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gktsm mbbs y4 smec osce revision: emtl ae

Contents. 1.0 Aims2.0 Cannulation: IVI fluids / IV medication3.0 Suturing4.0 Pre-op assessment5.0 Primary and secondary survey 6.0 BLS / ALS7.0 General Advice . 1.0 Aims. RevisionKey points ONLY

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gktsm mbbs y4 smec osce revision: emtl ae

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    1. GKTSM MBBS y4 SMEC OSCE Revision: EMTL (A&E / Anaesthetics)

    3. 1.0 Aims Revision Key points ONLY – brief over view Common stations – ALS/BLS, moulage, cannulation, suture ?Q&A post-each skill

    4. 2.0 Cannulation: IVI fluids / IV medication SITE Dorsum of non-dominant hand, if unsuccessful work proximally Easier to cannulate at junction of 2 veins Avoid: av fistula, joints and dominant hand   EQUIPMENT Cannula: Blue – difficult veins, slow iv fluids, iv medication Pink – maintenance iv fluids (not shock) Green – blood transfusion Grey – emergency   Fluid bag: Check... > contents, concentration > best before date > any holes in the bag or contaminants in the fluid

    5. 2.0 Cannulation: IVI fluids / IV medication Before procedure: Check... > name tag > drug/fluid chart - allergies During procedure: Release tourniquet before taking out needle If IVI fluids – ensure no bubbles – insert into end port of cannula - watch it work If IV injection – dilute medication – ensure no bubbles – wipe top port of cannula - flush

    6. 2.0 Cannulation: IVI fluids / IV medication After procedure: Sign drug chart Check cannulation site – infection? swelling? haematoma? Monitoring/assessing > for IVI fluids: OE / Obs / bloods 1. OE: > signs of dehydration – skin, mucous membranes > overload – jvp, oedema (pedal, sacral, abdominal) 2. Obs: BP,UO 3. Bloods: u&e > Maintenance fluids – dex / dex / saline > for insulin – BMs / antibiotics - HR, T, symptoms-se / analgesia – HR, symptoms- se

    7. 3.0 Suturing INDICATION > Wounds > Drains CONTRA-INDICATION > infection > foreign body SUTURE Absorbable (deep wound) vs non-absorbable (superficial wound ) 3-0 scalp > 6-0 face > 3-0 trunk > limbs 4-0 > feet/hand 5-0 (“36345”)

    8. 3.0 Suturing Examine: 1. Foreign body, dirt - CI 2. Muscle/tendon involvement - ?T&O surgeons 3. Bone involvement – fracture? Infection? (x-ray) 4. Distal neurovascular function - ?Vascular surgeons   Forceps: 1. Artery – hold suture (whilst making knot) 2. Needle holding forceps – hold needle 3. Toothed – hold skin

    9. 3.0 Suturing During procedure: 1. Clean the wound – iodine povidine / chlorhexidine gluconate or NaCl – in>out 2. Drape 3. Apply anaesthetic – 10ml of 1% lignocaine – aspirate on insertion – apices/edge 4. Ask patient signs of toxicity: tongue-tingling, metallic taste / ears – ringing / eyes – poor focus 5. Suture – MOST IMPORTANT – 2 (clockwise)-1 (anticlockwise)-2 (clockwise) – ensure equidistant (5mm) – knot to one side – start in middle – not to tight/loose – edges apposing   After procedure: Clean and dress Tetanus status (10 years) Wound care – wash >48h, dressing No heavy lifting for 6w / drive – emergency stop Suture remove: 6d scalp > 3d face > 6d trunk > 9d arm > 12d feet/hand

    10. 4.0 Pre-op assessment HISTORY PMH COPD, IHD (exercise tolerance), DM, RA, GORD Porphyria, haemophilia, scd Surgery? Anaesthetic? Complications? Malignant hyperpyrexia, suxamethonium apnoe   Family history of above   Drugs Insulin (hypo), anticoagulants (bleeding), antibiotics (infection), steroids (hypotension), COC (DVT) OTC / allergies (antiseptic, plaster, latex) Social Drugs / alcohol / smoking Support network

    11. 4.0 Pre-op assessment EXAMINATION 1. BMI 2. dentition (loose? Caps? Crowns?) > mallampati pharyngeal assessment (uvula/soft palate visible?) > jaw (mobile?) > neck (mobile?) > thyromental distance (<7cm?), 3. general: cv/resp/abdo/neuro ex 4. ASA physical status rating (American Society Anaethesiologists)

    12. 4.0 Pre-op assessment INVESTIGATION 1. Bloods: G+S / Xm U&E, fbc, lft, crp Clotting screen Glucose – DM, steroids, obesity, antipsychotics Sickle cell screening – afro-Caribbean and Mediterranean Drug levels 2. ECG 3. X-ray: chest / c-spine 4. lung function tests

    13. 4.0 Pre-op assessment EXPLAIN PROCEDURE Fasting (solids/fluids) > pre-medication (BDZ, anaesthetic)> anaesthetic > post-op (analgesia/anti-emetics) > home > follow up

    14. 5.0 Primary and Secondary survey Primary survey   aka Moulage Medical emergency / severe injury KNOW YOUR EQUIPMENT SCENARIO CHANGES > START FROM BEGININNG AND RE-ASSESS Inspect – danger? Response?

