case 16 - emergency medicine Flashcards
1
Q
what is a symptom sieve and why is it used?
A
list of pathological categories that can be worked through systematically to come up with a broad list of differentials
2
Q
give examples of symptom sieves used in clinical practice
A
VITAMIN C DEF
MAGIC ADDITIVE
MEDIC HAT PINE
MIDNIT
3
Q
explain the symptoms sieve: VITAMIN C DEF
A
4
Q
explain the symptoms sieve: MAGIC ADDITIVE
A
5
Q
explain the symptoms sieve: MIDNIT
A
6
Q
explain the symptoms sieve: MEDIC HAT PINE
A
7
Q
what is the A-E assessment?
A
the approach to managing a deteriorating or critically ill patients
A - airways
B - breathing
C - circulation
D - disability
E - exposure
8
Q
in ABCDE, how are the airways assessed?
A
9
Q
in the following circulation assessment, which reading requires the most urgent attention and why?
A
blood pressure of 89/64mmHg
= hypotension risks hypoperfusion of the tissues risking ischaemia which can progress to tissue infarction causing multiple organ failure
(must prevent circulatory shock!)
10
Q
throughout your ABCDE assessment, how would you manage a result that is concerning?
A
address and manage the concerning result as soon as you discover it
= do not (!!!) leave it to return to and manage later
11
Q
what are the possible reasons for airway obstruction?
A
foreign objects in mouth
excessive secretions
mouth/tongue swelling
12
Q
what are some signs of respiratory distress?
A
increased breathing rate (tachypnoea)
cyanosis
grunting
sweating
wheezing
13
Q
what is the peripheral capillary refill?
A
the time taken for color to return to an external capillary bed after pressure is applied to cause blanching
14
Q
what does the capillary refill time indicate and why is it important?
A
indicates blood volume and perfusion levels
= indicative of hypovolemia or hypoperfusion (possibly caused by peripheral vasconstriction)
15
Q
what is ACVPU?
A
a scale used to assess and track a patient’s neurological status and level of consciousness
(alert, confusion, voice, pain, unresponsive)
16
Q
what is GCS?
A
the most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury
(Glasgow Coma Scale)
17
Q
what is PEARL?
A
Pupils
Equal
AND
Round/Reactive (to)
Light
= used when assessing head injuries and brain function
18
Q
how is the GCS of a patient assessed?
A
add together the scores from eye-opening, verbal response and motor response to obtain a value out of 15
= allows evaluation of patient consciousness and informs management
19
Q
what is the normal capillary refill time?
A
a normal CRT is 1 to 2 seconds
= consistent with a normal blood volume and perfusion
(a CRT longer than 2 seconds suggests poor perfusion due to peripheral vasoconstriction)
20
Q
what does a CRT longer than 2 seconds suggest?
A
a CRT longer than 2 seconds suggests poor perfusion due to peripheral vasoconstriction
21
Q
what is circulatory shock?
A
when inadequate blood flow results in damage to body tissues
= due to inadequate oxygen delivery to tissues and therefore inadequate substrates for aerobic cellular respiration
22
Q
what are the four classes of circulatory shock?
A
cardiogenic shock (cardiac dysfunction)
hypovolemic shock (blood loss)
obstructive shock (obstruction to blood flow)
distributive shock (vasodilation)
23
Q
what are the subtypes of distributive shock?
A
septic
anaphylactic
neurogenic
24
Q
what is hypovolemic shock?
A
shock caused by severe blood or other fluid loss makes the heart unable to pump sufficient blood to the body
25
what causes hypovolemic shock?
haemorrhage
severe vomiting (salt & water loss)
diarrhoea
burns
26
explain the pathophysiology of hypovolemic shock
depletion of intravascular volume
= body compensates w increased heart rate, increased cardiac contractility, and peripheral vasoconstriction BUT
= reduced blood pressure due to reduced blood volume
= hypoperfusion of organs
= ischaemia and infarction
27
what is cardiogenic shock?
caused by failure of the heart to pump correctly, either due to damage to the heart muscle or through cardiac valve problems
28
what causes cardiogenic shock?
acute myocardial infarction
cardiomyopathy
cardiac rupture
valve problems
29
explain the pathophysiology of cardiogenic shock
reduction in myocardial contractility
= diminished cardiac output + hypotension
= systemic vasoconstriction
= cardiac afterload that overburdens damaged myocardium
= impaired stroke volume and cardiac output
= cardiac ischemia
= diminished oxygenated blood flow to peripheral tissue
= vital end‐organ damage
30
what is obstructive shock?
caused by an (extra-cardiac) obstruction of blood flow outside of the heart
31
what are the causes of obstructive shock?
pulmonary embolism
cardiac tamponade (pericardial space gets filled w fluid)
tension pneumothorax
(pericardial effusion)
32
explain the pathophysiology of obstructive shock
obstruction
= reduce blood flow in the great vessels or critical, rapid drop in cardiac output and global oxygen supply
= shock with tissue hypoxia in all organ systems
33
what is distributive shock?
