acute emergencies Flashcards
GORD presentation
Retrosternal chest pain radiating to the neck
Worse after food and lying down after meal
Takes NSAIDs for arthritis
Better with antacids
Smoker, excess etoh, pregnant
pericarditis presentation
Retrosternal sharp stabbing chest pain radiating to shoulder and neck
Fever
Worse on inspiration and coughing
Relieved by sitting forward
SOB
MI presentation
Localised sharp chest pain worse on movement and breathing
Better with NSAIDS
Manual job difficult to do
PE presenation
Sudden onset sharp localised chest pain and SOB
Worse on inspiration and coughing
Haemoptysis
Past history recent surgery, smoker, take OCP
presentation of angina
Gradual onset central dull chest pain induced by exercise and relived by rest
Past history HTN, smoker, DM, hyperchol, obese
presentation of aortic dissection
Sudden onset (always thing AD)
10/10 tearing chest pain radiating to back
Syncope, pallor, clammy
Previous HTN, smoker, connective tissue disorder
presentation of gall stones
40 year old female
Dull right lower chest pain radiating to shoulder tip
Started 3 days ago
Approx. 2 hours after meal
Nausea, vomiting and fever
Eats fatty food, excess etoh, obese
investigations for cardiac chest pain
Bloods: troponin, fasting lipids, fasting glucose and FBC
Resting and exercise ECG
CXR – HF
investigations for non cardiac chest pain
CXR (pneumonia), abdominal US (gallstones), serum amylase (acute pancreatitis)
Risk factors of CHD
Smoking
Hypertension
Hyperlipidaemia
DM
Obesity
major causes of non-cardiac pain
Gall stones
GORD
PE
MSK
Anxiety and depression
major causes of cardiac pain
ACS and angina
Aortic dissection
Pericarditis
blood volume resus in chidlren
and with DKA?
If there are signs of circulatory compromise, establish venous or intraosseous access rapidly and give 20ml/kg bolus of 0.9% sodium chloride
In DKA initial bolus is 10ml/kg due to risk of cerebral oedema
Venous access in children can be difficult fluid resus should not be delayed give intraosseous
choking in children
In choking patient who is conscious and seems to be coughing effectively, encourage coughing
If cough becomes ineffective: 5 back blows followed by 5 chest thrusts
ABCDE - disability resus
low concious?
low BG?
Consider intubation to stabilise airway in any child with conscious level graded P or U
Treat hypoglycaemia with bolus 2ml/kg 10% glucose IV or IO, followed by glucose infusion to prevent recurrence
In cases of suspected raised intracranial pressure consider mannitol and neuroprotective measures
classic signs of anaphylaxis
aetiology of anaphylaxis
flushing, urticaria, angio-oedema
Allergen reacts with specific IgE antibodies on mast cells and basophils (type 1 hypersensitivity reaction), triggering the rapid release of stored histamine and rapid synthesis of newly formed mediators, causing:
Capillary leakage
Mucosal oedema
Shock
Asphyxia
Usually occur over a few minutes or occasionally biphasic (may be delayed. By a few hours)
presentation of anaphylaxis
skin
airway
general
Usually history of previous sensitivity to an allergen or recent exposure to a new drug
Skin symptoms
Itching
Urticaria
Erythema
Rhinitis
Conjuncitivits
Angio-oedema
Airway involvement
Early: Itching of the palate or external auditory meatus
Dyspnoea
Laryngeal oedema (strodros)
Wheezing (bronchospasm)
General symptoms
Palpitations
Tachycardia
Nausea
Vomiting
Abdominal pain
Fain
Sense of impending doom
Common triggers of anaphylaxis
Peanuts
Eggs
Milk
Venom e.g. bee sting
Drugs
Antibitoics
Opioids
NSAIDs
Contrast
Anaesthetic
emergency treatment of anaphylaxis
Rapid assessment: A-E
Give high flow oxygen
Lay patient flat and raise legs
Adrenaline IM in anterolateral aspect of the middle third of thigh
Adult 500mg IM
Child IM
>12 500mg
6-12- 300 mg
<6 years 150mg
Should be repeated after 5 mins if no clinical improvement
IV fluid challenge- warmed crystalloid solution e.g. Hartmanns or saline to raise BP
Antihistamine e.g. Chlorphenamine
Steroid e.g. Hydrocortisone
Continuing resp deterioration bronchodilators e.g. salbutamol
Monitor
Pulse oximetry
ECG
investigation for anaphylaxis
after treatment
Serum mast-cell tryptase - clarify diagnosis - demonstrates mast-cell degranulation
what is:
acute, subacute and chronic breathlessness?
