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Year 4 ACC > Emergency Medicine > Flashcards

Emergency Medicine Flashcards

1
Q

What are the causes of airway obstruction? (11)

A
  1. Foreign body
  2. Infection - e.g. Epiglottitis, Retropharyngeal abscess, Ludwigs angina, Laryngotracheitis, Tetanus
  3. Immune - angioedema, anaphylaxis
  4. Tumour
  5. Trauma - neck haematoma, burns
  6. Poisoning and toxic exposures - smoke inhalation
  7. Laryngospasm/bronchospasm - drug-induced, asthma
  8. Congenital - vascular rings
  9. Altered level of consciousness
  10. Paralysis
  11. Cranial nerve palsy
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2
Q

How does airway obstruction kill? (5)

A
  1. Cerebral oedema
  2. Pulmonary oedema
  3. Exhaustion
  4. Hypoxic brain injury
  5. Secondary apnoeas
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3
Q

What are the causes of breathing problems? (3 categories- 1 is disorders of lung function with 7 examples)

A
  1. CNS depression causing decreased/no respiratory drive
  2. Poor/diminished respiratory effort from muscle weakness/pain
  3. Disorders of lung function e.g. pneumonia, pneumothorax, haemothorax, asthma, COPD, PE, ARDS, oedema
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4
Q

How can breathing problems kill? (5)

A
  1. Hypercapnia and apnoeas
  2. Pulmonary oedema
  3. Exhaustion
  4. Hypoxic brain injury
  5. Secondary cardiac ischaemia
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5
Q

What are the causes of circulation problems? (2)

A
  1. Primary cardiac e.g. MI, ishcaemia, arrhythmias, cardiac failure, tamponade, rupture, myocarditis
  2. Secondary e.g. tension pneumothorax, blood loss, hypoxia, hypothermia, septic shock, hyperthermia, rhabdomyolysis
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6
Q

What is the circularly problem that kills?

A

Cardiac arrest

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7
Q

What information do you need in order to spot a deteriorating patient? (6)

A
  1. Collateral information
  2. How patient looks/appears
  3. What the patient says
  4. Patients current NEWS score/obs
  5. Patients clinical examination
  6. New investigations (nearside vs distant tests)
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8
Q

In terms of RRAPID, what needs to be done in the airway category? (3)

A
  1. Look for signs of airway obstruction
  2. Treat the obstruction as an emergency
  3. Give oxygen at high concentration
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9
Q

In terms of RRAPID, what needs to be done in the breathing category? (9)

A
  1. Look, listen and feel for respiratory distress
  2. Count the RR
  3. Assess quality of breathing
  4. Note any deformity
  5. Record FiO2 and SpO2
  6. Listen near the face, then palpate, percuss and auscultate the chest
  7. Trachea position?
  8. Initiate treatment
  9. ABG, pulse oximetry, CXR, O2 therapy
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10
Q

In terms of RRAPID, what needs to be assessed in the circulation category? (10)

A
  1. Look at and feel the hands
  2. Assess peripheral and central CRT
  3. Assess venous filling
  4. Count HR and look at cardiac monitor
  5. Palpate central/peripheral pulses
  6. Measure blood pressure
  7. Listen to the heart
  8. Look for signs of poor cardiac output
  9. Look for haemorrhage
  10. Treat the cause of CV collapse
    - Cap re-fill
    - Skin turgor
    - Oedema
    - Urine output
    - Fluid management
    - ECG
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11
Q

What is preload?

A

Preload is the volume of blood returning to the ventricles during diastole. The large the preload, the bigger the stroke volume. Preload will decrease if the person is dehydrated or bleeding. There comes a stage when myocardial fibres become overstretched if the preload is too great, at this point they can lose their contractility - this is heart failure

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12
Q

How can myocardial contractility change?

A

If there is an increase in preload, or increased sympathetic nervous system activity e.g. stress response, or drugs e.g. adrenaline.
Contractility can be reduced by low preload (hypovolaemia), cardiac disorder (e.g. ischaemic heart disease, heart failure_), hypoxia, hypercapnoea, acidosis and electrolyte disturbances.

