Heart Failure,The UnDifferentiated Patient,Unconscious Patient,seizures Flashcards
ECM is made up of what?
What is the first sign of intravascular depletion and why?
Give three cases thatll cause this
Tachycardia w hypotension shows the patient has lost massive amount of fluid true or false
After tachycardia and hypotension set in and still you dont do anything what happens?
Secure a large ball cannula green or grey for patients w diarrhea and vomiting and pink is for normal patients who dont need bunch fluid
So immediately yoj hear pulse is high and bp is low,put in cannula
True or false
What is an isotonic solution
Give example of such fluid in hospital
If you give dextrose in a diarrhea patient or patient w low intravascular volume ,what will happen
Mannitol is used if you suspect brain edema. If you give mannitol in patients w low intravascular volume what happens
Extracellular matrix js made up of intravascular space,interstitial fluid space(space between the vessels and the cell. (Fluid in intestines form part of interstitial fluid so if you have diarrhea youre losing contnet of intestinal fluid,CSF form part,synovial fluid between the joints )
Fluid in the intestines has a balance w the fluid in the vessesl and fluid in other spaces so if youre losing more fluid from one side, the protiens and all in the other side get COncentrated. So if you lose fluid from intestines itll cause hyperconcentration in the vessels So fluid moves from the vessels to the intestines and person keeps getting diarrhea and losing the fluid and keeps depleting intravascular volume
This reduces cardiac return ,this affects the amount of fluid pumped by the heard and this affects cardiac output
Brain tells heart to pump more through the sympathetic system
This causes theheart to beat more
You can increase cardiac output by increasing stroke volume or volume by each beat or increasing heart rate
The heart beats faster against the small stroke volume there
First sign of intravascular depletion is higher pulse and (but at first itll be normal bp-cuz intial increase of stroke volume and heart rate increase increases cardiac output to an extent and when it occurs saa while no new volume or fluid from outside is coming in,itll cause low bp after 15-30minutes if you dont nourish the person w fluids .
Hemorrhagic patient
Diarrhea and vomiting
True
Person gets confused and mutters weird weird stuff
If still nothing is done,patient gets aggressive
If still
Nothing is done,patient gets unconscious or less alert and doesnt respond unless you elicit pain
Bp keeps dropping
Because intravascular space has decreased so much ,blood isnt even being pumped by the heart so organs arent getting oxygen
This causes oxygen saturation to reduce
This can lead to reversible cell injury
If still nothing happens
Irreversible cell injury then cell death
Fluid youll be replacing is the fluid of the ECM so dont give fluid thatll comrpomise the concentration
If you give fluid thatll dilute the intravascular space,osmosis will occur and youll still be losing fluid
Fluid that have the same concentration in plasma are isotonic solution
Normal saline ,ringer’s lactate ,Downwards solutiona ,achma solution(please check both on internet), 5-4-1
These will solve the fluid problem and osmosis will not set in
The cells will pick the glucose and leave the water behind, the water left behind will cause dilution of plasma conc and when this happens osmosis occurs and water moves into the cells
Dextrose is hypotonic solution
Mannitol is hypertonic solution
Its conc is higher than that of the cell plasma
This pushes fluid from the cell into the vessel
This alerts the kidneys that theres hypervolemia and the kidney excretes more body fluids
In the body every organ has a benchmark . Any organ found performing below what’s expected is said that the organ has failed.
When will the heart fail
Problems associated w osteovelemic or autovelemic cells(check) are called ?
Examples of these problems
When baby cries,air hits the alveoli
Message is sent to the medulla oblongata and it kicks start the respiratory centre
So when the baby is delivered,dont rush to cut the umbilicus,make sure the baby starts crying before you cut the umbilicus
True or false
Recoiling feature of the artery is what causes resistance
When the force within the vessel is so stromg that you need more force to stretch em for blood to foow through,hypertension has occured
True or false
What is hypertension using mmhg?
