Clinical Synthesis and Special Cases Flashcards
What is the HHAARMS mnemonic to consider prior to RSI in an OSCE?
Represents the factors that need to be considered and/or corrected prior to intubation
H- Hypotension
H- Hypoxia
A- Acidosis
A- Alkalosis
R- Respiratory rate (post intubation but also pre if needing to BVM)
M- Medications
S- Sepsis (give ABx, consider PPE and precauations)
What are the 7 P’s to consider prior to and during RSI in an OSCE?
P- Preparation (tube, laryngoscpe, adjuncts, suction etc)
P- Pre-oxygenation
P- Pre-treatment (ie fluids and inotropes)
P- Paralysis and induction
P- Positioning
P- Placement proof (ie CO2, CXR, equal air entry, misting of tube etc)
P- Post intubation management
Volatile Substance use SCBD?
Main Hydrocarbons
- Toluene
- Terpentine
- Carbon tetra chloride
- Chloral hydrate (medication)
Sudden Sniffers Death
- Hydrocarbon (usually Toluene) causes sensitization of the myocardium to catecholamines
- Sudden catecholamine surge (ie when running from police) can induce arrhythmias such as VT/VF
- Chloral hydrate has similar issue and this is the mechanism responsible for overdose arrhythmias
Other Hydrocarbon side effects
- Chemical Pneumonitis (chronic or large doses)
- Liver failure AKA hydrocarbon induced hepatitis
- hyperchloraemic NAGMA and hypokalaemia due to nephrotoxicity and RTA 1 (distal)
- Hydrocarbon induced encephalopathy (coma, seizures, ataxia)
- Asphyxiation
Deviation of Resuscitation
- Due to the hydrocarbon induced cardiac catecholamine sensitization, adrenaline is contraindicated
- If strong suspicion of hydrocarbon use causing arrest, dont give adrenaline as part of ALS algorithm
- Consideration for beta blockers and Fentanyl as sympatholytics (ie Esmolol 50mcg/kg/min)
Deviation to Intubation
- Ketamine could potentiate VT, consider opioid induction (ie fent)
- Be careful with blood pressure, usinng Norad/Adrenaline to prevent induction hypotension may cause VT
- Can consider Phenylephrine or Metaraminol as vasopressors
Patients with previous spinal cord injuries SCBD?
Autonomic dysreflexia
- Occurs in patients with lesions above T6
- Below T6 intact splanchnic vessel innervation allows for compensatory dilation of the vascular bed
- Noxious stimuli below the level of the lesion leads to exaggerated sympathetic tone below the lesion and compensatory parasympathetic tone above it
- Often have hypertension with bradycardia
- BP >20mmHg more than baseline with symptoms is concerning
Autonomic dysreflexia Mx
- Raise the head of bed (sit up)
- Remove tight fitting garments
- Bladder scan and relieve any urinary obstruction (including kinked/blocked catheter)
- Scan/rectal exam for impacted faeces and treat constipation
- Assess for and treat any obvious other noxious stimuli
- Short acting antihypertensives with frequent BP monitoring (unstable BP) ie using GTN patch
- Can also use IV hdralazine, nifedipine PO and Labetalol if HR will tolerate it
Difficulties
- Can’t localise sources of pain easily
- Long term catheterising leads to commensals and inability to interpret urine specimens
Common issues
- Constipation and obstruction
- recurrent UTI’s, calculi and retention
- Pneumonia
- PVD and PE/DVT
- ACS/CVA
- Skin infections, pressure ulcers and deeper infections (ie osteomyelitis)
- Ingrown toenails
Constipation approach?
Acute vs Chronic
- Chronic >3months
Congenital
- Hirschsprungs
- Anorectal atresia or imperforate anus
Primary
- Irritable bowel
- Slow transit
Secondary
- Neurologic (SCI, parkinsons, MS etc)
- Metabolic (diabetes, hypothyroid, hypoK/Mg, hyperCa)
- Structural (prolapse, tumour, stricture)
- Drugs (opiates, CCB’s, anticholinergics, antipsychotics, iron and calc supplements etc)
- Others (psychological, abuse, pregnancy, eating disorders, dehydration, immobility)
- Myopathies (Amyloid, systemic sclerosis)
Red Flags
- Fevers
- Nausea/Vomiting
- anorexia, weight loss
- Acute onset constipation
- FHx colon cancer
Refugee Health approach?
Pre-Arrival
- Location
- Immigration circumstances (ie fleeing persecution etc)
- PHx, immunisations, exposures
- Sexual and physical assault
Health assessment on arrival or in detention
- Did this occur?
- Anything found
- TB, HIV, syphilis HepB/C
- Malaria
- H pylori, strongyloides, schistosomiasis, parasites
- Non-infectious (hearing and vision, mental health, anaemia, nutritional deficiencies etc)
- People seeking asylum or who have come across via alternate methods may not have had all the health screening performed
Community management
- Address presenting problem
- SW/refu involvement
- Case manager, financial help, medicare
- DV, pregnancy, breast feeding and FGM screening
Important Scoring Systems
Chest pain
HEART score
ADDRS score
? TIMI score
VTE
Wells DVT and PE scores
PERC score
AF
CHADSVASC
HASBLED
Liver Failure
Childs-Pugh score
Pancreatitis
Ransons criteria (Pancreatitis mortality, initial in ED, then 2nd part 48hrs into admission)
ICU Mortality
APACHE II score (for any severe illness, predictor of mortality, helpful for giving survival chances to family in EOL discussions, widely used and well validated)
Sepsis
Q-SOFA score (high risk of sepsis)
SOFA score (Risk of dying in ICU)
Upper GI Bleed
Rockall Score
Glascow-Blatchford score
Headache
Ottawa SAH score
Pound score for migraine
COPD
Gold Criteria
Neck Injury
NEXUS (mnemonic SPINE, Spinal tenderness, Painful distracting injury, Intoxication, Neurology, Encephalopathy or altered GCS)
Canadian C-spine
Head Injury
Canadian CT brain
Paediatric Head Injury
- Pecarn (mostly widely validated) (BOS#, GCS <14 or less, AMS then scan; LOC/vomiting/severe headache or severe mechanism then observe vs scan)
- CHALICE and CATCH (good but not as well validated, take longer to use)