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13
Q

What is myocardial contractility?

A

The force with which the myocardium contracts which is a major determinant of stroke volume

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14
Q

What is afterload?

A

The ‘load’ against which the heart must contract to eject blood. It is the tension in the left ventricle during systole. Increased afterload results in increased myocardial work and a decreased stroke volume. One component of afterload is the systemic vascular resistance.

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15
Q

In terms of RRAPID, what does the disability category entail? (7)

A
  1. Review and treat ABCs, check no hypoxia and hypotension
  2. Check drug chart for reversible drug-induced GCS
  3. Examine the pupils
  4. Assess GCS or AVPU
  5. Check lateralising signs
  6. Check capillary glucose
  7. Ensure airway protection
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16
Q

What is angina?

A

Pain in the chest, neck, shoulders, jaws and/or arms caused by insufficient supply to the myocardium

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17
Q

What is angina usually caused by?

A

Coronary artery disease - atherosclerotic plaques in the coronary arteries cause progressive narrowing of lumen, and symptoms occur when blood flow does not provide adequate amounts of oxygen to the myocardium at times when oxygen demand increases e.g. during exercise

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18
Q

What is the difference between stable and unstable angina?

A

Stable angina occurs predictably with physical exertion or emotional stress, and tends to last no more than 10 minutes, and is relieved within minutes of rest/with sublingual nitrates
Unstable angina is new onset or abrupt deterioration of previously stable angina. Often it occurs at rest and requires immediate admission or referral to hospital.

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19
Q

What are the complications of angina (caused by coronary artery disease)? (6)

A
  1. Stroke
  2. MI
  3. Unstable angina
  4. Sudden cardiac death
  5. Anxiety, depression
  6. Reduced quality of life
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20
Q

What are the causes of chest pain?

A
  1. Cardiovascular events
  2. MSK disorders
  3. GI disease
  4. Stable angina
  5. Psychosocial and psychological disorders
  6. Respiratory diseases
  7. Non-specific chest pain
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21
Q

What % of all consultations in primary care deal with chest pains?

A

1-2%

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22
Q

What % of A&E visits are due to chest pain? and chest pain makes up what % of emergency hospital admissions?

A

5% A&E

40% emergency hospital admissions

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23
Q

Trauma deaths occur in what kind of distribution?

A

Trimodal distribution

  1. First peak at time of injury (seconds to minutes)
  2. Second peak minutes to hours post-injury
  3. Third peak days to weeks post-injury
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24
Q

In terms of injury severity score, what score indicates a ‘major trauma’?

A

Above 15

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25
Q

What time is most important when a traumatic injury occurs?

A

The hour after injury - the golden hour. It is a window of opportunity that can potentially allow clinicians to improve the mortality or morbidity of patients through quality treatment

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26
Q

Why is it important to know the mechanism of injury? (2)

A
  1. The mechanism may give information about the magnitude of energy transfer, which is key to severity of injury.
  2. Particular mechanisms give rise to definite patterns of injury, allowing detection of occult injury through an index of suspicion
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27
Q

What does occult mean?

A

A disease/process not accompanied by readily discernible signs or symptoms

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28
Q

In airways management, what are the signs of obstruction or airway injury? (6)

A
  1. Absent breath sounds
  2. Snoring/stridor/gurgling
  3. Hoarse voice
  4. Obtundation or cyanosis
  5. Paradoxical movements/accessory muscles
  6. Tracheal deviation laryngeal crepitus
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29
Q

What injuries can compromise the airway? (4)

A
  1. Facial fractures/facial burns
  2. Neck wounds
  3. Epistaxis/vomiting
  4. Head injury with low GCS
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30
Q

Whats the process of managing inadequate airways?

A
  1. Improve oxygenation
  2. Airway maintenance techniques:
    - chin lift manoeuvre
    - jaw thrust
    - oropharyngeal/nasopharyngeal airway
    - LMA
    - Endotracheal intubation
    - Surgical airways
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31
Q

What are the definitive airway techniques. and what makes them definitive?

A
  1. Endotracheal intubation
  2. Surgical airways
    - because the patient cannot aspirate with these in-situ
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32
Q

What is the mnemonic used to remember the life threatening thoracic injuries?

