic or respiratory muscle fatigue.

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2
Q

What are some causes of airway compromise?

A
  • Inhaled foreign body
  • Blood in the airway: epistaxis, haematemesis and trauma
  • Vomit/secretions in the airway: alcohol intoxication, head trauma and dysphagia
  • Soft tissue swelling: anaphylaxis and infection (e.g. quinsy, sub-mandibular gland swelling)
  • Local mass effect: tumours and lymphadenopathy (e.g. lymphoma)
  • Laryngospasm: asthma, GORD and intubation
  • Depressed level of consciousness: opioid overdose, head injury and stroke
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3
Q

What should you do if you see airway obstruction during your A-E?

A
  • Seek immediate expert support from anaesthetist and crash team
  • Basic airway manoeuvres while you wait for senior input
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4
Q

What are some specific manoeuvres you could do for airway?

A
  • Head-tilt chin-lift manoeuvre
  • Jaw thrust
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5
Q

How to perform a head-tilt chin-lift manoeuvre?

A
  1. Place one hand on the patient’s forehead and the other under the chin.
  2. Tilt the forehead back whilst lifting the chin forwards to extend the neck
  3. Inspect the airway for obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to try and remove it.
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6
Q

When is a jaw thrust better than a head-tilt chin-lift?

A

If the patient is suspected of having suffered significant trauma with potential spinal involvement,

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7
Q

How do you perform a Jaw thrust?

A
  1. Identify the angle of the mandible
  2. Place two fingers under the angle of the mandible (on both sides) and anchor your thumbs on the patient’s cheeks
  3. Lift the mandible forwards
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8
Q

What are some airway adjuncts you could use to maintain a pts airway?

A

oropharyngeal airway

asopharyngeal airway

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9
Q

Which airway adjunct is better for a conscious pt?

A

NPAs are typically better tolerated in partly or fully conscious patients than oropharyngeal airways.

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10
Q

Specific causes of airway compromise:

Anaphylaxis :

what should be the rapid treatment?

A

IM adrenaline

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11
Q

Specific causes of airway compromise:

Blood, vomit, secretion in airway :

what should be the rapid treatment?

A

Suction
Pt positioned in the left lateral position

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12
Q

Specific causes of airway compromise:

Stridor :

what should be the rapid treatment?

A

sit the patient upright, urgent anaesthetic/ENT input

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13
Q

Specific causes of airway compromise:

Foreign body :

what should be the rapid treatment?

A

basic life support choking algorithm

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14
Q

Breathing: when you observe the patient what is a normal respiratory rate?

A

between 12-20 breaths per minute

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15
Q

What are some causes of Bradypnoea?

A
  • sedation
  • opioid toxicity
  • raised intracranial pressure (ICP)
  • exhaustion in airway obstruction with CO2 retention/narcosis (e.g. COPD)
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16
Q

What are some causes of Tachypnoea?

schema: resp vs non resp

A

RESP:

  • airway obstruction
  • asthma
  • pneumonia
  • PE
  • pneumothorax
  • pulmonary oedema

NON RESP
* heart failure
* anxiety

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17
Q

Breathing: you review the pts 02 sats

what are normal Sp02 ranges?

A
  • 94-98% in healthy individuals
  • 88-92% in patients with COPD at high risk of CO2 retention
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18
Q

Breathing: the pts oxygen sats are low: what are some causes of Hypoxaemia?

A

*PE
*aspiration
*COPD
*asthma
*pulmonary oedema

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19
Q

Breathing: General inspection - what signs might you see suggesting underlying pathology?

A
  • Cyanosis
  • Shortness of breath
  • Cough
  • Stridor
  • Cheyne-Stokes respiration
  • Kussmaul’s respiration
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20
Q

Breathing: Cyanosis

what is it? What might be the cause?