For each cardiac output the heart is to pump 5Litres so When the heart cardiac output is below 5Litres the heart is said to have failed
Atrial fibrillation
Ventricular fibrillation
Atrial flutter
If the systolic has risen 25 mmHg above your normal and diastolic has risen 15mmhg above your normal
This helps those with a low bp that is normal
140/90 mmhg is a severe hypertension for a normal patient whose hypertension is 90/60mmhg (baseline bp for them)
Its easier to find baseline bp for women whove been pregnant before or are pregnant so its easier to see if the 90/60 would be normal or not
Ehat are the classification of heart failure
Signs and symptoms of left and right and explain why the signs and sympotms occur
Hydrostatic force and oncotic force functions
What happens to hydro in congestion
How is heart failure managed
Investigations for heart failure
Left
Right
Congestive cardiac failure (means both sides have failed)
Right-
Veins become overdistended and pull fluid to themselves causing congestion
This can occur in anaphylactic shock(there are release of vasodilators which makes veins dikate paa this makes them pull fluid to themselves and this jncreases venous return and reduces cardiac output
Right heart failure,blood isnt moving from the extremeties into the right part of the heart,causing vaso congestion
The congestion causes
There is distended jugular veins
Jugylar vein is directly connected to the superior vena cava so if nlood isn’t moving from the superior vena cava into the right atrium therell be congestion causing distended neck veins
Lymphatic veins is also directly connected to the inferior vena cava so when theres a congestion the liver will fill up w fluid causing hepatomegaly(soft and tender and enlarged liver)
Hydrostatic pressure or force-pushes water from vessels to interstitium
Oncotic-pulls water and makes it stable
Creating a balance
When theres a congestion the vessel water level rises increasing hydro pressure against oncotic pressure causing waterto be pushed into the interstitium
Body compensates for it by the lymohatic vessels in the interstitium and so these vessels take it back jnto the vessels
When the hydro pushes more fluid into the interstitium
Against the lymphatic drainage,edema occurs
Dysnpea
Left:
Cough w light sputum (or small sputum)
Protein sputum
So when left side causes right heart to fail,congestive cardiac failure occurs
Or when somehow both sides fail
Ccf occurs
Massive hypoxia occurs cuz cardiac output is low and youre not getting oxygen too from the lungs
Admit the patient
ABCDE assessment
Prop patient up in bed (45 degrees)
Give intranasal oxygen cuz patient can breathe but is suffering to breathe cuz of the congestion thats why you dont give ambu bag
Drain the fluid in the lungs using high dose IV lasix or furosemide
Causing patient to pee the extra intravasvular fluid accumulated that is causing congestion thereby increasing concentration and water moving from lungs into the vessels
And water from the tissues i other parts of the body move into the vessels
As youre giving treatment be checking the bp
So if patient pees plenty too much kraa causing bp to drop then it means the lasix is bunch
The kidneys cause the urination is if you have kidny failure plus CCF the kidney cant cause you to pee even after youve been given lasix so the fluid still stays so you refer cuz the prognosis is poor
So you give small fluid at a low drop rate
The edema must shrink gradually
Then take detailed history and exam and do necessary labs to check what led to the congestion when the patient has been stabilized
HF:
Diagnostic-chest X ray
ECG
Echo
Supportive:
FBC
Lipid profile
BUE Cr
Thyroid function etc
Who is an undifferentiated patient
How do you approach an undifferentiated patient
Clinical signs used to figure out where blood is hiding
Life threatening causes of death in trauma
Signs of tension pneumothorax
Patient w pin point pupils and shallow breathing or breathing slowly is a sign of what?