A

ATOM FC

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33
Q

What does ATOM FC refer to?

A 
A - airway obstruction
T - tension pneumothorax
O - open chest wound
M - massive haemothorax
F - flail chest
C - cardiac tamponade
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34
Q

What are the signs that may suggest thoracic injury? (7)

A
  1. Abnormal oxygen saturations or respiratory rate
  2. Abnormal chest movement
  3. Chest wall bruising, wounds or surgical emphysema
  4. Tracheal deviation
  5. Rib, clavicular, scapular or sternal fractures
  6. Abnormal percussion note
  7. Abnormal air entry
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35
Q

What are the causes of shock in trauma?

A
  1. Haemorrhagic (hypovolaemic)
  2. Obstructive
  3. Cardiogenic
  4. Neurogenic
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36
Q

Which mnemonic is used to assess circulatory signs, and is helpful when a patient may be suffering from shock?

A

HEP B

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37
Q

What does HEP B stand for?

A

H - hands
E - end organ perfusion
P - pulse
B - blood pressure

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38
Q

What does the hands of HEP B refer to?

A

Look/feel hands for - temperature, sweating and capillary re-fill time

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39
Q

How does you assess end organ perfusion?

A

Conscious levels and urine output

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40
Q

What information can the pulse provide?

A

Rate, quality and rhythm

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41
Q

What problem with the blood pressure is a late sign of shock?

A

Hypotension

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42
Q

Haemorrhagic shock is very common in trauma, and may not be occult. What mantra is useful to remember, and where are the locations of major blood loss in the body?

A

On the floor and four more:

  1. External wounds
  2. Chest cavity
  3. Abdominal cavity (including retroperitoneal)
  4. Pelvic cavity
  5. Long-bone fractures (femurs)
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43
Q

What is the management of inadequate circulation? (7)

A
  1. Optimise oxygenation
  2. Splints/torniquets/direct pressure for active haemorrhage
  3. Large bore IV access X2 in the antecubital fossa
  4. Fluid resuscitation (crystalloid (warm) and bood)
  5. IV tranexamic acid if haemorrhaging
  6. Consider activation of the massive transfusion protocol
  7. Definitive haemostasis
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44
Q

What % of prehospital trauma-related deaths involve bran injury?

A

90%

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45
Q

What is the goal during initial management with head injury patients?

A

To prevent secondary brain injury caused by inadequate oxygenation, hypoperfusion or hyperglycaemia.

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46
Q

What is the clinical grading system used to assess head injury?

A

GCS

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47
Q

What are the components of the CGS and how many points is assigned to each?

A

Eye-opening: 4=spontaneous, 3=to speech, 2= to pain, 1= none
Verbal: 5=orientated, 4= confused, 3=inappropriate words, 2=sounds, 1=none
Motor: 6=obeys commands, 5=localises to pain, 4=normal flexion, 3=abnormal flexion, 2=extension, 1=none

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48
Q

In addition to GCS, what are signs can indicate a head injury (elements of disability in ABCD)?

A
  1. Facial or scalp bruising or haematoma (panda eyes)
  2. Scalp or facial lacerations
  3. Pupil size and reaction
  4. Capillary glucose
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49
Q

How is neurodisability managed immediately?

A
  1. Optimise oxygenation
  2. Maintain cerebral perfusion (BP >90mmHg)
  3. Avoid hypoglycaemia
  4. Avoid pyrexia
  5. Definitive imaging and treatment
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50
Q

What are the spinal cord syndromes that are important to be aware of? (4)

A
  1. Central cord syndrome
  2. Anterior cord syndrome
  3. Brown-Sequard syndrome
  4. Complete spinal cord syndrome
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51
Q

What are the signs of spinal injury? (7)

A
  1. Diaphragmatic breathing
  2. Evidence of neurogenic shock
  3. Responds to pain only above the clavicles
  4. Priapism
  5. Flexed posture of upper limbs or flaccid areflexia
  6. Patient complains of loss of sensation or function
  7. Spinal tenderness, bruising or swelling on log-roll
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52
Q

What is the immediate management of spinal injury? (8)

A
  1. Optimise oxygenation
  2. Ensure adequate ventilation
  3. Maintain spinal cord perfusion
  4. Maintain immobilisation
  5. Document thorough spinal cord examination
  6. Urinary catheterisation and NG tube
  7. Definitive imaging
  8. Early specialist advice
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53
Q

What does MSK trauma essentially relate to?

