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Y5 Emergency Medicine > 7 - A-E Assessment and Acute Presentations > Flashcards

7 - A-E Assessment and Acute Presentations Flashcards

1
Q

What tool is used to determine whether someone with a PE can be treated as an outpatient?

A

PESI

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2
Q

How should you approach someone with SOB in ED?

A
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3
Q

What questions should you ask when a patient presents to ED with shortness of breath?

A
  • Onset
  • Duration
  • Severity
  • Precipitating events
  • Associated symptoms
  • Postural changes
  • Previous episodes
  • PMHx
  • SHx
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4
Q

What are some differentials you need to consider in ED when someone presents with SOB?
How can you differentiate between the different conditions based on their presenting symptoms?

A
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5
Q

What are the important exams to do on top of an A to E assessment when someone presents with SOB?

A
  • Respiratory
  • Cardio
  • Abdominal
  • General (see image)
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6
Q

What investigations should you do in ED if someone presents with SOB?

A
  • Sats
  • ABG
  • CXR
  • ECG
  • D-dimer or CTPA if Well’s score suggests PE
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7
Q

How would the following presentations show on a CXR?

A
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8
Q

What is the acronym to remember the management of SOB caused by pulmonary oedema?

A

Pour SOD

  • Pour away (stop) their IV fluids
  • Sit up
  • Oxygen
  • Diuretics (40mg Furosemide STAT)
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9
Q

If initial management of pulmonary oedema is not working what can you do next?

A

PODMAN

  • Intravenous opiates to act as vasodilators
  • NIV like CPAP
  • Inotropes if on ITU
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10
Q

What life threatening differentials do you need to consider when a patient presents with chest pain?

A
  • ACS (STEMI/NSTEMI/Unstable angina)
  • Aortic dissection
  • PE
  • Pneumothorax
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11
Q

Once you have ruled out life threatening differentials, what are some other causes of chest pain that may present to ED?

A
  • Anxiety
  • Shingles
  • Costochondritis
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12
Q

How may aortic disecction present?

A

Chest pain PLUS 1

  • Radiates to back or neck
  • Any neurological symptoms
  • Limb ischaemia
  • Renal colic type pain
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13
Q

What test should you order if you suspect an aortic dissection?

A

CT angiogram of Aorta

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14
Q

What is the acronym for the ACS initial protocol?

A

MONAC
- Morphine
- Oxygen if sats <94%
- Nitrates
- Aspirin
- Clopidogrel

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15
Q

How should you approach a patient in ED with chest pain?

A
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16
Q

How will the following causes of chest pain present?

A
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17
Q

What are some risk factors you need to enquire about in the history of a patient with acute chest pain as it could mean they are more likely to have an ACS, aortic dissection or PE?

A
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18
Q

What investigations should you perform for a patient with acute chest pain?

A
  • ECG
  • CXR
  • Serial troponins
  • D-dimer/CTPA/VQ if indicated
  • CT angiogram of aorta if indicated
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19
Q

What signs may be found on examination of a patient with acute chest pain and the following diagnosis (especially aortic dissection and MI)

A

Aortic dissection will have different blood pressures in both arms and may have neurological symptoms

MI often has diaphoresis. May be silent in women and diabetics, may present as indigestion.

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20
Q

What is included in an A to E assessment?

21
Q

What are the signs of a compromised airway?

A
  • Stridor/stertor
  • Reduced breath sounds
  • Cyanosis
  • Confusion
  • Rapid shallow breathing
  • Unconscious
22
Q

What are some common causes of a compromised airway?

A
  • Allergic reaction
  • Foreign body
  • Trauma to airway
  • Inhalational injury
  • Bacterial/viral infections e.g croup, epiglotitis
  • Asthma
  • COPD
23
Q

What are some techniques to combat a compromised airway?

A
  • Heimlich manouevre
  • Head tilt chin lift/jaw thrusts
  • Oro/nasopharyngeal airways
  • I-gel
  • Laryngeal mask
  • Endotracheal intubation
  • Tracheostomy
24
Q

What is type 1 and type 2 respiratory failure and some causes of each?

A

Type 1 (PaO2 <8)

Hypoxic (pneumonia, pulmonary oedema, PE)

Type 2 (PaO2<8 PCO2>6)

Hypercapnia (coma, COPD, asthma, pneumothorax, intracerebral haemorrhage)

25
Q

What is the difference between type 1 and type 2 respiratory failure?

A

**Type 1 - **V/Q mismatch
Type 2 - Alveolar hypoventilation

26
Q

How do you take an ABG?

A

https://geekymedics.com/wp-content/uploads/2021/04/OSCE-Checklist-ABG-Sampling.pdf

27
Q

What do you need to remember when cannulating?