(i.e. vasodilative shock)
caused by an abnormal distribution of blood to tissues and organs
34
what are the causes of distributive shock?
sepsis
anaphylaxis
neurogenic
35
explain the pathophysiology of distributive shock
systemic vasodilation
= decreased blood flow to the brain, heart, and kidneys damaging vital organs
= ischaemia + infarction
36
explain the three possible causes of vasodilative/distributive shock
sepsis/anaphylaxis = inflammatory immune cells release cytokines and histamines to fight infection/antigen, causing vasodilation
neurogenic = loss of sympathetic tone leads to a significant decrease in systemic vascular resistance e.g. spinal cord injury
37
what are the most common types of shock?
distributive (septic) = 62%
cardiogenic = 16%
hypovolemic = 16%
38
what does arterial hypotension lead to?
tissue hypoperfusion
39
what are the main signs of tissue hypoperfusion?
brain = altered mental state
skin = mottled, clammy
kidney = oliguria (reduced urine output)
heart = tachycardia, elevated blood lactate
40
what is the first thing that is assessed when the circulatory shock is suspected?
cardiac output
41
how is circulatory shock confirmed?
echocardiography
42
what kind of circulatory shock does the following suggest?
normal cardiac chambers and (usually) preserved contractility
distributive (vasodilative) shock
43
what kind of circulatory shock does the following suggest?
small cardiac chambers and normal/high contractility
hypovolemic shock
44
what kind of circulatory shock does the following suggest?
large ventricles and poor contractility
cardiogenic shock
45
what kind of circulatory shock does the following suggest?
tamponade; pericardial effusion; small ventricles; dilated IVC; pulmonary embolism
obstructive shock
46
how is the type of circulatory shock determined?
schematic
47
what are the four stages of sepsis?
SIRS (systemic inflammatory response to sepsis)
sepsis
severe sepsis
septic shock
48
what is the criteria for SIRS (sepsis stage 1)?
\>2 of the following:
- temperature (either \>38 or \<36)
- heart rate (\>90 bpm)
- respiratory rate (\>20)
- WBC count (\>12/\<4 x10^9/L)
49
what is the criteria for sepsis (sepsis stage 2)?
meets the SIRS criteria with evidence of infection
(confirmed on a blood culture)
50
what is the criteria for severe sepsis (sepsis stage 3)?
sepsis (stage 2) with evidence of either
- organ dysfunction (urine output)
- hypotension
- hypoperfusion (lactate)
51
what is the criteria for septic shock (sepsis stage 4)?
severe sepsis (stage 3) with HYPOTENSION which does not improve despite adequate fluid resuscitation
52
which temperature reading is required (in conjunction with at least one other indication of sepsis) to confirm the diagnosis of SIRS?
\>38 OR \<36 degrees Celsius
(together w one of the following: HR \> 90; RR \> 20; abnormal WBCC)
53
which heart rate is required (in conjunction with at least one other indication of sepsis) to confirm the diagnosis of SIRS?
\>90 bpm
(together w one of the following: temp \>38/\<36; RR \> 20; abnormal WBCC)
54
which respiratory rate is required (in conjunction with at least one other indication of sepsis) to confirm the diagnosis of SIRS?
\>20 breaths per minute
(together w one of the following: temp \>38/\<36; HR \> 90; abnormal WBCC)
55
which WBC count is required (in conjunction with at least one other indication of sepsis) to confirm the diagnosis of SIRS?