A

Pelvis fractures and limb injuries

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54
Q

What device can be applied pre-hospital when there is potentially a pelvic fracture and why?

A

Pelvic binders, as the stabilise the fractured pelvis and prevent movement and disruption of haematoma in the pelvic cavity

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55
Q

Why is it important to keep trauma patients at the appropriate temperature (warm)?

A

As hypothermia will contribute to the patients demise, and induces coagulopathy, and thus increased mortality from haemorrhagic shock.

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56
Q

What complications can occur in MSK trauma injuries? (3)

A
  1. Compartment syndrome
  2. Skin necrosis
  3. Nerve compression
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57
Q

What is shock?

A

Shock is often considered to be a circulation problem, but is actually fundamentally about inadequate oxygenation. The definition is: clinical syndrome caused by inadequate tissue perfusion and oxygenation leading to abnormal metabolic function

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58
Q

Shock is either physiological or clinical. What are the clinical types of shock?

A
  1. Cardiogenic
  2. Hypovolaemic
  3. Sepsis
    etc.
59
Q

What are the 6 steps to oxygen transportation to cells?

A
  1. Convection of O2 from environment to body (ventilation)
  2. Diffusion of O2 into the blood (oxygen uptake)
  3. Reversible chemical bonding with Hb
  4. Convective transport of O2 to the tissues (cardiac output)
  5. Diffusion into the cells/organelles
  6. The redox state of oxygen
60
Q

Physiological shock is hypoxia, which is then classified in one of four ways, what are the four forms of hypoxia?

A
  1. Hypoxic hypoxia - (decreased O2 supply)
  2. Anaemic hypoxia - (decreased haemoglobin function)
  3. Stagnant hypoxia - (inadequate circulation)
  4. Histotoxic hypoxia - (impaired cellular O2 metabolism)
61
Q

What is the trauma triad of death?

A
  1. Coagulopathy (causes lactic acidosis)
  2. Hypothermia (causes coagulopathy)
  3. Metabolic acidosis (decreases myocardial performance)
62
Q

What is the definition of clinically significant hypothermia?

A

Body temperature <36 degrees for 4 hours or more

63
Q

How does hypothermia occur in trauma?

A

A major haemorrhage leads to tissue hypoperfusion, and decreased oxygen delivery (shock), leading to decreased heat generation

64
Q

How else is hypothermia aggravated in a hospital setting/scene of injury?

A

Environmental factors can aggravate hypothermia, e.g. resus room and/or surgical intervention

65
Q

What can hypothermia lead to? (4)

A
  1. Cardiac arrhythmias
  2. Decreased cardiac output
  3. Increased systemic vascular resistance
  4. Left shift of oxygen-haemoglobin dissociation curve
66
Q

Why does hypothermia also increase the risk of sepsis?

A

As it can induce coagulopathy by inhibition of the coagulation cascade and impair immunological functions

67
Q

How exactly does hypothermia interfere with the coagulation cascade?

A

It causes imbalance between thromboxane and prostacyclin - thus causing platelet dysfunction and inhibits coagulation enzymes function

68
Q

How does shock lead to lactic acidosis?

A

Shock is tissue hypoperfusion with reduced oxygen delivery. This leads to anaerobic respiration and lactic acidosis.

69
Q

What impact does acidaemia have on the heart?

A

Acidaemia causes reduced cardiac output as it depresses myocardial contractility and so exacerbates shocked state.

70
Q

What is the Munro-Kellie doctrine?

