ABCDE disability Flashcards
Assessment disability ABCDE
Vitals:
GCS
Look:
Pupils
Move:
Move all limbs
Invetsigations disability ABCDE
Blood glucose
Ketones
If GCS <8 what do you do
anaesthetics!
Management of hypoglycameia
If the patient is alert, a quick-acting carbohydrate may be given (as above).
If the patient is unconscious or unable to swallow, subcutaneous or intramuscular injection glucagon may be given.
Alternatively, intravenous 20% glucose solution may be given through a large vein
Management of DKA
- Fluid resucitation until SBP >90
- Once SBP is >90mmHg, give 1L of normal 0.9% sodium chloride over 1 hour. Monitor K+ with ABG/VBG and add it to the fluids accordingly.
- Commence a fixed rate intravenous insulin infusion. 0.1 units/kg/hr (prescribed as Actrapid)
+ Make sure to continue the patient’s long acting insulins subcutaneously
diagnosing DKA?
Blood glucose > 11mmol/L or known diabetes mellitus*
Ketonaemia ≥ 3.0 mmol/L or significant ketonuria (more than 2+ on standard urine stick).
Bicarbonate <15mmol/L and/or venous pH < 7.3. (Use venous readings to assess acidosis rather than arterial unless gas exchange must be assessed)
what elements of DKA pathogenesis will kill the pt
dehydration, potassium imbalance and acidosis.
why does GCS need to be monitored closely DKA
CEREBRAL OEDEMA
Neurological observations (i.e. GCS) should be monitored very closely (e.g. hourly) to look for signs of cerebral oedema. Be concerned when patients being treated for diabetic ketoacidosis develop headaches, altered behaviour, bradycardia or changes to consciousness.
Management options for cerebral oedema are slowing IV fluids, IV mannitol and IV hypertonic saline. These should be guided by an experienced paediatrician.
what trigger should you look for DKA
sepsis
presentation DKA
Polyuria
Polydipsia
Nausea and vomiting
Weight loss
Acetone smell to their breath
Dehydration and subsequent hypotension
Altered consciousness
Symptoms of an underlying trigger (i.e. sepsis)
why is it important that fluid and hyperglycaemia correction is done slowly DKA
CEREBRAL OEDEMA
Dehydration and high blood sugar concentration cause water to move from the intracellular space in the brain to the extracellular space. This causes the brain cells to shrink and become dehydrated. Rapid correction of dehydration and hyperglycaemia (with fluids and insulin) causes a rapid shift in water from the extracellular space to the intracellular space in the brain cells. This causes the brain to swell and become oedematous, which can lead to brain cell destruction and death.
causes of seizures?
Vascular: haemorrhagic stroke
Infectious: meningitis, encephalitis, systemic infection lowering seizure threshold, febrile seizures paeds
Trauma: head injury
Metabolic: Electrolyte disturbances: hyponatraemia, hypernatraemia, hypoglycaemia, hypocalcaemia, hypokalaemia, ammonia (hepatic encephalopathy)
Iatrogenic: tricyclic overdose, alcohol and benzodiazepine withdrawal
Neoplastic: space occupying lesion,
Environment: alcohol, stress, sleep deprivation
Functional: non-epileptic seizure
Pregnancy: eclampsia
what are breakthrough seizures
seizures that occur in known epileptics. These can be caused by poor medication compliance or precipitating factors such as sleep deprivation, alcohol and stress.
complications of prolonged seizures?
Airway:
Hypoxic brain injury due to airway occlusion and aspiration
Develop epilepsy after a prolonged seizure w hypoxic brain injury
Aspiration pneumonia
Injury:
Anterior dislocation of shoulder
Trauma and injury eg falling down stairs
Muscles contracting:
Electrolyte complications- lactic acidosis -
Creatinine kinase as a result of muscle breakdown - raised - rhabdomyolysis - kidney failure
Potassium intracellular so as muscles breakdown it is released - hyperkalaemia
Heart:
Arrhythmias
when should you treat a seizure?
Emergency treatment should be sought or given once a seizure has persisted, or there are serial seizures, for five minutes or more.
what is status epilepticus?
a single seizure lasting >5 minutes, or
>= 2 seizures within a 5-minute period without the person returning to normal between them
what should you consider as the cause for seizures first?