\>12 x10^9 or \<4x10^9 (/L)
(together w one of the following: temp \>38/\<36; HR \> 90; RR \> 20)
56
how is SIRS diagnosed?
following NEWS reading and FBC (for the WBCC)
57
how is sepsis (stage 2) diagnosed?
blood cultures (to provide evidence of infection)
58
how is severe sepsis diagnosed?
urine output (indicative of organ dysfunction)
lactate (indicative of hypoperfusion)
BP measurement (indicative of hypotension)
59
how is septic shock diagnosed?
if hypotensive patient does not show improvement despite adequate fluid resuscitation
60
what are the sepsis six?
for a patient with suspected sepsis, you give three things and take three things
give
- oxygen to keep sats above 94%
- IV antibiotics
- a fluid challenge
take ('measure')
- blood cultures
- lactate (in an ABG/VBG)
- urine output
61
why are blood cultures taken in a patient with suspected sepsis?
to check for infection (sepsis stage 2)
62
why is lactate measured in a patient with suspected sepsis?
to check for organ hypoperfusion (severe sepsis)
= hypoperfusion causes hypoxia which triggers a switch from aerobic to anaerobic metabolism of respiratory substrates causing lactic acidosis
63
why is urine output measured in a patient with suspected sepsis?
to check for organ dysfunction (severe sepsis)
= if renal function is impaired or the kidneys are hypoperfused, oliguria can occur
64
why is oxygen given to a patient with suspected sepsis?
as hypoperfusion occurs as a result of sepsis, they require higher levels of oxygen delivery to maintain aerobic metabolism
= also given to reduce lactic acidosis
(only given if sats are below 94%)
65
why are IV antibiotics given to a patient with suspected sepsis?
(bacterial) infections are the most common cause of sepsis
= IV antibiotics target the infection as quickly as possible to prevent deterioration into septic shock
66
what must you remember when administering IV antibiotics to a patient with suspected sepsis?
the earlier they are administered the better (!!)
(!!) MUST be administered AFTER blood cultures are taken (otherwise can interfere with results)
67
what is a fluid challenge?
identifies and simultaneously treats volume depletion
250-500ml of crystalline fluid (NaCl or Hartmann's)
68
why is lactate taken as part of an ABG/VBG instead of a full blood test?
quicker results through an ABG/VBG
and don't have to wait two hours for the blood test results
69
what is the purpose of a fluid challenge?
250-500ml of crystalline fluid (NaCl or Hartmann's)
= increases blood volume to increase perfusion of the tissues
70
which of the following blood test results support the diagnosis of sepsis and why?
CRP
WBC
neutrophils
lactate
71
why must elevated CRP be interpreted cautiously?
(CRP = acute phase protein produced in the liver as a sign of infection or inflammation)
it is non-specific = so could be raised in a non-infectious inflammatory condition/malignancy
72
how do elevated creatinine and urea have to be interpreted in terms of sepsis?
have to be compared to previous creatinine and urea results as what appears abnormal can be 'normal' for the patient
= must check before concluding that it is a sign of hypoperfusion to kidney injury
73
what is GGT and why is it an important blood test?
gamma glutamate transferase
(part of the LFTs)
= increased in patients with liver disease (cirrhosis, hepatitis, fatty liver) as a result of alcohol/drugs/toxins etc
74
why is a lactate measurement important in the diagnosis of sepsis?
lactate levels are elevated in severe sepsis
= indicative of switch to anaerobic metabolism due to hypoxia secondary to hypoperfusion
(red flag sepsis = lactate \> 2 mmol/L)
75
which blood markers indicate an infection?
(elevated) CRP, WBC, neutrophils
76
what does a positive serum ethanol suggest?
alcohol consumption
77
calculate a NEWS2 score from the following data set
3
(1 for high systolic BP, 1 for high pulse, 1 for high temperature)
78
what is a NEWS2 score?
a NATIONAL system for scoring a patient's beside observations and determining current health status
= to identify acutely unwell, deteriorating patients
79
which physiological parameters make up a NEWS2 score? (6)
respiration rate
oxygen saturation (scale 1 or scale 2)
systolic blood pressure
pulse rate
level of consciousness or new confusion
temperature
80
how is respiratory rate calculated for a NEWS2 score?
calculated manually (without telling the patient as this can alert them to their breathing)
- high resp rate one of the first signs of a deteriorating patient
- above 20 = immediate score of 2
81
how is oxygen saturation calculated for a NEWS2 score?
using an oximeter
- scale 1 for the majority of patients
- scale 2 for patients with hypercapnia respiratory failure (type II)
82
how is oxygen saturation calculated for a NEWS2 score?
using an oximeter
- scale 1 for the majority of patients
- scale 2 for patients with hypercapnia respiratory failure (type II)
83
what is the oxygen target for patients on SpO2, scale 2?
