general primary assessment

Question 1

Pre-assessment (5 fts)

Answer 1

(1) Identity of patients
(2) Basic info - NEWS score/PC
(3) Introduce yourself - to pt and ward
(4) PPE + handwashing
(5) general assessment of severity

Question 2

Pre-assessment main three outcomes

Answer 2

• arrest/peri-arrest (based on vitals/observation) - send out arrest call
• poorly but not arresting - A-E
• Fairly comfortable - general A-E approach + focused history

Question 3

Assessment of airways

Answer 3

• maintains airway = talking

- compromised airway = reduced consciousness; additional noises (gargling, snoring, stridor, secretions)

Question 4

Action in A - obvious obstruction

Answer 4

• vomit/fluid = suction

- object/food = use forceps if confident it is accessible

Question 5

Action in A - additional noises

Answer 5

= opening airways

• if no concerns about C-spine injury = head tilt, chin lift
• if ? C-spine injury = jaw thrust

Question 6

Action in A - persistant occlusion or reduced consciousness

Answer 6

= airway adjunts

Question 7

List types of airway adjuncts

Answer 7

• Nasopharyngeal airway
• Oropharyngeal airway/Guddel
• Laryngeal Mask Airway (LMA)/iGel
• Endotracheal tube (ET) = requires anaesthetist
• Surgical circothyroidectomy

Question 8

Indications and contraindications for a Nasopharyngeal airway

Answer 8

Indication: more conscious (better tolerated)
Contraindication: ?basal skill fracture (panda eyes, mastoid bruising, ear bleeding) bc can go through the cribiform plate

Question 9

Indication for an Oropharyngeal airway/Guddel

Answer 9

if tongue is obstructing airway (less consciouss)

Question 10

Indications for a supraglottic airway - Laryngeal Mask Airway (LMA)/iGel

Answer 10

• more definitive airway w/out specialist needed
• closes off epiglottis = prevents aspiration (unconsciouss + secretions)
• can aspirate stomach contents

Question 11

Indications for an endotracheal tube (ET)

Answer 11

• unable to protect airway (GCS < 8, risk aspiration, need muscle relaxants)
• potential for obstruction (airway burns/haematoma, epiglottitis)
• inadequate ventilation/oxygenation (severe resp failure/head injury)

Question 12

Indications for surgical cricoidectomy

Answer 12

• acute upper airway obstruction prevents the insertion of an ET

Question 13

Breathing assessment

Answer 13

• General - cyanosis; increased WOB
• pulse oxymetry - >94%; if known resp disease >88
• respiratory rate - 12-22bpm
• chest examination - cyanosis (perihperal/central); tracheal deviation; chest - accessory muscles, expansion, palpation, auscultation
• calf tenderness

Question 14

Causes of bradypnoea

Answer 14

= depressed respiratory drive

• reduced consciousness
• drug-induced = benzodiazepines or opiates -> counter w/ naloxone

Question 15

Breathing - investigations to order (3)

Answer 15

(1) gas - ABG if underlying resp disease/very low sats; otherwise VBG
(2) CXray - consider if portable is needed
(3) sputum culture

Question 16

Breathing - management of hypoxia

Answer 16

• proning (sitting up)
• Oxygen therapy - 15L non rebreathe mask; if known retainer/underlying resp start with 2-4L venturi aiming for stats 88-92%
• if continues hypoxic/hypercapnic at max therapy = non-invasive/invasive ventilation
• treat obvious cause

Question 17

Breathing management - wheeze

Answer 17

bronchodilator therapy

• Salbutamol 2.5mg neb
• Ipratropium 500mg neb

Question 18

Circulation assessment (6)

Answer 18

• BP - hypovolaemia <100 systolic
• HR - 60-100bpm; regularity
• Central cap refill/peripheral temperature
• JVP <4cm over sternal angle
• Heart auscultation
• Hydration - dry/overloaded - check mucous membranes + peripheral oedema
• press on abdomen to ?bleed

Question 19

Circulation general management

Answer 19

• fluid balance - record intake and excretion
• place wide bore Cannula + take bloods (VBG +/- cultures)
• any arrhythmia = 3-lead cardiac monitoring

Question 20

Circulation management of hypotension

Answer 20

fluid challenge

• 500mL Hartman’s/Saline 0.9% STAT
• if very small/known risk of overload (HF/frail elderly)= 250mL
• monitor response by HR, BP and urine output

Question 21

Circulation - management of shock

Answer 21

• 2 larger bore cannulae
• take bloods - VBG + G&S/crossmatch
• fluid challenge = 1L Hartman’s/Saline 0.9%
• if blood loss replace blood : typing takes 15mins so start with O neg + 2222/lab to activate massive blood loss protocal (for red cells + FFP +/- platelets)

Question 22

Circulation - reassessing/escalation

Answer 22

• responds fully: give maintenance fluids
• responds by BP falls again: more fluids - usually 20-30mL/kg STAT
• No response: escalate – may be overloaded (needs inotropes), may be very depleated (needs vasopressors)

Question 23

Circulation - initial investigations (5)

Answer 23

• ECG
• Serum troponin
• BNP levels (if not known)
• ECHO cardiogram
• CXray if not already done - fluid/cardiomegally

Question 24

Disability assessment

Answer 24

• Consciousness - AVPU + ; if more confused use GCS
• DEFG!! - should be on VBG or do BM
• Temperature
• Pupil reactivity
• Pain
• Consider NBM

Question 25

Disability - analgesia

Answer 25

- paracetamol - IV over 15mins every 4-6 hrs >50kg = 1g, max 3g/day <50 is 15mg/kg, max 60mg/kg/day - severe pain = morphine 10mg in 10mL saline given slowly

Question 26

Everything else assessment

Answer 26

- Exposure: bleeds, rashes, injuries - Focused exam - Escalate - handover/inform senior and refer to colleague - Document - brief came summary; under A-E headings with findings and managmeent - Review results

Question 27

Investigatigations format

Answer 27

BOXES - Bloods - mark as urgent; ABG (if low sats) or VBG; group&save; FBC, U&E, CRP, LFTs, Clotting + other; capillary glucose; blood cultures (if pyrexial) - Orifice tests: test relevant excretions (sputum, urine dip, faeces culture) - Xray /imaging - ECG +/- 3 lead monitoring - Special tests: depending on likely cause