Medical abdomen has no surgical relevance while trauma abdomen problem has surgucal relevance
True or false
A patient who comes to the ER and you dont know what’s wrong w the person
Look at the general appearance of the patient to determine if the patient looks severely ill like will die soon ill or a dying patient ill ,is in danger ill or just ill
Vitals can determine if patient is dying
If patient is sick,
Put in two large ball cannulas,secure IV line and take samples on standby and wait for investigations youll do after youve done your exam
Put patient on oxygen if you realize patient is suffering to breathe
Use appropriate oxygen delivery devices
Put patient on cardiac monitor to show the ECG and vitals and check vitals frequently especially in the early stage every five minutes or every fifteen minutes but more every five minutes)
Review your triage sheet(check vitals and ehy patient is there)
ABCDE assessment
SAMPLE history(S-
Think about or generate the initial lethal or life threatening differentials or differentials that can kill the patient at that instance(not malaria,not peptic ulcer or those non life threatening diseases)
Investigations and initial treatment
Secondary survey
Rediagnose
FAST-focused abdominal sonography test to find out where the blood is hiding in trauma patients
Open pneumothorax Tension pneumothorax Cardiac tamponade Massive haemothorax or pneumothorax PE
Mostly they come w Accident or blunt chest injury or penetrating injury Tachypnea Spo2 is low Bp drops Obstructive shock is common in tension pneumothorax Neck veins pop out Tracheal shift Reduced air entry at affected side Hyperresonance on percussion
Put cannula in second or fifth intercostal space to relieve whats causing the pneumothorax
Ifou have to refer,refer w the cannula in situ dont remove the cannula the patient eill die before getting there
Opioid abuse
What happens in secondary survey
What is SAMPLe history(intial addessment is done together at the same time not one after the other
How do you know if youre bagging well?
When you have time to take detailed hsitory,physical exam (head to toe history and exam of all systems) after stabilizing patient
Rearrange or redefine differentials
Investigate
Treat
Then you refer or you send patient away to other departments
S-signs and symptoms (what happened,time when it happened)
A-allergies
M-Medications
P-past medical history
L-last meal(to prevent aspiration pneumonia ,taking precautions to see if patients stomach is full or empty
Cuz if full,patient can aspirate gastric contents and die
If youre mot sure when they last ate. Assume the stomach is full)
Dont bag w pressure cuz pressure more than 20mmhg will open the oesophagus
So if youre bagging and the chest is rising then youre doing a good job
Event-event leading to the problem
Based on the initial asdessment and sample history you get the differentials
Differentials start as soon as you see the patient
Think about lethal diagnosis
Think about worst case scenario and sort it out.
True or false
Put patient in perspective
Dont think outside the patient concerning the lethal diagnosis
Lethal Ddx for chest pain and breathlessness
Which should you treat first? MI or aortic dissection cuz they both come w central chest pain and theres ST elevation for both and Mi can be confused w aortic dissection
How do you check for aortic dissection
Dont trust the machines
If youre given values,try to recheck yoirself using your clincial expertise cuz labs can be wrong and machines can be wrong
True or false
Go for common lethal differentials not weird ones like SLE
All true
Cardiac tamponade Myocardial infarct Stroke Massive PE Aortic dissection
When you suspect MI
Make sure there’s no aortic dissection
Best thing is to treat the aortic dissection to rule it out before uou treat the MI
If uou treat the MI first patient will die
If you suspect both Mi and aortic dissection
Aortic dissection should be your first ddx before MI comes
Check bp in left and right srm
If the difference in systolic values is more than 20mmhg its a red flag for aortic dissection
Chest X ray the mediastinum is widened in aortic dissection
You use patients words or story to determine if there’s trauma or not
What are lethal ddx
How do you check for disability in D
Do not treat labs,treat the signs from the patient
Fastest eay to check airway patency is by talking to the patient
After doing secondary survey uou can tedefine uour diagnsois and you can add not necessarily imminently life threatening diagnosis such as malaria or other diseases that eont kill the patient immediately
We have diagnositc and supprtive ivestigations true or false
True
Ddx that are there untill proven theyre not. they or do not pose a threat to the patients life or they can be ruled out
By using GCs
Before you say the reason. Payient is unconscious is due to psychiatric problems you should have ruled out all the other causes of unconsciousness
True or false
Who us an unconscious patient
When js a patient said to be in coma
How will you know if a patient is intentionally being unresponsive
What is the procedure for checking unconscious patients
True
Spectrum ranging from non alertness to coma
Coma: GCS of 8 and below
If the eyes are rolling under the eyelids when youre stabding close to them and you stare at their faces for a while
Make sure patient isnt dying now by optimizing your ABCDE
- make sure your safety is assured if youre going to be checking this patient
- Check if patient looks sick
- do ABCDE
- Do secondary exam
- Invdstigations and treatment
- Get patient out of ER
What do you check for in ABC of the ABCDE assessment of an unconscious patient
If air entry isn’t symmetrical what problem can come to mind
IN PE,what will be heard in the lungs and what eill hapoen to spo2
In cardiac tamponade what is seen in yhe neck veins and ehat happens to spo2
What emergency intervention is given in cardiac tamponade
What is the energency intervention for PE
Why arent thinners used in emergency PE?
