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csi (phase 1b) > case 16 - emergency medicine > Flashcards

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 used to come up with a broad list of differentials

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2
Q

give examples of symptom sieves used in clinical practice

A

VITAMIN C DEF

MAGIC ADDITIVE

MEDIC HAT PINE

MIDNIT

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3
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

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4
Q

in ABCDE, how are the airways assessed?

A
  • verbalising
  • foreign objects in mouth
  • excessive secretions
  • snoring
  • mouth or tongue swelling
  • decreased GCS
  • use of accessory muscles
  • central cyanosis (turning blue)
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5
Q

How is breathing assessed?

A
  • respiratory rate
  • oxygen saturation
  • respiratory distress e.g cough
  • wheezing
  • smoker
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6
Q

what are some signs of respiratory distress?

A

increased breathing rate (tachypnoea)

cyanosis

grunting

sweating

wheezing

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7
Q

How is circulation assessed?

A
  • blood pressure
  • heart rate
  • heart sounds
  • ECG
  • peripheral capillary refill time
  • temperature of peripheries
  • colour of hands
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8
Q

How is disability assessed?

A
  • blood glucose
  • temperature
  • ACPVU and GCS
  • limb movement
  • evidence of alcohol or drug use
  • head injuries (PEARL)
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9
Q

what is PEARL?

A

pupils equal and reactive to light

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10
Q

How is exposure assessed?

A
  • rashes
  • injection/track marks
  • trauma
  • external bleeding
  • abdominal examination (e.g distension or tenderness)
  • clinical history
  • patient notes
  • lab investigations
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11
Q

Why does low blood pressure require urgent attention?

A

hypotension risks hypoperfusion of the tissues risking ischaemia which can progress to tissue infarction causing multiple organ failure

(must prevent circulatory shock!)

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12
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)

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13
Q

what is ACVPU?

A

a scale used to assess a patient’s neurological status and level of consciousness

(alert, confusion, voice, pain, unresponsive)

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14
Q

what is Glasgow Coma Scale/GCS?

A

scoring system used to describe the level of consciousness in a person following a traumatic brain injury

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15
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

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16
Q

what does a CRT longer than 2 seconds suggest?

A

poor perfusion due to peripheral vasoconstriction

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17
Q

what is circulatory shock?

A

when inadequate blood flow results in damage to body tissues

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18
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)

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19
Q

what are the subtypes of distributive shock?

A

septic
anaphylactic
neurogenic

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20
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

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21
Q

what causes hypovolemic shock?

A

haemorrhage
severe vomiting (salt & water loss)
diarrhoea
burns

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22
Q

what is cardiogenic shock?

A

caused by failure of the heart to pump correctly, either due to damage to the heart muscle or through cardiac valve problems

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23
Q

what causes cardiogenic shock?

A

acute myocardial infarction
cardiomyopathy
cardiac rupture
valve problems

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24
Q

what is obstructive shock?

A

an obstruction of blood flow outside of the heart

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25
Q

what are the causes of obstructive shock?

A

pulmonary embolism

cardiac tamponade (pericardial space gets filled w fluid)

tension pneumothorax

(pericardial effusion)

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26
Q

what is distributive shock?

A

an abnormal distribution of blood to tissues and organs

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27
Q

what are the causes of distributive shock?

A

sepsis
anaphylaxis
neurogenic

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28
Q

explain the three possible causes of vasodilative/distributive shock

A

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

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29
Q

what are the most common types of shock?

A
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30
Q

what does arterial hypotension lead to?

A

tissue hypoperfusion

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31
Q

what are the main signs of tissue hypoperfusion?

A

brain = altered mental state

skin = mottled, clammy

kidney = oliguria (reduced urine output)

heart = tachycardia, elevated blood lactate

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32
Q

what is the first thing that is assessed when the circulatory shock is suspected?

A

cardiac output

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33
Q

how is circulatory shock confirmed?

A

echocardiography

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34
Q

what kind of circulatory shock does the following suggest?

normal cardiac chambers and (usually) preserved contractility

A

distributive (vasodilative) shock

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35
Q

what kind of circulatory shock does the following suggest?

small cardiac chambers and normal/high contractility

A

hypovolemic shock

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36
Q

what kind of circulatory shock does the following suggest?

large ventricles and poor contractility

A

cardiogenic shock

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37
Q

what kind of circulatory shock does the following suggest?

tamponade; pericardial effusion; small ventricles; dilated IVC; pulmonary embolism

A

obstructive shock

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38
Q

what are the four stages of sepsis?

A
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39
Q

how is SIRS diagnosed?

A

following NEWS reading and FBC (for the WBCC)

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40
Q

how is sepsis (stage 2) diagnosed?

