CPP Case Studies Flashcards
What is your fluid endpoint in a patient that you suspect has internal bleeding?
- Titrate to maintain radial pulse, approx. SBP 80 mmHg
- Normal mentation
What does an EEA do when the patient reaches the hospital?
Detains them for 6 hours to allow a medical professional to further assess and treat them and can be extended up to 12 hours.
What are some common drugs that may be administered during a hypoglycaemic emergency?
- Glucose Gel
- Glucose 10%
- Glucagon
What is the appropriate management for a pulsatile cord present in the vaginal opening?
- Assist the mother into the exaggerated SIMS position
- Ask the mother to gently push the cord back into the vagina (this must be done carefully to avoid vasospasm) using a dry pad
What are the expected vital signs of a 1 year old?
Weight: 10kg
HR: 90-150bpm
RR: 25-50rpm
SBP: 70-100mmHg
What are the signs suggestive of placental separation during labour?
- Uterus rises in the abdomen and becomes firmer and globular
- Fresh show/trickle of blood
- Lengthening of the umbilical cord
What are some intrapartum (during labour) risk factors for primary PPH?
- Expedited or prolonged second stage
- Prolonged third stage greater than 30 minutes
- Macrosomia (large baby)
- Polyhydraminos (excess amniotic fluid)
- Infection/Prolonged rupture of membranes
What are some common causes of palpitations?
- Strong emotional distress
- depression
- Stimulants
- Exercise/physical exertion
- Fever
- Hormones changes
- Thyroid hormones – too much or too little
Describe how beta blockers might impact a patient’s presentation?
Beta blockers bind to B1 and B2 receptors, inhibiting the catecholamines adrenaline and noradrenaline, reducing the inotropic and chronotropic effects on the heart
unable to have a tachycardic response
What are some questions to ask parents of a seizing patient with a history of seizures?
- What has concerned mum the most in this seizure compared to other ones – length, different type of seizure?
- Has she been unwell recently?
- Do they have midazolam at home and have they given any prior to our arrival (take into drug protocol)
- Was the Pt her normal self prior to the seizure?
- How often does she have seizures?
- How long do they normally last?
- Is the buccal midazolam usually effective?
Define Obtunded
lessened interest in the environment, has slowed responses to stimulation, and tends to sleep more than normal, with drowsiness in between sleep states
What are some neonate complications associated with shoulder dystocia?
- Brachial plexus injuries
- humeral and clavicular fractures
- hypoxic brain injury
- stillbirth
What are your actions with a newborn that doesn’t respond to stimulation?
- IPPV room air for 30 secs (20-30 breaths)
- Reassess: sats probe on right hand, HR should be >100
Describe and justify your management for a pt with COPD, with low SPO2, fever and low BP
- 4L oxygen via nasal prongs to increase SPO2 to between 88-92% and increase partial pressure of oxygen to aid in oxygen binding to haemoglobin
- salbutamol
- IV access – to administer fluids and medications
- IV fluids – titrate to maintain radial pulse if lost - and increase blood pressure and possibly secondary effect of reducing fever and BGL
- antipyretic
What is the cause of acute febrile illness headaches?
Pneumonia, URTI, viral infections or UTIs
What are the risk factors associated with the development of pre-eclampsia?
- Diabetes
- Extremes of maternal age
- Family history
- Gestational hypertension
- History pre-eclampsia
- Multiple pregnancies
- Obesity
- Renal disease
What is the definition of TIA and can it be differentiated from stroke?
stroke signs and symptoms caused by a temporary occlusion, that self resolve within 60 minutes to 24 hours.
It can’t be differentiated at the time of treatment by paramedics.
What questions specific to females should you ask a female patient who has fainted/had a syncopal event?
- Sexual activity
- Contraceptive use
- Chance of pregnancy
What tools can be used to identify Sepsis?
QAS sepsis criteria:
Temperature
AVPU
Respiration rate
Heart rate
Systolic BP
Outline the NEXUS criteria.
- ALOC
- focal neurological deficit
- midline tenderness
- intoxication
- distracting injury
If patient is positive for at least one of the criteria, c spine precautions need to be implemented
What is the cause of meningitis headaches?
Inflammation of the meninges
What are the signs and symptoms for peritonitis and sepsis?
- Fever or low body temperature/rigors
- rash
- ALOC
- Lethargy/weak/fatigue
- Thirst
- Loss of appetite
- Tachypnoea
- Hypotension
- Tachycardia
- Abdominal pain or tenderness
- Bloating or a feeling of fullness in the abdomen
- Nausea/vomiting/diarrhea
- Decreased urine output
- Not able to pass stool or gas
What are some risk factors for aortic aneurysm?
- Age
- Male gender
- Family history
- Hypertension
- Hx aortic dissection
- Preexisting cerebral aneurysm
- Several syndromes (marfan, turner)
- Trauma (particularly deceleration)
+3 Sedation Assessment Tool (SAT) behaviour score description
combative, violent, out of control
What are the common signs and symptoms of mild alcohol withdrawal?
- anxiety
- anorexia
- insomnia
- hypertension
- tachycardia
- nausea
- coarse tremor
Define Delirious
disorientated; restless, hallucinating, sometimes delusional
What are your post ROSC cares for a paediatric drowning pt?
Continue ventilations and oxygen, maintain SPO2 >94%, ETCO2 35-45mmHg, PEEP
Circulation – SBP >80 mmHg, consult for fluids if needed
Consider C spine mobilisation, warming patient, rapid transport
Post ROSC cares
What are some considerations/queries on the way to a job for third trimester pregnant patient with a headache?
Gestation
Prenatal cares
Complications with this pregnancy
In labour
What is Atacand Plus presribed for?
hypertension
Outline the different types of hallucinations that can occur.
Visual – seeing things that aren’t there
Auditory – hearing things that aren’t there
Tactile – feeling things on skin that aren’t there
Olfactory – smelling things that aren’t there
Somatic – feeling of being touched when you aren’t
Gustatory – strange or unpleasant taste in mouth with nothing in it
Describe the body’s normal glucose homeostasis mechanisms.
The balance and interaction of insulin and glucagon
What does the mental status assessment affect component assess?
Emotion as observed (Objective)
Westley Croup Score LOC Variables and Scores
Disorientated - 5
Normal, including sleep - 0
Define Faeculent vomiting
vomiting faecal material
What do you look for when you inspect the placenta?
Completeness, smoothness and integrity – missing parts or ragged membranes
What does the mental status assessment perceptions component assess?
How they perceive their world
Describe the methods to deliver effective chest compressions in the newborn?
- 2 fingers/or 2 thumbs
- Rotate 2 minutes
What occurs in the second stage of labour?
full dilation of the cervix and birth of the baby
What is Zocor presribed for?
hypercholesterolaemia
What should you do if you notice ongoing bleeding post delivery and why?
Fundal massage until firm and central – increases uterine tone, expresses clots and reduces haemorrhage
What is Zoloft presribed for?
anxiety
What are the signs and symptoms of shock?
- Hypotension
- Tachycardia
- anuria
- unconsciousness
What are the expected vital signs of a 9 year old?
Weight: 34kg
HR: 70-120bpm
RR: 15-25rpm
SBP: 90-115mmHg
What are some high risk signs for sepsis in paediatrics?
- Capillary refill 3 seconds or longer
- Hypoglycaemia
- Moderate respiratory distress/tachypnoea
- Moderate tachycardia
- Pale or flushed/mottled/cold extremities
- Reduced urine output
- Unexplained pain or restlessness
What is the definition of sepsis?
Life-threatening organ dysfunction caused by a dysregulated host response to infection
What class of drug is ventolin?
bronchodilator/short acting beta agonist
What is the presentation of uterine rupture?
- abnormal labour or failure to progress
- severe localised abdominal pain
- non-reassuring foetal heart patterns
- uterine tenderness
- loss of intrauterine pressure or cessation of contractions
- vaginal bleeding
- maternal hypovolaemic shock
Describe the steps of the Valsalva manoeuvre?
- Explain the procedure to the patient
- Position them supinely
- Take a baseline 12 lead ECG
- Have them forcefully blow into a 10ml syringe for 15 seconds
- Repeat 12 lead ECG
Describe the pathophysiology of seizures and common types of seizures.
Abnormal electrical discharges (neuronal activity) within the brain causing random, uncontrolled neuronal depolarisation to one or more regions of the brain.
What are the clinical features of acute febrile illness headaches?
Fever and symptoms of underlying cause eg URTI, tonsillitis
Outline your initial management of an unrespnsive patient, with a snore, RR 4, slow radial pulse and cold, and why?
- Reposition to supine with neutral head alignment to open airway and remove snore
- IPPV 15L oxygen to supplement RR of 4 and add additional and supplementing breaths to increase resp rate to 18 p/min to improve oxygenation and reverse any hypoxia that may have already occurred
- Place blanket over patient to improve body temperature
What are the clinical features of encephalitis headaches?
reduced conscious level
confusion
fever
What is the pathophysiology of croup?
virus causes swelling of the larynx and trachea causing the airways to narrow and breathing to become more difficult
What red flags may arise in history taking, suggesting non-accidental injury?
- Poor history or account of the injury occurring
- Hx of unwitnessed trauma
- Hx or family violence (may or may not know this)
- Mechanism non compatible with child’s age or development capabilities
- Hx does not match with patient findings
- Inconsistencies in hx
- Delay in seeking medical attention for an injury in a non ambulatory infant
- Patterns of bruising or shapes, old bruising
Outline reverse wood’s screw manoeuvre
apply pressure to posterior of foetus posterior shoulder and rotate in opposite direction to Wood’s Screw manoeuvre
What are the expected vital signs of a 10 year old?
Weight: 37kg
HR: 70-120bpm
RR: 15-25rpm
SBP: 90-115mmHg
What is the pathophysiology of peritonsilar or retropharyngeal abscess?
infection from tonsilitis
What are the effects of a life threatening serotonin toxicity?
- Seizures
- Hyperthermia
- Cardiovascular dysfunction
- QT prolongation
- Torsades de pointes
- Multiorgan failure
- Rigidity
What are the general categories of acute behavioural disturbances?
- Substance toxicity
- Medical and organic disorders
- Acute mental health conditions
- Situational/behavioural
What is the management for stroke?
- Position Pt with 45 degree head elevation
- Consider:
Midazolam
IV Access
IV fluids
Oxygen
Analgesia
Antiemetics - Repeat stroke assessment to trend condition
- Rapid transport to appropriate facility
What are some common causes of abdominal distension?
- Fat
- Fluid (ascites)
- Flatus
- Faeces
- Foetus
- Filthy big tumour
What is the drug flixotide and what is it used for?
corticosteroid
asthma and allergies
What characterises a mild airway obstruction?
- patients themselves will optimise position (e.g. siting forward)
- effective cough
- crying or verbal responses present
- able to take breath before coughing
- fully responsive
What are some differential diagnoses of headaches in pregnancy?
Pre-eclampsia
Eclampsia
Central venous thrombosis
Primary headache
Secondary headache
What is the treatment for an anaphylaxis patient and the mechanism of management?
appropriate dose adrenaline IM – sympathomimetic agent alpha and beta adrenergic receptor antagonist that makes the heart beat faster and harder due to alpha 1 causing peripheral vasoconstriction and beta 1 increasing ventricular irritability, contractile force, conductivity and AV node. Beta 2 stabilises mast cells to negate their deregulatory effect
What is the treatment for epiglottitis?
Reassure
Consider oxygen – mask and rate dependent upon SPO2
Position of comfort
Rapid transport
What is the pathophysiology of agitated delirium?
Hyperthermia causing rhabdomyolysis and acidosis due to antagonism of M1 and M2 muscarinic receptors
What class of drug is lantus?
long acting insulin
What organs are in the Left Iliac Region?
- parts of sigmoid colon
- descending colon
- small intestine
What gynaecological history questions should you ask a female patient who has abdomen pain?
- Are her menses regular?
- Has she had any PV bleeding?
- Is there a possibility that she could be pregnant?
- Does she have any gynaecological Hx in general?
- Does she take contraceptives?
What is the drug salbutamol taken for?
asthma
COPD
What are the main principles to consider when speaking with someone who is suicidal?