A

What?
* bluish skin discolouration due to poor circulation

Cause
* e.g. peripheral vasoconstriction secondary to hypovolaemia
* inadequate oxygenation, e.g. right-to-left cardiac shunting

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21
Q

Breathing: SOB

what are signs may see in SOB?

A
  • nasal flaring
  • pursed lips
  • use of accessory muscles
  • intercostal muscle recession
  • tripod position
  • The inability to speak in full sentences indicates significant shortness of breath.
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22
Q

Breathing: Cough
possible causes?

A

Productive cough:
* pneumonia
* bronchiectasis
* COPD
* cystic fibrosis.

A dry cough may suggest:
* asthma
* interstitial lung disease.

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23
Q

Breathing: Stridor
what is it?
what causes it?

A

What?
* a high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways.

Causes?
* foreign body inhalation (acute)
* subglottic stenosis (chronic

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24
Q

Breathing: Cheyne-Stokes respiration
what is it? what causes it?

A

What?
* Cyclical apnoeas, with varying depth of inspiration and rate of breathing.

Cause:
* stroke
* raised ICP
* pulmonary oedema
* opioid toxicity
* hyponatraemia
* carbon monoxide poisoning.

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25
Q

Breathing: Kussmaul’s respiration

what is it? what causes it?

A

What?
* deep, sighing respiration

Cause:
* associated with metabolic acidosis (e.g. diabetic ketoacidosis).

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26
Q

Breathing: Tracheal position

What conditons cause the trachea to deviate AWAY from it?

A
  • tension pneumothorax
  • large pleural effusions
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27
Q

Breathing: Tracheal position

What conditons cause the trachea to deviate TOWARDS it?

A
  • towards lobar collapse
  • pneumonectomy
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28
Q

Breathing: chest expansion to look for reduced chest wall movement.

What could symmetrical reduced chest expansion indicate?

A
  • pulmonary fibrosis
    reduces lung elasticity, restricting overall chest expansion
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29
Q

Breathing: chest expansion to look for reduced chest wall movement.

What could ASYMMETRICAL chest expansion indicate?

A
  • pneumothorax
  • pneumonia
  • pleural effusion
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30
Q

Breathing: Percussion of the chest

what finding would be ‘normal’?

A

should be resonant in healthy individuals

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31
Q

Breathing: Percussion of the chest

what are some abnormal findings and what would they indicate?

A
  • Dullness: suggests increased tissue density (e.g. cardiac dullness, consolidation, tumour, lobar collapse)
  • Stony dullness: an underlying pleural effusion
  • Hyper-resonance: the opposite of dullness, suggestive of decreased tissue density (e.g. pneumothorax)
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32
Q

Breathing:
You auscultate the chest
what are some abnormalities you can find?

A
  • Bronchial breathing
  • Quiet/reduced breath sounds
  • Wheeze
  • Coarse crackles
  • Fine end-inspiratory crackles
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33
Q

Breathing: Auscultate

Bronchial breathing
What is it? What could it indicate?

A

What?
* harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal, and there is a pause between.

Indicate:
* associated with consolidation

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34
Q

Breathing: Auscultate

Quiet/reduced breath sounds:

What is it? What could it indicate?

A

suggest reduced air entry into that lung region (e.g. pleural effusion, pneumothorax).

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35
Q

Breathing: Auscultate

Wheeze

What is it? What could it indicate?

A

What?
* a continuous, coarse, whistling sound produced in the respiratory airways during breathing (expiration).

Indicate:
* Wheeze is often associated with asthma, COPD and bronchiectasis.

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36
Q

Breathing: Auscultate

Coarse crackles:

What is it? What could it indicate?

A

What?
* discontinuous, brief, popping lung sounds

Indicate:
* typically pneumonia, bronchiectasis and pulmonary oedema.

37
Q

Breathing: Auscultate

Fine end-inspiratory crackles:

What is it? What could it indicate?

A

What?
* often described as sounding similar to the noise generated when separating velcro.

