Clin prac 6 patho/signs and symptoms

Question 1

Pathophysiology of asthma

Answer 1

Asthma is categorised by bronchospasm (bronchoconstriction), mucosal oedema (chronic inflammation ) and mucus-plugging (and increased mucus secretions). Asthma has an either an impaired autonomic control or inflammatory processes. Asthma is generally caused by an allergen which is detected by the body, such as smoke or dust, which then brings about a response. The pathogenesis of the disease is bought about by certain physiological mediators, such as histamine and prostaglandins. Once these inflammatory mediators are released, the body brings about a response which includes bronchoconstriction, chronic inflammation and increased music secretions.

Question 2

Acute coronary syndrome define/patho

Answer 2

The blanket term covers the spectrum of cardiac illnesses ranging from angina to unstable angina to myocardial infarction (MI). Acute coronary syndrome involves hardening and narrowing of the of coronary arteries due to plaque buildup called atherosclerosis. There is an accumulation of lipids and collagen in the cell wall. The narrowing of the arteries causes a more turbulent blood flow (high blood pressure) which can cause the plaque to rupture and initiate the clotting cascade causing a thrombus. The thrombus causes a blockage within the coronary arteries which can cause a decrease level of oxygenated blood to the heart, which can also lead to the patient feeling pain and/or nausea and vomiting and most importantly chest pain.

Question 3

Unstable angina: define

Answer 3

Unstable angina: This involves sudden, unexpected chest pain or pressure, even while resting. It’s a warning sign of a heart attack and occurs when stable angina worsens.

Question 4

How does nitrate therapy (GTN) provide benefit when managing a patient presenting with acute coronary syndrome?

Answer 4

Venous dilation – encourages venous pooling (decreases preload)
- Arterial dilation – reduces SVR (systemic vascular resistance) and therefore decreases left ventricular afterload (the arterial resistance fighting against ejection)
- This reduces myocardial workload
- Decreases SBP, DBP whilst maintaining coronary perfusion pressure
- Mild collateral coronary arterial dilation – improved blood flow
- Reduced o2 demand

GTN exerts therapeutic action by relaxing vascular smooth muscle, therefore producing both arterial and venous vasodilation

Question 5

Why do we use aspirin in ACS

Answer 5

to minimise platelet aggregation and thrombus formation in order to reduce the progression of coronary artery thrombosis in ACS

Question 6

Symptoms of ACS

Answer 6

• Aching
• Burning
• Heaviness
• Numbness
• Pressure
• Tightness
  OTHERS
  May feel nausea, dizziness, lightheadedness, sweating, fatigue

WOMEN
- Nausea or vomiting.
- Pain that spreads to the shoulders, neck, abdomen or jaw.
- Shortness of breath (dyspnea).

Question 7

Why give salbutamol for asthma

Answer 7

Causes bronchodilation so they widen and relax your airway

Question 8

why give ipratropium bromide for asthma

Answer 8

It is a bronchodilator that inhibits the cholinergic bonchomotor tone which blocks the vagal reflexes which mediate bronchoconstriction

Question 9

Why do we give dexamethasone to asthma pt

Answer 9

They help reduce the inflammation in your lungs caused by flare-ups and provides immunosuppression

Question 10

Why does excessive tachycardia have an adverse effect on blood pressure?

Answer 10

There is inadequate time for ventricular filling hence stroke volume is reduced.
There is also little or no input from the atrium

Blood pressure reduces since cardiac output reduces.
Systemic vascular resistance (vasoconstriction) rises to compensate

Question 11

Anaphylaxis
define

Answer 11

Anaphylaxis, also called allergic or anaphylactic shock, is a sudden, severe and life-threatening allergic reaction that involves the whole body. The reaction is marked by constriction of the airways, leading to difficulty breathing.

Histamines, the substances released by the body during an allergic reaction, cause the blood vessels to expand, which in turn causes a dangerous drop in blood pressure. Fluid can leak into the lungs, causing swelling (pulmonary edema). Anaphylaxis can also cause heart rhythm disturbances.

Question 12

Why do we use adrenaline in anaphylaxis?

Answer 12

Adrenaline is the first line treatment for anaphylaxis and acts to reduce airway mucosal oedema, induce bronchodilation, induce vasoconstriction and increase the strength of cardiac contraction.

Question 13

Why do we nebulise adrenaline in anaphylaxis?

Answer 13

It induces relaxation of the bronchial smooth muscle by acting on beta-adrenergic receptors to alleviate wheezing and difficulty breathing via the airway.