Acute breathlessness — when it develops over minutes.
Subacute breathlessness — when it develops over hours or days.
Chronic breathlessness — when it develops over weeks or months.
cardiac causes of breathlessness
Silent MI
Cardiac arrhythmia
Acute pulmonary oedema
Chronic heart failure
pulmonary causes of breathlessness
Asthma
COPD
Pneumonia
PE
Lung cancer
Pleural effusion
other common causes of breathlessness
Anaemia
Diaphragmatic splinting (ascites, obesity, pregnancy)
Psychogenic breathlessness
silent MI:
risk factors?
symptoms?
signs?
investigations?
Risk factors — coronary artery disease, smoking, high blood lipid levels, hypertension, obesity, diabetes, family history.
Atypical presentations of myocardial infarction such as isolated breathlessness are more common in the elderly, in women and in people with diabetes, chronic renal disease and dementia.
Symptoms — breathlessness, general malaise, sudden collapse, upper body discomfort, nausea.
Signs — breathless (sometimes), abnormal pulse rate, sweating, reduced peripheral perfusion, hypotension.
Electrocardiogram (ECG) — features suggestive of acute MI include ST depression with T-wave inversion, persistent ST elevation, or new left bundle branch block. Q-waves do not give an indication of the age of an MI as remain permanent following infarction.
cardiac arrythmia
risk factors?
symptoms?
signs?
investigations?
Risk factors — heart failure, valvular heart disease, ischaemic heart disease.
Symptoms — palpitations, breathlessness, chest pain, syncope (or near syncope).
Signs — bradycardia or tachycardia.
ECG — diagnosis of arrhythmia relies on ECG obtained during the arrhythmia
pulmonary oedema
risk factors
symptoms
signs
Risk factors — chronic heart failure, ischaemic heart disease, valvular heart disease.
Symptoms — severe breathlessness, orthopnea, coughing (rarely with frothy blood-stained sputum).
Signs — elevated jugular venous pressure, gallop rhythm, inspiratory crackles at lung bases, and (occasionally) wheeze. Peripheral circulation is shut down.
cardiac tamponade summary
risk factors?
symptoms?
signs?
Risk factors — trauma, autoimmune disease, malignancy, myxoedema, myocardial infarction.
Symptoms — breathlessness, collapse.
Signs — tachycardia, pulsus paroxodus, engorgement of neck veins and face peripheral cyanosis shock.
chronic heart failure
risk factors?
symptoms?
signs?
Risk factors — trauma, autoimmune disease, malignancy, myxoedema, myocardial infarction.
Symptoms — breathlessness, collapse.
Signs — tachycardia, pulsus paroxodus, engorgement of neck veins and face peripheral cyanosis shock
pleural effusion summary
causes?
symptoms?
signs?
Causes — heart, liver, or renal failure, pneumonia, pulmonary embolism, cancer (including mesothelioma), tuberculosis, pleural infection (empyema), and autoimmune disease.
Symptoms — progressive breathlessness, pleuritic pain and symptoms of the underlying condition.