Indicate:
* Fine end-inspiratory crackles are associated with pulmonary fibrosis.

38
Q

What are some investigations you might order while assessing breathing? why?

A

ABG
* asses hypoxia severity and look for underlying causes

CXR
* Portable xray
* suspect pneumonia, pneumothorax, pulmonary oedema

39
Q

What are some interventions you might implement in Breathing?

A

Patient position
* upright - help with oxygenation

O2
* non-rebreathe mask with an oxygen flow rate of 15L.
* trial titrating oxygen levels downwards after your initial assessment.

40
Q

Breathing: Interventions if your pt has COPD?

A
  • target SpO2 levels accordingly (88-92%)
  • consider using a venturi mask: 24% (4L) or 28% (4L)
  • Consider discussing non-invasive ventilation (NIV) with a senior in acute exacerbations of COPD if evidence of type 2 respiratory failure.
41
Q

Breathing: specific interventions in case of acute asthma?

A
  • nebulised bronchodilators (salbutamol/ipratropium),
  • orticosteroids and other agents (e.g. magnesium sulphate, aminophylline)
  1. oxygen 2. salbutamol nebs and pred 3. ipratropium. 4. mag sulph IV 5. escalate
42
Q

Breathing: specific interventions in case of Exacerbation of COPD?

A
  • bronchodilators (salbutamol/ipratropium),
  • corticosteroids, antibiotics (if evidence of infection)
43
Q

Circulation: Observation heart rate
what is a normal HR ?

A

A normal resting heart rate can range between 60-99 beats per minute

44
Q

Circulation: What are some causes of tachycardia?

A

HR>99
* hypovolaemia
* arrhythmia
* infection
* hypoglycaemia
* thyrotoxicosis
* anxiety
* pain
* drugs (e.g. salbutamol)

45
Q

Circulation: What are some causes of bradycardia?

A

(HR<60)
* acute coronary syndrome (ACS)
* ischaemic heart disease
* electrolyte abnormalities (e.g. hypokalaemia)
* drugs (e.g. beta-blockers)

46
Q

Circulation: BP
what is a normal range?
What should you do when assessing a pts BP?

A

Normal range: 90/60mmHg and 140/90mmHg,

  • Review previous readings to gauge the patient’s usual baseline BP
47
Q

Circulation: BP what are some causes of hypertension

A
  • hypervolaemia
  • stroke
  • Conn’s syndrome
  • Cushing’s syndrome
  • pre-eclampsia

Severe hypertension (systolic BP > 180 mmHg or diastolic BP > 100 mmHg)
may present with
* confusion
* drowsiness
* breathlessness
* chest pain
* visual disturbances.

48
Q

Circulation: some causes of Hypotension

A
  • hypovolaemia
  • sepsis
  • adrenal crisis
  • drugs (e.g. opioids, antihypertensives, diuretics).
49
Q

Circulation: Fluid balance assessement : how to

A
  • Calculate using the pts fluid balance chart (e.g. oral fluids, IV fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts
50
Q

Circulation: how is reduced urine output (oliguria) defined? WHat are some causes?

A

Defined as:
* less than 0.5ml/kg/hour in an adult

Causes:
* dehydration
* hypovolaemia
* reduced cardiac output
* acute kidney injury

51
Q

Circulation: General inspection, what can Pallor suggest?

A

suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure)

52
Q

Circulation: general observation: what can oedema suggest?

A

typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (ascites) and may indicate underlying heart failure

53
Q

Circulation : you assess the patients temp by placing the dorsal aspect of your hand on the pts.

What would cool hands indicate?
What would cool and sweaty hands indicate?

A

Cool hands
* poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome)

Cool AND sweaty/clammy hands
* poor peripheral perfusion and autonomic dysfunction (e.g. acute coronary syndrome

54
Q

Circulation: Capillary refill time
where to check?
Abnormal findings and why?