88-92%, on air
84
what classifies a patient into the SpO2 category?
if they have type 2 respiratory failure (i.e. hypercapnia respiratory failure)
85
what are the possible causes of hypercapnic respiratory failure?
can be caused by COPD, severe asthma, drug overdose, myasthenia gravis etc
86
why is the oxygen target for type II RF patients lower than that for other patients?
in type II RF, there is ventilation-perfusion mismatch
= as in type II RF there is increased physiological dead space so giving more oxygen would be futile as you are merely oxygenating dead space
87
how is blood pressure calculated for a NEWS2 score?
using a blood pressure monitor (but can be manual - rare)
- not very concerned w HIGH systolic blood pressure until it is really high (not too concerned about hypertension)
- biggest cause of concern is hypotension (systolic BP fall below 110)
88
how is blood pressure calculated for a NEWS2 score?
using a blood pressure monitor (but can be manual - rare)
- not very concerned w HIGH systolic blood pressure (hypertension) until it is really high
- biggest cause of concern is hypotension (systolic BP fall below 110)
89
how is pulse calculated for a NEWS2 score?
using the observations machine
- most concerning when patient is tachycardia w pulse above 90
- bradycardia is also concerning but comparatively less so unless it is really low (\<50)
90
how is consciousness calculated for a NEWS2 score?
alert IF = awake, and looking around and readily responds to questions or initiates conversation
```
C = confusion
V = responds to Voice
P = responds to Pain
U = unresponsive
```
= anything NOT alert will score 3 automatically
91
how is temperature calculated for a NEWS2 score?
using the observation machine
= both elevated (above 38) and decreased (below 36) is an issue that scores
= can have cold sepsis (rare), but possible in patients who cannot mount the temperature response in infection
92
what does a NEWS chart look like?
93
how frequently do patients with a NEWS score of 0 need to be monitored?
minimum 12 hourly
94
what is the clinical response to patients with a NEWS score of 0?
continue routine NEWS monitoring
95
how frequently do patients with a NEWS score of 1-4 need to be monitored?
minimum 4-6 hourly
96
what is the clinical response to patients with a NEWS score of 1-4?
- inform registered nurse who must assess the patient
- registered nurse then decides whether increased frequency of monitoring and/or escalation of care is required
97
how frequently do patients with a NEWS score of 3 in a single parameter need to be monitored?
minimum 1 hourly
98
what is the clinical response to patients with a NEWS score of 3 in a single parameter?
- registered nurse to inform medical team caring for the patient, who will review then decided whether escalation of care is necessary
99
how frequently do patients with a NEWS score of 5 or more need to be monitored?
minimum 1 hourly
100
what is the clinical response to patients with a NEWS score of 5 or more?
- registered nurse to immediately inform the medical team caring for the patient
- registered nurse to request an urgent assessment by clinician or team with core competencies in the care of acutely unwell patients
- provide clinical care in an environment that has monitoring settings
101
how frequently do patients with a NEWS score of 7 or more need to be monitored?
continuous monitoring of the vital signs
102
what is the clinical response to patients with a NEWS score of 7 or more?
- registered nurse to immediately inform the medical team caring for the patient (at least at specialist registrar level)
- emergency assessment by a team with critical care competencies and practitioner with airway management skills
- consider transfer of care to a level 2/3 clinical care facility (HDU/ICU)
- clinical care delivery in a place with monitoring equipment
103
what does the following CT report suggest and why?
a) colerectal adenocarcinoma
b) sigmoid diverticulitis
c) acute kidney injury
d) appendicitis
b) sigmoid diverticulitis
- multiple diverticulae present in the colon
- the wall of the sigmoid colon is much thicker
- peri-colic fat stranding
- fluid-filled mass in the anterior abdomen/free fluid in LLQ
104
what are diverticulae?
small, bulging pouches that can form in the lining of your digestive system
(involve all the gut layers)
105
what is peri-colic fat stranding?
change in attenuation of fat around an inflamed structure
- lower attenuation = larger adipocytes and increased fat content
- higher attenuation = lower lipid content and smaller adipocytes
106
what does thickening of the sigmoid colon wall indicate?
may be caused by neoplastic, inflammatory, infectious, or ischaemic conditions
107
what does free fluid in the left quadrant indicate?
free diverticular perforation results in the extravasation of air and fluid into the pelvis and peritoneal cavity
= peritoneal fluid in cavity
108
where can diverticula form?
anywhere in the GI tract from the oesophagus to the rectum
109
how do diverticulae present?