Bronchodilators (saulbutamool) must not be used as first line medication for anaphylaxis as they do not prevent or relieve upper airway obstruction, hypotension or shock.

Question 14

Hypoglycaemia
define

Answer 14

Hypoglycemia occurs when your blood sugar (glucose) level falls too low for bodily functions to continue. There are several reasons why this can happen. The most common reason for low blood sugar is a side effect of medications used to treat diabetes.

Question 15

blood sugar regulation (hyperglycaemia)
define

Answer 15

When you eat, your body breaks down foods into glucose. Glucose, the main energy source for your body, enters the cells with the help of insulin — a hormone produced by your pancreas. Insulin allows the glucose to enter the cells and provide the fuel your cells need. Extra glucose is stored in your liver and muscles in the form of glycogen.

When you haven’t eaten for several hours and your blood sugar level drops, you will stop producing insulin. Another hormone from your pancreas called glucagon signals your liver to break down the stored glycogen and release glucose into your bloodstream. This keeps your blood sugar within a standard range until you eat again.

Your body also has the ability to make glucose. This process occurs mainly in your liver, but also in your kidneys. With prolonged fasting, the body can break down fat stores and use products of fat breakdown as an alternative fuel.

Question 16

Possible causes of diabetes

Answer 16

If you have diabetes, you might not make insulin (type 1 diabetes) or you might be less responsive to it (type 2 diabetes). As a result, glucose builds up in the bloodstream and can reach dangerously high levels. To correct this problem, you might take insulin or other medications to lower blood sugar levels.

Question 17

Hyperglycaemia
define

Answer 17

Hyperglycemia happens when there’s too much sugar (glucose) in your blood. This happens when your body has too little insulin (a hormone) or if your body can’t use insulin properly (insulin resistance).

Glucose is absorbed and goes directly into your bloodstream after you eat, but it can’t enter the cells of most of the body’s tissues without the help of insulin. Insulin is a hormone made by the pancreas.

When the glucose level in the blood rises, the pancreas releases insulin. The insulin unlocks the cells so that glucose can enter. This provides the fuel the cells need to work properly. Extra glucose is stored in the liver and muscles.

This process lowers the amount of glucose in the bloodstream and prevents it from reaching dangerously high levels. As the blood sugar level returns to normal, so does the amount of insulin the pancreas makes.

Diabetes drastically reduces insulin’s effects on the body. This may be because your pancreas is unable to produce insulin, as in type 1 diabetes. Or it may be because your body is resistant to the effects of insulin, or it doesn’t make enough insulin to keep a normal glucose level, as in type 2 diabetes.

In people who have diabetes, glucose tends to build up in the bloodstream. This condition is called hyperglycemia. It may reach dangerously high levels if it is not treated properly. Insulin and other drugs are used to lower blood sugar levels.

Question 18

How does glucagon help in hypoglycaemia?

Answer 18

Glucagon is very safe to use. It is a hormone that raises the blood glucose level by telling the liver to release stored glucose into the bloodstream

Question 19

How does glucose help in hypoglycaemia?

Answer 19

raises your blood sugar levels

Question 20

How does dextrose 10% help in hypoglycaemia?

Answer 20

It is a slightly hypertonic crystalloid solution that provides a source of energy and supplies body water.

It is already in the form (of sugar and water) of sugar your brain and cells recognize and require for energy, making it the most rapidly absorbed source of carbohydrates if experiencing hypoglycemia

Question 21

Seizure
define

Answer 21

A seizure is a sudden, uncontrolled burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness.

Nerve cells in the brain, known as neurons, create, send and receive electrical impulses. This allows the cells to communicate. Anything that disrupts the communication pathways can lead to a seizure.

Question 22

Why do we give high flow oxygen to patients having a seizure?

Answer 22

Help any patient who is actively seizing or is postictal, regardless of their pulse-ox reading, to help with the increased metabolic demands of the brain for oxygen

Question 23

What can cause a seizure

Answer 23

• Hypoglycaemia
• Hypoxia
• Head trauma
• stroke/ICH
• electrolyte distrunace
• meningitis
• fever

Question 24

Three stages of seizures

Answer 24

• Prodrome (earliest warning that a seizure may occur, but it is not part of the seizure itself - auroa may happen)
• Ictal
• Postictal

Question 25

How does midazolam work on seizures?