A

It relates to the skull being an incompressible compartment with a fixed volume with no room for movement, and it contains blood, CSF and brain. Thus the contents are in a state of volume equilibrium. This means in the volume of one cranial constituent increases then one of the cranial constituents must compensate for this by decreasing in volume. If the pressure increases due to bleeding etc, then the body tries to reduce the amount of CSF fluid by retaining it in the spinal cord. It then tries to reduce blood flow to the brain. Eventually coning occurs - the brain is pushed out through the foramen magnum.

71
Q

What are the signs/symptoms of an increased intracranial pressure in adults? (8)

A
  1. Changes in LOC
  2. Eyes - papilloedema, pupillary changes, impaired eye movements
  3. Posturing - decerebrate, decorticate, flaccid
  4. Changes in speech
  5. Headache
  6. Seizures
  7. Changes in vital signs - Cushing’s triad
  8. Vomiting
72
Q

What are the signs of raised ICP in infants? (4)

A
  1. Bulging fontanels
  2. Cranial structure separation
  3. Increased head circumference
  4. High pitched cry
73
Q

What is Cushings triad?

A
  1. Increased systolic BP
  2. Decreased pulse
  3. Irregular respiratory pattern
74
Q

What does CPP = MAP - ICP refer to?

A 
CPP = cerebral perfusion pressure 
MAP = mean arterial pressure
ICP = intracranial pressure
75
Q

How is MAP calculated?

A

(2x diastolic BP + systolic BP) / 3

76
Q

Why is the body’s response to a fall in CCP bad?

A

The body responds by raising systemic blood pressure and dilating cerebral blood vessels. This accelerates intracranial haemorrhaging and increases ICP (due to an increase in cerebral blood volume), thus lowering CPP further.

77
Q

What does an elevated ICP correlate to with traumatic brain injuries?

A

Correlates with higher mortality rates, because raised ICP induces cerebral ischaemic and consequent infarction

78
Q

What are the signs that ICP has elevated?

A

Lateralising signs - dilated pupil, sluggish then fixed (CNIII palsy), aphasia - all due to herniation
The pupil response represents impending uncal herniation caused by raised ICP likely due to unilateral haematoma

79
Q

What are the priorities for preventing secondary brain injury?

A
  1. Prevent hypoxia
  2. Prevent hypocarbia
  3. Prevent hypoglycaemia
  4. Prevent hypotension
80
Q

How is a patients breathing assessed? (8)

A
  1. Look for signs of respiratory distress (e.g. tripod-ing, abnormal RR, exhausted, cyanotic/pale, agitation - can be a sign of hypoxia)
  2. Count respiratory rate
  3. Assess depth/quality of breathing
  4. Note chest deformity, raised JVP, abdominal distension
  5. Record FiO2 and SpO2 (FiO2 - expired concentration of oxygen, and record what saturations are on while on oxygen - important to document these together)
  6. Listen near the face then palpate, percuss and auscultate the chest
  7. Trachea position?
  8. Decide upon specific treatment (oxygen, nebulisers (salbutamol/ipratropoium), steroids, diuretics, decompression/chest drain,
81
Q

When is oxygen prescribed?

A

To treat hypoxaemic patients - it does not treat breathlessness in the absence of hypoxaemia.

82
Q

What is the oxygen saturation range for people without COPD?

A

94-98%

83
Q

What is the oxygen sat range that is aimed for, for people with COPD?

A

88-92%

84
Q

What is the flow rate of a nasal cannula?

A

1-6 litres (but if needing more than 4, then normally switched to a face mask)

85
Q

What is the flow rate for a hudson (simple face mask) mark?

A

5-10 litres

86
Q

What is a venturi mask?

A

It is a normal face mask which has a valve which can regulate the flow rate - dependent upon which valve is used.

87
Q

Why are venturi masks useful?

A

They are used for patients with COPD who are at risk of developing hypercapnia due to hypoxic drive

88
Q

What it the difference between a bag valve mask and a non-rebreathe mask?

A

The BVM means they are being ventilated - someone is creating a positive pressure to aid breathing, whereas a non-rebreathe mask means the patient breathes for themselves

89
Q

What is CPAP?

A

Continuous positive airway pressure - looks like someone about to go into space. This means unlike normal breathing in and out, the alveoli are maintained open due to the positive pressure which gives a longer time for gas exchange (pressure normally 5-10)

90
Q

What is BiPAP?