most people with diverticulae are asymptomatic
= only (accidentally) discovered on imaging/colonoscopy
110
what is diverticulosis?
the presence of diverticulae
= a condition that occurs when small pouches, or sacs, form and push outward through weak spots in the wall of your colon
111
what is diverticulitis?
when one or more of these pouches (diverticulae) become inflamed or infected = diverticulitis results
112
give one way in which diverticulitis can develop
stool becomes trapped (constipation, low fibre diet) and acts as a source of infection for diverticulitis
113
differentiate between diverticulosis and diverticulitis
diverticulosis = presence of several outpouchings in the wall of the colon
diverticulitis = when these small, bulging outpouches become inflamed or infected
114
what is the approach to all deteriorating/critically-ill patients?
ABCDE assessment
| (airways, breathing, circulation, disability, exposure)
115
what must you remember during and ABCDE assessment?
1) treat life-threatening problems before moving to the next part of assessment (!!)
= treat a problem you discover then and there, do not prolong
2) assess the effects of treatment
3) call for help when needed
4) use all members of the team
5) communicate effectively using SBAR or RSVP
116
when are the airways considered safe?
can be considered safe if the patient is able to speak
117
what happens if there is an airway obstruction?
emergency and calls for immediate expert help
= prolonging treatment can lead to hypoxia, organ damage cardiac arrest and death
118
what are the possible problems associated with airways?
decreased GCS (GCS ≤8 usually requires intubation)
excessive secretions
foreign body
airway swelling/inflammation
trauma
119
which GCS score indicates a requirement for intubation?
usually \<= 8
120
how does partial airway obstruction present?
may be noisy breathing (snoring, stridor, wheeze) with diminished air entry
121
how does total airway obstruction present?
there will be no breath sounds at the nose or mouth
122
what is a late sign of airway obstruction?
central cyanosis
123
what is central cyanosis?
generalised bluish discoloration of the body and the visible mucous membranes
= due to inadequate oxygenation
124
if the airways are found to be abnormal in an ABCDE assessment, what actions are taken
1) airway opening manoeuvers (head tilt, chin lift, jaw thrust)
2) suction to remove debris
3) simple airway adjuncts (nasopharyngeal, oropharyngeal)
4) complex airway adjuncts (supraglottic airway)
5) advance airway interventions (intubation, emergency surgical airway)
= then OXYGEN at HIGH concentrations
125
what are some airway opening maneouvers?
head tilt, chin lift, jaw thrust
126
how is debris removed from the airways?
suction
127
what are simple airway adjuncts?
devices prevent the occlusion of the airway (by tongue) and thereby provide an open conduit for air to pass
- oropharyngeal airway
- nasopharyngeal airway
128
what is a supraglottic airway?
a group of airway devices that can be inserted into the pharynx to allow ventilation/oxygenation without the need for endotracheal tubing
129
what are some advanced airway interventions?
intubation, emergency surgical airway
130
what are the possible problems associated with breathing?
- reduced GCS
- acute severe asthma/ COPD
- pneumonia
- pulmonary oedema
- (tension) pneumothorax or haemothorax (latter often associated w trauma)
- pulmonary embolism
- respiratory depression (e.g. secondary to drug toxicity)
131
how is breathing assessed in an ABCDE assessment?
- obtain oxygen sats and RR
- are they able to talk in sentences? words? not at all?
- look for respiratory muscles, central cyanosis
- look/feel for symmetry of chest/deformity
- assess tracheal deviation
- percuss the chest
- auscultate the chest
- look at the calves
132
how are airways assessed in an ABCDE assessment?
- look for chest/abdominal movements
- look for partial/total obstruction
- look for central cyanosis
133
what does tracheal deviation indicate?
displacement away from lesion
- tension pneumothorax
- large pleural effusion
displacement towards side of lesion
- lobar collapse
- pneumonectomy
- pulmonary fibrosis
134
what does hyper-resonant chest percussion indicate?
pneumothorax
135
what does dull chest percussion indicate?
consolidation or pleural fluid
136
what do you auscultate the chest for?
to hear air and any other added sounds (crackles, wheeze, stridor)
137
what do absent/reduced lung sounds indicate?
complete obstruction
= pneumothorax, pleural fluid, lung consolidation
138
why do we look at the calves when assessing breathing?
if there are signs of DVT
= could also indicate pulmonary embolism
139
what actions are taken after a breathing ABCDE assessment?