Answer 25

It is a short-acting CNS depressant that helps reduce anxiety, is a sedative and anti-convulsant

Question 26

Croup
define

Answer 26

Croup refers to an infection of the upper airway, which becomes narrow, making it harder to breathe. Croup also causes a cough that sounds like barking.

The cough and other signs and symptoms of croup are the result of swelling and irritation around the voice box (larynx), windpipe (trachea) and bronchial tubes (bronchi). When a cough forces air through this narrowed passageway, the swollen vocal cords produce a noise like a seal barking. Taking a breath often produces a high-pitched whistling sound called stridor.

Question 27

How does adrenaline work in the setting of croup?

Answer 27

The croup patient has inflammation of the upper airway structures, which is causing their clinical presentation. Nebulised adrenaline causes peripheral vasoconstriction via the alpha receptors. This therefore reduces bronchial & tracheal epithelial vascular permeability, decreasing airway oedema, increasing airway radius and improving airflow.

Question 28

What is the benefit of administrating dexamethasone to the croup patient?

Answer 28

Croup (or laryngotracheobronchitis) is an inflammation of the upper airway structures. Dexamethasone is a corticosteroid & aims to relieve the inflammation occurring in this area & provide immunosuppression. Although the administration of steroids generally doesn’t have effect within the out-of-hospital environment (remember the onset of dexamethasone is 30-60 mins), the anti-inflammatory effects can have positive impact on long-term patient prognosis.

Question 29

Epiglottitis
define

Answer 29

Epiglottitis happens when the epiglottis — a small cartilage “lid” that covers the windpipe — swells. The swelling blocks the flow of air into the lungs. Epiglottitis can be deadly.

An infection or injury causes epiglottitis.

Question 30

Febrile Illness

Answer 30

Fever is defined as a temperature greater than or equal to 38°C.

Question 31

Meningococcal Septicaemia
define

Answer 31

Meningococcal disease is a rapidly progressing bacterial infection that’s caused by the bacteria Neisseria meningitidis. In patients who are either immunocompromised, unvaccinated or currently unwell providing an opportunistic environment for the bacteria to enter, this organism can lead to septicaemia & spread into the CSF, leading to meningitis.

It is caused by excessive clotting activation & breakdown, leading to microthrombi obstructing blood flow to peripheral tissues & organs, leading to organ ischemia & infarction. Additionally, the consumption of clotting factors creates a deficiency in further clot formation, leading to micro haemorrhaging.

Question 32

Ceftriaxone why do we use it for Meningococcal Septicaemia

Answer 32

It works by killing bacteria or preventing their growth

Question 33

Eppigoltti symptoms

Answer 33

Dysphagia: Difficulty swallowing.
Dysphonia: Hoarseness or an abnormal voice.
Drooling: When saliva flows out of your mouth involuntarily (lots of drooling)
Distress: Difficulty breathing or lack of oxygen.

Difficulty and pain when swallowing (a main symptom in older children and adults).
Difficulty breathing (a main symptom in children).
Abnormal or high-pitched breathing noises (a main symptom in children).

Question 34

Why we do not give Midazolam with head injury

Answer 34

Midazolam drops blood pressure

When there is bleeding in the brain the ICP increased which leads to the CPP decreasing
The body compensates for this by increasing MAP and keeping the CPP working

If we drop BP, our CPP goes down meaning less perfusion to the brain and ICP goes up which means we are creating more of a brain injury

If given Midazolam will decrease blood pressure which will decrease MAP which leads to CPP not working and oxygen not getting to the brain
So more of the brain will be damaged or die

Question 35

Why do we not always get an SAT score of -1

Answer 35

Because we may give too much sedation which could lead them to be SAT -2 or -3

This could be due to multiple reasons like
- miscalculated their weight
- miscalculated their SAT score (our bias and personal opinion)
- gave them the wrong dose
- have drugs or alcohol in their system
- other medications they take reacted to the sedation

Question 36

Why is maintaining normothermia important in a trauma patient?

Answer 36

Maintaining normothermia in a trauma patient is crucial because hypothermia can exacerbate coagulopathy, impairing blood clotting and increasing the risk of uncontrolled bleeding. Additionally, it helps to prevent metabolic acidosis and maintain optimal organ function, improving overall outcomes and survival rates.

Question 37

After a patient has been sedated and restrained what is the minimum repeat assessments that should be conducted list at least 3:

Answer 37

• Airway patency
• RR/HR
• Sp02
• SAT score
• Neurovascular status of restrained limbs
• Injury from mechanical restraint
• Blood Pressure

Question 38

When administering sedation for an agitated patient, what is the aim regarding their conscious state?