- Safety for everyone
- Clear communication
- Tell the person you care and can help them at this time
- Gather pertinent information about their situation from family, friends, carers, bystanders or other credible sources or health services
- Taking time to listen to the person
What are some common anti-depressants and their mechanism of action?
- Selective serotonin reuptake inhibitors (SSRIs) – Serotonin (5HT) reuptake inhibitors– fluoxetine, sertraline, citalopram
- Serotonin noradrenaline reuptake inhibitors (SNRIs) –5HT & noradrenaline reuptake inhibitors– venlafaxine, desvenlafaxine, duloxetine
- Tricyclic antidepressants (TCAs) - 5HT & noradrenaline reuptake inhibitors & receptor blockers - amitriptyline, imipramine, nortriptyline
- Monoamine oxidase inhibitors (MAOIs) - Inhibits breakdown of 5HT, noradrenaline, & dopamine, and catecholamines - phenelzine, tranylcypromine, moclobemide
Outline the mechanism of serotonin toxicity.
Increased concentrations of serotonin in the CNS interacting with G-protein-coupled receptors, inhibit auto receptors, causing increased serotonin synthesis and decreased reuptake – makes serotonin and stops the body from re-uptaking excess serotonin
What organs are in the Left Hypochondriac Region?
- spleen
- large/small intestines
- left kidney
- pancreas
- stomach
- tip of the liver
Describe the pathophysiology of pulmonary embolism during pregnancy
hypercoagulable state and decreased blood flow from uterine veins can cause blood clots in the legs
How does the baby present in a footling breech?
One or both feet presents first, with the buttocks at a higher position. The hips and knees are flexed so that the foetus is sitting cross-legged, with feet beside the buttocks.
List some common psychostimulants
- Cocaine
- methamphetamine
- methylenedioxymethamphetamine (MDMA)
What does a mental status assessment include?
- Appearance
- Behaviour
- Perceptions
- Speech
- Affect
- Mood
- Thought content
- Thought form
- Insight & Judgement
How may a beta blocker overdose present?
- Pulmonary oedema
- Hypotension
- Bradycardia
- Heart block
- Cardiogenic shock
- Hypoglycaemia/hyperglycaemia
- Seizures, coma (propranolol)
What is the treatment for bacterial tracheitis?
symptomatic
What occurs in the third stage of labour?
delivery of the placenta
What are the expected vital signs of a 5 year old?
Weight: 22kg
HR: 80-140bpm
RR: 20-30rpm
SBP: 80-110mmHg
What type of drug is metoprolol?
beta blocker
What are some red flags associated with headaches?
- Thunderclap headache (intense, exploding, and hyperacute onset)
- Headaches associated with fever, rash or ALOC
- Meningeal signs (stiff neck, photophobia, or vomiting)
- New onset headache in patients > 50 or < 10
- Persistent morning headache with nausea
- New onset of headache in Pt with cancer or HIV
- Progressive headache worsening over weeks
- Headaches associated with postural changes
- Aura (warning sensation) that lasts longer than an hour, is different from previous aura, or occurs for first time on using oral contraceptive
Define wheezing and its mechanism
high-pitched whistling noise – sound of air moving in constricted airways
What are some causes for an altered level of consciousness?
- Stroke
- Inadequate cerebral perfusion
- Hypoxia
- Increased carbon dioxide levels
- Metabolic disturbances
- Drugs or toxins
- Post ictal seizure
- Intracranial pathology
- Extracranial pathology
- AEIOUTIPS
Outline the steps involved in the management of a breech delivery.
- Call for backup
- Prepare for neonatal resuscitation
- Hands off - Delivery should proceed spontaneously through gravity, maternal effort and uterine action
- Assist with delivery of legs if needed
- Perform manoeuvres if complications or failure to deliver
- Thumbs on bum
- manoeuvres if needed - Lovesets 1, Lovesets 2, Lovesets 3
- MSV maneouvre (to deliver the head)
What considerations should you have when getting a history from older patients?
Forgetfulness/confusion
A lot of medications
Sudden decline in mobility, self care, chores etc
What is the pathophysiology of placental abruption?
Rupture of the maternal vessels in the pregnancy modified endometrium causing the placental to separate partially or completely from the uterine wall.
How does excess alcohol consumption contribute to the underlying mechanism of pancreatitis?
small pancreatic ducts blocked by viscous secretions and activation of lysosomal and digestive enzymes in acinar cells and association with GI bleed and ruptured varices
What is the Tx for a PE Pt?
anticipate deterioration and CPR
* High flow oxygen – PEs can be resistant to oxygen therapy
* Pain relief – morphine – indications, contraindications, consult for more
* 12 lead
* No need for aspirin
Consider:
* differential diagnosis
* IV fluids – max 1L due to failing RV and risk of increasing preload
* adrenaline
* CCP backup
* transport
* pre-notify as appropriate
What are the cholinergic signs and symptoms?
dumbbells
D - diarrhoea
U - urination
M – miosis
B – bronchorrhea
B – bradycardia
E – emesis
L – lacrimation
L - lethargy
S – salivation/sweating
What is the drug effect of Span-K?
increases levels of K+ in the blood
What suffix do a lot of TCAs end in?
ine
What options do you have to get a patient off the floor?
Manual lift
Raizer
Camel
Hover mat
What is the cause of encephalitis headaches?
Inflammation of active brain tissues from infection or autoimmune response
What assessments or clinical tests can you carry out to assist with a diagnosis of meningitis?
- Head to toe to identify and rashes – non-blanching purpuric or petechial rash or bruising
- Difficulty touching chin to chest with mouth closed
- Difficulty touching forehead to knee
- Brusinski sign
- Kernig’s signs
What does it mean when the baby’s head fails to restitute/what is this a sign of, and why does this occur?
Shoulder dystocia as the baby’s shoulders are too wide for the pelvic inlet and the anterior shoulder impacts on the symphysis pubis
How is stimulant toxicity graded?
Mild, moderate, severe
What are some considerations you would have enroute to a chest pain call?
- Previous heart Hx/medical Hx
- ACS protocols – early 12-lead with serial printouts, aspirin, GTN
- Nearest cath lab
- Knowing what hospitals have different capabilities
- Differentials
What is the definition of secondary postpartum haemorrhage?
Abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks following birth, usually defined as more than one heavily soaked pad per hour
What are the clinical features of raised ICP headaches?
Worse on waking/sneezing
Raised BP
Reduced pulse rate
Define septic abortion
serious uterine infection before, during or shortly after a spontaneous or induced abortion
How can you differentiate between croup and epiglottitis?
Croup - gradual onset with hx of runny nose or illness that gets worse at night
Epiglottitis - acute fast onset
What is ALOC?
reduced alertness or inability to arouse
What type of drug is rosuvastatin?
statin
What is the pathophysiology of a focal seizure?
abnormal neuronal activity originates and is limited to one hemisphere of the cerebral cortex
What type of drug is rivaroxaban?
anticoagulant
Define induced abortion
intentional termination of a pregnancy by a procedure or medication
Compare and contrast the Valsalva and the modified Valsalva manoeuvre
The Valsalva manoeuvre requires the patient to be sitting in the one semi-recumbent position, however the modified Valsalva manoeuvre requires to patient to be initially semi recumbent, then supine with legs elevated and then back into a semi recumbent position
What are some risk factors for complications during pregnancy and possible consequences that can be associated?
- Alcohol or drug abuse – cause miscarriage, defects, early labour
- Eclampsia
- Extremes of maternal age – very young or older – increased risk of complications
- Foetal growth restriction
- Gestational or preexisting diabetes – macrosomic babies, foetal death, foetal malformations and growth restriction and increased need for interventiosn during labour
- Hypertensive disorders – chronic hypertenstion, preeclampseia, help
- Older women – increased risk of complications
- Preterm – baby at risk due underdeveloped
- Previous c sections/shoulder dystocia – increased risk of shoulder dystocia
- Prior preterm delivery, prior stillbirth – increased risk in subsequent pregnancies
Describe your ABD sedation brief to the team and what equipment you will have available.
- Allocation of sedation supervisor, sedation assistant and other required personnel
- Advising QPS of requirements for positioning of patient – avoiding pressure on the head, neck and chest/back
- Restraint of the patient to occur as late as possible
- Equipment on hand is resuscitation kit and defibrillator
What could be an additional differential in a pregnant patient presenting with chest pain and SOB?
Peripartum cardiomyopathy
Aortic dissection
Pulmonary embolism
What type of drug is Frusemide?
loop diuretic
Where do you clamp and cut the cord?
10cm, 15cm and 20cm
Cut between 15cm and 20cm
What is the definition of primary postpartum haemorrhage?
Blood loss of greater than 500 mls from birth canal within the first 24 hours following birth
What are some red flags for sepsis? Why may these factors be considered red flags?
- Re-presentation to a health care professional within 48 hours – treatment not working
- Age less than 3 months OR greater than 65 years – reduced immune system
- Recent trauma or surgery/invasive procedure/wound within last 6 weeks – possible cause of infection
- Indwelling medical devices (e.g. IDC) – possible cause of infection
*Immunocompromised/unimmunised – reduced immune system - Parental/family/health care professional concern for the patient – medical knowledge of health concern
- Aboriginal or Torres Strait Islander/Pacific Islander/Maori cultural backgrounds – reduced access to health care
Outline the important elements of the “golden hour” and the benefits that it may have.
- general management
- skin to skin contact
- delay non urgent parts of assessment
- early initiation of breast feeding
- keep bub warm
It promotes bonding and milk supply as well as the release of oxytocin in mum and bub
What is a thunderclap headache?
sudden onset of severe thunderclap type head pain
Define spontaneous abortion
natural loss of pregnancy prior to 20 weeks gestation
Provide some common calcium channel blocker drug names
- Verapamil
- Diltiazem
- Amlodipine
- Nifedipine
- Felodipine
- Lercanidipine
What are some differential diagnoses for a Pt who is:
tripoding - significant SOB
increased WOB
pale, clammy
sudden onset of sharp right-sided chest pain whilst mobilising and is worsened on inspiration?
- Pulmonary embolism – especially if tachycardic
- Spontaneous pneumothorax (tall skinny fellow) – diminished chest sounds
- Myocardial infarction
- Congestive Heart Failure
- Pericardial tamponade
- Pericarditis
- Infection
What is the management for a DKA patient and why?
- Oxygen – increase SPO2 >94% and reduce amount of CO2
- IV access - for drug administration
- IV fluids – to increase vascular volume to improve BP and maintain radial pulse and to dilute blood concentration of glucose
- Consult for salbutamol to shift K back to cells
- Rewarming - reversible cause of cardiac arrest
- Pads on - as can deteriorate
- CCP backup - to provide additional knowledge and assistance in treating
What is the management for a patient in cardiac arrest refractory to 3 stacked shocks?
- Amiodarone – (unless contra for TCA) 300mg IV slow push over 1-2 minutes
- after 5th DCCS 150mg IV slow push over 1-2 minutes
- after 6th DCCS adrenaline – 1mg IV every 3-5 minutes
What are the indications for an acute stroke referral?
Mandatory for all Pts with symptoms suggestive of stroke who meet the following:
* Onset of stroke symptoms less than 24 hours; AND
* The patient is able to be transported to an acute stroke centre (ASC) within 60 minutes (from stroke assessment)
Define inevitable abortion
uterine contractions causing cervix dilation leading to a complete or incomplete abortion
What other steps can be taken to assist with uterine contractions/haemorrhage control post delivery?
- Stimulate endrogenous oxytocin release by the commencement of breastfeeding
- Have mum urinate
What are the clinical features of tension type headaches?
Band around the head
Stress
Low mood
0 Sedation Assessment Tool (SAT) behaviour score description
Awake/calm and cooperative
What are the clinical features of migraine headaches?
Aura
visual disturbance
unilateral headache
nausea/vomiting
trigger
What is the pathophysiology of bacterial tracheitis?
bacteraemia and/or pathogenic invasion of the epithelial layer
What is Ezetrol presribed for?
hypercholesterolaemia
What does the mental status assessment judgement component assess?
ability to evaluate choices and make appropriate
choices
What is your initial management for an unconscious hypoglycaemic patient and justify why?
- IV access to administer glucose 10% as glucose is the preferred fuel source over glucagon. This is with the aim of returning his BGL back to within normal limits.
