CPGs- Value, time critical, clinical approach

Question 1

How does pulse oximetry work?

Answer 1

• emits 2 light waveforms, red and infrared.
• detector on other side of probe measures amount of light passing through vascular bed.
• both lights pulsate rapidly each second.
• Hb absorbs more light than oxyHb therefore greater concentration of oxyHb, greater amount of red light received by detector.
• both oxyHb and Hb absorb infrared equally which determines amount of Hb in arterial blood flow
• infrared = total amount of available Hb
• red light = saturated Hb

Question 2

Limitations of Spo2

Answer 2

• anaemia or hypovolaemia may give normal readings
• poor perfusion can cause inaccuracy incl., cardiac arrest, shock, burns, PVD, oedema/hypothermia
• movement
• nail polish
• skin pigmentation

Question 3

Oxy-Hb Dissociation curve - explain

Answer 3

Represents affinity of Hb for o2 at different levels of partial pressure. As Pao2 reduces from 100, initially little effect on spo2
Leftward shift: increased pH, reduced paco2, increased temp
Rightward shift: decreased pH, increased paco2, increased exercise, increased altitude, catecholamine release

Question 4

Ventilation - explain inspiration and expiration

Answer 4

Movement of air into and out of lungs due to pressure differences
Inspiration: air into lungs, pressure in lungs must be lower than atmospheric pressure. Pressure in lungs is lowered by increased volume. Muscles contract, expanding lungs.
Expiration: at end of resp phase, intrapulmonary pressure is already higher than atmospheric pressure causes air to follow pressure gradient = passive expiration

Question 5

Why is intrapleural space negative?

Answer 5

Parietal pleura (attached to chest wall), pulled outward.
Visceral pleura pulled inward by elastic recoil therefore constant pull in opposite directions caused 0 sub-atmospheric pressure hence preventing collapsed lung.

Question 6

Types of hypoxia?

Answer 6

Stagnant - good oxygenation but decreased blood flow eg. cardiac arrest, shock, haemorrhage
Anaemia - decreased o2 carrying capacity, decreased Hb levels e.g. hypovolaemia
Histotoxic - good oxygenation of blood but o2 unable to dissociate due to cellular blocking agent e.g. cyanide
Hypoxic - decreased o2 in pulmonary vascular system e.g. atmospheric changes, APO

Question 7

Assessment of Oxygen requiring patient

Answer 7

Acute/chronic
Respiratory status
Spo2
Causes
Bleomycin and paraquat poisoning

Question 8

Management of Adequate Spo2

Answer 8

greater than or equal to 92%

No O2 required, reassure pt

Question 9

Management of Mild-mod hypoxaemia

Answer 9

85-91%
2-6L via nasal prongs or 5-10L via face mask
titrate to 92-96%

Question 10

Management of severe hypoxaemia

Answer 10

less than 85% or critical illness:
-Arrest
-Trauma (head/major)
-Epilepsy
-Ketamine sedation
-Anaphylaxis
-Shock
-Sepsis
Non rebreather 10-15L/min - BVM if inadequate TV
Once pt haemodynamically stable, titrate to 92-96%
If deteriorates or Spo2 less than 85%, BVM 100%, consider SGA

Question 11

Management of Chronic Hypoxaemia

Answer 11

Kyphoscoliosis 
Neuromuscular disorders
Obesity 
COPD
Cystic fibrosis 
Bronchiecstasis 
-high concentration o2 may be harmful in COPD pts at risk of hypercapnic resp failure 
-titrate Spo2 88-92%

Question 12

Management regardless of SPo2

Answer 12

PPH
Inhalation (toxic)
Cord prolapse 
Cluster headache 
Decompression illness
Dystocia - shoulder 
-o2 via NRB 10-15l/min

Question 13

Unwell patients include

Answer 13

unconscious/altered conscious
SOB
pale/sweaty

Question 14

Definition of perfusion

Answer 14

The ability of the cardiovascular system to provide tissues with an adequate oxygenated blood supply to meet their functional demands at that time and to effectively remove associated metabolic waste products.

Question 15

Perfusion can be affected by:

Answer 15

temp
anxiety
altered consciousness

Question 16

When assessing perfusion, take into context:

Answer 16

presenting problem
pts meds
trends
response to mx

Question 17

Adequate perfusion

Answer 17

Warm, pink, dry skin
Pulse 60-100
BP over 100
Alert

Question 18

Borderline perfusion

Answer 18

Cool, pale, clammy
Pulse 50-100
BP 80-100
Alert

Question 19

Inadequate perfusion

Answer 19

Cool, pale, clammy
Pulse less than 50 greater than 100
BP 60-80
Alert or altered

Question 20

Extremely poor perfusion

Answer 20

Cool, pale, clammy
Pulse less than 50 greater than 110
BP less than 60
Altered or unconscious

Question 21

Normal respiratory status

Answer 21

Calm appearance 
Clear speech 
Quiet chest 
RR 12-16 
Regular rhythm
Normal effort
Normal skin
Pulse 60-100
Alert

Question 22

Mild respiratory distress

Answer 22

Mildly anxious appearance
Speaking sentences 
Sounds- mild exp wheeze, fine basal crackles, able to cough
Rate 16-20
Rhythm prolonged expiratory
Effort slightly increased
Skin normal 
Pulse 60-100
Alert