Answer 38

• You don’t want the patient deeply unconscious or unrousable. Rather, the aim is for a peaceful, restful state of rousable drowsiness.

Question 39

2. Use of sedation can come with risks to the airway, what are these risks and how could we mitigate them?

Answer 39

• Sedation can suppress a patient’s awareness and their airway reflexes. Therefore, it is imperative to monitor and manage the airway, ensuring that it remains patent, that potential obstruction is managed promptly.
• Mitigation of this airway risk would be to encourage/place the patient into recovery/lateral position.
• Use of nasal capnography prongs to monitor respiratory rate in real time.

Question 40

There are a few precautions listed for Droperidol as part of the pharmacology sheet. Can you recall them all?

Answer 40

In this particular case, acute alcohol intoxication is a precaution for Droperidol administration (listed as “Elderly/frail patients are more susceptible to adverse effects” as sedative medications including alcohol may cause oversedation. The combination of Droperidol coupled with the CNS depressing effects of alcohol is more likely to result in significant sedation & probable loss of airway tone & protection. Subsequently, reduced dosing in these circumstances is recommended to prevent over sedation. Other sedating/depressant drugs such as narcotics, GHB, Valium, etc have the same effect when combined with Droperidol & subsequently you need to be careful about the dosing you select. Intoxication of any sedative agent equates to frailty when applying this guideline.

Other precautions include Parkinson’s disease, Lewy body dementia and ECG monitoring re QT prolongation post sedation (reported rarely).

Question 41

What are Septicaemia signs:

Answer 41

• Fever, rigors, joint & muscle pains.
• Cool hands & feet
• Tachycardia, hypotension
• Tachypnoea

Question 42

What are Meningeal signs:

Answer 42

• Headache, photophobia, neck stiffness
• Nausea & vomiting
• Altered conscious state
• Irritability or whimpering.

Question 43

Does the rash always appear with meningococcal infection?

Answer 43

A rash will not always appear with meningococcal infection, or it may be one of the last symptoms to appear.

Question 44

Why is IM Ceftriaxone diluted with Lignocaine 1% instead of Water for injection?

Answer 44

Ceftriaxone injected into the muscle can cause a chemical irritation which in turn can cause extreme pain/discomfort. By co-administering with lignocaine, a local anaesthetic, we can minimise that discomfort. The use of 1% lignocaine as a diluent reduces the amount of pain by approximately 75%.

Question 45

Why is the co-administration of paracetamol with an opioid suggested for the management of moderate pain?

Answer 45

• Opioid administration can rapidly manage acute pain
• After the onset of paracetamol, it can provide ongoing and effective analgesia and reduces the need for ongoing opioid administration.
• Administration together is associated with improved analgesia, and fewer side effects such as nausea or vomiting.

Question 46

What are some non-pharmacological interventions that could assist with management of the patient’s pain?

Answer 46

• Position
• Heat/Cold Pack
• Distraction – toys/ technology/music

Question 47

Why baby may have abdominal pain?

Answer 47

• bowel (gut) problems – constipation, colic or irritable bowel
• infections – gastroenteritis, kidney or bladder infections, or infections in other parts of the body like the ear or chest
• food-related problems – too much food, food poisoning or food allergies
• problems outside the abdomen – muscle strain or migraine
• surgical problems – appendicitis, bowel obstruction or intussusception (telescoping of part of the gut)

Question 48

Why might you opt to administer salbutamol via the nebuliser rather than the pMDI in this patient’s situation?

Answer 48

Despite both options outlined in the paediatric anaphylaxis CPG, the benefit of administering salbutamol via a nebuliser is that oxygen is a driver for the device to work. This patient was hypoxic on arrival & will benefit from continual oxygen administration until resolution of episode.

Question 49

Febrile illness define

Answer 49

Is a NORMAL body adaption in response to an infection/ inflammation. This is required to raise the body’s metabolism to help mobilise the immune system to react to the pathogen that has been introduced to the body. Additionally, an elevated temperature creates an unfavourable environment for invading pathogens to thrive in, limiting its ability to replicate & invade the host.

Question 50

Why would you need to add saline into the nebuliser cup and what is the minimum volume required?

Answer 50

2.5ml is the minimum volume of fluid required to cause adequate misting and nebulisation of the medication. Therefore we should never let the volume in the nebuliser cup fall below 2.5mls, and top it up with either saline or medication as required.

