COTE Flashcards
Pressure Ulcers
Risk factors
- Malnourishment
- Incontinence
- Immobility
- Pain (reduction in mobility)
- Dehydration
- Lives alone
- Old age
- High BMI
- Reduced blood supply
Pressure Ulcers
Pathophysiology
- Hard surface
- Localised external pressure on the skin causes occlusion of the capillaries and compression of the tissue
- Leads to reduced oxygen and nutrition to the tissue
- Altered soft tissue hydration as the fluid is pushed away
- Worsened by friction –> shears skin off
Pressure Ulcers
What score would you use to assess risk of developing a pressure sore?
The Waterlow Score
Overview of the Waterlow Score
● 10 -14: At risk
● 15 – 19: high risk
● 20: very high risk
Takes into account: o BMI (low) o Skin type (dry/oedematous/clammy/broken) o Sex (female) o Age (older) o Incontinence (urine/faecal/both) o Mobility (restless/bed or chair bound) o Appetite (anorexia/feeding tube) o Neuro deficit (diabetes/paraplegia) o Organ failure o Peripheral vascular disease o Anaemia o Smoking o Medication (steroids/anti-inflammatories)
Pressure ulcers
Grade 1
Grade 1:
- Non-blanchable erythema of intact skin
- Discolouration of skin, warmth, oedema, induration or hardness may also be used as indicators (particuarly on darker skin)
Pressure ulcers
Grade 2
Grade 2:
- Partial thickness skin loss involving the epidermis, or dermis, or both
- Ulcer is superficial and presents clinically as an abrasion or blister
Pressure ulcers
Grade 3
Grade 3:
- Full thickness skin loss involving damage to or necrosis of SC tissue that may extend down to, but not through, the underlying fascia
- Slough
Pressure ulcers
Grade 4
Grade 4:
- Extensive destruction, tissue necrosis, damage to muscle, bone or supporting structures with or without full-thickness skin loss
- Slough, bone/tendon/muscle seen
Pressure ulcers
Differentials?
Deep tissue injury:
- Purple localised area of discoloured intact skin, or a blood-filled blister
Moisture lesion:
- Redness or partial thickness skin loss involving epidermis, dermis or both
Pressure ulcers
Investigations
● CRP/ESR ● Swab and blood cultures ● X-Ray for bone involvement ● Albumin (low will delay healing) ● General exam and history ● FBC’s (anaemia will delay healing)
Pressure ulcers
Management
SSKIN:
- S: Support surface - pressure redistributing mattress
- S: Skin assessment regularly
- K: Keep them moving - repositioning regime
- I: Incontinence and moisture - continence assessment and management
- N: Nutrition and hydration
Stages 3-4: TVN
Dressings:
- Hydrocolloid and hydrogels
Topical antimicrobial therapy:
- Silver, honey or iodine-impregnated dressing
- Maggots
Last resort - debridement
Delirium
Risk factors
- Age > 65 years
- Background of dementia
- Significant injury e.g. hip fracture
- Frailty or multimorbidity
- Polypharmacy
- Sensory impairments
Delirium
Precipitating events
- Infection: particularly urinary tract infections
- Metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
- Change of environment
- Any significant cardiovascular, respiratory, neurological or endocrine condition
- Severe pain
- Alcohol withdrawal
- Constipation
Delirium
Features
- Memory disturbances (short term > long term)
- Agitated or withdrawn
- Disorientation
- Mood changes
- Visual hallucinations
- Disturbed sleep cycle
- Poor attention
Four key features:
o Disturbance of consciousness
o Changes in cognition or development of perpetual disturbance
o Disturbance develops over a short period of time and fluctuates over the course of a day
o History supports an underlying medical condition, medication withdrawal or intoxication
Delirium
Management
- Treatment of the underlying cause
- Pain –> analgesia
- Polypharmacy –> drug review
- Laxatives for constipation
- Correct electrolytes
- Antibiotics for infection
- Modification of the environment
- Soft lighting, involve family, clocks and calendars, sleep hygiene, mobile and active, minimize provocation (loud rooms etc)
Delirium
Types
Hyperactive:
- Heightened arousal
- Sensitive to surroundings
- Verbally or physically aggressive
- Restless
- Carphologia (pulling at straws)
- Wandering and disorientation
- Unable to follow complex commands
Hypoactive:
- Confused with depression
- More common
- Reduced psychomotor activity
Delirium
Causes
DELIRIUM
- D: Drugs, Dehydration, Dementia
- E: Electrolyte disturbances, Epilepsy
- L: Lack of drugs (withdrawal), Low O2
- I: Infection
- R: Reduced sensory input, Renal failure, Retention
- I: Intracranial damage, Injury
- U: Unfamiliar environment, Uraemia
- M: Myocardial/pulmonary, Metastases, Malnutrition
Delirium
Sedation
- Haloperidol or Lorazepam
- NOT haloperidol in Parkinsons
Falls
What does a normal gait rely on?