- If can’t get IV access, go glucagon however if don’t have appropriate store of glycogen in liver, glucagon won’t work
Describe the general pharmacology of steroids.
Inhibit the inflammatory action of the phospholipase A2 enzyme and used for multiple reasons for infections in a variety of setting for long term disease processes
What is the pharmacology of a calcium channel blocker?
Restrict calcium ingress, slowing cardiac conduction and contractility and decreasing the oxygen demand of the heart
Verapamil and diltiazem also cause peripheral vasodilation, lowering arterial blood pressure and reducing ventricular afterload
What is the pathophysiology of a cardiac arrest with an underlying asthmatic disease process?
Air trapping causing obstructive shock which increases intrathoracic pressure and compressing inferior vena cava, stopping blood flow to right side of heart. Right ventricle depends on preload forcing contraction.
Define “coffee ground”
vomit that looks like it has coffee grounds in it due to coagulated blood
What is the underlying pathophysiology that contributes to the development of pre-eclampsia?
Unclear, however is thought to be from an abnormal placentation, endothelial dysfunction, inflammation, immune system activation, oxidised stress, renal involvement due to impaired kidney function, hormone imbalance or other genetic factors
Affects some pregnant women typically after 20 weeks and characterised by hypertension and protein in urine
Outline rubins II manoeuvre
insert gloved hand and apply posterior pressure to anterior shoulder of the foetus to rotate shoulders to oblique diameter
What are the three main priorities after administering an initial adrenaline dose in anaphylaxis?
High flow oxygen
Further appropriate doses adrenaline – appropriate time frame
Throughough head to toe – to identify any external cause
Under which act does an EEA operate?
Public Health Act 2005
How does paracetamol produce analgesia?
works through cox inhibition and production of prostaglandins
What risks are associated with cord prolapse?
- Foetal blood supply occluded, leading to hypoxia and death
- Vasospasm when manoeuvring the umbilical cord
Define the pattern of pain for Pancreatic pain
- left hypochondriac or epigastric region pain, worsened within minutes after eating or drinking, especially high fat foods, can become constant and more severe and can last several days
- Worsened when lying on back and can radiate to the back or below left scapula
What are the expected vital signs of a 11 year old?
Weight: 40kg
HR: 70-120bpm
RR: 15-25rpm
SBP: 90-115mmHg
What is the drug class and use of panadol-osteo?
analgesic
osteoarthritis
What are the clinical features of subarachnoid haemorrhage headaches?
‘Thunder-clap’ or very sudden onset headache
+/- stiff neck
What is your management if the newborn’s pulse drops below 60?
- Place on flat surface
- CPR: 3:1 (Compressions:breath)
- Paeds pads on
- If shockable rhythm, shock at 4joules/kg – manual defib setting
- IV access
- 50 mics (0.5ml) adrenaline every 3-5 mins (using 1:10,000 (100mic/1ml) ampoule)
What does GTN do?
reduces preload and afterload, allowing blood flow through cardiac arteries and veins and peripheral blood pooling to reduce workload of the heart
Using the above graphic, estimate the blood loss in each picture
- 30ml
- 100ml
- 500ml
- 60ml
- 350 ml
- 250ml
- 1000ml
- 2000ml
- 1500 ml
What is your management for an unresponsive patient presenting with:
Respiratory Status Assessment
* Rate – the intrinsic rate is 4
* Rhythm – regular
* Effort – decreased and shallow
* Sats – 85%
* Skin – pale
* Speech – none
* Sounds – normal
* Speech – none
* Sounds – normal
Cardiovascular Assessment
* HR – 50
* BP – 90/45
* BGL – 2.0
* Temp – 33.2°C
Neurological Assessment
* GCS – eyes do not open, no verbal response, nil motor response
* Pupils – size 2 and non-reactive
* Motor – nil
H-T
* Urinary incontinence
- Call for CCP backup and additional bravo crew – CCP can administer adrenaline
- Continue IPPV/NPA/OPA – to increase oxygen saturations
- Blanket on patient and open warming blanket and allow to warm up – takes 30 mins to warm up
- IV access to administer drugs
- IV glucose 10% - 15g (150 ml), repeated at 10g (100ml) every 5 minutes until BGL >4 mmol
- IV sodium chloride 0.9% - titrate to increase SBO >100 mmHg
- 12 lead ECG – to ascertain any ECG changes such as terminal R wave and QRS widening
- Place onto stretcher – once backup arrives to get off cold ground and to commence transport
Outline the McRoberts manoeuvre
mum laying supine with knees to nipples - to increase anteroposterior diameter of the pelvic inlet
-1 Sedation Assessment Tool (SAT) verbal score description
slurring or prominent slowing
What are the ECG features of AF?
- Absent P waves
- Chaotic irregularly baseline/fibrillatory waves
- Irregularly irregular
- Wide QRS
- Fibrillation waves may mimic p waves
What are the clinical features of meningitis headaches?
fever
photophobia
stiff neck
rash
limb pain
cold peripheries
mottled skin
bulging fontanelle (babies)
What is your management for a patient with a mild airway obstruction where back blows and chest thrusts have failed?
Removing the obstruction via direct laryngoscopy and magill forceps
Discuss the risks associated with the reversal agent.
Can cause APO due to catecholamne surge creating and adrenergic crisis causing volume to shift to pulmonary vasculature
-3 Sedation Assessment Tool (SAT) behaviour score description
no response to stimulation
What are the risks associated with the administration of droperidol in a patient presenting with sepsis?
Can cause profound hypotension – especially in urosepsis
Outline the different methods of arrhythmia termination that may be used within the emergency department
- Cardioversion
- Adenosine – stopping heart from beating for a short period of time
What are your first three priorities of management for a seizing patient?
- Checking the airway for vomitus and suctioning if required or postural drainage
- Oxygen administration – 15L/min via non- rebreather mask
- IM midazolam
How do benzodiazepines cause CNS depression?
strengthens the inhibitory neurotransmitter GABA within the CNS, which inhibits nerve transmission and reduces neuronal excitability
What is the cause of subarachnoid haemorrhage headaches?
leak of blood of rupture from intracranial vessel
What are the ventilation rates?
20 per minute = 1/3
18 per minute = 1/3
16 per minute = 1/4
14 per minute = 1/4
12 per minute = 1/5
What are some risks associated with CNS depression?
- loss of airway reflexes
- aspiration
- positional asphyxia
- hypotension
- bradycardia
- hypothermia
What is the appropriate management for a pregnant female in third trimester with a severe headache?
IV access for drug administration
CCP backup for IV magnesium sulphate
Paracetamol 1g – analgesia
Morphine 2.5mg – analgesia
What are the expected vital signs of a 6 year old?
Weight: 25kg
HR: 70-120bpm
RR: 15-25rpm
SBP: 90-115mmHg
Describe your immediate actions with a newborn that requires assistance.
- Initiate tactile stimulations
- Skin to skin contact
- Warm bub with skin to skin contact with mum and blanket over the top
- Suction mouth before nose
- Clamp and cut cord
- Consider: IPPV room air
What features are present for a diagnosis of pre-eclampsia?
- systolic blood pressure (SBP) ≥ 140 mmHg and/or
- diastolic blood pressure (DBP) ≥ 90 mmHg plus one or more of:
o neurological problems
o proteinuria
o renal insufficiency
o liver disease
o haematological disturbances
o foetal growth restriction
Define confused
disorientated; bewildered, and having difficulty following commands, not knowing date/month/year/location etc
What are some complications associated with breech delivery?
Footling and kneeling breech – prolapsed cord
What time is placed on the EEA?
Triage
What does the mental status assessment mood component assess?
Emotion as described (Subjective)
Outline the pathophysiology and management of febrile convulsions
Self-limiting muscle originating process - can’t regulate temperature and convulsing to create movement to decrease body temp through fanning type mechanism.
Active cooling of patient
What is a primary headache?
A headache caused by the issue itself does not have an underlying cause
What is the drug class and use of Crestor?
statin
hyperholesterolaemia
What are some causes of APH after 20 weeks?
- Placental abruption
- Placenta praevia
- Uterine rupture
- Loss of pregnancy
Describe your managment of a paediatric drowning pt with PEA?
- CPR: 15-2, good quality compressions, rotate officers
- suctioning/OPA/ETCO2
- Maintain normothermia
Define Rhonchi and its mechanism
low pitched wheezing/snoring – sound of air moving through mucous in bronchial tubes
What are some common opioid medications and their trade names?
- Heroin
- Morphine
- Fentanyl
- Oxycodone
- Codeine
- Buprenorphine
- Hydromorphone
- Methadone
- Tramadol
- Tapentadol
Westley Croup Score Chest Wall Retractions Variables and Scores
Severe - 3
Moderate - 2
Mild - 1
None - 0
What is the purpose of the shoulder dystocia interventions?
To increase the functional size of the bony pelvis and change the relationship between the size of the bony pelvis and the foetus and to reduce biacromial diameter of the foetus or to rotate foetus into oblique diameter
Westley Croup Score Air Entry Variables and Scores
Markedly decreased - 2
Decreased - 1
Normal - 0
What are the types of antidepressant drugs?
SSRIs
SNRIs
TCAs
MAOIs
What are some risks associated with new onset AF?
- Thromboembolism in lung vasculature
What is your definition of asthma?
Reversible obstructive lower respiratory disease characterised by chronic airway inflammation, bronchial hyperresponsiveness and intermittent airway narrowing, +/- excess mucous production and mucous plugging
Describe common seizure presentations in paediatric patients.
- Vacant stares
- Lack of gross muscle tonicity
- Fixed gaze
- Facial muscle twitching
What is the drug class and use of Ramipril?
ACE inhibitor
hypertension
What are the four classes of cardiovascular drugs?
I - sodium blockers
II - beta blockers
III - potassium blockers
IV - calcium blockers
What are the signs and symptoms for Uncontrolled gastrointestinal tract (GIT) haemorrhage?
- fatigue
- shortness of breath
- vomit that looks like coffee grounds or has bright red blood
- abdominal cramps
- black or tarry stool
- haematochezia - dark or bright red blood mixed with stool
- Shock
What are you looking for in a H2T of a Pt who you suspect has a pulmonary embolism?
swelling to legs to identify presence of thrombus with pain on palpation – especially calf
redness or swelling around incision sites to identify presence of infection
sensations
Can asthmatic pts tolerate 6-8 breaths per minute adult and 8-15 breaths per minute paeds?
yes
What are the signs and symptoms of acute pancreatitis?
- Fever
- Tachypnoea
- Hypotension
- Tachycardia
- Epigastric pain radiating to the back
- Nausea and vomiting
- Jaundice
- Ecchymosis
Outline some of the services that an elderly patient could be referred to for help at home
Home care
Community transport
Social worker
Services Australia website – nationwide number for state service
Dedicated dementia lines
Geri referral team
What is the mechanism of dexamethasone?
anti-inflammatory that reduces inflammation
Outline the pathophysiology of anaphylaxis
Exposure to allergens where IgE sensitisation occurs – additional exposures causes crosslinking of IgE causing mast cell deregulation and release of mediators that can cause symptoms or recruit inflammatory cells continuing a chain reaction resulting in a myriad of symptoms
What are some antenatal risk factors for primary PPH?
- Previous history of post-partum haemorrhage
- Anaemia
- Age greater 35 years
- Multiparity
- Prior uterine surgery, including caesarean section
- Pre-eclampsia and HELLP syndrome − these interfere with liver enzymes which in turn interferes with clotting factors.
- Obesity
- Uterine anomalies, including fibroids
- Abnormal placentation
- Multiple pregnancy
What immediate assessments indicate that the newborn requires assistance?
HR
breathing status
tone
What is the treatment for FBAO?
encourage cough
back blows
chest thrusts
laryngoscope/magills forceps & rapid transport
What are the common signs and symptoms of severe alcohol withdrawal?
- anxiety
- insomnia
- irritability
- seizures
- fever
- visual hallucinations
- hypertension
- tachycardia
- tremor
What are the common sodium blocker drugs?
TCAs - ‘ine’ suffix
flecainide (CVS)
propafenone (CVS)
propranolol (CVS)
dextropropoxyphene (opioid)
What are the signs and symptoms of ectopic pregnancy?
- abnormal vaginal bleeding
- hx of amenorrhoea (at least one missed period)
- nausea
- pelvic and/or abdominal pain
- presyncopal symptoms
What are some techniques for de-escalation?
