ACUTE CARE – PRIMARY SURVEY – “LOOK, HEAR & FEEL”
Problem Look /Listen/Feel Intervene
Direct trauma • Appearance (the sweaty tachypnoic) Position
• Disruption • Colour (look grey, pale) • Upright (best) at least 30o to optimise breathing
• Oedema (later sign due to • Posture (LOC) • L) lateral position if unconscious
disruption) • C-spine immobilise Prepare + SUCTION è CLEAR AIRWAY
• Airway obstruction signs • Gloved finger + suction
Airway Obstruction
• FB
o Stridor – swelling in larynx Adjunct airway – centre of mouth to angle of jaw
o hoarse voice • Manoeuvres = Chin lift/jaw thrust or neutral in
• Food vomitus • Signs of imminent airway collapse infants
• Bloody Vomitus (e.g. severe trauma, burn) • Oropharyngeal (guedel)/Nasopharyngeal airway
• Soft Tissue oedema o Protruding tongue Intubation ® laryngoscope (CI = if NOT fasted)
(haematoma) o Drooling • Straighten the airway
o Trismus • LMA or ETT (8.0mm standard for adult males)
Other reasons for airway o Hypoxia (late sign) Surgical Airway (Can’t intubate, ventilate, LMA)
Ø Decreased LOC • Deteriorating consciousness • Cricothyroidotomy OR Tracheostomy
Ø SEVERE lung pathology
Ø CO poisoning • Choking Maintain in-line immobilisation (C-spine)
Ø Surgery (RSI = Rapid sequence induction) to prevent o 5 back blows • If LOC / head injuries
risk of aspiration pneumonia + increase FRC o 5 chest blows • Manually, sandbags, cervical collar
1. Massive flail ribs (part of ribs separated from rest of • Colour – Cyanosis+ Diaphoresis • Recheck vitals + trends + meds
chest wall ® ¯¯ LOC/poor resp effort) • Chest expansion ® asymmetry and • Max FiO2 ® mech. Ventilation
2. Simple pneumothorax reduced
o If in doubt = 4L/min Hudson mask (titrate after)
3. Massive haemothorax • Accessory muscle + posture
Breathing 4. Tension pneumothorax ® impaired VR (compresses • ↑WoB + ↑RR +↓Sats
• Needle aspiration ® 2nd IC in MCL
Tachypnoea = 1st sign IVC = distended neck veins) (100% sats = CO, methamoglobin) • Tube thoracostomy: 3-bottle chest drain ®
of sepsis and 5. Open Pneumothorax • Tracheal dev. + abdo breath + 5th IC in MAL ® hug lower 6th rib (avoid
distended neck veins neurovascbundle in costal groove superiorly)
metabolic acidosis 6. High SCI OR TAMPONADE
• Speaking in complete sentences • Open pneumothorac è Cover open wound (3
side occlusive) dressing to let air out but not in
• Noisy breathing (stridor, wheeze)
• Percussion (dullness, hyper-
resonance, surgical emphysema)
• Auscultate (BS, Creps, wheeze)
Bleeding (Big 5) Heart • Colour (pale, sweaty) 1st line = 2x IV or IO access –14-16g cannula
1. External (obs) • Tension • Warm (distributive), cold (other) 1) Bloods = cultures FBC, Coags (DIC), X-match, ABG
Circulation 2.
3.
Chest (CXR)
Abdomen (FAST, DPL) •
pneumothorax
Pericardial
• HR, BP, CRT, JVP 2) IV ABx empirical
3) IVF = crystalloids (0.9% NS 500mL bolus),
• Urine output
“stop bleeding” 4. Pelvis (PXR)
•
tamponade
Contusion
• Fluid overload signs 4) IVF colloids (pRBC – O neg)
5. Femurs (Clin. Exam) (raised JVP or distended neck veins, 2. Pelvic stabiliser
*Combination • Infarction peripheral oedema) 3. Needle thoracostomy / pericardiocentesis
**DPL = diagnostic peritoneal • Dehydration signs ED thoracotomy (REBOA) – catheter via femoral
lavage (tachycardia, hypoTN, ↑RR, dry MM, vein to stop inferior blood flow via balloon inflation
reduced skin turgor, altered LOC) 4. Transfer to ICU or monitor on ward
• Peripheral Pulse – quality, regularity 1) Inotropes / vasopressors
• Palpate apex beat (best for HF)
• Auscultate (HSDNM)
Long-term:
Microcirculation 1. Monitor Fluid balance
1. Skin – warmth? o INPUT (IV)= PO/IVF, NGT
2. Renal – oliguria? o OUTPUT = IDC, NGT,
3. Brain – hypoxia?LOC? drains, tubes
2. Monitor EUC
• AVPU ® GCS ≤ 8 (intubate)
• Cognition/ behaviour = orientation to Position
• 2o brain injury (due to inadequate oxygenation
Disability to brain tissue) ® can amplify damage caused •
place, person and time.
