Chapter 3 Recognising deterioration

Question 1

How many people will survive an in-hospital cardiac arrest?

Answer 1

20% overall (though much lower if a non-shockable rhythm)

Question 2

What are the consequences of a partial airway obstruction

Answer 2

Cerebral oedema
Pulmonary oedema
Exhaustion
Secondary apnoea
Hypoxic brain injury
Cardiac arrest

Question 3

Name some causes of upper airway obstuction (11 answers)

Answer 3

CNS depression
Blood
Vomitus
Foreign body
Direction trauma to face/throat
Epiglottitis
Pharyngeal swelling (infection, oedema)
Laryngospasm
Bronchospasm
Bronchial secretions
Blocked tracheostomy tube

Question 4

Treatment available to assist with airway problems

Answer 4

Suction
Place in lateral position or head up (help prevent aspiration)
Oxygen
Oro or naso-pharyngeal airway
Intubation
Front of neck access

Question 5

What are the three levels/systems at which respiratory function can be impaired?

Answer 5

Respiratory drive (CNS drive e.g decreased GCS)

Respiratory effort (muscles of respiration e.g fatigue, failure, paralysis)

Lung disorders (pneumothorax, haemothorax, COPD, asthma, PE, contusion, ARDS, APO)

Question 6

When assessing breathing problems, what does RATES stand for?

Answer 6

R: respiratory rate
A: auscultate
T: tracheal position
E: effort of breathing
S: saturations SpO2

Question 7

What treatment options are available for breathing problems?

Answer 7

High flow O2 (non-rebreather)
Thoracocentesis (needle decompression)
Thoracostomy and ICC insertion
Non-invasive ventilation (CPAP, BIPAP if fatigued)
Endotracheal intubation

Question 8

What are the primary heart problems leading to circulatory problems?

Answer 8

Ischaemic heart disease
Heart block
Electrocution
Drugs
Structural heart disease
Cardiac failure
Cardiac tamponade
Cardiac rupture
Myocarditis

Question 9

What are the triggering causes of ventricular fibrillation?

Answer 9

Acute coronary syndrome
Hypertensive heart disease
Valvular heart disease
Drugs (antiarrhythmics, adrenaline, tricyclic antidepressants, digoxin)
Inherited cardiac disease (eg long QT syndrome)
Acidosis
Abnormal electrolyte concentration (K, Mg, Ca)
Hypothermia
Electrocution

Question 10

What are the secondary causes of circulatory problems?

Answer 10

Airway obstruction
Hypoxia
Anaemia
Hypovolaemia/haemorrhage
Severe septic shock

Question 11

What are the causes of sudden cardiac death?

Answer 11

COMMON
Coronary artery disease
Non-ischaemic cardiomyopathy
Valvular heart disease

LESS COMMON
long/short QT syndrome
Brugada syndrome
Hypertrophic cardiomyopathy
Arrhythmogenic right ventricular cardiomyopathy
Congenital heart disease

Question 12

What are high risk feature in a patient with syncope?

Answer 12

Syncope while supine
Occurring during or after exercise (though after exercise is often vasovagal)
Brief or no prodromal symptoms
Repeated episodes of unexplained syncope
Family hx of sudden cardiac death or inherited cardiac condition

Question 13

What options are available to support circulation?

Answer 13

IV fluids/blood
Defibrillation/pacing
Correct electrolytes
Correct acid/base disturbance
Inotropes

Question 14

After a rapid “look, listen and feel” you establish the patient is critically unwell. What is your next step?

Answer 14

Call for help

Question 15

What monitoring do you want on a critically unwell patient?

Answer 15

Sats probe
BP
ECG monitoring

Question 16

How do you thoroughly assess breathing ?

Answer 16

RATES (rate, auscultate, trachea, sats)
Look, listen, feel
Assess for raised JVP
Percussion 
Feel for surgical emphysema

Question 17

What is the cause of shock until proven otherwise?

Answer 17

Hypovolaemia

Question 18

How do you assess the circulation?

Answer 18

BP, take not of pulse pressure (low diastolic  = vasodilation e.g anaphylaxis, narrow = vasoconstriction e.g haemorrhage)
Assess hand colour
Assess capillary refil time
Assess limb temperature
Assess veins (underfilled/flat?)
Palpate peripheral and central pulses
Assess GCS/mentation
Assess for oliguria
Auscultate for murmur, pericardial rub or muffled heart sounds
Look for haemorrhage (drains, wounds)

Question 19

Immediate treatment for ACS?

Answer 19

Aspririn 300mg
GTN
Oxygen
Fentanyl/morphine

Question 20

When would you consider a smaller (250ml) bolus?

Answer 20

Trauma

Cardiac failure

Question 21

What is the signs of excessive fluid resusitation?

Answer 21

Raised JVP
3rd heart sound
Dyspnoea
Pulmonary crackles

Question 22

What are the common causes of decrease GCS?

Answer 22

Profound hypoxia
Hypercapnea
Cerebral hypoperfusion
Sedative drugs/analgesia

Question 23

How do you assess someone with decrease GCS?

Answer 23

Rapidly assess level of consciousness using AVPU system
Review ABC and treat if necessary
Check drug chart ( sedatives) and reverse if needed (naloxone)
Check allergies
Examine pupils
Measure glucose
Check medi-alert jewellery
Review chart
Nurse unconscious patient in lateral position to protect airway

Question 24

How to assess exposure

Answer 24

Examine entire body
Check temperature
Look for rash, bites, swelling, oedema, skin breaks
Look in mouth, nose (possibly other orrifices)
Review drains and dressings
Look for appliances beneath skin ( ports, partches, pacemakers, insulin pumps)
Assess wounds