- treat based on cause
- ABG
- give oxygen if sats are below 94%
- sit patient up if short of breath
- use bag-mask/pocket mask ventilation = if insufficient rate/depth of breathing
- may require NIV or intubation or ventilation in extreme cases if breathing does not improve
140
why can you do if the patient is short of breath?
sit them up
141
what do you do if the patient's breathing rate and depth is too low?
use a bag-mask or pocket mask ventilation
+ expert help
142
if breathing does not improve despite intervention, what is the maangement?
NIV
ventilation
intubation
143
why can you not give some COPD patients oxygen?
as they have chronic hypercarbia (increased CO2 in the blood)
= their stimulation for ventilation is hypoxia ('hypoxic drive') not CO2 levels
= so giving oxygen can depress respiratory system
= end-organ damage, cardiac arrest
144
what must be considered the primary cause of circulatory shock?
hypovolemia (until proven otherwise)
145
what does the treatment of cardiovascular collapse involve?
fluid replacement
haemorrhage control
restoration of tissue perfusion
146
what problems with circulation can occur?
hypovolemia (burns, diarrhoea, vomiting, bleeding, dehydration)
pump failure
- cardiogenic (heart failure, MI, arrhythmia)
- non-cardiogenic (cardiac tamponade, tension pneumothorax, PE)
vasodilation (sepsis, anaphylaxis)
147
how is circulation assessed in an ABCDE assessment?
- look at colour of hands/digits
- limb temperature
- measure CRT
- heart rate
- 12-lead ECG
- look at JVP
- palpate peripheral and central pulses
- measure blood pressure
- auscultate
148
how is limb temperature assesed?
by feeling the patient's hands: cold or warm?
149
how is CRT measures?
apply cutaneous pressure for 5 seconds on a fingertip held at heart level to cause blanching
time how long it takes for the skin to return to its previous colour after releasing
150
how are CRT results interpreted?
normal CRT is \< 2 s
prolonged CRT suggests poor peripheral perfusion (but can also be due to cold surroundings and old age)
151
what can an elevated JVP indicate?
heart failure or fluid overload
152
what do barely palpable pulses indicate?
poor cardiac output
(bounding pulse = sepsis)
153
why can blood pressure be normal in circulatory shock?
compensatory mechanisms increase peripheral resistance in response to reduced cardiac output
154
what is possible if you cannot successfully hear heart sounds?
cardiac tamponade
155
how is the circulation of a patient managed in an ABCDE assessment?
- insert IV cannula
- measure lactate levels
- give fluid challenge (if BP is low)
- give blood if there is blood loss
156
why are lactate level smeasured in a deteriorating patient?
to indicate tissue perfusion levels
157
what is a fluid challenge?
approx 250ml up to 1000ml of crystalloid fluid, depending on the
patient and the situation
(not given to the elderly w heart failure!)
158
how is the BP managed if it does not improve upon fluid resuscitation?
intensive care
specific drug infusion that stimulate vasoconstriction
159
which problems are associated with disability in the ABCDE assessment?
profound hypoxia or hypercapnoea
drugs – sedatives, opioids, toxins, poisons
cerebral hypoperfusion (eg from profound hypotension)
raised intracranial pressure
CVA
metabolic dysfunction eg hypoglycaemia
160
what is disability in the ABCDE assessment?
looks at level of consciousness and neurological functioning
161
how is disability assessed?
- abcDEFG = don't ever forget glucose!
- temperature
- neurological status (either ACVPU/GCS)
- check PEARL
- assess for pain
- drug chart
162
what action is taken to address diasbility?
- oral and parentral glucose
- analgesia for pain
- specific treatment for specific problems (e.g. specialist inout if raised ICP)
163
how is the body examined?
examine head to toe, front and back
look for bleeding, swellings, rashes, sores, wounds, catheters
perform an exam of the relevant system(s) (e.g. abdo)
take a full clinical history
review notes, charts, lab results etc
164
differentiate between ACVPU and GCS
rapid assessment - ACVPU (Alert, Confused, respond to Voice, respond to Pain, Unresponsive)
formal assessment - GCS
165
what is PEARL?
pupils equal and reactive to light
166
according to the NEWS chart, what is an acceptable respiration rate?
12-20
167
according to the NEWS chart, what is an acceptable SpO2 (scale 1)?
\>=96% on air
168
according to the NEWS chart, what is an acceptable SpO2 (scale 2)?
88-92%
(\>=93% on air)
169
according to the NEWS chart, what is an acceptable systolic blood pressure?