A

blood cultures (to provide evidence of infection)

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41
Q

how is severe sepsis diagnosed?

A

urine output (indicative of organ dysfunction)

lactate (indicative of hypoperfusion)

BP measurement (indicative of hypotension)

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42
Q

how is septic shock diagnosed?

A

if hypotensive patient does not show improvement despite adequate fluid resuscitation

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43
Q

what are the sepsis six?

A

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
44
Q

why are blood cultures taken in a patient with suspected sepsis?

A

to check for infection (sepsis stage 2)

45
Q

why is lactate measured in a patient with suspected sepsis?

A

to check for organ hypoperfusion (severe sepsis)

hypoperfusion causes hypoxia which triggers a switch from aerobic to anaerobic metabolism causing lactic acidosis

46
Q

why is urine output measured in a patient with suspected sepsis?

A

to check for organ dysfunction (severe sepsis)

= if renal function is impaired or the kidneys are hypoperfused, oliguria can occur

47
Q

why is oxygen given to a patient with suspected sepsis?

A
  • hypoperfusion increases levels of oxygen required to maintain aerobic metabolism
  • also given to reduce lactic acidosis
  • only given if sats are below 94%
48
Q

why are IV antibiotics given to a patient with suspected sepsis?

A

target the infection as quickly as possible to prevent deterioration into septic shock

49
Q

what is GGT and why is it an important blood test?

A
  • gamma glutamate transferase
  • increased in patients with liver disease (cirrhosis, hepatitis, fatty liver) as a result of alcohol/drugs/toxins etc
50
Q

which blood markers indicate an infection?

A

(elevated) CRP, WBC, neutrophils

51
Q

what does a positive serum ethanol suggest?

A

alcohol consumption

52
Q

calculate a NEWS2 score from the following data set

A

3

(1 for high systolic BP, 1 for high pulse, 1 for high temperature)

53
Q

what is a NEWS2 score?

A

a NATIONAL system for scoring a patient’s beside observations and determining current health status to identify acutely unwell, deteriorating patients

54
Q

which physiological parameters make up a NEWS2 score? (6)

A

respiration rate

oxygen saturation (scale 1 or scale 2)

systolic blood pressure

pulse rate

level of consciousness or new confusion

temperature

55
Q

how is respiratory rate calculated for a NEWS2 score?

A

calculated manually (without telling the patient as this can alert them to their breathing)

56
Q

how is oxygen saturation calculated for a NEWS2 score?

A

using an oximeter

  • scale 1 for the majority of patients
  • scale 2 for patients with hypercapnic respiratory failure (type II)
57
Q

what are the possible causes of hypercapnic respiratory failure?

A

COPD, severe asthma, drug overdose, myasthenia gravis etc

58
Q

how frequently do patients with a NEWS score of 0 need to be monitored?

A

minimum 12 hourly

59
Q

how frequently do patients with a NEWS score of 1-4 need to be monitored?

A

minimum 4-6 hourly

60
Q

how frequently do patients with a NEWS score of 3 in a single parameter need to be monitored?

A

minimum 1 hourly

61
Q

how frequently do patients with a NEWS score of 5 or more need to be monitored?

A

minimum 1 hourly

62
Q

how frequently do patients with a NEWS score of 7 or more need to be monitored?

A

continuous monitoring of the vital signs

63
Q

what is the clinical risk for an aggregate NEWS score of 0-4?

A

low clinical risk

64
Q

What is diverticulosis?

A
  • small, bulging pouches that can form in the lining of your digestive system (diverticulae)
  • involve all the gut layers
65
Q

at what NEWS2 score should you begin to suspect sepsis in an unwell patient

A

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

66
Q

what is the clinical risk for a red NEWS score of 3 in a single parameter?

A

low-medium risk

67
Q

what is the clinical risk for an aggregate NEWS score of 5-6?

A

medium risk

68
Q

what is the clinical risk for an aggregate NEWS score of 7 or more?

A

high

69
Q

where can diverticulae form?

A

anywhere in the GI tract from the oesophagus to the rectum

70
Q

how do diverticulae present?

A

most people with diverticulae are asymptomatic so only (accidentally) discovered on imaging/colonoscopy

71
Q

what is diverticulitis?

A

when one or more diverticulae become inflamed or infected leading to localised abdominal pain, fever, nausea and vomiting

72
Q

What causes diverticulosis?

A

constipation from a low fibre diet is the most common cause

73
Q

What are the complications of diverticulosis?