Rule out hypoxia and hypoglycemia before considering other causes
Assessment of prolonged seizure
ABCDE
Airway
Nasopharyngeal airway works well
Suction if anything visible
Recovery position if at risk of aspiration
Breathing
Oxygen
ABG may show metabolic acidosis (lactic acid from muscle contraction)
Circulation
At risk of
ECG monitor as at risk of CA and because of drugs you will use
Disability
GCS
Blood glucose!!
Exposure
Check for head trauma
PPting factors: acute illness, possible toxic exposure, trauma, recent heavy alcohol intake or cessation of chronic drinking, change in antiseizure medications
invetsigations
ABG (For acute prolonged seizures looking for hypoxia and hypercapnia)
Blood tests: FBC, U&Es (including serum calcium, magnesium and phosphate) LFTs, glucose
Urine test: urine toxicology screen
Imaging: CT Head
who should undergo RSI - rapid sequence endotracheal intubation and mechanical ventilation?
●Unprotected or unmaintainable airway
●Apnea or inadequate ventilation
●Hypoxemia
●Status epilepticus lasting ≥30 minutes
●Need to protect airway for urgent brain imaging (eg, in a patient with preceding trauma or signs of basilar territory stroke)
prolonged seizure treatment algorithim
- Benzodiazepine dose 1
- If still fitting after 10 mins, benzodiazepine dose 2
- Phenytoin or levetiracetam (keppra)
- If beyond 30 mins - Refractory status epilepticus (RSE) is defined as status epilepticus that continues despite treatment with benzodiazepines and one antiepileptic drug. - rapid sequence endotracheal intubation and mechanical ventilation - thiopentone in fitting pt (has anti-seizure properties)
what benzodiazepine should you use in prolonged seizure algorithim in diff settings?
Pre-hospital buccal midazolam 10mg may be given by carers etc
Hospital setting w/o IV access - give rectal diazepam 10mg
Hospital setting w IV access - give 4mg IV lorazepam
benzodiazepine SE/risks
CNS depressive affects
resp depression
antidote benzodiazepines? works well for?
Flumazenil is antidote (selective competitive antagonist of the gamma-aminobutyric acid (GABA) receptor)
- Flumazenil may be effective in reversing the sedation that occurs in a benzodiazepine overdose, but its effects on reversal of depressed breathing is less predictable.
Phenytoin considerations and dosing
20mg/kg loading dose
then 100mg every 6-8 hrs
DO NOT GIVE LOADING DOSE IF ALREADY ON PHENYTOIN - THEORETICAL RISK
It is Contraindicated in:
Second- and third-degree heart block; sino-atrial block; sinus bradycardia; Stokes-Adams syndrome, pregnancy
Ask if pregnant
Ask about medications and risk of CA
ECG monitor
What alternative drugs could you use if phenytoin is contraindicated?
Sodium valproate
Phenobarbital
what induction agent RSI fitting
thiopentone in fitting pt (has anti-seizure properties)
what is hypoglycaemia
Hypoglycemia occurs when glucose concentration falls below the normal fasting glucose level. Generally, this is defined as blood glucose levels below 3.3 mmol/L.
why are episodes of hypoglycaemia common in diabetic patients?
due to the variable response of blood glucose levels to their medications
symptoms of hypoglycaemia at different BG levels?
Blood glucose concentrations <3.3 mmol/L cause autonomic symptoms due to the release of glucagon and adrenaline (average frequency in brackets):
Sweating (66%)
Shaking (55%)
Hunger (44%)
Anxiety (27%)
Nausea (13%)
Blood glucose concentrations below <2.8 mmol/L cause neuroglycopenic symptoms due to inadequate glucose supply to the brain:
Weakness (50%)
Vision changes (42%)
Confusion (33%)
Dizziness (26%)
Severe and uncommon features of hypoglycaemia include:
Convulsion
Coma
provoked seizures causes?
hypo
eclampsia
aclohol
management of alcohol withdrawal delirium tremens
Chlordiazepoxide in reducing regimen
Lorazepam if hepatic failure in reducing regimen
Carbamazepine
Consider need for thiamine (pabrinex)
Management of eclampsia
Management:
Obstetrician
Anaesthetist
Emergency theatres
Neonatal intensivist
May call general surgeons if obs not here yet
- Magnesium sulphate
IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
The only definitive treatment of eclampsia is delivery of the fetus.
what is the main risk of magnesium sulphate to treat eclampsia ? management of this?
respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
how long should magnesium sulphate be continued for in eclampsia
treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
