acute and emergency Flashcards
presenting symptoms of aspirin overdose
may be initially asymptomatic
early symptoms:
- flushed
- fever
- sweating
- hyperventilation
- dizziness
- tinnitus
- deafness
- vomiting
later symptoms:
- lethargy
- confusion
- convulsions
- drowsiness
- respiratory depression
- coma
key questions in aspirin overdose case
how much was taken
when was it taken
were any other drugs taken
any alcohol
pathophysiology of aspirin overdose
aspirin is a weak acid with poor water solubility
increases RR and depth buy stimulating respiratory centre and causes resp. alkalosis
increased urinary bicarb and potassium excretion causes dehydration and hypokalaemia
loss of bicarb, uncouples oxidative phosphorylation, and lactic acid build up can cause metabolic acidosis
CNS depression and resp failure in severe cases
toxicity levels of aspirin
150mg/kg = mild
250mg/kg = moderrate
>500mg/kg = severe
>700mg/kg = potentially fatal
physical examination findings in aspirin overdose
fever
tachycardia
hyperventilation
epigastric tenderness
rare:
reduced GCS
seizures
hypotension
heart block
pulmonary oedema
hyperthermia
investigations for aspirin overdose
bloods:
- salicylate/other drug levels
- FBC
- U&E (hypokalaemia)
- LFT (high AST/ALT)
- clotting screen (high PT)
- ABG
ECG: signs of hypokalaemia
- flattened/inverted T waves
- U waves
- prolonged PR interval
- ST depression
management of aspirin
sodium bicarbonate
define anaphylaxis
acute life-threatening multi system syndrome
caused by sudden release of mast cell and basophil derived mediators
type 1 IgE mediated hypersensitivity
aetiology of anaphylaxis
immunogenic:
- IgE mediated
- immune complex/complement-mediated
non-immunogenic:
- anaphylactoid reaction
- mast cell/basophil degranulation
* without involvement of antibodies
pathophysiology of anaphylaxis
inflammatory mediators released causing:
- bronchospasm
- increased capillary permeability
- reduced vascular tone
tissue oedema affecting:
- larynx
- lids
- tongue
- lips
common allergens in anaphylaxis
drugs
latex
peanuts
shellfish
eggs
strawberries
semen
* repeated blood products in patients with selective IgA deficiency
presenting symptoms of anaphylaxis
wheeze
SoB
choking sensation
sweating
palpitations
pruritus
rash
diarrhoea and vomiting
physical examination findings in anaphylaxis
tachypnoea
hypotension
tachycardia
wheeze
swollen upper airways and eyes
cyanosis
urticarial rash
erythema
rhinitis
conjunctival infection
investigations for anaphylaxis
requires clinical dx
supporting investigations:
- serum tryptase
- histamine/urinary metabolites of histamine
investigations following an anaphylactic attack
allergen skin testing
IgE immunoassay (identifies food specific IgE)
immediate management for anaphylaxis
ABCDE
stop suspected cause
100% O2 +/- intubation if respiratory obstruction imminent
0.5mg adrenaline IM
10mg chlorpheniramine IV
100mg hydrocortisone IV
salbutamol +/- ipratropium (bronchospasm)
maintain fluids
if patient remains hypotensive:
- transfer to ICU
- IV adrenaline +/- aminophylline
- nebuliser salbutamol
pulse oximetry
ECG
BP
post-attack management of anaphylaxis
ward admittance
monitor ECG
mast cell tryptase monitoring 1-6hrs after
continue chlorpheniramine
MedicAlert bracelet
self-injected adrenaline education
skin prick tests
complications of anaphylaxis
shock
organ damage resulting from shock
prognosis of anaphylaxis
good with prompt treatment
what is a stroke?