Eyes = PEARL, nystagmus, ptosis
•
•
C-spine protection
Controlled ventilation – prone position
by 1o brain injury • Speech = slurred • Craniotomy (e.g. EDH, SDH) + Neurosurg
• INTRA= haematoma, oedema, fitting • Motor (power/tone) /sensation = • Closed reduction OR realign fractures
• Extra – hypoxia, hypoTN, ↓/↑ CO2, BSL Facial asymmetry, seizures, abnormal
• Debride ischaemic or contaminated wound
or absent limb movement
• GLUCOSE
Medications
o CHECK med chart (insulin, OHA)
• For sedation
o Hypo Sx (confusion, low BSL,
polydipsia, disorientated) • Analgesia
o Diaphoresis (Sweaty, cold, • Anti-emetics
clammy)
1. Hypothermia • Take OFF everything • Remove all clothes
Exposure 2. Rashes – location, distribution,, blanching?, • Prepare for 2o survey Monitor Temp o Rashes
3. Thrombin (COAGS) – hidden bleeds o Skin appearance
• Check wounds, drains, IDCs o Abdo exam
• Warm fluids, blankets,
• Heat mattress = bair hugger -3M
• Increase room temp.
Fluid status • Urine Output and Glucose
• Beside = ECG,(arrythmia) Urine dipstick (UTI, DKA), CXR (pneumothorax), , pelvis X-ray, (PELVIC bleed)
Glucose
• Bloods = ABG (check lactates, base excess – cellular function = ischaemia), IDC (UO), NGT (decompress bowel in SBO/LBO)
Hardware / lines • FAST/eFAST (fcosu assessment w/ sonography in trauma è air/blood in pleural cavity + blood in abdo cavity + heart/liver)
Investigations • 2ND Survey ® ABx, tetanus prophylaxis
, ADVANCED LIFE SUPPORT - ALS
New points:
Ø C ® B ® A (NOT abc)
Ø Cycles are 2 minutely (AVOID interruptions - COACHED)
Ø CPR is the MOST IMPORTANT & PROVEN Rx
o 30:2 (adults), 15:2 (child) – rate is critical for sufficient
preload and cardiac output
o Fun Fact: cough before going into arrest - to
increase afterload
Ø Early defibrillation is key – 200J (adult), 4J/kg (child)
Ø AVOID XS ventilation
Ø 1mg Adrenaline (after 2nd shock) at 4mins
o Nb: Lower dosage of adrenaline used in anesthetics
(25mcg, 50mcg – since potent vasoconstrictor)
Post -resus care (stabilise and transfer care)
Ø Team-based approach
Ø 2nd survey = don’t forget spine injuries
Ø AMPLE history + collateral (bystander, ambo)
Ø Bloods = FBC, EUC, LFT, Blood/Urine cultures,
Ø Bedside = ECG, CXR, Urine dipstick, BSL, ABG, FAST
Ø Imaging – CT brain/chest/abdo
Ø Identify and treat causes
Keep stable
Ø Analgesia (intranasal fentanyl (child/adult) or morphine (adults)
What’s the worst thing? = 1st dx Ø Sedation (e.g. midazolam, propofol)
AAA, PE, ACS, aortic dissection, GI Ø Maintain O2 at 94-98%
perforation, tension pneumothorax
Ø Central Temp, glucose, and CO2 (capnography)
Ø Always come up with 3 DDX
AIRWAY (LEMON)
Assessment
1. History: AMPLE
2. Exam: LEMON, LOC, haemodynamics
(LEMON = should we intubate?)