A

Only withdraw the needle slightly until you get the plastic tube full in

28
Q

What are some common causes of tachypnea?

A
  • First sign of shock
  • Anxiety
  • Asthma
  • PE
  • COPD
  • DKA
  • Pleural effusion
  • Pneumonia
  • Sepsis
29
Q

What are some common causes of bradypnoea?

A
  • Opioids/drug induced
  • Raised ICP
  • Hypothyroidism
  • Low GCS
  • Electrolyte imbalances
  • High blood pressure
  • Head injury
  • Stroke
30
Q

How may bradypnoea be treated?

A
  • Reversal of drugs
  • BiPAP
  • Oxygen
31
Q

Is CPAP classed as NIV?

A

NO - it does not ventilate only oxygenates and holds airway open

NIV is a way to ventilate, usually BiPAP

32
Q

What are the indications for CPAP?

A
  • Hypoxia in the context of chest wall trauma despite adequate anaesthesia and high flow oxygen (pneumothorax should be ruled out using CXR before CPAP)
  • Cardiogenic pulmonary oedema
  • Pneumonia
  • Sleep apnea
33
Q

What are the indications for NIV?

A
  • COPD with respiratory acidosis (pH 7.25-7.35)
  • Hypercapnic respiratory failure secondary to chest wall deformity (scoliosis, thoracoplasty) or neuromuscular disease
  • Weaning from tracheal intubation
  • Cardiogenic pulmonary oedema unresponsive to CPAP
34
Q

What monitoring has to be done whilst on CPAP/NIV?

A
  • Pulse oximetry
  • ECG
  • BP
  • RR
  • Consciousness
  • Pulse
  • ABG before starting and 30-60 minutes after any change in settings
35
Q

What are some complications with NIV?

A
  • Mask leak
  • Stomach inflation and aspiration
  • Pressure sores
36
Q

What is the modified Wells score for PE and how do you interpret the findings?

37
Q

What is circulatory failure?

A

Inadequate effective blood flow leading to tissue hypoperfusion and hypoxia

38
Q

What are the different types of shock and how do they present?

A

- Septic:hypotensive, warm, flushed, tachycardic
- Hypovolemic: pale, cool, tachycardic
- Neurogenic: hypotensive, bradycardic, neurological deficits
- Cardiogenic: pale, clammy, cool, raised JVP, basal lung creps, tachycardia or profound bradycardia
- Anaphylactic: flushed, warm, rapid weak pulse, wheeze, stridor, urticaria, oedema

39
Q

What are some causes of cardiogenic and hypovolemic shock?

A

Cardiogenic (pump failure or inadequate filling)
- Outflow obstruction e.g aortic dissection
- Dysrhytyhmia
- PE
- Cardiac tamponade
- Tension pneumothorax

Hypovolemic
- External blood loss
- Internal blood loss e.g ruptured AAA
- Dehydration
- Excess fluid loss e.g vomiting
- 3rd space losses e.g pancreatitis

40
Q

How do you treat non-haemorraghic hypovolemic shock?

A
  1. Lay pt flat and elevate legs
  2. 15l oxygen non-rebreathe
  3. IV access and take blood
  4. 1L 0.9% NaCl STAT
  5. Identify likely cause
  6. Catheterise and fluid balane chart
41
Q

How do you investigate and manage cardiogenic shock?
(go over causes again)

A

MANAGE BEFORE INVESTIGATIONS AS LIFE THREATENING

Ix: ECG, CXR, ABG, ECHO
Mx:15L O2 and definitive management of above

42
Q

How should you initially treat neurogenic shock?

A
  1. Lay flat and elevate legs (only if no spinal injury)
  2. 15L O2
  3. 1L 0.9% NaCL STAT
  4. Involve spinal surgeons
  5. If epidural stop and consult anaesthetist
43
Q

What is the pathophysiology behind neurogenic shock?

A

Decrease in peripheral vascular resistance mediated by marked vasodilation due to decrease in sympathetic tone

This results in decreased preload and thus decreased cardiac output (Starling’s law)

44
Q

What is the main cause of cardiogenic shock?

45
Q

What are the causes of a normal anion gap metabolic acidosis?

46
Q

What are the causes of a raised anion gap metabolic acidosis?

47
Q

How is haemoraghic shock managed?

A
  1. Lay pt flat and elevate legs
  2. Apply direct pressure to bleeding
  3. 15L O2
  4. IV Access and blods (FBC, clottinh, urgent cross match)
  5. 1L 0.9% NaCL
  6. O -ve blood, do not give lots of fluid resus as will dilute clotting factors. Permissive hypotension allowed initially
48
Q

How do you treat hypoglycaemia?

A

Don’t forget the long acting carbohydrate afterwards

Y5 Emergency Medicine (14 decks)

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