- Respect personal space
- Do not be provocative
- Establish verbal contact
- Be concise
- Identify wants and feelings
- Listen closely to what the patient is saying
- Identify areas upon which to agree
- Set clear limits
- Offer choices and optimism
- Evaluate the outcome of de-escalation and consider further options
What are the signs and symptoms of testicular torsion?
- nausea and vomiting
- abdominal pain on the same side as the torsion
- sudden, severe pain in the scrotum
- swelling of the scrotum, redness, tenderness or hardening of the scrotum
- the testicle being in a strange position, such as higher than normal or on an unusual angle
- one testicle looks larger than the other
- tenderness if the area is touched
- discolouration of the scrotum
- difficulty walking
What are the benefits of delayed cord clamping?
- Increases baby’s blood volume by around 80-100mls, possibly up to 300mls
- Improved iron scores at 3-6 months
- Supports transition from foetal to neonatal circulation
- Reduced risk of brain haemorrhage and ischaemic gut in premature babies
- Reduced risk of baby becoming anaemic
- Transferring blood rich in antibodies and stem cells – boosting immunity
What organs are in the Epigastric Region?
- liver
- stomach
- pancreas
- duodenum
- spleen
- adrenal glands
What is the pathophysiology of an acute asthma attack?
Response to allergen or environmental factors – exercise, weather, infective causes – releasing endogenous irritant and inflammatory mediators that cause reversible airway obstruction and narrowing from airway smooth muscle constriction
What are the indications for pre-hospital administration of fibrinolysis?
- Pt located more than 60 minutes transport time (from first STEMI 12-Lead) to a pPCI capable hospital
- GCS = 15
- Classic ongoing ischaemic chest pain less than 6 hours in duration (excluding atypical ischaemic chest pain)
- 12-Lead consistent with STEMI
What is the drug metropolol taken for?
angina
hypertension
heart failure
previous MI
tachyarrhythmias/AF
it controls heart rate
Outline the management involved with the administration of fibrinolysis.
Complete informed consent for tenecteplase (weight based) and given in conjunction with 300mg clopidogrel and 30mg IV enoxaparin followed up at 15 mins with 1mg/kg enoxaparin subcut dose
Define Somnolent
sleepy, responding to stimuli only with incoherent mumbles or disorganised movements
How quickly should the shoulders be delivered under normal circumstances?
60-90 seconds
What is Kernig’s Sign?
inability to straighten the leg when the hip is flexed to 90 degrees
What is your first pharmacological agent of choice for croup and why?
Adrenaline NEB – 5mg, single dose only – as had stridor at rest
Is a 12 lead ECG warranted in a ptient with abdominal pain?
Yes, as abdominal pain can be present rather than chest pain in ACS
What are common stroke symptoms?
- Thunderclap headache
- ALOC
- Focal neurological deficits
- Dysphasia/asphasia
- Hemiplegia
- Nausea
What is the presentation of placental abruption?
- Constant pain in the abdomino-pelvic region
- Fundal height may increase due to expanding intrauterine haemorrhage
- Tetanic uterine contractions
- Uterine hypertonicity – feels rigid on palpation
- Bleeding may range from absent to profuse, occurring in waves as the uterus contracts
- Signs of maternal shock
What is Betaloc presribed for?
hypertension/angina
What are the symptoms of brain hypoxia?
Loss of concentration
Poor decision making
Memory loss
Cyanosis/pallor
Coma
Seizures
Brain death
Define Pleural friction rub and its mechanism
rough, scratchy sound – pleural membranes rubbing together
What are some differential diagnoses of confusion in the elderly?
- Stroke/TIA
- Infection/UTI
- Sepsis
- Polypharmacy overdose
Describe the pathophysiology of peripartum cardiomyopathy
hormones of late pregnancy causing endothelial dysfunction and cardiomyocyte death
What are your first actions for a patient who is supine in bed, cyanotic, speaking in phrases with an audible respiratory sound and SPO2 of 50%?
- Reposition pt to semi-recumbent – to increase available space in the thorax
- Administer 15L oxygen via non rebreather mask – to return sats to a normal level and improve hypoxemia
If a patient who has just delivered a baby haemorrhages and continues to deteriorate, outline your ongoing management and justify your reasoning.
IV TXA, 1g, slow push over 10 minutes, single dose only – to assist with blood clotting
How long should each shoulder dystocia manoeuvre be done for?
30 seconds
Define missed abortion
pregnancy stops developing but products of conception remain in the uterus and the cervical os is closed
How does alcohol cause CNS depression?
strengthens the inhibitory neurotransmitter GABA within the CNS, which inhibits nerve transmission and reduces neuronal excitability. It also inhibits glutamate which affects memory, cognition and mood
What is cervical shock and what are some differential diagnoses that could contribute to presentation?
Neurocardiogenic shock form dilation of the cervix
Hypovolaemic shock
What are some common risk factors for developing hypoglycaemia in diabetics?
- Took insulin and forgot to eat
- Increased age
- Skipping meals
- Erratic eating patterns
- Heavy exercise
- Weight loss
- Beta blockers
- Using same injection site too frequently
- Antidepressants
- Alcohol
- Cognitive dysfunction
- Underlying kidney damage
- Underactive thyroid
- Gastroparesis
- Chronic diabetes
- Pregnancy
What is your pharmacological management for a pregnant patient with suspected pre-eclampsia who begins to convulse?
5mg IM midazolam, repeated every 10 mins, max 20 mg; OR if have IV access;
5mg IV every 5 minutes, max 20 mg
No as it will not correct the underlying cause of peripheral vasoconstriction and increased tone
Describe how patients should be restrained for sedation and the rationale behind this.
Laterally with hands in front to ensure that the patient’s face is visible at all times for monitoring and airway maintenance and restrained for as short a time as possible
What are some risk factors for shoulder dystocia?
- Previous SD
- Macrosomia (large foetus > 4 kg)
- Maternal diabetes mellitus
- Maternal obesity (BMI > 30)
- Older maternal age
- Post term pregnancy
- Excessive weight gain in pregnancy
How do you manage a croup patient with global expiratory wheeze and prolonged expiratory phase after administering adrenaline?
Salbutamol NEB 2.5mg, PRN
Dexamethasone 0.5ml, PO – anti-inflammatory steroid
Paracetamol 150mg (6ml), PO – antipyretic
What is the pathophysiology of an ischaemic stroke?
intracranial or perforator artery occluded by a thromboembolism from within the brain or one which has travelled from the heart or distal limb which causes hypoxia in downstream brain tissue
What is metoprolol administered for?
Hypertension
Angina
Suspected MI
Migraine prophylaxis
What are some examples of activities of daily living, and how may they be measured in the elderly?
Walking – walking frame/stick
Cleaning – cleaning themselves or having cleaners come in
Self care – showering themselves or having carers come in
Westley Croup Score Cyanosis Variables and Scores
At rest - 5
With agitation - 4
None - 0
What are the expected vital signs of a 6 month old?
Weight: 7kg
HR: 100-160bpm
RR: 25-50rpm
SBP: 70-100mmHg
What are the clinical features of cluster headaches?
Usually male
Often a smoker
Nightly pain in 1 eye for 2−3 months then pain free for at least a year
What are some stroke mimics?
- Conversion disorder (results from psychological stress)
- Electrolyte derangement
- Encephalitis
- Hypoglycaemia
- Infection (particularly with fever in elderly) and sepsis
- Migrainous aura and/or hemiplegia (with/without pain)
- Space-occupying cerebral lesions
- Seizures and post-ictal periods
Westley Croup Score Components
Level of consciousness - disorientated/normal
Cyanosis - at rest/with agitation/none
Stridor - at rest/with agitation/none
Air entry - markedly decreased/decreased/normal
Chest wall retractions - severe/moderate/mild/none
What is the appropriate management for a pregnant female in third trimester with a severe headache who is refractory to initial analgesia with increasing hypertension?
Morphine 2.5mg IV – analgesia
Position of comfort and quiet environment - consult for GTN for hypertension
What is the estimated weight of a newly born and expected vital signs?
- Weight: 3.5kg (CPG says 3-5)
- Heart rate: 100-160 bpm
- Respirations: 25-50 rpm
- Systolic blood pressure: 60-70 mmHg
- SPO2: low post delivery and increases over 10 minutes
What are some yellow flags associated with headaches?
- Worsening headache following recent trauma to head
- Taking an anticoagulant or antiplatelet drug
- Hypertension during pregnancy
- Previous Hx of intracranial bleeding
- Onset during sexual activity
- Family history of cerebral vascular abnormalities
What are the clinical features of head injury headaches?
bruising and/or history of injury
reduced conscious level
periods of lucidity and amnesia
What are some mechanisms that cause orthostatic syncope?
- Volume depletion (haemorrhage, diarrhoea, vomiting)
- Medications (vasodilators or diuretics)
- Cardiovascular autonomic dysfunction
What organs are in the Umbilical Region?
- duodenum
- the small intestine
- transverse colon
Outline your plan of management for an overdose patient who presents as:
Neurological Assessment
* GCS – eyes do not open, groans, withdraws
* Pupils – size 4 and reactive
* Motor – nil
Respiratory Status Assessment
* Rate – 38
* Rhythm – regular
* Effort – shallow
* Sats – 92%
* Skin – pale
* Speech – none
* Sounds – normal
Cardiovascular Assessment
* HR – 60
* BP – hypotensive
* BGL – 1.2
* Temp – 36.3°C
- CCP backup for atropine and adrenaline for low HR
- 6L oxygen via face mask to increase SPO2 >94%
- IV access to administer drugs
- IV glucose 10% at 0.25g/kg (2.5ml/kg) repeated at 0.1g/kg (1ml/kg) until BGL >4 mmol = 2.5g (25ml) repeated at 1g (10ml)
- IV fluids to increase SBP to MAP 90 or SBO to 10p - 120
- 12 lead ECG
If can’t get IV access 0.5mg glucagon IM, single dose only
Westley Croup Score Results
MILD CROUP: <2
MODERATE CROUP: 3 to 5
SEVERE CROUP: 6 to 11
SEVERE RESPIRATORY FAILURE: >12
What are the expected vital signs of a 12 year old?
Weight: 43kg
HR: 70-120bpm
RR: 15-25rpm
SBP: 90-115mmHg
What is the treatment for refractory anaphylaxis and why?
Persistent wheeze
* NEB Salbutamol – appropriate dose, PRN, no max dose – affects B2 receptors causing bronchodilation
* IV Hydrocortisone – appropriate dose, single dose only, slow push over 1 minute (dilute with 2 ml sodium chloride, then discard 0.24 ml) – stabilises mast cells
Persistent hypotension/shock
* Glucagon – increases accessory pathway of cyclic amp to increase myocardium calcium release, increasing hr and contractility via non adrenergic pathway
* Fluid for hypotension – end goal of return of radial pulse
Upper airway obstruction
* Neb adrenaline – if persistent stridor – providing localised vasoconstriction to target tissues in larynx and airways reducing capillary leakage and airway oedema
Describe the consequences of hypoxia on the brain.
Hypoxia triggers a cascade of physiologic events on the brain including energy failure due to impaired cellular respiration leading to disfunction of ion pumps and accumulation of excitatory neurotransmitters resulting in cellular swelling leading to additional hypoxia and oxidative stress causing cell death
How do you manage a focal seizure?
- Airway
- Breathing
- Circulation
- Positioning – 45 degrees to allow for cerebral drainage
- 5mg IM midazolam if required
- Backup
- Transport
What is the definition of septic shock?
subset of sepsis with profound circulatory, cellular, and metabolic abnormalities that are associated with a greater risk of mortality
What are the signs and symptoms of Ovarian torsion?
- Nausea and vomiting
- Cramping
- Severe sudden pain in lower abdomen
List some common causes of acute gastrointestinal bleeding
- Crohn’s disease
- Diverticulitis
- Haemorrhoids
- Mass lesions
- Oesophageal varices
- Pancreatitis
- Peptic ulcers
- Portal hypertension gastropathy
- Ruptured abdominal aortic aneurism
- Severe gastritis
- Severe oesophagitis
- Ulcerative colitis
- Upper GIT haemorrhage
What is the drug effect of rosuvastatin?
