case 16 - emergency medicine Flashcards
what is a symptom sieve and why is it used?
list of pathological categories that can be used to come up with a broad list of differentials
give examples of symptom sieves used in clinical practice
VITAMIN C DEF
MAGIC ADDITIVE
MEDIC HAT PINE
MIDNIT
what is the A-E assessment?
the approach to managing a deteriorating or critically ill patients
A - airways
B - breathing
C - circulation
D - disability
E - exposure
in ABCDE, how are the airways assessed?
- verbalising
- foreign objects in mouth
- excessive secretions
- snoring
- mouth or tongue swelling
- decreased GCS
- use of accessory muscles
- central cyanosis (turning blue)
How is breathing assessed?
- respiratory rate
- oxygen saturation
- respiratory distress e.g cough
- wheezing
- smoker
what are some signs of respiratory distress?
increased breathing rate (tachypnoea)
cyanosis
grunting
sweating
wheezing
How is circulation assessed?
- blood pressure
- heart rate
- heart sounds
- ECG
- peripheral capillary refill time
- temperature of peripheries
- colour of hands
How is disability assessed?
- blood glucose
- temperature
- ACPVU and GCS
- limb movement
- evidence of alcohol or drug use
- head injuries (PEARL)
what is PEARL?
pupils equal and reactive to light
How is exposure assessed?
- rashes
- injection/track marks
- trauma
- external bleeding
- abdominal examination (e.g distension or tenderness)
- clinical history
- patient notes
- lab investigations
Why does low blood pressure require urgent attention?
hypotension risks hypoperfusion of the tissues risking ischaemia which can progress to tissue infarction causing multiple organ failure
(must prevent circulatory shock!)
what does the capillary refill time indicate and why is it important?
indicates blood volume and perfusion levels
= indicative of hypovolemia or hypoperfusion (possibly caused by peripheral vasconstriction)
what is ACVPU?
a scale used to assess a patient’s neurological status and level of consciousness
(alert, confusion, voice, pain, unresponsive)
what is Glasgow Coma Scale/GCS?
scoring system used to describe the level of consciousness in a person following a traumatic brain injury
what is the normal capillary refill time?
a normal CRT is 1 to 2 seconds
= consistent with a normal blood volume and perfusion
what does a CRT longer than 2 seconds suggest?
poor perfusion due to peripheral vasoconstriction
what is circulatory shock?
when inadequate blood flow results in damage to body tissues
what are the four classes of circulatory shock?
cardiogenic shock (cardiac dysfunction)
hypovolemic shock (blood loss)
obstructive shock (obstruction to blood flow)
distributive shock (vasodilation)
what are the subtypes of distributive shock?
septic
anaphylactic
neurogenic
what is hypovolemic shock?
shock caused by severe blood or other fluid loss makes the heart unable to pump sufficient blood to the body
what causes hypovolemic shock?
haemorrhage
severe vomiting (salt & water loss)
diarrhoea
burns
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
what causes cardiogenic shock?
acute myocardial infarction
cardiomyopathy
cardiac rupture
valve problems
what is obstructive shock?
an obstruction of blood flow outside of the heart
what are the causes of obstructive shock?
pulmonary embolism
cardiac tamponade (pericardial space gets filled w fluid)
tension pneumothorax
(pericardial effusion)
what is distributive shock?
an abnormal distribution of blood to tissues and organs
what are the causes of distributive shock?
sepsis
anaphylaxis
neurogenic
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
what are the most common types of shock?
what does arterial hypotension lead to?
tissue hypoperfusion
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
what is the first thing that is assessed when the circulatory shock is suspected?
cardiac output
how is circulatory shock confirmed?
echocardiography
what kind of circulatory shock does the following suggest?
normal cardiac chambers and (usually) preserved contractility
distributive (vasodilative) shock
what kind of circulatory shock does the following suggest?
small cardiac chambers and normal/high contractility
hypovolemic shock
what kind of circulatory shock does the following suggest?
large ventricles and poor contractility
cardiogenic shock
what kind of circulatory shock does the following suggest?
tamponade; pericardial effusion; small ventricles; dilated IVC; pulmonary embolism
obstructive shock
what are the four stages of sepsis?
how is SIRS diagnosed?
following NEWS reading and FBC (for the WBCC)
how is sepsis (stage 2) diagnosed?
blood cultures (to provide evidence of infection)
how is severe sepsis diagnosed?
urine output (indicative of organ dysfunction)
lactate (indicative of hypoperfusion)
BP measurement (indicative of hypotension)
how is septic shock diagnosed?
if hypotensive patient does not show improvement despite adequate fluid resuscitation
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
why are blood cultures taken in a patient with suspected sepsis?
to check for infection (sepsis stage 2)
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 causing lactic acidosis
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
why is oxygen given to a patient with suspected sepsis?
- hypoperfusion increases levels of oxygen required to maintain aerobic metabolism
- also given to reduce lactic acidosis
- only given if sats are below 94%
why are IV antibiotics given to a patient with suspected sepsis?
target the infection as quickly as possible to prevent deterioration into septic shock
what is GGT and why is it an important blood test?
- gamma glutamate transferase
- increased in patients with liver disease (cirrhosis, hepatitis, fatty liver) as a result of alcohol/drugs/toxins etc
which blood markers indicate an infection?