focal/neurological disturbance to the brain lasting >24hrs
Types of stroke
- ischaemic (85%)- neurological disturbance caused by ischaemia causing brain/ spinal chord death due to vessel occlusion/ stenosis (larger extracranial carotid/ vertebral arteries, intracranial arteries, smaller lacunar arteries)
- Haemorrhagic (15%)- caused by blood collection due to ruptured blood vessel in brain
- Silent strokes- pathological infarction without neuroloical
causes of ischaemic stroke
- thrombus (also in prothrombotic state - dehydration/ pregnancy/malignancy)
- embolus of fatty deposit from larger arteries cause occlusion (from carotid dissection/ atherosclerosis/ venous blood clots pass through VSD)
- hypotension
- vasculitis
- cocaine (arterial spasm)
causes of haemorrhagic stroke
- intracerebral haemorrhage (usually due to hypertension)
- subarachnoid haemorrhage (bleeding into subarachnoid space from cerebral vessels, burst aneurysm, vascular malformations)
What is a silent stroke?
pathological sign of infarction without neurological disturbance
presenting symptoms of stroke
- SUDDEN ONSET *(motor, sensation, speech, balance, vision)
- impaired fine motor co-ordination and gait
- weakness
- confusion
- sensory loss (numbness/ parathesia)
- visual impairment (loss/ diplopia)
- headache
- face + neck pain
- dizziness/ vertigo/ loss of balance
- speech problems (dysarthria)
- nausea/ vomiting
examination findings of a stroke
- FASt (facial weakness, arm weakness, slurred speech)
Neurological examination
- Specific cranial nerve deficits such as unilateral tongue weakness or Horner’s syndrome (miosis, ptosis, and facial anhidrosis)
- sensory/ visual/ cognitive impairment
- impaired fine motor coordination + gait
-
investigations + findings for stroke
- Blood pressure + pulse (check for AF/ hypertension)
- Bloods: Clotting profile (check for thrombophillia) + blood glucose
- ECG (check for arrythmias)
- Echocardiogram (check for cardiac thrombus/ endocarditis/ emboli source)
- Doppler ultrasound (check for carotid artery disease-atherosclerosis)
- CT brain (check for haemorrhages)
- MRI brain (check for infarction - less available)
- CT cerebral Angiogram (look for carotid dissection/ stenosis)
management for suspected acute stroke:
- maintain homestasis (control blood glucose 4-11mmol/L)
- Nil by mouth until swallowing assessment
- CT/MRI <1hr- exclude haemorrhage so can start on thrombolysis
1. anti-platelets- ASPIRIN 300mg for 2 weeks, then long term antithrombotics
2. thrombolysis (ALTEPLASE)
3. thrombectomy - for large artery occlusion in proximal anterior circulation
secondary prevention for future stroke
lifestyle (reduce CVD risk): stop smoking, improve diet (less salt/sat fat), exercise, reduce alcohol
drugs: anti-platelets (clopidogrel), statin (atorvostatin), anti-hypertensives (thiazide-like diuretic/ CCBs)
*persistant AF => warfarin anti-coagulation
prognosis for stroke
10% mortality
50% of survivors after stroke dependant
10% risk of recurrence
haemorrhagic worse than ischaemic
What scoring system is used to identify sepsis?
NEWS2
- score >5
- score >3 in one parameter
Presenting symptoms + signs of sepsis
ABCDE approach to assess + manage
- B- tachypnoea- raised RR >20
- C- tachycardia (raised HR)
- D-altered mental status/ confusion
- E- raised temp, rigors (sudden fever + chills)
Infection cause specific:
Lung - cough, sputum, chest pain
Genitourinary- dysuria, discharge abdo pain
Skin- rashes, join pain, erythema
CVS- headaches, photophobia
GI- vomiting, diarrhoea, abdo pain, jaundice
Investigations for sepsis
First-line
- blood cultures
- raised serum lactate- due to increased aerobic glycolysis causing imbalanced O2 delivery/use
- hourly Urine output (reduced = poor perfusion/ cardiac output)
- Bloods- FBC, U&Es, CRP, glucose
- clotting
- ECG
Second line
- urinalysis
- CXR
- lumbar puncture- analyse CSF for infection
- CT/ MRI
Management of sepsis
Give:
- IV antibiotics
- IV fluids- 500ml saline max 30ml/kg
- oxygen (maintain >94%) for CELLULAR HYPOXIA
Take
- blood cultures- identify pathogen
- lactate level- sign of severe sepsis
- urine output
Further:
- increase bp (catecolamine vasopressors - NA/ metariminol)
- reduced cardiac function (inotropes- Adrenaline)