A-Take C spine precautions if theres trauma
Check if there’s an obstruction
Use appropriate airway maneuvers
B-check if breathing
Is air entry symmetrical( if not symmetrical it could be tension pneumothorax)
Added sounds
Check Spo2 (normal is 95% and above)
C-circulation :is there a pulse
If no pulse there may be shock so find the type of shock thats occuring either obstructive or distributive
Capillary refill
Check for signs of bleeding if theres a trauma
If theres no carotid pulse,call for help but know why youre calling for help and what exactly you want from your team before doing so ,before starting CPR
In PE: lungs will be clear but Spo2 will be low
Cardiac tamponade: distended neck veins with normal spo2
Pericardiocentesis: The needle insertion site is in the fifth left intercostal space close to the sternal margin. Advance the needle perpendicular to the skin (at the level of the cardiac notch of the left lung).
The most commonly used medications to treat VTE blood clots are anticoagulants (also referred to as “blood thinners”). But there are also “clot busting” medications called thrombolytics which quickly dissolve or get rid of clots so youll give thrombolytics in an emergency and not anticoagulants cuz the former will dissolve the clot faster
Example of thrombolytics: Eminase (anistreplase)
Retavase (reteplase)
Streptase (streptokinase, kabikinase)
What are the causes of unconsciousness
Why will you be worried if an alcoholic or elderly patient hits their head on something?
(T- Trauma (head hitting on a surface ) I-Insulin P-poisoning,psychiatric S-seizures,syncope A-alcohol,acidosis E-endocrine,electrolytes I-Intracranial pressure O-Opiates U-Uremia
Cuz they can have subdural hematoma(bleeding between the dura and the brain)
Drinking too much alcohol over a long period of time can also gradually cause the brain to shrink and make the brain’s blood vessels more vulnerable to damage. So if theres a trauma to the head jt can cause the hematoma
With aging, the mass of the brain decreases leading to an increase in the space between the brain and the skull from 6% to 11% of the total intracranial space. This causes stretching of the bridging veins and the greater movement of the brain within the cranium makes these veins vulnerable to trauma
What are you to do in secondary exam in the unconscious patient
In examination of the eye,bilateral constricted pupils may indicate what cause of unconsciousness?
When one pupil is dilated and the other isnt or there an unequal sizes of pupils (anisocoria) what may cause this?
When both pupils are dilated what can cause this?
Give examples of drugs thatll cause pupil dilation
Pn chest exam what does a low Resporatory rate mean?
What does Kussmaul breathing suggest and state what that kind of breathing is,Cheyne stokes breathing is seen in which diseases,what is Cheyne stokes breathing ? What do you check in the eyes to confirm Cheyne stokes after hearing the breathing pattern?
In looking at the patients appearance or face,what does a toad like appearance indicate? A scared or scary face appearance indicate and a moon face or round face indicate?