- The neurological system - basal ganglia and cortical basal ganglia loop.
- The musculoskeletal system (which must have appropriate tone and strength).
- Effective processing of the senses such as sight, sound, and sensation (fine touch and proprioception).
Falls
Risk factors
- Female
- Neurological disease
- Cognitive decline
- Visual defect/bifocals
- Hearing problems
- Muscle weakness
- Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson’s disease etc)
- Incontinence
- > 65 yrs
- Fear of falling
- Postural hypotension
- Psychoactive drugs
Mechanical:
- Walking aids
- Footwear
- Home hazards
- Polypharmacy (4+ medications)
Falls
Risk assessment
- Where and when was the fall?
- Did anyone see the fall? (collateral Hx)
- What happened before, during, after?
- Why do they think they fell
- Have they fallen before? How many this year (>2 = significant)
- Systems review
- PMH - especially balance/sight/gait/cognition/continence
- Osteoporosis RFs
- Social history
Falls
Medications that can cause postural hypotensions
- Nitrates
- Diuretics
- Anticholinergics
- Antidepressants
- Beta-blockers
- L-Dopa
- ACE-Inhibitors
Falls
Medications that can cause falls due to other mechanisms
- Benzos
- Antipsychotics
- Opiates
- Anticonvulsants
- Codeine
- Digoxin
- Other sedative agents
Falls
Investigations
Bedside tests:
- Basic obs
- Lying and standing BP
- Blood glucose
- ECG
- Urine dip
Bloods:
- FBC- anaemia/infection
- U&Es - dehydration, AKI, diuretic use and clearance (e.g. opioids)
- CK - if long lie
- Bone profile
- LFTs/TFTs
Imaging:
- CXR
- XR of any injured limbs
- CT head if indicated
- Cardiac echo - if ejection systolic murmur
- Tilt table testing
- 24hr tape
Falls
Management
- Identify all individuals who have fallen in the last 12 months.
- As per above identify why they are at risk.
- For those with a falls history or at risk complete the ‘Turn 180° test’ or the ‘Timed up and Go test’.
Falls
Management
- Identify all individuals who have fallen in the last 12 months.
- As per above identify why they are at risk.
- For those with a falls history or at risk complete the ‘Turn 180° test’ or the ‘Timed up and Go test’.