A

Check
* centrally on the sternum and compare to peripheral CRT on fingertip

  • peripheral CRT > 2 seconds suggests poor peripheral perfusione e.g. hypovolaemia, congestive heart failure) and the need to assess central CRT
55
Q

Circulation: When assessing radial and brachial pusle what are you assessing?

A

Rate, rhythm, volume and character

56
Q

Circulation: pulse
An irregular pulse is associated with …

A

arrhythmias such as atrial fibrillation

57
Q

Circulation: pulse
A slow-rising pulse is associated with…

A

Aortic stenosis

58
Q

Circulation: pulse
A pounding pulse is associated with …

A

Aortic regurgitation as well as CO2 retention

59
Q

Circulation: pulse

Circulation: pulse
A thready pulse is associated with…

A

intravascular hypovolaemia (e.g. sepsis).

60
Q

Circulation: JVP

what are causes of a raised JVP?

A

Right HF
* caused by Left HF (e.g. secondary to fluid overload).
* Pulmonary HTN due to COPD, ILD

Tricuspid regurgitation:
* infective endocarditis and rheumatic heart disease.

Constrictive pericarditis:
* idiopathic
* RA, TB underlying causes.

61
Q

Circulation: Auscultation of the heart

what are some acute cardiovascular conditions you could find?

A
  • pericardial rub or muffled heart sounds —–> underlying pericarditis or cardiac tamponade
  • A third heart sound —> congestive heart failure
  • A new / recent murmur —-> recent MI (e.g. papillary muscle rupture) or endocarditis
62
Q

Circulation: Ankles and sacrum what checking and cause?

A

Assess for evidence of oedema,
typically associated with heart failure.

63
Q

Circulation: What are some interventions could do here?
(headings for now)

A
  • Cannula
    wide-bore 14G or 16G
  • Blood tests FBC, U&E, LFT and cultures
  • ECG
  • Bladder scan - retention / obstruction
  • Urine pregnancy test
  • Cultures / swabs e.g. sputum, urine, line
  • Fluid output / Catheterisation
  • Fluid resuscitation
  • Blood transfusion
64
Q

Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you conisder if you suspect:

sepsis?

A

CRP, lactate and blood cultures

65
Q

Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:

Haemorrhage or surgical emergency?

A

coagulation and cross-match

66
Q

Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:

Acute coronary syndrome?

A

troponin

67
Q

Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:

Arrhythmia?

A

Calcium, magnesium, phosphate, thyroid function tests, coagulation

68
Q

Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:

Pulmonary embolism?

A

D-dimer (if appropriate based on Well’s score)

69
Q

Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:

Overdose?

A

toxicology screen (e.g. paracetamol levels)

70
Q

Circulation: Blood tests
assuming you have collected FBC, U&E, LFTS for an unwell pt. What else would you consider if you suspect:

Anaphylaxis?

A

consider serial mast cell tryptase levels

71
Q

Circulation: You have recorded a 12 lead ECG, in what pts would you consider continuous cardiac monitoring?

A

critically unwell patients (e.g. MI, severe electrolyte abnormalities requiring replacement).

72
Q

Disability: How to asess a pts Consciousness?

A

ACVPU scale:
* Alert: fully alert
* Confusion: new onset / worse confusion
* Verbal: response when you talk to them (e.g. words, grunt)
* Pain: responds to a painful stimulus (e.g. supraorbital pressure)
* Unresponsive: no evidence of any eye, voice or motor responses to pain

for a more detailed assessment of the patient’s level of consciousness, use the Glasgow Coma Scale (GCS).

73
Q

What are causes of depressed consciousness?

A
  • Hypovolaemia
  • Hypoxia
  • Hypercapnia
  • Metabolic disturbance (e.g. hypoglycaemia)
  • Seizure
  • Raised intracranial pressure or other neurological insults (e.g. stroke)
  • Drug overdose
  • Iatrogenic causes (e.g. administration of opiates)
74
Q

Disability: Pupils

what inspect / Asess?

