emergency med

Question 1

What is a symptoms sieve?

Answer 1

Symptom sieve is used to get broad categories explaining pathological processes behind a condition

Question 2

What does the A in the A-E assessment stand for and what does it involve looking for?

Answer 2

Airways - if compromised, treat before moving on

• Verbalising intermittently
• No foreign objects in mouth or excessive secretions
• No snoring/stridor
• No mouth or tongue swelling

Question 3

What does the B in the A-E assessment stand for and what does it involve looking for?

Answer 3

Breathing

• Resp rate - 14
• No cyanosis
• Sats at 94 on 2L oxygen and initially 90%
• No evidence of respiratory disease
• Mild wheeze
• Smoker
• Auscultation of chest - wheeze
• Do Arterial Blood Gas - to give info about CO2

Question 4

What does the C in the A-E assessment stand for and what does it involve looking for?

Answer 4

Circulation

• Blood pressure
• Heart rate
• Heart sounds
• 12 lead ECG
• Peripheral capillary refill brisk bilaterally < 2 seconds
• Warm peripheries

Question 5

What does the D in the A-E assessment stand for and what does it involve looking for?

Answer 5

Disability

• Blood glucose - 5.7
• Temperature - 38.2°C
• ACVPU/GCS E3 V5 M6
• PEARL: pupils equal and reacting to light

Question 6

How does the GCS score work?

Answer 6

3 is lowest and means you are not doing anything or saying anything - 1 in each category

Eye - 4 is max and means spontaneous eye opening

Verbal - 5 is max and means you are orientated

Motor - 6 is max and means you are obeying commands

Question 7

What does the E in the A-E assessment stand for and what does it involve looking for?

Answer 7

Exposure

• Rashes
• Sites of injection/track marks
• Evidence trauma to head or limbs
• Evidence of external bleeding
• Abdominal examination: abdomen distension, tenderness

Question 8

What should be done when systolic is less than 90?

Answer 8

This is concerning and should be intervened with by giving IV fluids to increase blood pressure.

This also tells us if the BP is low due to hypovolemia (if responds).

If not treated, this could lead to hypovolemic shock.

Question 9

What is meant by circulatory shock?

Answer 9

Used when inadequate blood flow results to damage to body tissues

Question 10

List the four types of circulatory shock and explain briefly what causes each of them

Answer 10

• Hypovolemic: loss of blood volume
• Obstructive: physical obstruction to blood flow
• Cardiogenic: due to ventricular failure
• Distributive: due to vasodilation due to sepsis, anaphylaxis (allergic reaction), neurogenic

Question 11

Why is altered mental state considered a sign of sepsis?

Answer 11

Decreased cerebral perfusion due to histamine and cytokine release leading to vasodilation and this can cause altered mental state

The decreased cerebral perfusion can be due to circulatory shock initiated by sepsis

Question 12

What is a renal sign of hypoperfusion?

Answer 12

Another sign is low urine output as kidneys are not receiving enough blood

Question 13

What are 2 other signs of hypoperfusion?

Answer 13

Mottled skin and tachycardia also shows hypoperfusion

Question 14

What is the diagnosis criteria for SIRS?

Answer 14

≥2 of:

• Temp >38 or <36 (elderly)
• Heart rate >90bpm
• Resp rate >20
  
  • First sign of deterioration is tachypneoa
• WBC Count >12x10^9 or <4x10^9/L

Question 15

Other than meeting criteria for SIRS, what else is required for a sepsis diagnosis?

Answer 15

• Meets SIRS criteria and evidence of infection
• Blood cultures

Question 16

What is needed to diagnose a patient with severe sepsis?

Answer 16

• Sepsis with evidence of organ dysfunction, hypotension or hypoperfusion
• Lactate, Urine output

Question 17

When would someone be considered to be in septic shock?

Answer 17

Severe sepsis with hypotension despite adequate fluid resuscitation

Question 18

If you suspect sepsis, you are supposed to do the Sepsis 6, what are these?

Answer 18

1. Give Oxygen to keep stats above 94%
2. Take blood cultures - sign of sepsis
3. Give IV Abx - if you suspect sepsis then give Abx within an hour
4. Give a fluid challenge - give a bit of fluid fast 250-500ml of crystalline solution within 15 mins (stat)
5. Measure lactate - sign of hypoperfusion
6. Measure urine output - sign of hypoperfusion

Question 19

After seeing the patient has increased CRP, Lactate and WBC/Neutrophilia, why are these each suggestive of sepsis?

Answer 19

CRP - inflammation
Produced by liver and produced when we have an inflammatory response

Lactate - anaerobic respiration
Part of sepsis 6
Vasodilation meaning hypoperfusion which means there is no oxygen and so anaerobic respiration occurs and this leads to increased lactate

WBC and neutrophilia - sign of infection
Neutrophil is suggestive of bacterial infection

Question 20

Why is abnormal urea not suggestive of sepsis?

Answer 20

There are too many causes of abnormal urea and renal injury therefore not specific to sepsis

Question 21

Why is raised GGT in this case not used to suggest sepsis diagnosis?

Answer 21

Not GGT due to chronic elevated levels of ethanol - history of alcohol abuse