(elevated) CRP, WBC, neutrophils
what does a positive serum ethanol suggest?
alcohol consumption
calculate a NEWS2 score from the following data set
3
(1 for high systolic BP, 1 for high pulse, 1 for high temperature)
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
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
how is respiratory rate calculated for a NEWS2 score?
calculated manually (without telling the patient as this can alert them to their breathing)
how is oxygen saturation calculated for a NEWS2 score?
using an oximeter
- scale 1 for the majority of patients
- scale 2 for patients with hypercapnic respiratory failure (type II)
what are the possible causes of hypercapnic respiratory failure?
COPD, severe asthma, drug overdose, myasthenia gravis etc
how frequently do patients with a NEWS score of 0 need to be monitored?
minimum 12 hourly
how frequently do patients with a NEWS score of 1-4 need to be monitored?
minimum 4-6 hourly
how frequently do patients with a NEWS score of 3 in a single parameter need to be monitored?
minimum 1 hourly
how frequently do patients with a NEWS score of 5 or more need to be monitored?
minimum 1 hourly
how frequently do patients with a NEWS score of 7 or more need to be monitored?
continuous monitoring of the vital signs
what is the clinical risk for an aggregate NEWS score of 0-4?
low clinical risk
What is diverticulosis?
- small, bulging pouches that can form in the lining of your digestive system (diverticulae)
- involve all the gut layers
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
what is the clinical risk for a red NEWS score of 3 in a single parameter?
low-medium risk
what is the clinical risk for an aggregate NEWS score of 5-6?
medium risk
what is the clinical risk for an aggregate NEWS score of 7 or more?
high
where can diverticulae form?
anywhere in the GI tract from the oesophagus to the rectum
how do diverticulae present?
most people with diverticulae are asymptomatic so only (accidentally) discovered on imaging/colonoscopy
what is diverticulitis?
when one or more diverticulae become inflamed or infected leading to localised abdominal pain, fever, nausea and vomiting
What causes diverticulosis?
constipation from a low fibre diet is the most common cause
What are the complications of diverticulosis?
- diverticulitis
- peritonitis (abscess)
- diverticular hemorrhage
- colonic obstruction
name the four abdominopelvic quadrants
right upper quadrant
right lower quadrant
left upper quadrant
left lower quadrant
name the nine abdominopelvic regions
right hypochondriac
right lumbar
right iliac
epigastric
umbilical
hypogastric (or pubic)
left hypochondria
left lumbar
left iliac
what is sometimes considered the tenth abdominopelvic region?
perineum (the area beneath the hypogastric region at the bottom of the pelvic cavity)
what is the purpose of the abdominal divisions?
categorise the abdominal organs by their location and function
help diagnose the source of abdominal pain and determine appropriate treatment
which two planes intersect to form the four abdominopelvic quadrants?
sagittal plane
umbilical plane (transverse plane through the navel)
what does the right upper quadrant contain?
- 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
what is pain the RUQ most commonly associated with?
infection or inflammation of the gallbladder/liver
peptic ulcers of the stomach
what does the left upper quadrant contain?
- left liver
- left kidney
- spleen
- part of the stomach
- pancreas
- transverse and descending colon
- small intestine
what is pain in the LUQ usually associated with?
malrotation of the intestine and colon
what does the right lower quadrant contain?
- caecum
- appendix
- ascending colon
- small intestines
- right half of the female reproductive system
- right ureter
what is pain in the RLQ usually associated with?
appendicitis
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
what is pain in the LLQ usually associated with?
colitis (inflammation of the large intestine)
pelvic inflammatory diseases
ovarian cysts (in females)
which planes intersect to form the nine abdominopelvic regions?
two parasagittal planes
two transverse planes (around the navel)
what does the right hypochondriac region contain?
- right liver
- gallbladder
- right kidney
- small intestine
what does the right lumbar region contain?
- liver
- gallbladder
- right kidney
- ascending colon
what does the right iliac fossa region contain?
appendix, cecum
what does the epigastric region contain?
- majority of the stomach
- pancreas
- liver
- spleen
- adrenal glands
- duodenum
what does the umbilical region contain?
small intestine (duodenum , jejunum, ileum)
part of the transverse colon
bottom parts of the left and right kidney
what does the suprapubic/hypogastric region contain?
sigmoid colon
organs of the reproductive system (uterus/ovaries in females; prostate in males)
bladder, rectum, anus
what does the left hypochondriac region contain?
- spleen
- left kidney
- stomach
- pancreas
- parts of the colon
what does the left lumbar region contain?
descending colon
left kidney
part of the spleen
what does the left iliac fossa region contain?
descending colon, sigmoid colon
where are diverticulae most commonly found?
lower part of the large intestine (the colon)
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
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
what is the treatment for diverticulosis?
increasing fibre intake
what is the easiest way to increase fibre intake?
eat more fruits, vegetables or grains
what are supplemental fibre products?
psyllium, methylcellulose or polycarbophil
how are minor cases of infection in diverticulitis treated?
usually treated with oral antibiotics and do not require admission to the hospital
how are repeated attacks of diverticulitis managed?
may require surgery to remove the affected portion of the colon
how is severe, persistent diverticular bleeding managed?
hospital stay
IV fluids
blood transfusions
colonoscopy = to determine cause of bleeding and treat it
maybe surgery
what does a higher than normal creatinine suggest in terms of sepsis?
poor renal clearance, hypoperfused kidneys
how is diverticulitis linked to sepsis?
diverticulitis is a common cause of sepsis from the abdomen