Offer a multidisciplinary assessment by a qualified clinician to all patients over 65 with:
- > 2 falls in the last 12 months
- A fall that requires medical treatment
- Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’
- Physiotherapy - strength and balance training
- Occupational therapy - home hazards assessment
- Medical review - bone profile, medication, postural hypotension, diagnose any new conditions, cataracts, cognitive screening, optimize comorbidities
- Tx any consequences of fall
Syncope
Definition
Transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery
Syncope
3 main types
- Cardiac syncope
- Reflex syncope (neurally mediated)
- Orthostatic syncope
Syncope
Cardiac syncope
Causes
Arrhythmias:
- Bradycardias (sinus node disease, AV conduction defections)
- Tachycardias (Supraventricular, ventricular)
Structural:
- MI
- Valvular
- Cardiomyopathy (hypertrophic)
- Pericardial disease/tamponade
Others:
- PE
- Severe pulmonary HTN
- Aortic dissection
Drug-Induced:
- Antiarrhythmics
- Antianginals
- Antiemetics
- Antipsychotics
- Inotropes
Syncope
Reflex syncope
Definition
- Most common cause of syncope
- Transient loss of consciousness due to inappropriate cardiovascular responses of vasodilation or bradycardia, cerebral hypoperfusion
Syncope
Reflex syncope
Causes
- Vasovagal: triggered by emotion, pain, stress
- Situational: coughing, eating, micturition, post-exercise, weight lifting, playing wind instrument
- Carotid sinus syndrome
Syncope
Orthostatic syncope
Definition
- Symptomatic systolic BP drop of 20 mmHg or diastolic BP drop of 10 mmHg within 3 mins of standing
- Occurs as consequence of impaired vasoconstriction due to chronic impairment of autonomic sympathetic activity
Syncope
Orthostatic syncope
Causes
Primary autonomic failure:
- Pure autonomic failure
- Parkinson’s disease (w autonomic failure)
- Lewy body dementia
- Multi-system atrophy
Secondary autonomic failure:
- Diabetic neuropathy
- Amyloidosis
- Spinal cord injury
- Uraemia
Drug-induced:
- Diuretics
- Alcohol
- Antihypertensives
- Vasodilators
- Phenothiazines
- Antidepressants
Volume-depletion:
- Haemorrhage
- Diarrhoea
- Vomiting
- Dehydration
Carotid sinus syndrome
Pathophysiology
- Disease of autonomic nervous system
- Hypersensitive baroreceptors -> causes dilation and drop in BP, bradycardia, collapse
Carotid sinus syndrome
Diagnosis
- Diagnosis with tilt table and carotid massage
- Ventricular pause of > 3 seconds and a fall in systolic BP of > 50 mmHg following carotid sinus massage
Sick sinus syndrome
- Usually caused by sinus node fibrosis
- Sinus node becomes dysfunctional, in some cases slowing to the point of sinus bradycardia or sinus pauses
- Diagnose with history, ECG and carotid sinus massage
Vascular steal syndrome
- Subclavian artery stenosis
- Means you can’t get blood from subclavian due to stenosis, so blood is ‘stolen’ from the circle of Willis instead
- Leads to collapse
Define multimorbidity
The presence of two or more long-term health conditions, including: Defined physical or mental health conditions, learning disabilities, symptom complexes such as chronic pain, sensory impairments and alcohol or substance misuse
What is the START criteria
START suggests medications that may provide additional benefits ie proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk
What is the STOPP criteria
STOPP identifies medications where the risk outweighs the therapeutic benefits in certain conditions
Especially consider stopping the use of medications such as NSAIDS, warfarin and aspirin in patients with peptic ulcer disease, and pay particular attention to the prescription of reno-toxic or renally cleared drugs in reduced renal function
Physiological markers of frailty
- Increased inflammation (increased CRP, IL6, factor VIII and fibrinogen)
- Elevated insulin and glucose levels in fasting state
- Low albumin
- Raised D dimer and α 1-antitrypsin
- Low vitamin D levels
Stress incontinence
Definition
- Sphincter weakness
- Detrusor pressure > closing pressure of the urethra
- Involuntary leakage on effort and exertion
Stress incontinence
Causes
- Menopause (low oestrogen levels)
- Radiotherapy
- Pelvic surgery
