Emergencies Lecture 13 Flashcards
Causes of vasovagal syncope?
pain, anxiety, fatigue, fasting and high temperature or humidity
Signs and symptoms of vasovagal syncope?
Pallor, cold and moist skin, uncomfortable or agitated, yawning, hypotension, slow, weak pulse, dizziness, nausea on some occasions and loss of consciousness
Normal time periods of vasovagal syncope?
Usually a few senconds, 10-30minutes is uncommon, rare for 1-2 hours
If longer than 5 minutes then need to call ambulance
Hypotension returns to normal in 2 hours
Can report malaise, anxiety and weakness for 1-2 days
Management of vasovagal syncope?
- DRSABC
- lay patient flat
- loosen any tight clothing (relieve compression on neck and maintain airway
- Oxygen
- Monitor pulse and respiration
- Convulsions can occur if there is a delay in treating cerebral hypoxia
If recovery from vasovagal syncope is not rapid?
- Consider other causes of collapse
- Call for medical assistance
- Monitor ABC and institute CPR if necessary
- Check BSL
- Continue monitoring heart rate and blood pressure
Prevention?
- Previous history should not be ignored
- Ensure patients have had something to eat
- Professional manner
- Lying patients down
Postural hyptoension most likely to effect?
- Those on anti-hypertenisves
- After prolonged periods of lying down
- The elderly
- Vasovagal tendency
Postural hypotension prevention
-In susceptible patients changing gradually from lying to standing
Hypoglycemia, causes?
Type 1 and type 2 diabetes, more common when the patient doesn’t eat.
Hypoglycemia signs and symptoms?
- Sweating
- Hunger
- Agitation
- Confusion
- Coma
- Drowsiness
- Tremor
Hypoglycemia management?
Assume any diabetic with impaired consciousness has hypoglycemia until proven otherwise
- Rapid acting glucose/sucrose source followed up by long acting carbohydrates
Hypoglycemia prevention?
- Early morning appointments
- Ensure the patient have had normal food insulin intake
- Ensure appointment runs on time
- Check BSL prior to treatment
- If haven’t eaten recently then give sugary drink prior to commencement of treatment
Common anaphylaxis causes
- Penicilin
- Latex
- Additives to LA
- Rarely LA
Signs and symptoms of anaphylaxis?
- Usually occurs within a few minutes of exposure, but may be delayed for 30 minutes or more
- Facial flushing, swelling, itching and paraesthesia
- Generalised uticaria or itching
- Wheezing and difficulty breathing
- Loss of consciousness, rapid or weak impalpable pulse
- Falling blood pressure
- Pallor going on to cyanosis
- Cardiac arrest
Main features of anaphlaxis
- Uticaria
- Bronchospasm
- Hypotension
- Tachycardia
- Angiodema
Management of anaphylaxis?
- Stop administration of drug
- Call for help and ambulance DRASBC
- Keep patient in most comfortable position for breathing (usually sitting up)
- If loose consciousness or is hypotensive then lay flat with legs raised
- Maintain the airway and give oxygen
- 0.6mL 1:1000 adrenaline IM (600 micrograms), repeat in a few minutes if no improvement
Epilepsy triggers?
- Flashing lights
- Stress
- Starvation
- Alcohol
- Medications
Signs and symptoms of Epilepsy?
- Aura
- Sudden loss of consciousness ( Rigid extended appearnce (tonic phase) alternate with Clonic phase generalised jerking movements
- Frothing from the mouth
- Urinary incontinence
Do patients automatically regain consciousness after a seizure?
No they may in fact remain unconscious and flaccid for some time
Status epilepticus?
Repeated fitting seizures lasting longer than 5 minutes is a medical emergency and requires urgent control. Call ambulance
Management of epilepsy?
- Protect the patient from hurting themselves
- Do not place anything in the mouth
- Keep airway clear
- Place the patient in the recovery position
- Ensure ABC is observed
- Allow the patient to recover
If ongoing epileptic convulsions?