Causes liver to make less cholesterol and increases its uptake of cholesterol from the blood
What are the patient’s possible outcomes when placed under an EEA?
They can be admitted or discharged following examination or referred for further assessment.
What is Span-K administered for?
hypokalaemia
Do asthma and anaphylaxis present similarly in some cases?
yes as pathophysiology is similar
What is Xarelto presribed for?
AF
-1 Sedation Assessment Tool (SAT) behaviour score description
asleep
What does the mental status assessment behaviour component assess?
attitude
manner
observed behaviours
What is the drug effect of metoprolol?
Relaxes blood vessels and slows HR improving blood flow and decreasing BP
What are the common MAOI drugs?
phenelzine
tranylcypromine
moclobemide
What is the drug effect of rivaroxaban?
stops blood clotting
Define Stridor and its mechanism
squeaking sound – sound of air moving around airway blockage
What are the four main presentations for breech birth?
complete
footling
kneeling
frank
What are some green flags associated with headaches?
- Symptoms associated with influenza
- Known headache with ‘usual; symptoms and triggers
- Normal vital signs, normal assessment using FAST technique and able to walk normally
What are some of the physiological changes that occur with ageing and how do they impact the patient? Be systematic.
CNS and peripheral nervous system
* Decrease in baroreceptor responses
* Decreased in b adrenergic response in receptors
* Decreased transduction through general CNS
Pulmonary:
* Decreased vital capacity
* Decreased lung compliance/elasticity
* Increased residual volume
Cardiovascular:
* Decreased endothelial dependent vasodilation
* Increased peripheral resistance
* Decreased intrinsic heart rate and ability to increase heart rate to compensate for stressors
* Increased av conducting time and ectopics
Metabolism
* Decrease in overall ability to metabolise drugs
Describe the airway management in a newborn doesn’t respond to stimulation and initial IPPV?
- PEEP on BVM with good seal (2 person)/ETCO2
- neutral positioning with towel etc
- keep warm
- If need to suction – make sure it is brief or can stimulate reflexes and cause bradycardia
What is the pathophysiology of a pulmonary embolism?
recent insult/surgery (within 2-3 weeks) associated with period of stasis leads to formation of DVT in lower limbs that works its way through circulation and into microcirculation within pulmonary vasculature.
What is the mangement of an overdose patient who deterioriates into cardiac arrest?
- Pads on
- 3 stacked shocks
- Check temp as may need to alter doses if hypothermic
- Amiodarone – 300mg slow push over 1-2 minutes
- After 5th DCCS – Amiodarone – 150 mg slow push over 1-2 minutes
- After 6th DCCS – Adrenaline – 1mg every 3-5 minutes, no max dose
- Good quality compressions – 1/3 depth chest, 100 per minute
What is the treatment for tonsilitis/abscess/Quincy?
symptomatic
What are some differentials of centralised upper abdominal pain?
- Aortic aneurysm
- Acid reflux/heart burn
- Cholecystitis
- Pancreatitis
- Renal colic
What are some differences between adult and paediatric components of breathing?
- Obligatory nasal breathers
- Increased resp rates
- Smaller tidal volume
- Decreased functional residual capacity – reduced ability to tolerate occluded airway
- Diaphragmatic breathers
- Greater oxygen demand
What are some considerations for mandatory transport for a hypoglycaemic pt?
- Injury sustained from hypoglycaemic episode requiring further investigation
- Intentional overdose of glucose lowering agent
- Newly diagnosed diabetes
- No previous diagnosis of diabetes
- Not returned to normal mental state within 20 mins of IV glucose or incomplete recovery to normal conscious state
- Pt taking long acting oral hypoglycaemic agent that causes hypoglycaemia
- Pregnancy
- Recovered but unable to be monitored by a responsible adult for 4 hours or unable to self care
- Risk of prolonged or recurrent hypoglycaemia
- Seizure
- Severy hypoglycaemia episode within previous 48 hours
- Suspected cause of hypoglycaemia due to illness that requires further investigation
- Unable tor unwilling to consume long acting carbohydrate
- Unwitnessed onset or prolonged episode
What are some causes of psychosis?
- Primary psychotic disorder - Schizophrenia
- disillusion disorders
- brief psychotic disorders
- organic causes – infection, inflammatory processes
- elderly pts with UTI
- substances/medications/alcohol
What is the age group for paediatric pad use?
under 6
What organs are in the Right Hypochondriac Region?
- Liver
- gallbladder
- right kidney
- large/small intestine
What is the cause of head injury headaches?
Bruising, swelling or injury to the brain tissue
What does the acronym AEIOUTIPS stand for?
A - Acidosis/ Alcohol
E - Epilepsy
I - Infection
O - Overdose
U - Uremia
T - Trauma to head
I - Insulin: too little or or too much
P - Pyschogenic
S - Stroke
In a patient that presents in cardiac arrest in the first instance, what may be some signs that suggest a FBAO?
- Difficulty ventilating
- Equal rise and fall of the chest
- +/- hx of eating or playing with small objects prior
What are likely causes of headache and ACS-type presentations in psychostimulant overdose patients? Why?
Psychostimulants are sympathomimetic substances (fight or flight syndrome) that cause significant vasoconstriction particularly in the microcirculation of brain and heart
What is the drug class and use of Esomeprazole?
proton pump inhibitor
acid reflux
What are the causes of PPH?
- Tone - Poor uterine tone (70%)
- Tissue - Retained products (10%)
- Trauma - tears of the vulva, vagina or cervix, as well as uterine rupture (20%)
- Thrombin - Coagulopathy disorders (1%)
What are the common TCA drugs?
amitryptyline
imipramine (endep)
nortryptyline
Why can asthmatic Pts tolerate low resp rates in ROSC?
to prevent air trapping, and build up of intrinsic PEEP
Outline the normal management of the healthy newly born.
- Clean mouth and nose
- Initiate tactile stimulation
- Within 30 seconds assess heart rate and breathing status
- Apgar at 1 and 5 minutes
List some examples of time-critical abdominal emergencies
- Aortic dissection
- AAA
- Peritonitis and sepsis
- Uncontrolled gastro intestinal tract (GIT) haemorrhage
- Acute pancreatitis
- Ectopic pregnancy
- Acute bowel obstruction
- Testicular/ovarian torsion
What is your management of a patient refractory to 10mg droperidol?
CCP backup and second dose of Droperidol – IM – 10mg
What is rivaroxaban administered for?
AF
(atrial fibrillation)
What characterises a severe airway obstruction?
- absent or ineffective cough
- unable to vocalise
- worsening stridor
- quiet or silent chest / unable to breath
- cyanosis
- decreasing level of consciousness
What type of drug is span-k?
potassium chloride
What medications or ingestible agents can be fatal in small amounts in paediatric overdose?
- Antiarrhythmics
- Essential oils
- Opioids
- Organophosphate
- Paraquat
- Stimulants – MDMA, methamphetamine
- Alcohols
- TCAs
What are the components of FLACC
face
legs
activity
cry
consolability
What is your management of a pancreatitis patient and justify why?
- IV access – to administer analgesia and fluids
- IV fluids – to maintain radial pulse and SBP of 80 mmHg
- IV fentanyl 25 – 50 mcg – to reduce pain
- IV ondansetron 4 – 8 mg – to stop vomiting
- Oxygen – 15L min via non-rebreather - if shocked and to return SPO2 >94%
- Active warming as patient is hypothermic and to prevent coagulopathy
- CCP backup
What type of drug is nordip and what is it used for?
calcium channel blocker - hypertension
Outline the effects and mechanism of tricyclic antidepressant overdose
Acts on multiple receptor sites inhibiting the reuptake of serotonin and norepinephrine, blocks sodium channels and inhibits muscarinic, histamine and adrenergic receptors, causing anticholinergic effects, neurotoity and cardiotoxicity/ECG changes
What type of drug is inderal and what is it used for?
beta blocker - hypertension
What is your provisional diagnosis for an unresponsive patient, with a snore, RR 4, slow radial pulse, size 2 pupils and cold, and why?
opioid overdose due to symptoms of:
small pupils
decreased resp rate
environmental factors
What is the pathophysiology of epiglottitis?
Infection causing an inflammation of the lining of the cartilaginous tissue in the airway
What is the appropriate management for a non-pulsatile cord present in the vaginal opening?
- Assist mother to assume the knee-chest position
- Carefully attempt to push the presenting part off the cord
What are some risk factors for SPPH?
- Prolonged rupture of membranes
- Prolonged labour
- Emergency caesarean section
- Vaginal birth after caesarean (VBAC)
- Ragged membranes or incomplete placenta (unlikely after a caesarean section)
- Manual removal of the placenta
What is the cause of tension type headaches?
extracranial muscles become tense
What characteristics lead to a diagnosis of autism?
Persistent deficit in social communication and interaction across contexts from early childhood and manifests by:
* Abnormal speech, failure to engage in normal conversations
* Deficits from being able communicate
* Social communication and interaction in multiple situations
* Restricted interests and activities
* Repetitive patterns of behaviour
What are the signs and symptoms of acute bowel obstruction?
- fever
- nausea/vomiting
- sudden onset abdo pain
- abdominal distension
- obstipation (no movement of gas or stool)
- dehydration
- tachycardia
- orthostatic hypotension
- decreased urine output
- dry mucous
What are some differential diagnoses for a paediatric patient presenting with high-pitched grunting noise/barking seal like cough?
Croup
Epiglottitis
Bacterial tracheitis
Peritonsillar or retropharyngeal abscess
FBAO
What is the pathophysiology of DKA?
- High BGL draws water out of cells due to increased blood osmolality causing cellular dehydration, and osmotic diuresis and polyuria leading to severe dehydration & hypovolaemia
- Ketones (organic acids) produced from using alternative fuel sources resulting in metabolic acidosis
- Dehydration leading to polydipsia
- Loss of potassium from the body
What is your airway management for a pregnant patient with suspected pre-eclampsia who begins to convulse?
Suctioning the airway for 10-20 seconds
NPA if unable to open mouth due to trismus
Oxygen via non-rebreather mask – 15L minute
What is the drug tiotropium bromide taken for?
asthma
COPD
What are some of you considerations going to a PV bleed in a pregnant patient?
- Ectopic pregnancy
- Miscarriage
- Delicate emotional state in both mum and partner
Describe the ideal positioning of the patient for direct laryngoscopy and why is it beneficial?
Sniffing position to align the oropharyngeal laryngeal axis to improve visualisation of the glottis
What suffix do beta blockers end in?
lol
What is catopril administered for?
Hypertension
Congestive heart failure
What is the definition for hypertension during pregnancy?
Systolic blood pressure >140 mmHg
Diastolic blood pressure >90 mmHg
Severe
Systolic blood pressure >160 mmHg
Diastolic blood pressure >110 mmHg
How does oxygen administration effect patient’s with COPD?
It can cause hypoventilation due to increased blood flow to poorly ventilated alveoli, increasing V/Q mismatch dead space
How does fentanyl produce analgesia?
binds with opioid receptors altering pain perception
What are some risk factors for pancreatitis?
- Alcoholic
- Gallstones
- Obesity
- Smoking
- Type 2 diabetes mellitis (T2DM)
What is the definition of anaphylaxis?
Acute onset of illness with skin features of urticaria or erythema/flushing and/or angioedema WITH:
respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms; OR
acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is possible, even without skin features
What is the pharmacology of a beta blocker?
Antagonise beta adrenergic receptors, stopping the release of catecholamines, slowing the heart and reducing its contractility
What are some other priorities of management for a STEMI pt?
- Reversible causes – thrombus
- Consult for management pathway and prepping for cath lab or fibrinolysis depending on where you are
What should you do if a STEMI pt is accepted for PCI?
Complete the decision supported PCI checklist
transport to nearest hospital
call cardiologist at cath lab to accept pt for PCI and order for 5000 units of heparin and find out what drug they want administered (enoxaparin or clopidogrel)
What conditions can mimic or mask alcohol intoxication?
- other intoxications
- electrolyte imbalance (hypo or hypernatremia, hypercalcemia) – abnormal ECG
- hypoglycaemia - BGL
- hypothermia - temperature
- head injury – clinical assessments/history taking
- stroke – clinical assessments
- seizure
- encephalitis or meningitis
- sepsis
- renal failure
- encephalopathy (hepatic, HIV, Wernicke)
- hypothyroidism
What are the three categories of adrenal insufficiency?