A

Like CPAP, but pressure drops when breathing out

91
Q

If a 62 year old man with COPD presents with breathlessness productive cough, fever and pleuritic chest pain. His ABCDE assessment demonstrates he is not critically unwell. His sats are 90% on air… does he need supplementary oxygen?

A

No (his target sats are 88-92%)

92
Q

What can PE refer to?

A

A pulmonary embolism may be a venous thrombus embolism, but can also be a fat embolus, septic embolism.

93
Q

With a 25 year old man who has an operation on his femur, develops breathlessness and pleuritic chest pain. He has no other medical history and ABCDE is not critically unwell. His saturations are 90% on air… what supplementary oxygen do you give?

A

Nasal cannulae (commencing on 1L/minute up to maximum of 6L/minute)

(tempting to give more oxygen than this using face mask - remember this is a drug)

94
Q

In a 65 year old man with bronchiectasis arrives with increased sputum production and breathlessness. His saturations are 84% on the 24% venturi mask that was applied in the ambulance. What is the next step in his treatment?

A

As he has a chronic lung condition and his target sats are 88-92%, he needs a higher percentage of oxygen - 28% venturi mask and this concentrations needs to be increased until he reaches his target range

95
Q

A 19 year old man found collapsed semi-conscious at home. He has been vomiting and is pyrexial with a florid non-blanching purpuric rash. He is critically unwell. His sats are 99% on a simple face mask - what needs to be done now, does he need supplementary oxygen?

A

Yes - he should be on a non-rebreathe reservoir mask. As he is critically unwell.

96
Q

A 78 year old woman with COPD and long-term home oxygen, presents to the hospital with breathlessness, collapse, and reduced consciousness. She is ‘in extremis’ and making slow intermittent gasping breaths. Her saturations are unrecordable. What is her oxygen target, and what needs to be done?

A

88-94%
BVM - self-inflating bag valve mask and ventilate patient

(could be a tension pneumothorax!)

97
Q

48 year old man with pneumonia on the ward, increasingly breathless depress being on oxygen via nasal cannula at 6L/min. His sats are 93%. What needs to be done?

A

His target is 94-98%, yet while on oxygen still only 93%, so needs face mask - start at 5-6L/minute and increase if necessary.

98
Q

A 26 year old man with CF is recovering from pneumonia on the respiratory ward. His ABCDE assessment means he is not acutely unwell. His sats are 86% despite being on 60% venturi mask. What should his oxygen target be, and does he need supplementary oxygen?

A

88-92% due to chronic lung disease
He does need oxygen - 15L NRBM
- this indicates he is very unwell and needs critical care involvement

99
Q

What are the causes of pneumonia?

A
  1. Strep. pneumoniae
  2. Staph. aureus
  3. Mycoplasma pneumoniae
  4. Haemophilus influenzae
  5. Chlamydia
100
Q

Which drugs are given in the treatment of pulmonary oedema?

A
  1. Furosemide
  2. GTN
  3. Morphine
101
Q

Who should get an ABG? (8)

A
  1. Critically ill
  2. Unexpected or inappropriate hypoxaemia (or any patient requiring oxygen to achieve their target range)
  3. Deteriorating oxygen saturations/increasing breathlessness with stable hypoxaemia
  4. Deteriorating patient who now requires a significant FiO2 to maintain a constant oxygen saturation
  5. Risk factors for hypercapnic respiratory failure
  6. Breathlessness and at risk of metabolic conditions
  7. Acute breathlessness or critically ill/poor peripheral circulation and oximeter cannot obtain reading
  8. Any other evidence that would indicate a blood gas results which would be useful in the patients management
    ..so basically anyone
102
Q

For interpreting a blood gas, what is important to determine? (5)

A
  1. How is the patient clinically?
  2. Is the patient hypoxaemic?
  3. Is the patient academic or alkalaemic?
  4. What has happened to the PaCO2?
  5. What has happened to the base excess or bicarbonate?
103
Q

What must be assessed in a patient with hypotension?