- Give oxygen
- Call ambulance
- Benzodiazepines can be given by trained individuals
When to transfer to hospital in epilepsy?
- First seizure
- Ongoing fitting
- Injured themselves
- Post seizure confusion greater than 5 minutes
- Any post seizure breathing difficulty
Prevention of epilepsy?
- Ensure the patient has taken their medication
- Avoid stress and other triggers
- Get patient to warn you they feel they are going to have a seizure (not all are aware of a fit coming on, but some are)
Acute chest pain causes?
- Usually due to myocardial ischaemia
- Varying degrees of atheromatous coronary artery occlusion
- Angina usually experiences at times of increased cardiac workload such as stress and anxiety (adrenaline mediated)
- Myocardial infarction occurs when there is a rupture of atheromatous plaque cap with formation of thrombus.
Main differential diagnosis for acute chest pain?
Precipitating factors?
Pain experienced?
- Angina or Myocardial infartion
- Stress, exercise, emotion and anxiety
- Severe crushig restrosternal pain, that may radiate to the arm, neck or jaw (commonly the left side)
Features suggestive of angina?
- Pain is short lasting
- Relieved upon rest and glyceryl trinitrate
Features suggestive of Myocardial infarction?
- Pain is more severe and persistent and irreversible.
- Breathlessness, nausea and even vomiting
- Weak, irregular pulse
- Loss of consciousness
Management?
If angina: allow patient to take glyceryl trinate or their anti-anginal drugs. Once has resolved cease treatment and reschedule
- If no relief then assume it is an infarct:
- Send for help and call ambulance
- Don’t lay patient flat if increases breathlessness
- Give oxygen or entonox to relieve pain and anxiety
- Give 300mg of aspirin (chewed or sucked
- Re-assure the patient
- Monitor consciousness
- If lose consciousness commence basic life support
Causes of respiratory distress?
Acute asthmatic attack, inhaled foreign body, hyperventilation and angiodema
Signs and symptoms of asthma attack?
- Breathlessness and a tight chest
- Increased respiratory rate (>25)
- Expiratory wheeze
- Accessory muscles of respiration in action
- Can’t complete sentences (If patient can’t speak you are dealing with a potentially fatal episode)
- Tachycardia
Managements of asthma?
- Keep patient upright
- Allow patient to take their bronchodilator (preferably through a spacer)
- Oxygen if no bronchodilator
- Reassure patient
- If no improvement then call an ambulance
Prevention of asthma?
- Avoid anxiety, pain and known allergens
- Ensure patient has their bronchodilator with them.
Signs and symptoms of upper airway obstruction?
- Stimulate the cough reflex
- If the patient is choking the object is large enough to cause respiratory obstruction
Signs and symptoms of lower airway obstruction?
The patient may be totally unaware they have inhaled a foreign body
Management of airway obstruction:
a) If patient is not choking or having difficulty breathing?
b) If signs of partial obstruction?
c) Complete airway obstruction (patient cannot speak breathe or cough)?
a) If patient is not choking or having difficulty breathing:
- Check oral cavity and clothing for object
- If can’t find object or known to have gone into throat then put patient in supine patient with head down, allowing gravity to return the object to the oropharynx
- If still can’t be retrieved inform patient and refer to hospital for chest and abdominal x-rays. Surgery may be required to remove the object.
b) If signs of partial obstruction, if the object is larger and causing breathing difficulties or choking then:
- Encourage coughing to dislodge the object and call for ambulance
c) Complete airway obstruction:
- If patient in dental chair sit them up on the side of the chair
- Support chest with hand and give 5 sharp back blows between the shoulder blades with the heel of your hand
- If doesn’t dislodge then give 5 abdominal thrusts (Heimlich maneouvre)
- If unconscious then commence CPR with finger sweep between each cycle and consider cricothyroidotomy if no air entry
Signs and symptoms of hyperventilation?
- Hyperventilation
- Tingling of lips and fingers
- Tetanic spasms of the peripheries
- Anxious or distressed
- Flushed appearance
- Dizziness
- Rapid pulse rate
- All of these symptoms lead to worsening anxiety
Management of hyperventilation?
