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Acute Care Mahum Faisal 2021 Part I : A- E approach Basic Life Support Outline Part II: ISCE stations Common examinable conditions Key Conditions Airway Foreign body Croup Check to see if the airway is patent Epiglottis Laryngomalacia Anaphylaxis Assessment Asthma Vocal cord paralysis ● Is the trachea central? Laryngeal cancer Obstructive sleep apnoea Ludwig’s angina Interventions ● Suction, 5 back blows, abdominal thrusts ● Head tilt chin lift ● Airway adjuncts ● Intubation ● TracheostomyA B CBreathing Key Conditions Check for bilateral vesicular breathing Asthma Assessment COPD Pneumonia ● O2 saturations , RR Aspiration pneumonia ● Respiratory examination ● ABG Pneumothorax ● CXR Pulmonary oedema Pleural effusion Intervention ● High flow oxygen : 94-98% OR 88-92% ● Inhalers ● Steroids ● IV diuretics ● Needle decompression/ chest drainCirculation Check for signs of shock Key conditions ACS Assessment Atrial fibrillation Broad complex tachycardias ● OBS - HR, BP, Temperature Heart blocks ● Cardiovascular Examination Pulmonary embolism ● Cap refill ● Urinary output Haemorrhage ● ECG Sepsis Spinal cord injuries Interventions ● Fluid resuscitation ● CatheterisationDisability Check for level of consciousness Key conditions DKA Assessment Head injury ● AVPU Stroke ● Pupils Seizure ● Blood glucose ● GCS Intervention Medication review Treat the underlying causeExposure Assessment ● Check for rashes, penetrating injuries, fractures, track marks ● Plain X Rays ● Ultrasound Intervention Treat the suspected causeBasic Life support D- Danger R- Response S- Shout for help A- Airway B - Breathing C - Compressions Attach defibrillator ● shockable or non shockable Investigate causes ● 4 H’s and 4 T’sThe “H”s and The “T”s Hypoxia Thrombosis Hypovolaemia Tension pneumothorax Hyperkalaemia/ Hypokalaemia Tamponade Hypothermia ToxinsStation 1Student Briefing You are a 5th year medical student on placement in ED Setting ED Patient details Thomas Edwards (8) Task Thomas has been brought into the ED. Please take a history from his mother. You have 4 minutes to take a history . You will then be asked to answer some questions regarding clinical investigations and management. You will then need to perform a clinical skill.Case Summary Thomas is 8 year old child, generally fit and healthy. He was brought in by ambulance. He became quite short of breath after eating some cake containing nuts at a birthday party. He described the feeling as if his throat was closing. Associated symptoms included wheezing, generalised itching. PMH- Eczema. Drugs - Emollient, hydrocortisone. Allergies- NKDA. FH- N/A. Social - Lives at home with mum and dad, attends primary school. No developmental concerns. Vaccinations are up to date. Antenatal history - N/A On Examination : HR 112, BP 90/80, apyrexial, RR 22, 92%OA Widespread urticarial rash, angioedema What is your most likely diagnosis? How are you going to manage this patient?Medical management of anaphylaxis Adrenaline Hydrocortisone Chlorphenamine <6 months 150 micrograms 25 mg 250 micrograms 0.15 ml 1 in 1000 6 months- 6years 150 micrograms 50 mg 2.5 mg (0.15ml 1 in 1000) 6-12 years 300 micrograms 100 mg 5 mg 0.3 ml 1 in 1000 Adult and child 500 micrograms 200 mg 10 mg 0.5ml 1 in 1000Clinical Skill Unfortunately, after 2 repeated injections of adrenaline, the patient does not improve and is now unconscious. Please perform CPR.Station 2Student Briefing You are a 5th year medical student on placement in ED Setting ED Patient details Sarah Alicia (28)) Task This patient has been brought in by ambulance with shortness of breath. You have 4 minutes to take a history. The examiner will then stop you and ask you questions regarding clinical management. You will then be asked to carry out a clinical skill.Case summary Sudden onset of shortness breath today following an exercise class at gym. Associated symptoms include wheeze. No cough, or haemoptysis. PMH - Asthma. No previous exacerbations of asthma requiring hospitalisation. Drug history - Salbutamol. NKDA. FH- Father has asthma. Social - Smoker (10 a day for the past 3 years), drinks occasional alcohol, works in banking. On examination - Using accessory muscles, confused, inability to speak HR - 102,, BP- 90/82, Apyrexial , RR 29, O2 - 89% On auscultation, there are no breath sounds What is your most likely diagnosis?Data interpretation You successfully managed to do an ABG. The ABG results are as follows. Please interpret the results: PH - 7.2 (7.35 -7.45) O2 - 8.5 Kpa (10-14 kPa) PCo2 - 4.9 kPa (4.5-6.0 kPa) Hco3- 28 mmol/l (22- 30 mmol/l) Classification of Asthma Moderate Severe Life threatening PEFR 50-75% PEFR - 33-50 PEFR <33% best Speech is normal Can’t complete sentences O2 sats <92% RR<25 RR>25/ min Silent chest, cyanosis Pulse <110 Pulse >110 Hypotension, Exhaustion, confusion Conservative/ holistic Management of Asthma ● Patient education ● Smoking cessation Acute ● Avoiding triggers ● Vaccinations ● A-E assessment ● 2222, Senior help early ● Peak flow diary ● Oxygen ● Salbutamol and Arrange investigations: ● Check inhaler technique ● Medicine optimisation ipratropium bromide ● Bloods via nebuliser ● ECG ● Refer to GP for follow up ● Oral prednisolone / iV of asthma in community hydrocortisone ● Covid swab ● CXR ● Aminophylline ● Peak Flow, Spirometry Medical Magnesium sulphate ● Escalate to HDU/ intensive care 1. SABA 2. SABA +ICS 3. SABA+ ICT + LTRA 4. SABA +ICS+LTRA 5. SABA +/- LTRA (MART)Clinical Skill Your patient has been stabilised and is admitted under the respiratory team. The respiratory team would like to know the patients PEFR. Please explain to the patient how to do a peak flow.Station 3Student Briefing You are a 5th year medical student on placement in ED Setting ED Patient details Chris Thomas (55) Task This patient has been brought in by ambulance with chest pain. You have 4 minutes to take a history. Following this, the examiner will stop you and ask you questions regarding the patients clinical management. You will then be asked to perform a skill.Case summary Presented to ED with sudden onset central crushing chest pain. This started 1 hour ago. The pain radiates to his neck, jaw and down his left shoulder. Associated symptoms include nausea, vomiting and sweating. PMH- osteoarthritis, T1DM, hypertension, hypercholesterolaemia. NKDA. FH Father died of a cardiac arrest. Social- Ex smoker, drinks occasional alcohol, works as a builder. On examination, HR - 112 , BP - 90/86 Apyrexial, RR- 18, 02 - 92% On auscultation, chest is clear. Heart sounds are present. Systolic murmur heard in the 5th intercostal space, left midclavicular line, radiating to the axilla. JVP is not raised. No signs of peripheral oedema. What do you think is the most likely diagnosis?Data interpretationManagement of MI Conservative/ holistic approach Acute ● Patient education ● Lifestyle advice A-E assessment Investigations ● MDT approach ● Cardiac rehabilitation 2222 senior help early ● DVLA guidance Bedside ● Vaccination Morphine Obs, Bloods, ECG Oxygen Medical management Imaging ● Dual antiplatelet therapy Nitrates CXR ● Beta blocker Aspirin Special tests ● Ace inhibitor ● Spironolactone CT coronary angiogram ● Statin Ticagrelor Echo IV fluids Surgery ● Valve replacement Anti emetics Escalate - PCI / fibrinolysisClinical Skill You have called for help early. You decide Mr Edwards needs fluids. Please put in a cannula for the patient.Station 4Student Briefing You are a 5th year medical student on placement in ED Setting ED Patient details Chris Hughes (23) Task This patient has been brought in by ambulance following a collapse. Please take a collateral history from his friend. The examiner will then stop you and ask you some clinical questions regarding management. You will then be asked to perform a technical skillCase Summary Patient had attended a party where there was mixing of alcohol and drugs, 4 hours ago, noticed his friend was staring into space but was not speaking. Then all of a sudden his limbs went stiff, fell to the floor and his limbs started jerking. This lasted for 2 mins. He remained unconsciousand then had another similar episode shortly after lasting for 3 minutes. During these episodes he bit his tongue and lost control of his bladder. He came around 20 minutes later and was very confused. He could not remember what had happened. PMH- N/A. No regular medications. No known drug allergies. FH- N/A. Social- Smokes 20 a day for the past year, drinks 17 units a week, occasionally does cocaine. On examination - HR 117, BP - 95/86, 28.6, RR- 12 On auscultation, There are track marks along his left arm. Chest is clear. Heart sounds are normal with no extra added sounds. JVP is not elevated. Abdomen is soft non tender. On neurological examination, he is hypertonic and hyperreflexic. What is the most likely diagnosis?Data interpretation The patient is still confused, please interpret the following information: The patient opens his eyes on pressure applied to the supraorbital area. Patient is speaking full sentences but is not orientated to time, date or place. On application of a painful stimuli he is able to localise to pain. What is his GCS?Management of a Seizure Conservative/ Holistic ● Patient education Acute ● CAGE screening Investigations ● Refer to AAA A-E assessment ● Bloods ● Toxicology ● Refer to addiction services Get help early ● DVLA guidance screen Stop/ reverse the underlying ● ECG Medical cause ● CT head ● MRI Anti epileptic medication ● EEG IV lorazepam Generalised ● LP - 1. Sodium valproate 2. Lamotrigine, IV lorazepam carbamazepine Phenytoin/ phenobarbital Focal seizures Rapid sequence induction - 1. Carbamazepine or lamotrigine. 2. Levetiracetam, oxcarbazepine, sodium valproate.Clinical Skill You have managed to stop the seizure however, the patient now complains of chest pain. Please perform an ECG on this patient.Common Examinable Conditions Cardiac Respiratory GI Neuro Metabolic Anaphylaxis Acute asthma Acute upper GI Meningitis DKA bleed ACS Acute IBD Status Paracetamol exacerbations Epilepticus overdose of COPD Aortic Pneumothorax Head injury dissection Broad complex Pneumonia tachycardia Narrow Pulmonary complex embolism tachycardia BradycardiaQuestions?