    15. 5.0 Primary and Secondary survey AIRWAY & C-SPINE Ask re c-spine injury? Yes > equipment? No = manual in line stabilisation (MILS) – get a second person Yes = immobilise via stiff collar, sandbags and tape (“holy trinity of c-spine”)   KEY OBSERVATIONS: RR, SATS, TEMP   Assess A – hear breathing sounds look into mouth

    16. 5.0 Primary and Secondary survey 1. airway obstruction Yes > c-spine injury? Yes > jaw-thrust technique only No > head tilt and chin lift technique   fluid or foreign body? Yes > use suction device and/or mcgill forceps (ONLY if see object AND confident you can remove it)   GCS <8 / O2 < 8 / no improvement in breathing sounds ? Yes > add airway adjunct Oropharyngeal airway (“Guedel”) Nasopharyngeal airway (when gag reflex +ve)

    17. 5.0 Primary and Secondary survey Improvement? No > apply Laryngeal Mask Airway Improvement? No > call anaesthetist and ? ENT surgeons – Endotracheal tube Improvement? No > surgical airway – tracheostomy / laryngostomy 2. No airway obstruction> move onto B

    18. 5.0 Primary and Secondary survey BREATHING Assess B Look, listen, feel for breath sounds 1. No breathing = treat as respiratory arrest Equipment? No > mouth-to-mouth ventilation Yes > BVM with pocket face mask & guedel airway/ETT – O2 supply ASAP (100%=NRM) – 10bpm

    19. 5.0 Primary and Secondary survey 2. Laboured breathing Expose chest Inspect Rate (>30?), rhythm, depth (deep/shallow?), effort (accessory muscles?), symmetry, speaking sentences? Injuries? Wounds? Palpate: Tracheal deviation (tracheal notch and apex beat)

    20. 5.0 Primary and Secondary survey Palpate, percuss, auscultate: Flail segment Pneumothorax > needle thoracocentesis / chest drain Haemothorax > chest drain Asthma/COPD exacerbation > salbutamol/ipratropium nebulisers, iv hydrocortisone, po prednisolone > no improvement = iv theophylline / magnesium

    21. 5.0 Primary and Secondary survey Acute Ix: pulse oximetry / ABG / peak flow Subacute Ix: cxr / spirometry KEY OBSERVATIONS: RR, SATS, TEMP 3. Breathing normal > move onto C

    22. 5.0 Primary and Secondary survey CIRCULATION Inspect Foremost any visible bleeding? Eg long bones Yes > concept “plug in and turn tap on” Plug in = Position, Elevation, Pressure (PEP) Tap on = cannulate (2x large bore) > bloods out (Xm 2-4u) + IVI fluids in Pelvic> call T&O surgeons Chest > chest drain Abdomen > peritoneal lavage

    23. 5.0 Primary and Secondary survey Palpate and percuss: CRT , BP, JVP, heart sounds, colour/temperature, pulse (rate, rhythm) Signs of shock? Yes > as above (treat like bleed), urinary catheter / CVP   Acute Ix: ECG Subacute Ix: CXR / ECHO KEY OBSERVATIONS: HR, BP, UO

    24. 5.0 Primary and Secondary survey DISABILITY Assess: AVPU, pupils, tone BM EXPOSURE 1. remove clothing 2. inspect front and back 3. log-roll (palpate spine – bony tenderness? deformity?) 4. PR (blood/high riding prostate? anal tone?) 5. cover in blanket (avoid hypothermia)

    25. 5.0 Primary and Secondary survey Secondary survey   AMPLE history Head-to-toe examination Observations: HR, BP, RR, sat, UO, T, AVPU Investigations: bloods, ABG, BP, 12-lead ECG, catheter/ngt, cxr, BM Other investigations: trauma series xr, toxicology screen, amylase, ck

    26. 6.0 BLS / ALS

    27. 6.0 BLS / ALS

    28. 6.0 BLS / ALS DRsABCc Danger > Response > shout > Airway > Breathing > Circulation > call   1. check for Danger – remove any cables or anything around patient!   2. check for Response – shout > shake > sternal/orbital rub …if patient is responsive > recovery position …if unresponsive > s = shout for help   ask: “has there been any trauma which may have lead to a c-spine injury?” Examiner: no   3. check the Airway (head tilt + chin lift) Examiner: the airway is clear   4. check for Breathing and Circulation simultaneously – “I am looking, listening and feeling for signs of breathing for 10 seconds and simultaneously checking the carotid pulse” Examiner: there are no signs of breathing and there is no pulse