- Primary adrenal insufficiency (PAI)
- Secondary adrenal insufficiency (SAI)
- Tertiary adrenal insufficiency (TAI)
Outline the body’s processes for homeostatic acid-base balance?
- Bicarbonate buffer system counteracts pH changes within minutes
- Respiration rate changes to alter the blood’s carbon dioxide concentration within minutes to hours
- Kidneys change bicarbonate generation and reabsorption and cause the excretion of hydrogen ions via phosphate and amnionic buffers
- Phosphate buffer system proteins and haemoglobin
What is hemiplegia?
one-sided muscle paralysis or weakness
How do you test a rash to see if it is blanching?
pressing down on it with a clear glass etc – if it does not disappear under pressure it is non-blanching
What are the neurotoxicity effects of a TCA overdose?
- Sedation/Coma
- Seizures
Outline some features of common behavioural disorders.
- Conduct disorder - when you struggle with antisocial behaviours, following rules, and showing empathy towards those around you – usual onset around 16yrs – physical altercations, bullying or threatening peers, staling, destroying or breaking into private property
- Oppositional defiant disorder (ODD) – acting out in defiance - frequent questioning of authority, excessive arguing, refusing to comply, and intentionally engaging in behaviours that upset others.
- Attention deficit hyperactivity disorder (ADHD) – inability to sit still and concentrate – impulsivity, inability to pay attention, lack of time management skills, mood swings, low frustration threshold and trouble coping with stress
- Obsessive-compulsive disorder (OCD) - thoughts, actions, and impulses that are chronic, uncontrollable, and intrusive - constant washing and cleaning, repeating phrases or prayers, following strict routines, or repetitively counting and checking, the need to have things orderly or symmetrical, ideation about losing control or harming yourself or others, unwanted aggressive or sexual thoughts
- Behavioural addiction – can’t stop doing something due to brain associating pleasure and activating reward mechanism when engaging in the activity – gambling, sex, internet, shopping, video games, plastic surgery, binge eating and risky behaviours
What are some causes of cardiac arrest in a Pt with underlying asthma/COPD disease?
- Tension pneumothorax
- Hypovolaemia
- Arrhythmias
- Myocardial depression from prolonged hypoxia
Outline all fours position
mum on hands and knees to alleviate SD pressure to dislodge the shoulder
-3 Sedation Assessment Tool (SAT) verbal score description
nil
What elements of history taking may assist with defining the cause of syncope?
Medications
Past medical Hx
List of lasts
Events
What questions may be asked in the assessment of a child?
Gestational age at birth
NICU stay after birth
Pregnancy complications
Is child hydrated – wet nappies, bottle feeding appropriately, solids
Sick siblings
Going to school
Sickness at school
What is the drug effect of escitalopram?
increases serotonin levels
What is your immediate management of a child found at the bottom of a pool with bystander CPR in progress?
- Bystander continue CPR
- Cut off clothes, dry pt and move to dry location
- Towel under shoulders
- Manage airway, suction, IPPV, adjuncts
- Pads on (Paed pads if under 6 years)
- Assess rhythm and shock if required
- IV access
How may a calcium channel blocker overdose present?
- Seizures
- Coma
- Hypotension
- Bradycardia
- Heart block
- Cardiogenic shock
- Hyperglycaemia
- Metabolic acidosis
Describe your managment of a paediatric drowning pt with VF?
- Shock @ appropriate joules
- CPR – good quality compressions (one handed), rotate officers
- IV access
- Adrenaline @ appropriate dose every 3-5 minutes
- reassess
What is the pathophysiology of uterine rupture?
A spontaneous tearing of the uterus usually from trauma, genetic uterine wall weakness, prolonged labour augmentation or stretching of the uterine wall
Outline wood’s screw manoeuvre
keeping first hand in place, insert second hand and apply pressure to anterior of foetus posterior shoulder – to rotate foetus to oblique diameter
Define Steatorrhoea
stool containing excessive amounts of fat
Define incomplete abortion
partial loss of products of conception in the first 20 weeks gestation
Describe how and why fever occurs
Release of pyrogens from white blood cells or pathogen triggering the hypothalamus to raise body’s set point temp. Causes physiologic changes resulting in a change to body’s set point temperature, blood vessel constriction, metabolism increase, shivering/rigors to try to generate heat
Natural defence mechanism response to infection.
What would be your considerations surrounding transporting to the closest appropriate hospital versus patient’s preferred destination?
- Happy as they have all of the patient’s medical history, but have to call ahead for approval first
- The facilities available in the closest hospital and the preferred destination and where will they get better care
What are some mechanisms that cause reflex syncope?
Vasovagal response to emotional stress and/or pain, visualisation of blood, after urination defecation, coughing or straining
What is your ongoing managment of a paediatric patient who is no longer seizing?
- Maintain neutral positioning for airway patency (snoring)
- Prepare additional midazolam
- Continue oxygen administration – titrating to >92-96%
- Consider IV access
- Consult for fluids as hypotensive
- Consider administration of paracetamol to reduce fever if patient able to swallow
- CCP to help during transport
- Pre-notification
What is the treatment plan for an adult, with purulent leg ulcer, difficult to rouse with low sats, hypotensive and hypoglycaemic who has just finished a dose of steroids?
- Oxygen to increase SPO2 to above 94%
- IV access to administer fluids and medication
- IV glucose 10% - 15g (150 ml), repeated at 10g (100 ml), every 5 minutes until BGL is >4 mmol – to bring BGL to within normal limits
- IV fluids – titrate to maintain radial pulse – to increase blood pressure
- Consider hydrocortisone as treating possible adrenaline insufficiency
What are the common SNRI drugs?
venlafaxine (efexol)
desvenlafaxine
duloxetine
Why do you administer antiemetics to stroke patients?
to prevent vomiting and further increase in ICP
if haemorrhagic stroke as blood is toxic to the brain when not in blood vessels
What is the mechanism of shoulder pain in patient’s presenting with abdominal pain?
The phrenic nerve runs from the diaphragm up through to the spine, and blood in the abdominal cavity irritates the diaphragm causing this pain to travel through to the shoulders.
What are your considerations surrounding transport of a paediatric patient who is no longer seizing to hospital?
- Transport to nearest suitable hospital
- Have midazolam prepared, ready to go
- Have mum travel in ambulance if there is someone there to look after the other children
- Pre-notify
What are some indicators of serious aetiology syncope?
- History of cardiac disease
- New or unexplained dyspnoea
- Syncope during physical exertion
- History or physical signs of cardiac failure
- History of anemia
- Family history of sudden cardiac death and/or history of an inherited cardiac condition
- > 50 years age
- Evidence of new ECG abnormalities
What can you consult for in a PE cardiac arrest Pt?
autonomous fibrinolysis administration
What class of drug is Seretide?
corticosteroid
Define Crackles (Rales) and its mechanism
bubbling, rattling or clicking – sound of air moving through fluid in lungs
What is your management for VT when witnessed?
- Check for response
- Check for pulse – if no pulse - 3 stacked shocks
- Good quality compressions – 100 per minute – 1/3 depth chest
- Pharmacological prioritisation
What is the cause of cervicogenic headaches?
Issues with bones in neck eg arthritis, injury
What are some risk factors for non-accidental injury/DV?
- Known family dysfunction
- Child has multiple medical conditions
- Poor parental care
- Numerous separations for the child in 1st year of life
- Hx of psychiatric issues/stresses
- Criminal activity in older children
What are the expected vital signs of a 2 year old?
Weight: 13kg
HR: 80-140bpm
RR: 20-30rpm
SBP: 80-110mmHg
What are some considerations enroute to an imminent delivery patient?
- Drugs – oxytocin & TXA
- PPE maternity kit
- 2 Pts – role delineation
- CCP backup
What are some signs of imminent delivery?
- Loss of operculum mucous plug (bloody show) - (may have occurred days before)
- increasing frequency and severity of contractions
- with an urge to push, or open bowels
- membrane rupture (this may not occur and active membrane rupture will be required if the head has been delivered with the membrane intact)
- bulging perineum
- appearance of the presenting part at the vulva
What are some common classifications of syncope?
Orthostatic
Reflex
Cardiac
What happens if a patient absconds before assessment when detained under an EEA?
Authority to return completed by hospital and QPS or QAS requested to bring them back
+2 Sedation Assessment Tool (SAT) verbal score description
loud outbursts
What are some behavioural indications or warning signs of suicide?
- Talking about death or suicide
- Seeking methods for self harm
- Talking about feeling hopeless or having no reason to live
- Changes in drug and alcohol use
- Changes in sleeping patterns
- Reckless behaviour
- Feelings of isolation, desperation or feeling trapped - expressed in conversations.
- Social withdrawal or disengagement in usual activities
- Putting affairs in order
Why do DKA patients present the way they do?
- Acidosis and low cpp = low map
- Profound hyperkalaemia – osmolarity shift of water and K+ out of cells and cells uptake H ions and to maintain electroneutrality
How does paracetamol reduce fever? Do all patients with fever need to be treated?
inhibiting the hypothalamus prostaglandin production, reducing the body’s set temperature leading to heat dispersion and reduced body temperature
Define whooping and its mechanism
high-pitched gasp – respiratory infection
How can you assess pain in paediatric patients?
- FLACC – face legs activity crying consolability
- Wong baker faces
What are the post ROSC cares/goals?
Maintaining airway
Maintaining ventilation status
Maintaining cardiovascular status
Titrate fluid for SBP of 100 or greater
Q. Outline and justify management of a secondary postpartum haemorrhage.
- Fundal massage
- Patient to empty bladder
- Consider:
- Tone – fundal massage &Oxytocin
- Trauma – control external haemorrhage & Analgesia
- Tissue/temperature/Thrombin – fundal massage, inspect for membranes and pieces of placenta
- External aortic pressure
- Bimanual compression
What is the drug class and use of metformin?
anti-hyperglycaemic
diabetes
What makes children more vulnerable to FBAO?
- Smaller airway
- Can not generate the same force when coughing as an adult
- Commonly put objects in their mouth when they are discovering their environment
What is the pharmacology of naloxone?
Reverses the effects of opioids by competing for the same opioid receptors
How does the baby present in a complete breech?
hips and knees are flexed so that the foetus is sitting cross-legged, with feet beside the buttocks
What is the pathophysiology of a STEMI?
Atherosclerotic plaque buildup narrows lumen or breaks off (instigating clotting factors), obstructing blood flow distal to the occlusion, decreasing perfusion leading to injury and necrosis
Outline all fours running start
mum on hands and knees with one foot forward so it is near hand & apply gentle downward traction to foetus posterior shoulder or gentle upward traction to foetus anterior shoulder
What is the pharmacology of psychostimulants?
enhance prefrontal cortex norepinephrine levels and the activation of adrenergic receptors by binding to norepinephrine transporters in the prefrontal cortex
What are the elements of the paediatric assessment triangle?
Appearance – tone, interactiveness, consolability, look & gaze, speech and cry
Work of Breathing – nasal flaring, retractions, posturing, breath sounds, apnoea or gasping
Circulation to skin – pallor, mottling, cyanosis
How does the baby present in a kneeling breech?
kneeling position, with one or both legs extended at the hips and flexed at the knees.
What are differentials for syncope?
Cardiac syncope
Orthostatic syncope
Reflex syncope
Seizure
Describe the pathophysiology of alcohol withdrawal
Ethanol inhibited GABA and glutamate receptors no longer being inhibited resulting in unopposed sympathetic and central nervous system stimulation
+2 Sedation Assessment Tool (SAT) behaviour score description
very anxious and agitated
What is the pathophysiology of primary adrenal insufficiency (PAI)?
Direct adrenal gland dysfunction typically caused by an autoimmune disease such as Addison’s disease.
What is the cause of cluster headaches?
dysfunction of trigeminal nerve
Describe the physiological mechanisms by which the body compensates for insufficient perfusion.
Baroreceptors send negative feedback loop to cardiovascular centre to increase peripheral vasoconstriction and venous return – decreased perfusion detected in kidneys which stimulates the release of renin to stimulate renin angiotensin aldosterone system – causing many effects by increasing sympathetic nervous activity which directly stimulates peripheral vasoconstriction, aldosterone release to work in kidneys to stimulate the retention of sodium and water – and antidiuretic hormone from post pituitary gland further increasing water retention
How would you troubleshoot/what are your considerations in a difficult ventilation with an igel in a cardiac arrest due to underlying asthma/COPD Pt?
