Airway - signs of airway obstruction
- Paradoxical chest and abdominal movements (‘see-saw’ respirations)
- Use of accessory muscles of respiration
- Central cyanosis (late sign)
- No breath sounds (in complete obstruction) or diminished and often noisy entry (in incomplete obstruction)
Airway - treatment for airway obstruction
- Airway opening manoevers, Airway suction, insertion of oropharyngeal or nasopharyngeal airway
- Tracheal intubation may be required when these fail
- High concentration oxygen through non-rebreather mask with oxygen resevoir
Breathing - assessment of breathing
- Look, listen and feel for general signs of respiratory distress
- Respiratory rate (high = >25)
- Assess depth, rhythm and whether chest expansion is equal
- Note oxygen saturations
- Percuss the chest
- Auscultate the chest
- Chest position of the trachea in the suprasternal notch
- Note any chest deformity
- Feel the chest wall to detect surgical emphysema or crepitus (suggesting pneumothorax until proven otherwise
A subgroup of COPD patients are at righ of hypercapnic respiratory failure. Nevertheless, these patients will also sustain end-organ damage or cardiac arrest if their blood tensions are allowed to decreased. In this group aim for less than normal oxygen saturations. What percentage Venturi mask would you use and what oxygen saturation would you aim for?
Aim for target SpO2 range 88-92%. Give oxygen via Venturia mask at 24% or 28% initially and reassess.
Circulation - Assessment of Circulation
- Are peripheries warm? Assess colour of hands. Capillary refil time.
- Palpate peripheral and central pulses, assessing for presence, rate, quality, regularity
- Measure blood pressure
- Ausculate the heart
- ECG
- Look for other signs of low cardiac output, such as reduced consious level and oliguria
- Look thoroughly for evidence of external or internal haemorrhage
Circulation - immediate treatment
- Insert one or more large (14 or 16G) intravenous cannulae. (Consider intraosseous needle if failure to gain IV access)
- Take blood from cannula for routin haematological, biochemical, coagulation and microbiological investiations and cross-matching
- Give a bolus of 500ml crystalloid solution (use smaller volumes eg 250ml in patients with known cardical failure and use closer monitoring)
Immedicate treatment if the patient has primary chest pain and suspected ACS
- Record a 12 lead ECG early
- Aspirin 300mg orally as soon as possible
- Sublingual GTN
- Oxygen - only give oxygen if sats <94% on air
- Morphine IV, titrated to avoid sedation and respiatory depression
Disability - assessment
- Check drug chart for reversible drug-induced causes of depressed consiousness
- Examine the pupils
- Assess conscious level using ACVPU
- Meausre blood gluocse
- Check temperature
ACVPU
- A - alert
- C - new confusion
- V - responds to voice
- P - responds to painful stimuli
- U - unresponsive
How to treat glucose <4.0mmol/L in an unconscious patient
10% glucose 50mls IV, repeat every minute until patient has fully regained consciousness or total of 250ml of 10% glucose has been given.