    29. 6.0 BLS / ALS c = “I am now going to call for help; if my colleague was here then I’d send them and I’d stay here”… dial 2222 or 999… “hello, we have an unconscious patient here who is not breathing and has no pulse, we are on the ground floor of nhh, please arrive with the crash trolley and resuscitation team ASAP”   start compression 1st – “I am now going to commence CPR by beginning compressions at a rate of 100bpm in the centre of the chest to a depth of 4-5cm or 1/3 chest depth”   “I will be alternating between 30 chest compressions and 2 breaths”   Examiner: the crash team has now arrived

    30. 6.0 BLS / ALS >>> NOW SWITCH FROM ALS to BLS   “I will request one of my colleagues to take over with the chest compressions and another 2 of my colleagues will begin ventilating with a bag-valve mask via the Guedel airway, I will 1. switch “on” the defibrillator/monitor 2. apply the monitor leads and defibrillator pads/studs 3. use “lead select” and look for lead II 4. then I will assess the rhythm” (ask team to briefly stop CPR again and look at monitor)

    31. 6.0 BLS / ALS Examiner: gives you a rhythm strip to read… usually VF or VT initially… if VT, ask examiner, “is there a pulse?” (as pulseless VT is shockable) 5. this is VF, it is a shockable rhythm, so I will now select “200J” on this biphasic (360J on monophasic) defibrillator 6. and select “charge” 7. ensure the area is clear “top, middle, bottom away, self away, oxygen clear” 8. quickly re-check rhythm in a split second and select “shock” for the first time   “Now the team will resume CPR at a ratio of 30 compression to 2 breaths for 2 minutes”   Examiner may ask: how can you tell that the defibrillator is monophasic/biphasic?  

    32. 6.0 BLS / ALS Examiner may ask: what is the difference between monophasic/biphasic? 1. With a monophasic waveform, current flows in one direction, from one electrode to the other, stopping the heart so it has the chance to re-start on its own. With a biphasic waveform, current flows in one direction in the first phase of the shock and then reverses for the second phase (to help start heart?). 2. Research shows that biphasic waveforms are more effective and pose less risk of injury to the heart than monophasic waveforms- even when the shock energy level is the same!

    33. 6.0 BLS / ALS “Mean whilst I will ensure that 1. IV access is attained 2. the airway is patent and that oxygen is being delivered (BVM should be connected to continuous oxygen supply by now – oxygen cylinder) 3. once airway is secure chest compressions are given uninterrupted 4. electrodes are correctly positioned and that there is good skin contact 5. try and correct the reversible causes, the 4T’s …. And 4H’s…”

    34. 6.0 BLS / ALS Hypovolaemia > fluids (not dextrose!) / o negative blood Hypothermia > warm fluids Hypoxia > 100% O2 Hyperkalaemia / Hypocalcaemia > calcium bicarbonate H+ > sodium bicarbonate   Tension pneumothorax > needle thoracocentesis Tamponade > pericardiocentesis Thromboembolism > thrombolysis Toxins > specific antidote   [nb Hypo/Hyper – calcium, magnesium and potassium!]

    35. 6.0 BLS / ALS Examiner: 2 minutes has now passed   “I will now re-assess the rhythm strip” (ask team to briefly stop CPR again and look at monitor)   Examiner: gives you a rhythm strip to read… usually VF or VT initially… if VT, ask examiner, “is there a pulse?” (as ONLY pulseless VT is shockable) 5. this is pulseless VT, it is a shockable rhythm, so I will now select “200J” on this biphasic (360J on monophasic) defibrillator 6. and select “charge” 7. ensure the area is clear “top, middle, bottom away, self away, oxygen clear” 8. quickly re-check rhythm in a split second and select “shock” for the second time   “Now the team will resume CPR at a ratio of 30 compression to 2 breaths for 2 minutes”

    36. 6.0 BLS / ALS Examiner: 2 minutes has now passed   “I will now re-assess the rhythm strip” (ask team to briefly stop CPR again and look at monitor)   Examiner: gives you a rhythm strip to read… usually VF or VT initially… if VT, ask examiner, “is there a pulse?” (as pulseless VT is shockable) 5. this is still pulseless VT, it is a shockable rhythm, NOW BEFORE I GIVE THE THIRD SHOCK, I WILL GIVE 1mg OF ADRENALINE IV AT A CONCENTRATION OF 1 in 10,000 6. I will now select “360J” on this biphasic (360J on monophasic) defibrillator 7. and select “charge” 8. ensure the area is clear “top, middle, bottom away, self away, oxygen clear” 9. quickly re-check rhythm in a split second and select “shock” for the third time   “Now the team will resume CPR at a ratio of 30 compression to 2 breaths for 2 minutes”   State that “I will give 1mg of adrenaline every other cycle” (ie- every 4 minutes, as each cycle is 2 minutes!)