Bilateral decompression of chest to rule out haven’t transferred from asthmatic arrest due to bronchospasm to tension pneumothorax
Provide some common beta blocker drug names.
mostly end in lol
- Propranolol
- Sotalol
- Atenolol
- Bisoprolol
- Carvedilol
What is the drug effect of frusemide?
Makes person pee:
causes kidney to excrete higher levels of water and salt into urine
What organs are in the Right Iliac Region?
- appendix
- cecum
- ascending colon
- small intestine
List some normal gross motor milestones for children
6wks – good head control in vertical
3mths – no head lagging or pulling, lying on abdo with good head control
6mths – sits up with good support
12mths – taking first steps
13mths – walks unsupported
18mths – runs, climbs
2yrs – runs, walks down steps 2 feet at a time
3yrs – able to catch objects and hold a pencil to draw objects
4-5yrs – can climb, skip, hop and colour in neatly
Compare cholinergic and anticholinergic agents
Cholinergic agents activate acetylcholine receptors, stimulating the parasympathetic nervous system
Anticholinergic agents block the action of acetylcholine, inhibiting the parasympathetic nervous system
What are some common calcium channel blockers?
verapmil
diltiazem
What is status epilepticus?
seizure activity > 5 minutes in duration or recurrent seizure activity where the patient does not recover to a GCS of 15 prior to another seizure
Following your initial treatment, what is your ongoing management of a patient presenting with meningitis and justify why?
Airway – good oxygenation
Breathing
Circulation
* IV access – further doses morphine, possibly saline, ceftriaxone and ondansetron
* IV fluids – titrate to MAP 90
* Antiemetic – ondansetron 8mg IV, slow push over 2-3 minutes, to stop nausea and to also reduce ICP when vomiting
* Further doses of morphine to max 20mg to control pain, also has anti-anxiety properties which may help the Pt
* CCP backup
* Rapid transport
* Pre-notify hospital
* Consult for Ceftriaxone – 2g, slow push over 5 minutes as meets risk criteria for meningococcal bacteria
What is Frusemide administered for?
Hypertension
Oedema – heart, kidney & liver failure
What does the mental status assessment thought content component assess?
the content of their thoughts
0 Sedation Assessment Tool (SAT) verbal score description
speaks normally
What is Protonix presribed for?
acid reflux
What are the anticholinergic effects of a TCA overdose?
- Hot as a hare: increased body temperature
- Mad as a hatter: delirium
- Blind as a bat: mydriasis (dilated pupils)
- Red as a beet: flushed face
- Dry as a bone: dry mouth, dry eyes, decreased sweat
- Fast as a fox: tachycardia
- Full as a flask: urinary retention
What are some signs and symptoms of anaphylaxis?
Gradual or rapid onset of:
Cutaneous – urticaria (rash), angioedema (swelling), pruritus (itch), flushed skin
Respiratory – difficulty breathing, wheeze, upper airway swelling, rhinitis (runny nose)
Cardiovascular – hypotension, dizziness, bradycardia or tachycardia, collapse
Abdominal – nausea, vomiting, diarrhoea, abdominal pain
What are the contraindications for an acute stroke referral?
- Advanced terminal cancer with a life expectancy of less than 6 months
- Seizure/s at onset of symptoms
How do opioids cause CNS depression?
act on both opioid and non-opioid receptors in the nervous system, GIT, cardiovascular and immune systems blocking pain messages
What are some additional causes of SPPH?
- Perineal trauma / Perineal repair infection
- Uterine Abnormalities - Fibroids
- Vascular anomalies - arteriovenous malformation or pseudoaneurysm
- Caesarean section wound dehiscence / infection
- Bleeding disorders or coagulopathies
What is your management for a patient with a mild airway obstruction, unable to dislodge with their own efforts to cough?
5 back blows, checking to see if the obstruction has been dislodged between blows, and if unsuccessful, 5 chest thrusts, checking to see if the obstruction has been dislodged between blows
Define complete abortion
full loss of products of conception in the first 20 weeks gestation
Define Stuporous
profoundly reduced alertness and requiring continuous noxious stimuli for arousal
Define Haematochezia
per rectum bleed of fresh blood
What role does naloxone have in an overdose patient who deteriorates into cardiac arrest?
No role in cardiac arrest as it is secondary to opioid and Narcan/naloxone has no cardiac effects
What factors may support the patient’s presentation of an acute behavioural disturbance (ABD) being associated with a medical aetiology?
- first presentation/episode of ABD in a person aged 45 years or older
- abnormal vital signs
- focal neurologic findings
- decreased awareness of surroundings
- difficulty paying attention
- absence of a clear trigger for ABD
What is the pathophysiology of secondary adrenal insufficiency (SAI)?
Deficiency in adrenocorticotropin hormone (ACTH) secretion by the pituitary gland.
What would you consider appropriate analgesia for a pregnant patient with abdo pain and PV bleed?
2.5mg IV morphine, or
3ml methoxyflurane
Define Ascites
fluid build up in the spaces within the abdomen
What are some risks associated with post-term delivery?
- Macrosomia
- Shoulder dystocia
- Placental breakdown
- Infection
- Stillbirth
- Maternal mortality
What are some risk factors for Cholecystitis?
- Fat
- Female
- Fair (Caucasian)
- Fertile
- Over 40
- Pregnancy
- Hormone therapy
- Diabetes
What does the mental status assessment thought form component assess?
the amount of thought and the rate of
production
Define threatened abortion
vaginal bleeding in the first 20 weeks of gestation
What does the mental status assessment appearance component assess?
the general appearance of your pt
What does the mental status assessment insight component assess?
degree to which the client understands the importance of their illness or current state
Define HELLP syndrome and how it is different to other conditions.
A marker for severe pre-eclampsia, where 2 of the 3 elements of Haemolysis, Elevated Liver enzymes and Low Platelets are required for a diagnosis
What may be some common rhythms that may present as palpitations?
- Broad complex tachycardia
- Narrow complex tachycardia
- Sinus rhythm
Outline different agents that primarily cause CNS depression.
- Alcohol
- Benzodiazepines
- Opioids
What does the mental status assessment speech component assess?
volume at which they speak
What constitutes a normal birth?
- spontaneous onset
- low-risk at the start of labour
- remaining low-risk throughout labour and birth
- the newborn is born:
o spontaneously
o in the vertex position
o between 37 and 42 completed weeks gestation - After birth mum and bub in good condition
What is the pathophysiology of tertiary adrenal insufficiency (SAI)?
Hypothalamic dysfunction, resulting in a decrease in corticotropin releasing hormone (CRH), which stimulates the pituitary gland to produce ACTH. Sudden withdrawal from long-term exogenous steroid use is the most common cause of TAI
What is the presentation of placenta praevia?
- no pain, other than that associated with contractions
- a soft, non-tender uterus
- several small warning bleeds
- bright red blood
- significant blood loss, which may lead to hypovolaemic shock
What are the expected vital signs of a 4 year old?
Weight: 19kg
HR: 80-140bpm
RR: 20-30rpm
SBP: 80-110mmHg
What are some potential differential diagnoses for chest pain?
- Acute myocardial infarction
- Angina stable/unstable
- Aortic dissection
- Cardiac tamponade
- Pulmonary oedema
- Pericarditis
- Spontaneous pneumothorax
What are some high risk for sepsis in paediatrics?
- Severe tachycardia or bradycardia
- Severe respiratory distress/tachypnoea/apnea
- Needs oxygen to maintain SpO2 greater than 92%
- Hypothermia
- Non-blanching rash/mottled ashen/cyanotic
- Altered GCS/AVPU
What are the expected vital signs of a 7 year old?
Weight: 28kg
HR: 70-120bpm
RR: 15-25rpm
SBP: 90-115mmHg
Outline your management for a birth at 20 weeks gestation with the foetus having gasping respirations?
- Pull over and have second assist
- Backup with second crew to assist
- No resuscitation
- Wrap baby and present to mum
- Be very supportive and ensure psychological cares
- Manage mother as post delivery – oxytocin etc
Define the pattern of pain for Bowel obstruction
sudden onset of abdo pain in the periumbilical region, cramping waves every 4-5 minutes if in small bowel, or every 20 minutes if in large bowel
What are the signs and symptoms for AAA?
- ALOC
- shoulder tip pain
- myocardial infarction
- hypotension
- asymmetrical/absent distal pulses
- abdo pain
- palpable mass
- ecchymosis (bruising around flank)
- limb ischaemia
- shock (hypovolaemic)
What are focal neurological deficits?
signs or symptoms in which causation can be localized to an anatomic site in the central nervous system, eg paralysis, weakness, loss of muscle control, increased muscle tone, loss of muscle tone, tremors, sensation changes
Why is it important to guard the uterus when applying cord traction?
To prevent uterine inversion
What enroute considerations do you have for a child found at the bottom of a swimming pool, with CPR in progress?
- CCP QFS back up
- Do calculations:
o Pts weight (age x 3) + 7
o Defib joules weight x 4 (round up to next highest setting)
o Amiodarone – CCP administration after 3rd DCCS
o Adrenaline dose 10mic/kg, every 3-5, no max, after 5th DCCS - scene control
- Best facility to transport to
Define Comatose
state of deep, unarousable, sustained unconsciousness
What are some differences between adult and paediatric components of circulation?
- Increased hr
- Decreased ability to increase stroke volume
- Increased vagal tone
- Smaller blood volume – 9-10 ml/kg
Westley Croup Score Stridor Variables and Scores
At rest - 2
With agitation - 1
None - 0
What occurs in the first stage of labour?
gradual effacement and dilation of the cervix through regular contractions up to 10cm dilation
What is the maximum joulage of paediatric pads?
100 joules
What is the pathophysiology of placenta praevia?
The embryo implants in the lower part of the uterus causing the placenta to grow close to or over the cervical os
Why is rapid transport for a stroke patient essential?
for urgent stroke testing
What is Brusinksi Sign?
patient’s hips and knees flex when the neck is flexed
When do you administer naloxone to an opioid overdose patient?
to be administered after immediate cares commenced and resp rate and oxygen sats have improved – fix hypoxia first
Give it prior to immediate cares if unable to manage airway - anatomically difficult etc
What are some mechanisms that cause cardiac syncope?
- Structural cardiac abnormality (aortic stenosis, cardiomyopathy, aortic dissection)
- Cardiac arrhythmia (sinus node dysfunction, atrioventricular block, tachycardia)
What are the risk factors for epiglottitis?
Adults and children who are not vaccinated – haemophilis influenza type B (HIB)
What are some differences between adult and paediatric components of airway?
- Large head/occipult
- Small oral cavities and oral airway openings
- Large tongue
- Large tonsils
- Large floppy u-shaped epiglottis
- More proximal and anterior larynx
- Absence of tracheal ridge
What are some causes of arrhythmias?
- Ischemic heart disease
- Hypertension
- Heart failure
- Heart disease
- Diabetes
- Electrolyte disturbances
How do you instruct the mother to push when the head is crowning? Do you touch the baby?
Small pushes with contractions
Place 2 fingers against baby’s head to prevent explosive delivery of the head
-2 Sedation Assessment Tool (SAT) behaviour score description
physical stimulation
What type of drug is catopril?
ace inhibitor
What is the cause of migraine headaches?
traction or inflammation of cranial blood vessels
What other assessment needs to be completed with the NIHSS-8 score?
GCS
Compare and contrast DKA and HHS
DKA:
* T1DM
* BGL >10 mmoL
* +/- Kussmaul respirations
* rapid onset
* Not enough insulin to convert sugar into energy, so liver uses fats for energy instead of sugar, creating ketones
HHS:
* T2DM
* BGL > 40 mmoL
* does not have kussmaul respirations
* develops over long period
* pancreas creates insulin, but peripheral tissues resistant causing an increase in bsl
Outline the elements of the APGAR and when it is performed.
Appearance – skin colour
Pulse – count heart rate
Grimace – monitor response to stimulation
Activity – muscle tone
Respiration – count and assess resp rate
APGAR is performed at 1 and 5 minutes
What is the management for abdominal pain and why?
