Recognising the Sick Patient

Question 1

What is the definition of shock?

Answer 1

Reduction of effective blood flow and inadequate tissue perfusion with decreased delivery of oxygen to the capillary exchange bed.

Question 2

What is dysoxia?

Answer 2

A condition in which tissues cannot make full use of available oxygen
When you are in this, the only way to buffer in the immediate time is to start breathing faster. One of the first signs of something is not right is if you increase the respiratory rate.

Question 3

What is the ABCDE approach?

Answer 3

A - Airways and oxygenation 
B - Breathing and ventilation 
C - Circulation and Management of shock 
D - Disability 
E - Exposure, environment, events

Question 4

What is the approach to airway and oxygenation in the emergency management of a patient?

Answer 4

Signs: 
	• Ability to speak
	• Difficulty with breathing 
	• Noisy/silent breathing 
	- Stridor, wheezing, gurgling, snoring 
	• "see-saw" breathing pattern 

Treatment: 
	• Airway opening 
	- Head tilt-chin lift 
	• Removing foreign object 
	• Suctioning 
	• Simple adjuncts 
	- OP, NP, airways 
	• Advanced airway 
LMA, intubation

Question 5

What is the approach to breathing and ventilation in the emergency management of a patient?

Answer 5

Signs: 
	• Respiratory rate 
	• Work of breathing 
	- Accessory muscles, distress
	• Lung sounds 
	- Rales, creps, wheezing 
	• Oxygenation 
	- Cyanosis, SpO2

Treatment:
• Oxygen
• Treating the cause:
- E.g. draining a PTX
• Assisting ventilation
- CPAP, NIV
• Nebulizers for wheeze (steroids, magnesium)
• ? Decompression for pneumothorax, haemothorac etc
• NIV for hypercarbic respiratory failure?

Question 6

What is the approach to circulation and management of shock in the emergency management of a patient?

Answer 6

Signs: 
	• Pulse
	- Heart rate, volume 
	• Blood pressure 
	• Signs of heart failure: 
	- Neck veins, oedema, creps 
	• Perfusion: 
	- LOC, diuresis, CRT
	• Bleeding, fluid loss 
	• ECG: rhythm analysis 
	• aBG/vBG - lactate 

Treatment: 
	• IV line, blood tests 
	• Fluid 
	• Monitor 
	• Electric cardioversion 
	• Bleeding control 
	- Vasopressors

Question 7

What is the approach to disability in the emergency management of a patient?

Answer 7

Signs: 
	• AVPU or GCS
	• Pupils 
	• Blood sugar (BM) 
	• Fast neurologic assessment 

Treatment:
• IV glucose
- BM < 3mmol/l
IV thiamine

Question 8

What is AVPU?

Answer 8

• Alert
• Voice
• Pain
Unresponsive

Question 9

What is the Glasgow Coma scale?

Answer 9

Eyes: 
1 - Eyes do not open 
2 - Opens eyes in response to painful stimuli 
3 - Opens eyes in response to voice 
4 - Opens eyes spontaneously 

Verbal 
1- Makes no sound 
2 - incomprehensible sounds 
3 - utters inappropriate words 
4 - Confused, disorientated
5 - Orientated, converses normally

Motor
1 - Makes no movements
2 - Extension to painful stimuli (decerebrate response)
3 -Abnormal flexion to painful stimuli (decorticate response)
4 - Flexion / withdrawal to painful stimuli
5 - Localizes painful stimuli
5 - Obeys commands

Question 10

What is the approach to Exposure in the emergency management of a patient?

Answer 10

Signs: 
	• Remove clothes to enable thorough examination (maintain dignity) 
	• Detailed history 
	• Medications 
	• Allergies 

Treatment:
• Take temperature
• Avoid heat loss

Question 11

What are the 4 different types of shock?

Answer 11

1. Decrease in venous return
   
   2. Failure of the pump function
   3. Obstruction
   4. Loss of vascular tone

Question 12

What causes shock due to decrease in venous return?

Answer 12

due to a loss of circulating volume

- Due to internal or external loss of fluids

Question 13

What causes shock due to failure of the pump function of the heart?

Answer 13

results from a loss of contractility

Ischaemia, infarction, myopathy, myocarditis or a major arrhythmia

Question 14

What causes shock due to obstruction?

Answer 14

• Pulmonary embolism, tension, pneumothorax or cardiac tamponade

Question 15

What causes shock due to the loss of vascular tone?

Answer 15

results in maldistribution of blood flow

Sepsis, anaphylaxis or spinal injury

Question 16

What is a positive results of a fluid challenge?

Answer 16

• A positive response is an increase in cardiac output in response to the increased volume

- Heart rate decreases 
- Mean arterial pressure increases 
- Arterial pulse pressure increases 
- Urine output increases 
- Lactate clearance increases 
- Cardiac output or stroke volume increases

Question 17

What is Frank Starling’s law of the heart?

Answer 17

• The greater the heart muscle is stretched, the greater the force generated and the output from the ventricle.
The heart needs to pump all the venous return

Question 18

What is the early warning score?

Answer 18

The EWS aids the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes.	
• Temperature 
	• Heart rate 
	• Blood pressure (systolic scores) 
	• Respiratory rate 
	• Peripheral oxygen saturation 
	• Flow rate 
	• AVPU/ New confusion 

Each physiological observation will give a score form 0-3
Add them together to give you a score from 0-21

Question 19

What is SBAR in terms of communicating emergencies?

Answer 19

A way of communicating information that is important in a rapid way.
- S - Situation (a concise statement of the problem)
- B - Background (pertinent and brief information related to the situation
- A - Assessment (analysis and considerations of options - what you found/think)
R - Recommendation (action requested/ recommended - what you want)