A
  • diverticulitis
  • peritonitis (abscess)
  • diverticular hemorrhage
  • colonic obstruction
74
Q

name the four abdominopelvic quadrants

A

right upper quadrant
right lower quadrant
left upper quadrant
left lower quadrant

75
Q

name the nine abdominopelvic regions

A

right hypochondriac
right lumbar
right iliac
epigastric
umbilical
hypogastric (or pubic)
left hypochondria
left lumbar
left iliac

76
Q

what is sometimes considered the tenth abdominopelvic region?

A

perineum (the area beneath the hypogastric region at the bottom of the pelvic cavity)

77
Q

what is the purpose of the abdominal divisions?

A

categorise the abdominal organs by their location and function

help diagnose the source of abdominal pain and determine appropriate treatment

78
Q

which two planes intersect to form the four abdominopelvic quadrants?

A

sagittal plane

umbilical plane (transverse plane through the navel)

79
Q

what does the right upper quadrant contain?

A
  • right liver
  • gallbladder
  • right kidney
  • small portion of the stomach
  • head of the pancreas
  • portions of the ascending and transverse colon
  • portion of the duodenum
80
Q

what is pain the RUQ most commonly associated with?

A

infection or inflammation of the gallbladder/liver

peptic ulcers of the stomach

81
Q

what does the left upper quadrant contain?

A
  • left liver
  • left kidney
  • spleen
  • part of the stomach
  • pancreas
  • transverse and descending colon
  • small intestine
82
Q

what is pain in the LUQ usually associated with?

A

malrotation of the intestine and colon

83
Q

what does the right lower quadrant contain?

A
  • caecum
  • appendix
  • ascending colon
  • small intestines
  • right half of the female reproductive system
  • right ureter
84
Q

what is pain in the RLQ usually associated with?

A

appendicitis

85
Q

what does the left lower quadrant contain?

A

majority of the small intestine, some of the large intestine

left half of the female reproductive system

left ureter

86
Q

what is pain in the LLQ usually associated with?

A

colitis (inflammation of the large intestine)

pelvic inflammatory diseases

ovarian cysts (in females)

87
Q

which planes intersect to form the nine abdominopelvic regions?

A

two parasagittal planes

two transverse planes (around the navel)

88
Q

what does the right hypochondriac region contain?

A
  • right liver
  • gallbladder
  • right kidney
  • small intestine
89
Q

what does the right lumbar region contain?

A
  • liver
  • gallbladder
  • right kidney
  • ascending colon
90
Q

what does the right iliac fossa region contain?

A

appendix, cecum

91
Q

what does the epigastric region contain?

A
  • majority of the stomach
  • pancreas
  • liver
  • spleen
  • adrenal glands
  • duodenum
92
Q

what does the umbilical region contain?

A

small intestine (duodenum , jejunum, ileum)

part of the transverse colon

bottom parts of the left and right kidney

93
Q

what does the suprapubic/hypogastric region contain?

A

sigmoid colon

organs of the reproductive system (uterus/ovaries in females; prostate in males)

bladder, rectum, anus

94
Q

what does the left hypochondriac region contain?

A
  • spleen
  • left kidney
  • stomach
  • pancreas
  • parts of the colon
95
Q

what does the left lumbar region contain?

A

descending colon

left kidney

part of the spleen

96
Q

what does the left iliac fossa region contain?

A

descending colon, sigmoid colon

97
Q

where are diverticulae most commonly found?

A

lower part of the large intestine (the colon)

98
Q

explain how diverticulosis is associated with low-fibre diets

A

low fibre diet
= constipation
= increases pressure in the GI tract
= strains bowel movements
= increased pressure + straining leads to diverticulosis

99
Q

what are the symptoms of diverticulosis?

A

most are asymptomatic BUT can cause

  • bloating
  • abdominal cramps
  • constipation due to difficulty in stool passage through affected region of colon
100
Q

what is the treatment for diverticulosis?

A

increasing fibre intake

101
Q

what is the easiest way to increase fibre intake?

A

eat more fruits, vegetables or grains

102
Q

what are supplemental fibre products?

A

psyllium, methylcellulose or polycarbophil

103
Q

how are minor cases of infection in diverticulitis treated?

A

usually treated with oral antibiotics and do not require admission to the hospital

104
Q

how are repeated attacks of diverticulitis managed?

A

may require surgery to remove the affected portion of the colon

105
Q

how is severe, persistent diverticular bleeding managed?

A

hospital stay

IV fluids

blood transfusions

colonoscopy = to determine cause of bleeding and treat it

maybe surgery

106
Q

what does a higher than normal creatinine suggest in terms of sepsis?

A

poor renal clearance, hypoperfused kidneys

107
Q

how is diverticulitis linked to sepsis?

A

diverticulitis is a common cause of sepsis from the abdomen

csi (phase 1b) (8 decks)

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