3. Risk factors for difficult airway
a. Trauma, High BMI
b. FB, Congenital tumour
c. Burns
Management
1) Least invasive
2) Basic manoeuvres (chin lift with head tilt, or jaw
thrust – better for c-spine issue)
AIM to improve axis – straighten airway
3) Add adjuncts (Guedel, NPA, LMA)
4) BVM - 2 person technique
5) Advanced techniques (I+V)
Vortex
Ø After best attempt at any airway method
(e.g. LMA, BVM or Intubation)
Ø AIM = stay out of vortex
Ø Go for cricothyroidotomy (surgical airway)
NB: good sats may NOT mean a good airway
Airway Adjuncts Intubation Surgical airway
Guedel (OPA) NPA LMA I+V Tracheotomy
ALS ALS Anaesthesia 1) Create airway (blockage) Ø Can’t intubate,
Resus 2) Maintain airway (prevent) ventilate, LMA
Ind 3) Protect airway (LOC) Ø CI = futile airway, if
4) Ventilate (if lung pathology) able to secure airway
less invasively
Angle of jaw to incisors Ø Nostril to ear lobe Choose correct size Ø Cricothyroidotomy
Ø Lubricate (8mm -males, 7mm - Ø Tracheotomy
Mx females)
Ø Can cause blood loss (esp.
patient on aspirin) Ø Lubricate
, PATIENT SAFETY AND QUALITY SCENARIOS
Scenario #1 Scenario #2
Busy evening shift in a busy tertiary ED
Setting
Bed block
8yo F BIB mum 52 yo F
• Fevers at home, resolved with paracetamol Ø BIBA decreased LOC (GCS 3), found on park bench
Ø Evidence of head trauma
• Mum concerned, child not right Likely polypharmacy involved
Sx Ø
• No localising features. No PHx, IUTD Ø Patient known to ED and hospital, multiple admissions
• 2 siblings, some contacts unwell with coryza and fevers at Ø Homeless, PHx – Bipolar, T2DM poorly controlled, HT, IHD
school
• Exam completely normal VBG, US
Bloods, CT trauma, Foot Xray
• Obs BTF Initially
Workup
• Increasing RR, Increasing PR, CR prolonged on serial
assessment
• FUO - Most likely viral illness. Mother concerned • Polypharmacy OD – Alcohol, street fentanyl, ICE
• • Trauma / fall down stairs – Closed head injury, skull fracture ?acute ?old, 1 rib
DDx Obs worsening
fracture, Ankle closed fracture Weber A
• Need to consider serious bacterial infection • T2DM poorly controlled, BSL elevated 15-20 chronically no acute issues DKA etc
IVC, IVAB • Admission • Intubated for control è ICU admission required ® BUT still needs to have
particular specialty to be admitted under
Who to refer? NO other team wants to take her because of her problems:
• Neurosurgery = head injury
• Gen med (trauma) or gen surg (depends on what is available at hospital) -,
Mx HTN, polytrauma
• Orthopaedics – if minor – can be managed as outpatient (rib and Ankle ##)
• Cardiothoracics
• Endocrine consult but NOT admitted under – T2DM review for BSL control
• Mental health – polypharmacy, bipolar, homelessness
Ø Patient looks well • ICU admission required ® BUT still needs to have particular specialty to be
Ø Mother is concerned admitted under (but who with)
Patient
• Ensuring adequate care regardless of social context and previous healthcare
safety experience (beneficence) ® recognise the deteriorating patient since high-risk
complex patient
Potential for missed diagnosis and poor patient outcome • Potential for errors
Ø Challenging interactions#1 (if patient has previously assaulted staff member)
Importance of monitoring and vitals • Negotiate and de-escalate with nursing or senior staff who are upset
Ø Always look at trends (changes) • Report any issues to senior consultant (e.g. if senior team talks down on onto
Issues Ø Tachypnoea always 1st warning sign junior doctors) – resolve any issues together in small team discussions
• Should not jeopardise or delay patient care – the patient still needs to go to
Importance of listening to parental concern ICU (enforce
Ø They know best Esp for children Challenging interactions#2 (cannot be admitted under any team)
• Escalate issue to senior consultant
