Académique Documents
Professionnel Documents
Culture Documents
Daily management
Diagnosis required
plan
Definitive Care
Medical
surgical
Radiological
Immediate Management
ABCDE
Daily management
Diagnosis required
plan
Definitive Care
Medical
surgical
Radiological
Immediate management
Airway
Look, Listen and feel
Look for presence of central cyanosis, use of accessory muscles of respiration, tracheal tug, ACS, foreign bodies
Listen for abnormal sounds e.g. grunting, snoring, gurgling, stridor
Feel for airflow on inspiration and expiration
Breathing
Look, Listen and feel
Look for central cyanosis, signs of respiratory distress
Feel for position of trachea, equality of chest expansion, percussion
Auscultate for abnormal breadth sounds, heart sounds and rhythm
Circulation
Circulatory dysfunction in a surgical pt is due to hypovoleamia until proved otherwise, therefore haemorrhage
must excluded.
Look for reduced perfusion (pallor, coolness, collapsed or underfilled veins – BP may be normal in a shocked pt)
Feel for pulses – assess for rate, quality, regularity and equality
Exposure
Allows for better assessment and access to patient for therapeutic manoeuvres but beware of pt getting cold and
maintain dignity of the patient
Grades of hypovolaemic shock
Grade 1 (15% BV, 750ml)
Mild tachycardia
Grade 2 (15-30% BV, 750-1500ml)
Mod tachycardia, pulse pressure, cap return
Grade 3 (30-40% BV, 1500-2000ml)
BP, HR, U/O
Grade 4 (40-50% BV, 2000-2500ml)
Above plus profound hypotension
Question
You visit Mr AB on the ward after his operation. You find that he is slightly
drowsy, tachycardic and is cool peripherally.
What is your immediate assessment and management.
Immediate Management
ABCDE
Daily management
Diagnosis required
plan
Definitive Care
Medical
surgical
Radiological
Full patient assessment
Inspection of charts
Respiratory (RR, FiO2, SpO2), Circulation (HR, BP, UO, CVP, fluid balance), Surgical (temperature, drainage)
Check the drug chart to see what drugs have been given and which of the pt’s usual drugs might have been
forgotten.
Review of Results
Biochemistry (U&Es, ABGs, BSLs)
Haematology (FBE, clotting)
Microbiology
Radiology
Immediate Management
ABCDE
Daily management
Diagnosis required
plan
Definitive Care
Medical
surgical
Radiological
Decide and plan
Daily management
Diagnosis required
plan
Definitive Care
Medical
surgical
Radiological
Stable patient – Daily plan
Daily plan
Fluid balance
Drugs and Analgesia – antibiotics, DVT prophylaxis
Nutrition – route, how much
Removal of drains/tubes
Investigations (bloods, X-rays, referrals)
Physiotherapy
Immediate Management
ABCDE
Daily management
Diagnosis required
plan
Definitive Care
Medical
surgical
Radiological
Unstable patient - Diagnosis required
Resuscitation
Investigations (bloods, CXR, ECG, cultures)
Consider if patient needs urgent surgery
Consider urgent specialist referrals, MET call
Consider transferring to HDU or ICU
Post Op Analgesia
Airway
Loss of airway from over sedation esp. in the elderly, patients with OSA, post cranial surgery.
Breathing
Assess depth of breathing, RR and ability to cough
Inadequate analgesia can lead to poor respiratory function and a poor cough effort.
This is a more common scenario than respiratory depression from opioid overdosage
Circulation
Inadequate analgesia can cause persistent tachycardia or hypertension, this in turn contribute to MI esp. in a
pt who is already hypoxaemic
Epidural analgesia may lead to hypotension (sympathetic blockade - vasodilatation)
Disability
Opioid toxicity
Pain scoring systems
Functional assessment
Can you sit up? Can you cough?
Techniques available for Mx of Acute pain
NSAIDs
Used as adjuncts, Increase efficacy and reduce opioid use PCA
Can affect haemostasis and renal function, gastric ulceration
Opioids
Gold standard in severe pain
Multimodal
Codeine (weak analgesis, contipating), therapy
Tramadol (opoid-like, less respiratory depression effect, less tendency
to produce dependence but marked emetic effect)
Oxycodone, oral, S/C or IV Morphine (bolus or infusion)
Side effects – Respiratory depression (reduce sensitivity of the
respiratory centres in the brain stem), Sedation (may cause loss of airway),
Nausea and vomiting (direct stimulation of CTZ in the medulla and by
reduced gastric emptying) Single-agent
analgesia
Techniques available for Mx of Acute pain
PCA
self administered boluses of morphine with “patient lockout time”.
Epidural
Most effective way of producing profound analgesia, blocks afferent pain
pathways.
Lumbar or thoracic approach
Usually a combination of drugs e.g. a local anaesthetic like bupivacaine and an
opioid like fentanyl.
Aim is to get good pain relief with minimal sympathetic effects and no motor
block.