111-219
170
according to the NEWS chart, what is an acceptable pulse?
51-90
171
according to the NEWS chart, what is an acceptable temperature?
36.1 - 38
172
what is the clinical risk for an aggregate NEWS score of 0-4?
low clinical risk
173
what is the response for an aggregate NEWS score of 0-4?
ward based response
(inform registered nurse - then she decides
freq of monitoring OR escalation of care)
174
what is the clinical risk for a red NEWS score of 3 in a single parameter?
low-medium risk
175
what is the response for an aggregate NEWS score of 3 in a single parameter?
urgent ward based response
(inform medical team and they decide escalation of care)
176
what is the clinical risk for an aggregate NEWS score of 5-6?
medium risk
177
what is the response for an aggregate NEWS score of 5-6?
key threshold for emergency response
(inform medical team and clinician w core competencies + environment w monitoring facilites)
178
what is the clinical risk for an aggregate NEWS score of 7 or more?
high
179
what is the response for an aggregate NEWS score of 7 or more?
urgent or emergency response
(inform medical team and seniors and clinician w core competencies + environment w monitoring equipment, consider transfer to ITC/HDU)
180
name the four abdominopelvic quadrants
right upper quadrant
right lower quadrant
left upper quadrant
left lower quadrant
181
name the nine abdominopelvic regions
right hypochondriac
right lumbar
right iliac
epigastric
umbilical
hypogastric (or pubic)
left hypochondria
left lumbar
left iliac
182
which are bigger: quadrants or regions?
regions \> quadrants
183
what is sometimes considered the tenth abdominopelvic region?
perineum (the area beneath the hypogastric region at the bottom of the pelvic cavity)
184
what is the purpose of the abdominal divisions?
to describe and categorise the individual abdominal organs by their location and function
to help diagnose the source of abdominal pain and determine appropriate treatment
185
which two planes intersect to form the four abdominopelvic quadrants?
sagittal plane
umbilical plane (transverse plane through the navel)
186
what does the right upper quadrant contain?
right portion of the liver, gallbladder, right kidney,
a small portion of the stomach, head of the pancreas
portions of the ascending and transverse colon, and parts of the duodenum
187
what is pain the RUQ most commonly associated with?
infection or inflammation of the gallbladder/liver
peptic ulcers of the stomach
188
what does the left upper quadrant contain?
left portion of the liver, left kidney, spleen
part of the stomach, the pancreas
portions of the transverse and descending colon, and parts of the small intestine
189
what is pain in the LUQ usually associated with?
malrotation of the intestine and colon
190
what does the right lower quadrant contain?
caecum, appendix, ascending colon, part of the small intestines
right half of the female reproductive system
right ureter
191
what is pain in the RLQ usually associated with?
appendicitis
192
what does the left lower quadrant contain?
majority of the small intestine, some of the large intestine
left half of the female reproductive system
left ureter
193
what is pain in the LLQ usually associated with?
colitis (inflammation of the large intestine)
pelvic inflammatory diseases
ovarian cysts (in females)
194
which planes intersect to form the nine abdominopelvic regions?
two parasagittal planes
two transverse planes (around the navel)
195
what does the right hypochondriac region contain?
right portion of the liver, gallbladder
right kidney
parts of the small intestine
196
what does the right lumbar region contain?
part of the liver, gallbladder
right kidney
ascending colon
197
what does the right iliac fossa region contain?
appendix, cecum
(i.e. right inguinal region)
198
what does the epigastric region contain?
majority of the stomach, pancreas
part of the liver, part of the spleen, adrenal glands
part of part of the duodenum
199
what does the umbilical region contain?
small intestine (duodenum , jejunum, ileum)
part of the transverse colon
bottom parts of the left and right kidney
200
what does the suprapubic/hypogastric region contain?
sigmoid colon
organs of the reproductive system (uterus/ovaries in females; prostate in males)
bladder, rectum, anus
201
what does the left hypochondriac region contain?
spleen, left kidney
part of the stomach, the pancreas
parts of the colon
202
what does the left lumbar region contain?
descending colon
left kidney
part of the spleen
203
what does the left iliac fossa region contain?
descending colon, sigmoid colon
(i.e. left inguinal region)
204
what is diverticulosis?
a condition in which there are small pouches or pockets in the wall or lining of any portion of the digestive tract
205
when does diverticulosis occur?
when the inner layer of the digestive tract pushes through weak spots in the outer layer
= forms diverticulae
206
where are diverticulae most commonly found?
lower part of the large intestine (the colon)
207
who gets diverticulosis?