Question 51

Why should caution be used when administering salbutamol to children?

Answer 51

Salbutamol can cause profound lactic acidosis in children from B2 receptor stimulation.

Question 52

Pulse oximetry should be used throughout management of an asthmatic but should not be relied on as a sign of improvement in clinical condition, why?

Answer 52

Because asthmatic patients are dynamic and can show initial improvement and then rapidly deteriorate, hypoxaemia is often a late sign of deterioration.

Question 53

What are the signs and symptoms of dehydration as per the CPG’s?

Answer 53

• Postural perfusion changes including tachycardia, hypotension or dizziness
• Decreased sweating and urination
• Poor skin turgor, dry mouth, dry tongue
• Fatigue and/or altered consciousness
• Evidence of poor fluid intake compared to fluid loss.

Question 54

Why is paracetamol not given to children with a temperature anymore?

Answer 54

Paracetamol is indicated in these children for analgesia – not for fever control. Fever is a natural response to infection & is beneficial to create a hostile environment for invading organisms as well as to speed up metabolism. Remember just because the child is unable to tell you about pain, doesn’t mean they don’t have any & doesn’t require analgesia.

Question 55

Why is hypoxia a late sign of deterioration in asthmatic patients?

Answer 55

Hypoxia is a late sign in severe asthma because the early stages of an asthma attack primarily involve bronchoconstriction and increased airway resistance, leading to hyperventilation and a resulting decrease in carbon dioxide levels (hypocapnia). During this phase, oxygen levels in the blood are often maintained or even elevated due to the increased respiratory effort. It is only when the airway obstruction becomes severe and respiratory muscle fatigue sets in that hypoventilation occurs, leading to a drop in oxygen levels (hypoxia) as the body can no longer adequately compensate and heading into severe respiratory failure.

Question 56

2. What is gas trapping and how can this cause barotrauma?

Answer 56

Gas trapping is an inability to exhale completely causing an abnormal retention of air in the lungs – this is often seen during critical asthma where the ability to expire air is restricted due to bronchoconstriction, inflammation and swelling of the airways. Hyperinflation of the lungs then occurs and due to the changes in air pressures this can then result in injuries, or barotrauma to the lungs.

Question 57

Explain the mechanism of action of Adrenaline in the critically unwell asthmatic patient.

Answer 57

Adrenaline works directly on the beta-2 receptor causing for bronchodilation as well as decreasing production of mucous in the airways. Adrenaline also affects alpha-receptors with pulmonary vasoconstriction which reduces microvascular leakage and oedema, and inhibition of bronchoconstrictor neural pathways.
Adrenalines also works on beta-1 adrenergic receptors in the heart which causes vasoconstriction, increased cardiac contractility and increased heart rate which can assist in maintaining perfusion and oxygen delivery to cells.

Question 58

Why would ETCO2 be high in severe or critical asthma patients?

Answer 58

Due to gas trapping and the inability adequately ventilate – inspiration and especially expiration of air is severely restricted leading to excessive retention of carbon dioxide. High ETCO2 should be anticipated especially in intubated asthmatic patients.

Question 59

What criteria would you use to choose between Droperidol and Ketamine when administering emergency sedation for agitated behaviour?

Answer 59

Droperidol is suitable for a variety of sedation purposes including moderate agitation where the patient offers minimal risk to themselves or to those surrounding. Ketamine should only be called upon where agitation is severe and the patient unmanageable due to the uncontrolled and violent nature of their behaviour and they present as an immediate threat to either themselves or to others. The Sedation Assessment Tool (SAT) is an objective tool used to assess a Pt’s level of combativeness and sedation and is used to assist clinicians in both the sedative agent to utilise and also to monitor the effect of the sedation after administration

Question 60

How offten should a neruovasc obs be completed on the affected limb?

Answer 60

15 min distal to the fracture side

Question 61

Why do 1 year-olds not get salbutamol

Answer 61

The use of salbutamol had no effect on bronchiolitis in children <24 months of age. Moreover, the treatment can also lead to side effects, such as high heart rate.

Question 62

why do we administer adrenaline in double intervals when the patient is hypothermic in cardiac arrest

Answer 62

Drugs are often ineffective and will undergo reduced metabolism

Question 63

What is the role of adrenaline in cardiac arrest

Answer 63

It increases blood flow to the heart and increases the chance of restoring a heartbeat