- Calm, friendly reassuring manner
- Get patient to slow and count their breathing
- DO NOT re-breathe into bag as this actually makes things worse due to increased hypoxia
Prevention of hyperventilation?
- Minimise anxiety
- Having a calm and reassuring manner
- Talking through the patients anxieties with them
- Pharmacological agents maybe required
Adverse reactions to LA?
- Faint (most common adverse reaction to LA
- Intravascular injection
- Intramuscular injection
- Facial palsy
- Cardiovascular reactions
- LA overdose
- Fractured needle
- LA allergy
Intravascular injection signs and symptoms?
- Agitation
- Palpitations
- Failure of anaesthesia
- Fits/Loss of consciousness
- Drowsiness/confusion
Management of intravascular injections?
- Lay the patient flat
- Maintain airway
- Give oxygen
- Give reassurance
Most patients recover in half an hour. If fits or loss of consciousness then treat appropriately
Intravascular prevention?
- Use aspirating syringe
- Aspirate correctly
- Inject slowly
Signs and symptoms of intramuscular injections?
- Pain
- Trismus
Usually resolves over a few days
Intramuscular injection management?
- Gentle jaw exercises
- Analgesics
Intramuscular injection prevention?
Correct LA technique
Facial palsy signs and symptoms?
- Facial palsy
- Diplopia
Facial palsy management?
- Reassurance
- Explanation
- Eyelid closed and protective dressing applied until LA wears off
Facial palsy prevention?
Correct LA technique
Cardiovascular reaction signs and symptoms?
- Palpatations
- Tremor
Cardiovascular reaction management?
- Reassurance
- Minimise anxiety
- Usually resolves quickly
- If reaction is severe then treat as chest pain
Cardiovascular reaction prevention?
Correct LA technique
LA overdose signs and symptoms?
- Drowsiness to convulsions
- Respiratory failure and cardiac arrest
LA overdose management?
- Oxygen
- Call for assistance
LA overdose prevention?
Correct LA technique
Fractured needle management?
- If protruding end of the broken needle is visible then grasp it with mosquito forceps and remove.
- If not visible then immediate referral is required
Fractured needle prevention
- Correct LA technique
- Do not insert needle to the hub
- Avoid bending the needle
LA allergy signs and symptoms
- Facial flushing, swelling, itching and paraesthesia
- Generalised and isolated urticaria and itching
- Falling blood pressure
- Wheezing and difficulty breathing
- Loss of consciousness, rapid or weak pulse
- Falling blood pressure
- Pallor going to cyanosis
- Cardiac arrest
- Isolated rashes (added in for LA allergy)
LA allergy management?
- Stop administration of drug
- DRSABC (call ambulance)
- Place patient in most comfortable position to breathe (usually sitting up)
- If hypotensive or lose consciousness then lay them down and raise legs
- Maintain airway and give them oxygen
- 0.6mL 1:1000 adrenaline IMI (600 micrograms) repeat in a few minutes if there is no improvement.
- Also testing for LA sensitivities
LA allergy prevention?
- Avoidance of precipitating agents
Post operative bleeding, treatment?
Pinch soft tissue between the walls of the socket. This usually stops the bleeding from the soft tissues, while bleeding from the socket will continue to well up.
Aggressive or difficult behaviour, signs and symptoms?
Anxiety, confusion, aggression, disturbed or difficult behaviour
Aggressive or difficult behaviour management?
- Adapt a calm, understanding, reassuring and non-confrontational approach
- If the patient is unresponsive or difficult then summon assistance
- If the patient becomes very aggressive or disturbed call security or emergency services
- Do not put yourself or others at risk of injury from an aggressive patient or escort
Aggressive or difficult behaviour prevention?
- Calm inviting reception with alert and friendly staff
- Avoid keeping patients waiting
- Discuss the patients anxieties with them
- If anxiety is the main issue the use of a sedative suh as Temazapam 20mg 2 hours before surgery and 10mg the night before.