A
  1. Heart rate
  2. Volume status
  3. Cardiac performance
  4. Systemic vascular resistance
104
Q

What is shock?

A

A clinical syndrome caused by inadequate tissue perfusion and oxygenation leading to abnormal metabolic function

105
Q

What is the mnemonic to remember life threatening asthma?

A

33 92 CHEST

106
Q

What does each element of the mnemonic for life threatening asthma refer to?

A 
33 - PEFR <33%
92 - O2 sats <92%
C - cyanosis
H - hypotension
E - exhaustion
S - silent chest on auscultation 
T - tachycardia
107
Q

What important measurement would indicate near-fatal asthma?

A

Raised PaCO2

108
Q

How is acute severe asthma defined? (4)

A
  1. PEFR 33-50%
  2. RR >25/min
  3. HR >110/min
  4. Unable to complete sentence in one breath
109
Q

What are the key features that would suggest someone has a fat embolus? (4)

A
  1. Long bone fracture e.g. femur fracture
  2. Respiratory failure
  3. Neurological abnormalities
  4. Petechial rash
110
Q

In someone with a DKA, what type of respiratory signs may they show?

A

Kussmaul’s respiration - a deep sighing respiration

111
Q

What are the clinical features of someone with a DKA? (6)

A
  1. Polyuria/polydipsia
  2. Weight loss/weakness
  3. Hyperventilation/breathlessness
  4. Abdominal pain (DKA can present as an acute abdomen)
  5. Vomiting
  6. Confusion (coma occurs in 10%)
112
Q

On examining someone with suspected DKA, what would you look for? (3)

A
  1. Hydration status
  2. Ventilation rate/RR
  3. Smell for ketones
113
Q

What investigations are important to carry out in someone with DKA? (8)

A
  1. ABG - acideaemia
  2. U&Es
  3. Urinalysis
  4. FBC
  5. Blood glucose
  6. Septic screen
  7. CXR - signs of infection
  8. Amylase (acute pancreatitis occurs in 10%)
114
Q

What is needed to diagnose DKA? (3)

A
  1. Positive urinary/plasma ketones
  2. Arterial pH <7.30 (or serum bicarb <15mmol/L)
  3. They’re diabetic?! HbA1c/blood glucose?
115
Q

What commonly precipitates a DKA? (3)

A
  1. Infection
  2. Non-compliance with treatment
  3. Newly diagnosed diabetes
116
Q

What three things need to be replaced in terms of treatment for DKA?

A
  1. Fluid replacement (normally 0.9% saline)
  2. Potassium replacement (do not give if K+ >5.5mmol/L)
  3. Insulin replacement (Infusion fixed rate 0.1u/kg/h
117
Q

In a DKA, what are the mechanisms in which potassium is lost? (4)

A
  1. Insulin is heavily involved in the process of K+ being transported into cells, so in the absence of insulin, there will be high levels of serum/extracellular K+
  2. The hyperglycaemia promotes diuresis, and the body tries to retain sodium, at the expense of K+
  3. In addition to sodium ions being retained, as are hydrogen ions at the expense of K+
  4. In a state of acute hyperkalaemia, the GI tract retains hydrogen ions, causing vomiting and diarrhoea, which leads to loss of K+ ions.
118
Q

What are the complications of a DKA? (6)

A
  1. Hypokalaemia
  2. Hypophosphataemia
  3. Hypercholeraemic acidosis
  4. Hypoglycaemia
  5. Cerebral oedema in children
  6. Thromboembolism (due to tissue hypoperfusion)
119
Q

How may hypocalcaemia present?

A
  1. Abnormal neurological sensations and neuromuscular excitability
  2. Numbness around the mouth and paraesthesiae of the distal limbs
  3. Hyper-reflexia
  4. Focal or generalised seizures
  5. Hypotension, bradycardia, arrhythmias
  6. Chvostek’s sign - tapping facial nerve anterior to the ear causing contraction of facial muscles
120
Q

What are the causes of hypocalcaemia? (8)

A
  1. Vitamin D deficiency (more common in Asians)
  2. Hypoparathyroidism
  3. Chronic renal failure
  4. Loss of calcium from circulation e.g. acute pancreatitis
  5. Magnesium deficiency ( Vitamin D facilitates calcium’s absorption, and magnesium helps keep calcium out of the soft tissues and in the bones where it’s needed most)
  6. Sepsis
  7. Burns
  8. Chemotherapy
121
Q

If hypocalcaemia is proving difficult correct, what other deficiency may need to be checked?