Find what is causing the unconsciousness using TIPSAEIOU
Do the history w these causes in mind on ODQ
Do a head to toe exam
Eye:bilateral cosntricted or pinpoint pupils - opioid abuse (illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine)
Anisocoria-increased intracranial pressure which is causing third nerve palsy which is causing the anisocoria,focal head lesion which may cause paralysis of one side of the body as seen in stroke patients which nay cause one side of the eye to be dilated and the other constricted , high Intracranial pressure can cause cerebral herniation
Both pupils dilated: patient is breathing and other sibstance abuse
(Stimulants and psychotropic substances most commonly cause pupil dilation. However, this symptom can result from ingesting alcohol, mescaline, cocaine, ecstasy, LSD(hallucinogenic drug. Lysergic acid diethylamide, also known colloquially as acid, is a psychedelic drug ) ,psilocybin, amphetamines, cannabis, inhalants, narcotics, hallucinogens, bath salts, ketamine, and SSRI antidepressants)
Low RR may mean opioid overdose so you check the pupils to confirm and if the pupils are constricted w low RR then it’s definitely an opioid overdose
Kussmaul breathing suggests acidosis, DKA and sepsis
Kussmaul breathing is deep fast breaths or hyperventilation
Cheyne Stokes: can be caused by cerebral herniation
Check pupils if there is anisocoria to confirm cerebral herniation when you realize cheyne stokes breathing
Cheyne stokes breathing is when patient is breathing very fast (tachypnea ) (fast shallow breathing) then the rate starts decreasing (slow heavy breathing) and stops for like 20 seconds then all of a sudden the cycle starts again with fast breaths
Toad like appearance: hypothyroidism
Myxydema-hypothyroidism
Scared face - hyperthyroidism or Graves disease
Moon face- Cushing’s
What are the types kf resp failure and what type is asthma?
CKD can cause what thpe of encephalopathy?
High bp plus altered mentak state without focal neurological deficit (one side of the body is paralyzed) suggest what?
High bp w altered mental state with focal neurological deficit suggests what ?
What is syncope ?
What is the most important electrolyte that can cause unconsciousness?
Generalized seizures cause what?
Focal seizures cause what,
Paralysis after seizure can occur true or false?
Hypoglycemia abd hyperglycemia can cause seizures (Substantial changes in blood sugar—either low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia)—can affect the excitability of nerve cells (neurons), allowing seizures to occur more easily. )true or false
Type 1- caused by lung problems and causes hypoxia
Type 2- ventilation problems example neuromuscular disorders,brain fractures,opioids
Preventing you from breathing problem
Asthma starts w type 1 and wheb muscles become fatigued so its harder to breathe it becomes type2
CKD- uremic encephalopathy
High bp,altered mental state,without focal neurological deficit- hypertensive encephalopathy
With focal neurological deficit-stroke
Syncope :loss of consciousness
Example youre peeing then you black out then you wake up to find yourself in the hospital
You wont Remember what happened to you
How you fell, apart from the fact that you were peeing and thats a syncope
Sodium
Patients w seizures have post ictal sleep(this is being tired or sleepy after a seizure . The postictal state is a period that begins when a seizure subsides and ends when the patient returns to baseline. It typically lasts between 5 and 30 minutes and is characterized by disorienting symptoms such as confusion, drowsiness, hypertension, headache, nausea, etc.)
Generalized seizures youll lose consciousness and when you sleep and wake up you become confused
Focal seizures youll lose consciousness
True
True
When should you perform CPR
After how mani minutes does the brain die
When do you bag?
How do you bag?
Unresponsiveness,absent carotid Pulse ,not breathing or agonal breathing or gasping breath. If patient collapses it doesn’t mean patient is in cardiac arrest
Brain dies after 5 minutes
Bag when there’s no carotid pulse for ten seconds
How to bag:
Triangle should be on nose
Balloon Not supposed to be too full or too empty
Make sure seal doesn’t leak
ECE technique to make sure it’s fitted properly on the face or nose (airway maneuvers at the same time pressing down and making the seal )