Question 23

Moderate respiratory distress

Answer 23

Distress/anxious appearance
Speaking in phrases
Sounds - expiratory +/- inspiratory phase, basal to midzone crackles, able to cough 
Rate over 20 
Rhythm prolonged expiratory 
Effort increased and accessories 
Skin pale and sweaty
Pulse 100-120
Altered conscious

Question 24

Severe respiratory distress

Answer 24

Distressed, fighting to breath, catatonic appearance
Speaking words only or none at all
Sounds - inspiratory and expiratory wheeze, full field crackles, unable to cough, UAO: inspiratory stridor
Rate over 20 or less than 8
Rhythm prolonged expiratory
Effort increased and accessories, intercostal retraction, tracheal tugging
Skin pale/sweaty/cyanosed
Pulse over 120
Altered or unconscious

Question 25

GCS purpose

Answer 25

an objective measure of scoring level of consciousness and identifying trends

Question 26

GCS criteria

Answer 26

Eyes: spontaneous, to voice, to pain, none Verbal: orientated, confused, inappropriate words, incomprehensible sounds, none Motor: Obeys, localizes, withdraws, abnormal flexion, abnormal extension, none

Question 27

AVPU

Answer 27

Alert 15 To voice 10-14 To pain 7-9 Unresponsive less than 7

Question 28

Trauma time critical guidelines VSS

Answer 28

``` HR less than 60 or greater than 120 RR less than 10 or greater than 30 SBP less than 90 Spo2 less than 90 if 16 or over, GCS less than 13 if 15 or younger, GCS less than 15 ```

Question 29

Trauma time critical guidelines specific injuries

Answer 29

- All penetrating injury - Blunt injuries: to single region where loss of life or quality is at risk, or significant to more than 1 region - Specific injuries: fractured 2 or more long bones, fractured pelvis, crush injury, compound fracture/open dislocation, burns over 20% or resp tract, limb amputation, suspected SCI

Question 30

Trauma time critical guidelines high risk factors

Answer 30

- pedestrian impact - ejection from vehicle - explosion - fall over 3m - struck by object over 3m - motor/cyclist impact over 30km/hr - prolonged extrication over 30mins - MVA over 60k/hr

Question 31

Trauma time critical guidelines co-morbidities

Answer 31

age less than 12 or greater than 55 pregnant significant underlying medical condition

Question 32

Medical time critical guidelines ACTUAL

Answer 32

RSA - moderate or severe distress PSA- less than adequate perfusion GCS - less than 13 Spo2 - less than 90% RA or 93%o2 or 88% chronic

Question 33

Medical time critical guidelines EMERGENT

Answer 33

``` AAA Acute stroke ACS Sepsis Suspected meningococcal Severe undiagnosed pain Hyperbaric treatment Hypothermia Hyperthermia ```

Question 34

Mental status Assessment

Answer 34

``` Safety Appearance Behaviour Affect Speech Cognition Thought process Thought content Self-harm Environment Perceptions ```

Question 35

PILSDUCT

Answer 35

pain, irregularity, loss of function, swelling, deformity, unnatural movement, crepitis, tenderness

Question 36

5HEDS

Answer 36

5/60 LOC, head fracture apparent, emesis greater than 1, neuro deficit, seizure

Question 37

Paediatric Assessment Triangle

Answer 37

Appearance - tone, interactive, consolable, look/gaze, speech/cry Breathing - breathing sounds, posturing, retraction, nasal flaring Circulation - pallor, mottling, cyanosis

Question 38

Newborn age and weight

Answer 38

up to 24hours 3.5kg

Question 39

Small infant age and weight

Answer 39

less than 3 months | 3month old 6kg

Question 40

Large infant age and weight

Answer 40

3 to 12 months 6 month old 8kg 1yr old 10kg

Question 41

Small child age and weight

Answer 41

1-4yrs | 1-9: age x 2 +8

Question 42

Medium child age and weight

Answer 42

5-11yrs | 10-11: age x 3.3

Question 43

Newborn HR, BP and RR

Answer 43

HR 110-170 BP over 60 RR 25-60

Question 44

Small infant HR, BP and RR

Answer 44

HR 110-170 BP over 60 RR 25-60

Question 45

Large infant HR, BP and RR

Answer 45

HR 105-165 BP over 65 RR 25-55

Question 46

Small child HR, BP and RR

Answer 46

HR 85-150 BP over 70 RR 20-40

Question 47

Medium child HR, BP and RR

Answer 47

HR 70-135 BP over 80 RR 16-34

Question 48

Signs of respiratory distress in Paediatrics

Answer 48

- tachypnea - chest wall retraction - use of accessory muscles - tracheal tugging - abdo protrusion

Question 49

Paediatric time critical guidelines VSS

Answer 49

small infant: HR less than 100 over 180, RR over 60, BO less than 50, SPo2 less than 90, GCS les than 15 Large infant: HR less than 100 over 180, RR over 50, BP less than 60 Small child: HR less than 90 over 160, RR over 40, BP less than 70 Medium child: HR less than 80 over 140, RR over 30, BP less than 80