A

Magnesium

122
Q

What is the treatment for hypocalcaemia if the patient is symptomatic?

A
  1. 10mL 10% calcium gluconate (diluted in 100mL N saline or 5% glucose) over 10 minutes
123
Q

What is the mnemonic used to help remember the San Francisco Syncope Rules?

A

CHESS

124
Q

What does each element of CHESS refer to?

A 
C - history of congestive heart failure
H - hematocrit <30%
E - abnormal ECG
S - SOB
S - Systolic blood pressure <90
125
Q

What is the OESIL risk score?

A

It is used to calculate the risk of cardiac death after syncope episode

126
Q

What was the elements that make up the OESIL risk score?

A 
Age > 65 years
History of CV disease
Syncope without prodromes
Abnormal ECG
(a score greater than 2 indicates an increased risk of cardiac death)
127
Q

In order to remember causes of syncope, what are the different factors involved?

A

Head
Heart
Vessels
Drugs

128
Q

Name 3 HEAD causes of syncope?

A
  1. Epilepsy
  2. Hypoglycaemia
  3. Hypoxia
  4. Stroke
129
Q

Name 3 HEART causes of syncope?

A
  1. Emboli
  2. Aortic obstruction - stenosis
  3. Tachyarrhythmias
130
Q

Name 3 VESSELS causes of syncope?

A
  1. Vasovagal
  2. Ectopic pregnancy
  3. ENT - BPPV, labyrinthitis
131
Q

Name 3 DRUGS causes of syncope?

A
  1. Antihypertensives
  2. Beta blockers
  3. Alpha blockers
    “street drugs”
132
Q

What are the reflex syncopes?

A
  1. Vasovagal
  2. Situational
  3. Carotid sinus syncope
133
Q

What are the orthostatic (postural) hypotension causes? (4)

A
  1. Primary autonomic failure (Parkinson’s disease, Lewy body dementia)
  2. Secondary autonomic failure (diabetes, amyloidosis, spinal cord injuries)
  3. Drug induced - alcohol, diuretics, antidepressants
  4. Volume depletion - haemorrhage, diarrhoea, vomiting
134
Q

What are the cardiac syncopes?

A

Either arrhythmias or structural heart diseases

135
Q

What are the arrhythmias that can lead to cardiac syncope? (3)

A
  1. Bradycardia
  2. Tachycardia
  3. Drug induced
136
Q

What are the structural heart diseases that can cause cardiac syncope? (5)

A
  1. MI
  2. Hypertrophic cardiomyopathy
  3. Valvular disease
  4. Pericardial disease/tamponade
  5. Congenital anomalies of coronary arteries
137
Q

What is the criteria for performing a CT head scan for adults with a head injury, within one hour of arrival? (7)

A
  1. GCS less than 13
  2. GCS less than 15, 2 hours after the injury
  3. Suspected open/depressed skull fracture
  4. Basal skull fracture suspected
  5. Post-traumatic seizure
  6. Focal neurological deficit
  7. More than 1 episode of vomiting
138
Q

What is the criteria for performing a CT head scan in an adult with head injury, within 8 hours of the injury? (4)

A
  1. Age 65 years or older
  2. Any history of bleeding or clotting disorders
  3. Dangerous mechanism of injury
  4. More than 30 minutes retrograde amnesia one vents immediately before the head injury
139
Q

Whats the antidote for local anaesthetic toxicity?

A

20% lipid emulsion

140
Q

What is the antidote for beta blocker overdose?

A

Glucagon

141
Q

What is the medication to give for bradycardia?

A

Atropine

142
Q

What is the medication to give for tachycardia?

A

Adenosine

143
Q

What is the medication to give for TCA overdose?

A

Sodium bicarbonate

Year 4 ACC (11 decks)

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