Signs — reduced chest wall movements on the affected side, stony dull percussion note, diminished or absent breath sounds, decreased tactile vocal fremitus/vocal resonance and bronchial breathing just above the effusion. There may be signs of the underlying condition.
anaemia symptoms and signs
Symptoms — mild anaemia may be asymptomatic or cause mild fatigue. As it progresses, faintness/dizziness, exertional breathlessness, palpitations and chest pain can occur. Rapid blood loss may present with collapse.
Signs — paleness (for example of the conjunctiva or palms). More severe anaemia may lead to tachycardia or cardiac failure.
diaphragmatic splinting summary
causes
symptoms
signs
(due to ascites, obesity or pregnancy)
Symptoms — chronic breathlessness that develops in association with increasing abdominal size. There are no symptoms to suggest other causes of chronic breathlessness.
Signs — ascites (shifting dullness and fluid thrill) or obesity. There are no clinical features of other causes for chronic breathlessness.
patient with unilateral weakness differential
stroke
TIA
bells palsy
General presentation of stroke and TIA
Sudden onset of focal neurological symptoms, which cannot be explained by other conditions e.g. hypoglycaemia
Numbness
Weakness
Slurred speech
Visual disturbance
define transient ischaemic attack
is a transient (less than 24 hours) neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of acute infarction.
define bells palsy
symptoms of bells palsy include - think facial nerve
Bell’s palsy is an acute, unilateral facial nerve weakness or paralysis of rapid onset (less than 72 hours) and unknown cause.
Rapid onset (less than 72 hours).
Facial muscle weakness (almost always unilateral) involving the upper and lower parts of the face. This causes a reduction in movement on the affected side, often with drooping of the eyebrow and corner of the mouth and loss of the nasolabial fold.
Ear and postauricular region pain on the affected side.
Difficulty chewing, dry mouth, and changes in taste.
Incomplete eye closure, dry eye, eye pain, or excessive tearing.
Numbness or tingling of the cheek and/or mouth.
Speech articulation problems, drooling.
Hyperacusis.
management of bells palsy
The person should be advised to keep the affected eye lubricated by using lubricating eye drops during the day and ointment at night. The eye should be taped closed at bedtime using microporous tape, if the ability to close the eye at night is impaired.
For people presenting within 72 hours of the onset of symptoms, prescription of prednisolone should be considered.
Antiviral treatment alone is not recommended, but it may have a small benefit in combination with a corticosteroid; specialist advice is recommended if this is being considered.
management of TIA
-
For people who have had a suspected TIA within the last week
- Offer aspirin 300mg immediately (+PPI for those with GORD)
- Refer to specialist assessment and investigation team
-
For people who have had a suspected TIA more than a week ago
- Refer for specialist appointment with 7 days
- Give people with suspected TIA and their family/carers info for recognising a stroke
causes of stroke in the young
- Vasculitis
- Thrombophilia
- Subarachnoid haemorrhage
- Venous sinus thrombosis
- Carotid artery dissection e.g. via near strangling or fibromuscular dysplasia
causes of stroke in the old
- Thrombosis in situ
- Athero-thromboembolism e.g. from carotid arteries
- Heart emboli (e.g. atrial fibrillation, infective endocarditis or MI)
- CNS bleed associated with hypertension, head injury, aneurysm rupture)
- Sudden blood pressure drop by more than 40 mmHg
- Vasculitis e.g. giant cell arteritis
- Venous sinus thrombosis
risk factors for stroke
HTN
COCP
DM
hyperlipidaemia
previous TIA
preipheral arterial disease
clotting disorder
alchohol
PV
management of stroke
- Do not start anticoagulation or antiplatelet treatment in people following stroke until intracerebral haemorrhage has been excluded
- While awaiting transfer: ABDE and give supplemental oxygen if sats are less than 95%
- If ischaemic clot (identified by CT) can give tPA if meets guideline
- Potentially emergency endovascular procedures
- Other procedures
- Carotid endarterectomy
- Angioplasty and stents
- If haemorrhagic
- Emergency measures- stop blood thinners
- Surgical clipping
- Coiling
- Emergency measures- stop blood thinners