US = affects half of all people over 60 years of age and nearly everyone by the age of 80
(unusual in people below the age of 40; uncommon in Asia & Africa)
208
why is diverticulosis uncommon in Asia and Africa?
diets are high in fibre and rich in grains, fruits and vegetables
(diverticulosis associated with low-fibre diets)
209
explain how diverticulosis is associated with low-fibre diets
low fibre diet
= constipation
= increases pressure in the GI tract
= strains bowel movements
= increased pressure + straining leads to diverticulosis
210
what are the symptoms of diverticulosis?
most are asymptomatic BUT can cause
- bloating
- abdominal cramps
- constipation due to difficulty in stool passage through affected region of colon
211
how is the diagnosis of diverticulosis made?
usually found incidentally during evaluation for another condition or during a screening exam for polyps
212
how are diverticulae visualised?
1) uses a small camera attached to a lighted, flexible tube inserted through the rectum
= sigmoidoscopy or colonoscopy
2) can be seen in CT scans and barium x-rays
213
differentiate between a sigmoidoscopy and a colonoscopy
sigmoidoscopy = uses a short tube to examine only the rectum and lower part of the colon
colonoscopy = uses a longer tube to examine the entire colon
214
what is the treatment for diverticulosis?
usually asymptomatic but the symptoms that do present (bloating, abdominal pain and constipation) are usually addressed by
= increasing fibre intake
215
why is a high-fibre diet recommended for diverticulosis?
make stools softer and easier to pass
216
what is the daily recommended fibre intake?
20-35 grams a day
217
what is the easiest way to increase fibre intake?
eat more fruits, vegetables or grains
= apples, pears, broccoli, carrots, squash, baked beans, kidney beans, and lima beans are a few examples of high-fiber foods
218
what are supplemental fibre products?
psyllium, methylcellulose or polycarbophil
= in pill, powder, wafer form
219
why are supplemental fibre products prescribed?
help to bulk up and soften stool, which makes bowel movements easier to pass
220
what are the complications of diverticulosis?
inflammation, infection, bleeding or intestinal blockage
221
when does diverticulitis occur?
when the pouches become infected or inflamed
222
how does diverticulitis present?
usually produces
- localized abdominal pain
- tenderness to touch
- fever.
- nausea
- vomiting
- shaking, chills
- constipation
223
which imaging is ordered to confirm diverticulitis?
CT abdomen
224
how are minor cases of infection in diverticulitis treated?
usually treated with oral antibiotics and do not require admission to the hospital
225
what happens if diverticulitis is left untreated?
may lead to a collection of pus (called an abscess) outside the colon wall
or possibly a generalized infection in the lining of the abdominal cavity (peritonitis)
226
how is an abscess diagnosed and treated?
CT scan of the abscess
= hospital stay, IV antibiotics, drainage of the abscess
227
how are repeated attacks of diverticulitis managed?
may require surgery to remove the affected portion of the colon
228
what is diverticular bleeding?
bleeding in the colon may occur from a diverticulum
= most common cause of major colonic bleeding in over 40s
229
how is diverticular bleeding managed?
usually stops independently BUT if not then, colonoscopy
230
how is severe, persistent diverticular bleeding managed?
hospital stay
IV fluids
blood transfusions
colonoscopy = to determine cause of bleeding and treat it
maybe surgery
231
what can repeat attacks of diverticulitis lead to and how is this managed?
intestinal blockage
= surgery to remove affected colon
232
what do warm peripheries suggest?
vasodilation
233
what does a higher than normal creatinine suggest in terms of sepsis?
poor renal clearance, hypoperfused kidneys
234
how quickly do the sepsis 6 need to be carried out?
within the hour = 'golden hour'
235
how is diverticulitis linked to sepsis?
diverticulitis is a common cause of sepsis from the abdomen
236
at what NEWS2 score should you begin to suspect sepsis in an unwell patient
sepsis should be suspected in any patient with a NEWS2 score of 5 or more OR if a patient scores 3 in any of the NEWS2 parameters
237
how many of the conditions below are usually associated with left iliac fossa pain?
- diverticulitis
- inflammatory bowel disease
- ovarian cysts
- acute kidney injury
- appendicitis
three
- diverticulitis
- inflammatory bowel disease
- ovarian cysts
```
(appendicits = generalised/umbilical to RIF)
(AKI = 'loin to groin')
```