- 400 mg ibuprofen – to assist with pain
- 1g paracetamol to assist with pain
- 4-8 mg ondansetron - Antiemetic to stop nausea and vomiting if present
- IV access - to administer drugs
- 2.5 – 5mg IV morphine – to assist with pain
Define Melaena
dark sticky stool that contains partly digested blood from internal bleeding or swallowing blood
+1 Sedation Assessment Tool (SAT) behaviour score description
very anxious/restless
What type of drug is diamicron and what is it used for?
antihyperglycaemic, - T2DM
What are the benefits of active management of third stage of labour?
Speeds up the delivery of the placenta and reduces risk of post partum haemorrhage
What are some maternal complications associated with shoulder dystocia?
- postpartum haemorrhage
- severe vaginal and perineal trauma
- uterine or bladder rupture
- psychological distress
What is the drug class and use of Escitalopram?
SSRI
depression
What is your management plan for a STEMI? ie what will you do?
- CCP backup
- Pads on as deteriorate quickly
- Check contraindications
- 300mg, single dose Aspirin for antiplatelet properties to stop platelets aggregating
- 400 mics, every 5 GTN for vasodilation, reduction of preload and afterload, allowing blood flow through cardiac arteries and veins and peripheral blood pooling to reduce workload of the heart
- IV access
- 25mcs Fentanyl – analgesia and more efficacy with PCI drugs
- Commence pPCI pathway
What organs are in the Hypogastric Region?
- bladder
- parts of sigmoid colon
- small intestine
- and reproductive organs
What are high risk features of sepsis in adults?
- Respiratory rate greater than 25 breaths/min
- Systolic BP less than 90 mmHg (or a drop of greater than 40 mmHg from normal)
- Heart rate is equal to or greater than 130 beats/min
- Needs oxygen to maintain SpO2 greater than 92%
- Non-blanching rash/mottled/ashen/cyanotic
- Deterioration in mental status (from normal)
- Recent chemotherapy
- Anuria in last 18 hours OR significantly reduced urine output
What is the difference between active management of the third stage and physiological management of the third stage?
active management is the process of cord clamping, oxytocin and active cord traction
physiological management is all maternal effort
What are the clinical features associated with stimulant overdose?
- Psychosis
- Anxiety agitation paranoia
- Dilated pupils
- Tachycardia
- Hypertension
- ACS
- Cardiac dysrhythmias
- Diaphoresis
- Tremor
- Metabolic – dehydration, rhabdomyolysis, hyperkalaemia
- Acute renal failure
- Death
Define recurrent abortion
2 or more successive pregnancy losses
Define Haematemesis
vomiting fresh blood
What do each of the APGAR score ranges suggest?
- 0-3: indicates severe distress in the newborn requiring immediate resuscitation
- 4-6: indicates moderate distress that requires medical attention and extreme vigilance
- 7-10: indicates the newborn is coping well at that point in time
Define the pattern of pain for Peptic ulcer disease
burning or gnawing pain in the epigastrium that slowly builds for 1-2 hours, then gradually decreases
Is aggravated by meals
How does methoxyflurane produce analgesia?
by altering tissue excitability
What type of drug is cartia and what is it used for?
aspirin - antiplatelet
What organs are in the Left Lumbar Region?
- descending colon
- small intestine
- left kidney
What are the elements of the NIHSS-8 assessment?
- Level of consciousness
- Level of consciousness questions – ask age, current month
- Commands – open/close eyes, grip and release
- Best gaze – horizontal eye movements tracking
- Facial palsy – show teeth, close eyes, raise eyebrows
- Motor Arm – hold arms outstretched
- Dysarthia – slowly count to 5
- Extinction/Neglect – motor sensory with eyes closed & show fingers in both visual fields
What is Dysphasia/asphasia?
Full or partial loss of language
What is the definition of psychosis and what are the defining features?
a mental disorder where a person loses the capacity to tell what’s real from what isn’t
- Delusions
- Hallucinations
- Disordered thinking
- Disordered behaviour
- General thought disorganisation
What does the mental status assessment judgement component assess?
ability to evaluate and make appropriate choices
Outline supra-pubic pressure
pressure superior to symphysis pubis or continuous rocking motion (back of foetus towards front) – to reduce diameter of foetal shouters and rotate anterior shoulder into oblique diameter - do with McRoberts
What is the cause of raised ICP headaches?
Pressure on the brain due to increased amount of fluid and restricted room in skull
What is the pathophysiology of a generalised seizure?
abnormal neuronal activity rapidly engages both hemispheres of the cerebral cortex (absence, atonic, tonic, myoclonic and tonic/clonic)
What is the pathophysiology of a haemorrhagic stroke?
blood vessel within the brain ruptures and bleeds into surrounding tissue and possibly subarachnoid space, causing hypoxia in downstream brain tissue and increasing ICP
What is the treatment for croup?
Depending on Wesley croup score, dexamethasone +/- adrenaline
Dexamethasone, PO, 0.5ml, may be repeated once if spat out
Adrenaline, NEB, 2.5mg, single dose only
What is the pathophysiology of sepsis?
Infection penetrates the blood causing dysregulated inflammation response and body is overwhelmed by release of anti-inflammatory mediators increasing vascular permeability causing fluid shifts and cellular hypoxia. Fluid loss into interstitium causes increase in peripheral vascular resistance worsening tissue ischemia and increasing lactate. Within sepsis response microcirculatory dysfunction resulting in circulatory dysfunction and DIC
What are some causes of APH before 20 weeks?
- Miscarriage
- Ectopic pregnancy
- Implantation bleeding
What are the expected vital signs of a 3 year old?
Weight: 16kg
HR: 80-140bpm
RR: 20-30rpm
SBP: 80-110mmHg
+3 Sedation Assessment Tool (SAT) verbal score description
continual loud outbursts
What are the clinical features of cervicogenic headaches?
Unilateral or bilateral; band from
neck to forehead and scalp
tenderness
How does the baby present in a frank breech?
buttocks presents first, with the legs flexed at the hip and extended at the knees, placing the feet near the ears.
Define the pattern of pain for Renal colic
mild to intense pain beginning around the flank and moving anteriorly towards abdomen and inguinal region
What should you consider when deciding on medication doses in the elderly?
Decreased kidney function and ability to metabolise drugs
Name the 9 abdominal regions
right hypochondriac region
epigastric region
left hypochondriac region
right lumbar region
umbilical region
left lumbar region
right iliac region
hypogastric retion
left iliac region
At what point would you consider physical management of the PPH? Outline the procedures for each method and reasoning why?
If blood loss over the 10 minutes of TXA administration does not improve
* External aortic compression – manual compression of the abdominal aorta against the vertebral column to restrict uterine blood flow
* Bimanual compression - invasive two-handed technique to manually compress the uterus wall - continued through to definitive care (theatre).
What is the drug effect of catopril?
Decreases BP and improves contractility
Outline some of the common gaps in health outcomes and risk factors for First Nations people.
- Low birthweights
- More likely to die before 5th birthday
- Hearing problems in children
- More likely to smoke
- More likely to have physiological distress due to chronic medical conditions
- Higher rates of mental health issues
-2 Sedation Assessment Tool (SAT) verbal score description
few recognisable words
What are the common SSRI drugs?
fluoxetine (prozac)
sertraline
citalopram
Outline your treatment of a 2 year old presenting with shortening to right leg, swelling in thigh and bad nappy rash.
- Reassurance
- ABC’s in tact
- Check pedal pulse and mark location – future assessments
- Advise mother of what’s going to occur
- NAS fentanyl – 1.5mcg/kg
- Clean nappy if available or dressing to groin
- Traction
- Transport
- Notify triage of safety concerns
Describe the pathophysiology of aortic dissection during pregnancy
pregnancy hormones creating a hyperdynamic state in vasculature
What is the pathophysiology of epiglottitis?
Infection causing an inflammation of the lining of the cartilaginous tissue in the airway
How do you treat pregnant patients when it comes to analgesia?
same as non pregnant for analgesia – except for imminent delivery stage (as opioids can lead to resp depression when baby is born)
What are the manoeuvres designed to relieve shoulder dystocia?
Primary:
* All fours position
* McRoberts
* Supra-pubic pressure
Secondary:
* Rubins II
* Wood’s screw
* Reverse Woods screw
* All fours running start
What is your initial management for a patient with a mild airway obstruction?
position and encourage patient’s own effort to cough
What are some risk factors for suicide?
job loss/unemployment
legal/financial problems
stress
serious/mental illness
substance misuse
relationships
adverse childhood events
bullying
stigma associated with seeking help
What are the effects of a mild serotonin toxicity?
Mild - Moderate
* Tremor
* Hyperreflexia
* Diaphoresis
* Clonus
What are some protective factors for suicide risk?
- Future orientation
- Engagement in help seeking behaviours
- Coping and problem solving skills
- Connections to friend, family and community supports
- Availability of physical and mental health care
- Limiting the access to lethal means
What are the cardiotoxicity/ECG changes of a TCA overdose?
- Hypotension
- Prolonged PR and QRS interval
- Prominent terminal R wave in aVR
- Ventricular tachycardia
What are some important questions to ask to ascertain pertinent points of the maternal history for an imminent delivery pt?
- How many weeks gestation?
- Singleton or multiparity?
- Antenatal care up to date?
- When was last antenatal visit?
- Any complications with this pregnancy?
- Any foetal movements today?
- Any complications with previous pregnancy or delivery?
- What was the gestation period for last pregnancy?
- How long did the last delivery take?
- Any postpartum haemorrhage
- Gravidity and Parity
- Last known position of foetus
What is your initial management of a pregnant patient with PV bleed and abdo pain?
Fresh pad – to monitor amount of bleeding
IV access – to administer drugs
IV morphine – 2.5mg, every 5 if required, max dose 20 mg – pain management
Reassure mum and partner
Rapid transport
What does Aspirin do?
stop platelets aggregating
What organs are in the Right Lumbar Region?
- ascending colon
- small intestine
- right kidney
How can you differentiate between syncope and seizure?
- Seizures have a post-ictal period where the patient can be drowsy, confused, have a headache and nauseous
- Ask – muscular jerking, how long did it last for
- Incontinence occurred
What are your priorities of management for a patient who has been sedated for ABD?
- maintain normothermia
- capnography
- Pads on – for monitoring
- IV access – to administer medications
- Transport
How does morphine produce analgesia?
binds with opioid receptors altering pain perception
Define the different types of delusions
- Grandiose delusions: the person believes they are very talented, rich or influential
- Paranoid delusions: the person believes others want to harm them or are persecuting them
- Somatic delusions: the person believes there is something wrong with a part of their body, or that part of them is missing
- Reference delusions: the person believes other people’s thoughts or actions are directed towards them, or that special messages are being sent to them via the TV or radio
- Bizarre delusions: the person believes in something that is physically impossible
- Delusional jealousy: the person believes their partner is being unfaithful, even when that’s impossible
- Misidentification syndrome: the person believes someone they know has been replaced by an imposter who looks identical to that person
+1 Sedation Assessment Tool (SAT) verbal score description
normal/talkative
Outline the maternal changes that occur during pregnancy.
- Respiration increases
- HR increase as is responsible to maintain cardiac output
- Normal ECG changes
- Blood volume increases 30-40%
- Vasodilation secondary to hormone release – increases cardiac output and decreased systemic vascular resistance
- Clotting factor changes – more likely to clot – hypercoagulable state
- Fluid retention
- Urinary stasis – increasing risk of UTI
- Reduction in sphincter tone
Why are rashes non-blanching?
- DIC – thrombosis – tiny blood clots preventing blood from displacement when pressure applied
- Vessel damage or inflammation – vasculitis – inflamed and effecting ability to blanch under pressure
Define the pattern of pain for Biliary pain
right upper quadrant
tender on palpation and may radiate to back and right shoulder. Intense pain lasting at least 30 minutes, reaching plateau within hour and will resolve with 6 hours.
What are the expected vital signs of a 8 year old?
Weight: 31kg
HR: 70-120bpm
RR: 15-25rpm
SBP: 90-115mmHg
What are the main signs of epiglottitis?
sitting forward
don’t want to swallow
drooling
upper airway sounds
What class of drug is novorapid?
hyperglycaemic