A

Inspect:
* size and symmetry of the patient’s pupils
Assess
* direct and consensual pupillary responses which may reveal evidence of intracranial pathology (e.g. stroke).

75
Q

Disability: Pupils

what might:
* pinpoint
* Dilated
* Asymetrical
pupils indicate?

A

pinpoint pupils
* opioid overdose

dilated pupils
* tricyclic antidepressant overdose)

Asymmetrical pupillary size
* intracerebral pathology (e.g. stroke, space-occupying lesion, raised intracranial pressure).

76
Q

Disability: brief neuro assessment

A

Perform a brief neurological assessment by asking the patient to move their limbs.

If a patient cannot move one or all of their limbs, this may be a sign of focal neurological impairment, which requires a more detailed assessment.

77
Q

Disability: why might a quick drug chart review be helpful?

A

Review the patient’s drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives, anxiolytics).

78
Q

Disability : investigations

A
  • Blood glucose and ketones
  • CT head if intracranial pathology is suspected after discussion with a senior.
79
Q

Disability: Investigations
Blood glucose:
normal fasting plasma glucose?
Hypoglycaemia def in hospitalised pt?

A

The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.

Hypoglycaemia if plasma glucose less than 3.0 mmol/l.

In hospitalised patients, treat a blood glucose ≤4.0 mmol/L if symptomatic.

80
Q

Disability: Interventions …

A
  • Maintain airway if concerned about pt conscious level
  • GCS or 8 or lower
  • P or U on ACVPU scale
  • urgent expect help
  • Correct hypoglycaemia
81
Q

Disability: what are specific interventions for
* Opioid overdose
* DKA
* Seizures
* Hypercapnia

A

Opioid overdose:
* ventilation, naloxone

DKA
* intravenous fluids and insulin

Seizures
* maintain airway, benzodiazepines

Hypercapnia
* urgent senior clinician review for consideration of ventilation

82
Q

Exposure: …..

A
  • ask if in pain

Inspect:
* rashes (men sepsis)
* Bruising (coag, trauma, surgery)
* signs of infection (cellulitis)

Review:
* insitu IV line for erythema / discharge

Expose:
* Abdomen for distention / hernia
* calves for erythema / swelling (DVT)
* Surgical woulds for Haematoma, bleeding, infeciton (purulent discharge)
* Output of pts catheter / surgical drains for blood, fluid loss and pus

83
Q

Exposure: Palpate…

A

Briefly palpate the abdomen for signs of peritonism or other life-threatening pathology (e.g. abdominal aortic aneurysm).

Palpate the calves for tenderness which may suggest a deep vein thrombosis.

84
Q

Exposure : temp

What is normal?
causes of high temp?
Causes of a low temp?

A

A normal body temperature range is between 36°c – 37.9°c

  • > 38°c is most commonly caused by infection (e.g. sepsis)
  • <36°c may also be caused by sepsis or cold exposure (e.g. drowning, inadequate clothing outside)
85
Q

Exposure: investigations

A
  • Cultures / swabs for infeciton source e.g. line tip
86
Q

Exposure: interventions

A

Control bleeding
* active: stop loss, estimate total blood loss and rate of blood loss
* re-assess for signs of hypovolaemia shock e.g. hypotension, tachy, pre-syncope)

Warm patient
* blankets
* active warming e.g. Bair Hugger or warmed fluids

Treat infection
* e.g surgical wound leaking pus - reassess for signs of sepsis and start sepsis 6 if appropriate

87
Q

After you have done your A-E what next?

A

Re-assess using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.

Any clinical deterioration should be recognised quickly and acted upon immediately.

Seek senior help if the patient shows no signs of improvement or if you have any concerns.

88
Q

Escalating to other teams using an SBAR handover…..

What teams that might be approproate to call based on where in the A-E the problem is?

A
89
Q
A

YEAR 5 ED (11 decks)

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