    37. 6.0 BLS / ALS Examiner: 2 minutes has now passed   “I will now re-assess the rhythm strip” (ask team to briefly stop CPR again and look at monitor)   Examiner: gives you a rhythm strip to read… usually VF or VT initially… if VT, ask examiner, “is there a pulse?” (as pulseless VT is shockable) 5. this is still pulseless VT, it is a shockable rhythm, NOW BEFORE I GIVE THE FOURTH SHOCK, I WILL GIVE A ONE-OFF DOSE OF 300mg AMIODARONE IV 6. I will now select “360J” on this biphasic (360J on monophasic) defibrillator 7. and select “charge” 8. ensure the area is clear “top, middle, bottom away, self away, oxygen clear” 9. quickly re-check rhythm in a split second and select “shock” for the fourth time   “Now the team will resume CPR at a ratio of 30 compression to 2 breaths for 2 minutes”

    38. 6.0 BLS / ALS Examiner: 2 minutes has now passed   “I will now re-assess the rhythm strip” (ask team to briefly stop CPR again and look at monitor)   Examiner: gives you a rhythm strip to read… this time a non-shockable rhythm… either PEA or asystole/slow PEA(bradycardia)… ask examiner, “is there a pulse?” 5. this is a non-shockable rhythm, so I will give 1mg OF ADRENALINE IV AT A CONCENTRATION OF 1 in 10,000   “Now the team will resume CPR at a ratio of 30 compression to 2 breaths for 2 minutes”

    39. 6.0 BLS / ALS Examiner: 2 minutes has now passed   “I will now re-assess the rhythm strip” (ask team to briefly stop CPR again and look at monitor)   Examiner: gives you a rhythm strip to read… this time a non-shockable rhythm… either PEA or asystole/slow PEA (bradycardia)… ask examiner, “is there a pulse?” Examiner: there is no pulse “this is a PEA (commonly due to hypovolaemia), so I will give 1mg OF ADRENALINE IV AT A CONCENTRATION OF 1 in 10,000”   “Now the team will resume CPR at a ratio of 30 compression to 2 breaths for 2 minutes”

    40. 6.0 BLS / ALS Examiner: 2 minutes has now passed   “I will now re-assess the rhythm strip” (ask team to briefly stop CPR again and look at monitor)   Examiner: gives you a rhythm strip to read… this time another non-shockable rhythm… asystole/slow PEA (bradycardia)   “this is asystole/bradycardia, so I would like to give ONE-OFF DOSE OF 3mg OF ATROPINE IV”   “Now the team will resume CPR at a ratio of 30 compression to 2 breaths for 2 minutes”   State that “I will give 1mg of adrenaline every other cycle” (ie- every 4 minutes, as each cycle is 2 minutes!)

    41. 6.0 BLS / ALS Examiner: 2 minutes has now passed   “I will now re-assess the rhythm strip” (ask team to briefly stop CPR again and look at monitor)   Examiner: gives you a rhythm strip to read… sinus rhythm!.. ask the examiner: is there a pulse? Yes   State: “I would now resume post-resus care”

    42. 6.0 BLS / ALS Examiner: what is post-resus care?   1. continued resuscitation after return of spontaneous circulation A/B – intubation+ventilation? Oxygen via facemask? ausculate C – monitor pulse, ECG, BP, assess peripheral perfusion, auscultate D/E - GCS 2. continued monitoring and investigations – fbc/biochemistry, ECG, CXr, ABG 3. safe transfer of patient - to “intensive/coronary care unit” 4. ensuring optimal organ function – CVS: BP, Urine Output Neuro: cerebral perfusion, control seizures, control temperature Other: blood glucose 5. assessment of prognosis after cardiac arrest Once the heart has been resuscitated to a stable rhythm and cardiac output, the brain has the most important influence on survival – day 3 post-arrest: (1) coma, (2) absence of papillary light reflexes or (3) absent motor response to pain are independent predictors of a poor outcome - ie death/persistent vegetative state  

    43. 7.0 General Advice Practice makes perfect Examiners can tell who has/has not practiced Read emergencies section OHCM For moulage – know ALL equipment Suturing – practice with different forceps and be able to recognise them ALS – make sure you know how to use the defib! Smile and be confident ;p

    44. mohammed.faraaz@heartofengland.nhs.uk

    45. Questions ???

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