- Congenital weakness
- Pregnancy/vaginal delivery
Stress incontinence
Presentation
- Cough
- Laugh
- Lifting
- Exercise
- Movement
Stress incontinence
Management - conservative
- Encouraged to lose weight
- PELVIC FLOOR MUSCLE TRAINING - 3 months
- Vaginal cones
Stress incontinence
Management - pharmacological + MoA
- Duloxetine (SSRI)
- A combined noradrenaline and serotonin reuptake inhibitor
- Mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
contraction
Stress incontinence
Management - surgical
- Restore pressure transmission
- Support/elevate urethra:
- TVT (tension-free vaginal tape)
- Sling
Urge incontinence (overactive bladder)
Definition
- Involuntary detrusor muscle contractions during the filling phase
- May be spontaneous or provoked (e.g. by coughing)
- Urgency +/- urge incontinence
Urge incontinence (overactive bladder)
Causes
Usually idipathic
Urge incontinence (overactive bladder)
Presentation
- Urgency
- Frequency
- Nocturia
- Key in door
- Hand wash
- Sexual intercourse
- Stress incontinence
- Childhood enuresis is common
- Urine diary will show frequent passage of small volumes of urine, particularly at night
- Examination is often normal but may find incidental cystocoele
Urge incontinence (overactive bladder)
Management - conservative
- Bladder drill retraining - min of 6 weeks
- Reduced fluid intake if excessive
- Avoid caffeine etc
Urge incontinence (overactive bladder)
Management - pharmacological + MoA
Anticholinergics/antimuscarinics: Suppress the detrusor muscles (parasympethetic nervous system - M2 and M3 acetylcholine-activated receptors) - Oxybutynin - Solifenacin - Tolterodine
Mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
Others:
- Oestrogens
- Botulinum toxin A
Overflow incontinence
Definition
Due to bladder outlet obstruction, e.g. due to prostate enlargement
Initial investigations of incontinence
- Bladder diaries for a minimum of 3 days
- Vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles
- Urine dipstick and culture
- Urodynamic studies
Hypothermia
Definition
Unintentional reduction of core body temperature below the normal physiological limits
- Mild = 32-35
- Moderate or severe = < 32
Hypothermia
Epidemiology
- Most common during winter
- Elderly are particularly susceptible
- Many occur indoors due to poor heating etc
Hypothermia
Causes
- Exposure to cold in the environment
- Inadequate insulation in an operating room
- Cardiopulmonary bypass
- Newborn babies
Hypothermia
Risk factors
- General anaesthesia
- Substance abuse
- Hypothyroidism
- Impaired mental status
- Homelessness
- Extremes of age
Hypothermia
Signs and symptoms
- Shivering
- Cold and pale skin. Frostbite occurs when the skin and subcutaneous tissue freeze, causing damage to cells.
- Slurred speech
- Tachypnoea, tachycardia and hypertension (if mild)
respiratory depression, bradycardia and hypothermia (if moderate) - Confusion/ impaired mental state
Newborn: may look healthy but may be limp, quiet and refuse to feed
Hypothermia
Investigations
- Temp (low-reading rectal thermometers if available)
- ECG: J WAVES, acute ST elevation, Osborn waves
- FBC, serum electrolytes:
- Low platelets and WBCs
- High Hb and haematocrit
- May have hypokalaemia
- Blood glucose
- ABG
- Coagulation factors
- CXR
Hypothermia
Management
- Removing the patient from the cold environment and removing any wet/cold clothing,
- Warming the body with blankets
- Securing the airway and monitoring breathing,
- If the patient is not responding well to passive warming, you may consider maintaining circulation using warm IV fluids or applying forced warm air directly to the patient’s body
+ rapid re-warming can lead to peripheral vasodilation and shock
- In severe cases, be prepared to conduct CPR. IV drugs should be avoided if possible, as the patient is more likely to have a drastic response to the drug.
Hypothermia
What NOT to do
Don’t put the person into a hot bath.
Don’t massage their limbs.
Don’t use heating lamps.
Don’t give them alcohol to drink.
Common features of frontotemporal dementia
Onset before 65
Insidious onset
Relatively preserved memory and visuospatial skills
Personality change and social conduct problems
