Medical emergencies Flashcards
What is shock?
Life-threatening failure of adequate oxygen delivery to the tissues due to decreased blood perfusion, inadequate oxygen saturation or increased oxygen demand. There is decreased end organ oxygenation and dysfunction
What are the 4 types of shock?
Hypovolaemic, Distributive, Obstructive, Cardiogenic
What is hypovolaemic shock?
Shock caused by loss of intravascular volume from haemorrhage e.g. trauma or GI bleed, 3rd space loss (fluid in extravascular and extracellular spaces), burns, GI loss from vomiting or diarrhoea
What is the classification for haemorrhagic shock?
Class 1 - <15% blood lost, vitals normal, slightly anxious
Class 2 - 15-30% blood lost, resps 20-30/min, 100-120bpm, BP normal, pulse pressure decreased, may need blood
Class 3 - 30-40% blood lost, resps 30-40/min, 120-140bpm, BP decreased, pulse pressure v decreased, low urine output, anxious confused, needs blood
Class 4 - >40% blood lost, resps >35/min, >140bpm, BP very low, pulse pressure super decreased, negligable urine output, confused, lethargic, massive transfusion protocol
What are the end-organs damaged in shock?
Heart - decreased perfusion, risk of arrhythmias and ischaemia
Lungs - acute respiratory distress syndrome
Kidneys - reduced perfusion, reduced urine output, increased creatine, acute tubular necrosis
Brain - altered GCS e.g. confusion and can be unconscious
What is distributive shock?
Fluid in intravascular compartments moving to extravascular compartments - decreased systemic vascular resistance - vasodilation (warm peripheries on examination)
What are the causes of distributive shock?
Sepsis
Anaphylaxis
Neurogenic (injury to spinal cord - autonomic dysregulation)
What is cardiogenic shock?
Pump dysfunction - results in reduced end organ perfusion
What is obstructive shock?
Physical obstruction of circulation into or out of heart
What are the causes of cardiogenic shock?
MI - blood slow decreased to heart muscle - ischaemia
Acute dysrhythmia - tachy or brady
Cardiomyopathy - walls thickened/stiff - heart failure from long term high BP, metabolic disorder, nutritional def, alcohol, genetics, infection
What are some examples of obstructive shock?
Tension pneumothorax - air trapped displacing mediastinal structures
Cardiac tamponade - blood/fluid between pericardium and sack, pressure on heart, ventricles cant expand
Pulmonary embolism - blood clot blocks pulmonary artery - increased pressure right ventricle and it fails
In the management of shock, what does A in ABCDE mean you should do?
- Check patency of airway
- Remove any obvious obstructions e.g. loose dentures
- Airway manoeuvres - head tilt chin lift, jaw thrust
- Airway adjuncts - oropharyngeal airway e.g. Guedel and nasopharyngeal airway
In the management of shock, what does B in ABCDE mean you should do?
- High flow O2 via non-rebreathe mask
- Pulse oximetry - O2 sats between 94-98%
- Chest auscultation
- Not excessive oxygenation as linked to coronary vasoconstriction in MI
What type of shock may be an issue when you are managing using ABCDE?
Obstructive shock - B - e.g. tension pneumothorax
In the management of shock, what does C in ABCDE mean you should do?
Circulation - ausclatate heart, BP, ECG
IV access - bloods and fluids to increase intravascular volume
Urinary catheter
In the management of hypovolaemic shock what is required in the management (at C)?
Volume needs boosting -crystalloid fluid first
In the management of distributive shock what is required in the management (at C)?
May have issues with vasoregulation - may need isotropes (improve contractility e.g. dopamine) or vasopressors (tighten blood vessels e.g. noradrenaline)
In the management of shock, what does D in ABCDE mean you should do?
Assess GCS/AVPU
If GCS<8 consider intubation
Temperature
Pupillary response
In the management of shock, what does E in ABCDE mean you should do?
Look for possible causes of haemorrhage: CLAP
Chest, Long bones, Abdomen, Pelvis
How is hypovolaemic shock treated?
Identify and control bleeding. Replace fluids and bloods
How is cardiogenic shock treated?
MI - revascularisation : PCI, coronary artery bypass graft (CABG), thrombolysis
Arrhythmias - correct chemically or electrically
How is distributive shock treated?
Sepsis - sepsis 6
Anaphylaxis - resuscitation guidelines - adrenaline, steroids, antihistamine, airway and circulatory support
How is obstructive shock treated?
Tension pneumothorax or cardiac tamponade - relieve pressure with chest drain, pericardiocentesis
What are the causes of burns?
Thermal Radiation Chemical Friction/abrasion Electrical
In a local burn, what is the zone of coagulation?
Rapid and irreversible cell death - in centre of burn
In a local burn, what is the zone of stasis?
Tissue perfusion compromised and can become necrotic if untreated (middle ring of burn)
In a local burn, what is the zone of hyperaemia?
Perfusion increased with local inflammatory mediators
What are the systemic effects when a burn covers more than 20% of the body?
Respiratory - bronchoconstriction, adult respiratory distress syndrome
Metabolic - rate increased 3x, muscle wasting, hypocalcaemia, hypovolaemia
Immune - reduced, increase risk sepsis
CVS - reduced contractility, increased capillary permeability, loss of proteins
GI - breakdown of GI barriers, translocation of bacterial and ulceration
How are burns assessed?
Total body surface area - Wallis rules
Palmer surface method for smaller burns
What is a superficial burn/1st degree burn?
Erythema involving epidermis only. Dry painful no ulceration. Sunburn. Sensation intact. Heals 7 days no scarring
What is a partial thickness burn/2nd degree?
Involves epidermis and upper dermis. Wet painful and blistered. Scalds. Sensation intact. Heals 10-14 days with little or no scarring
What is a deep partial thickness burn/3rd degree?
Involves epidermis, dermis and damage to appendages. Dry and insensate - not as painful. Typical of flame or contact injury. Healing longer - if not healed 14 days will scar
What is a full thickness burn/4th degree?
Involves underlying subcutaneous tissue, tendon and bone. Thick white, black, charred, no sensation. Typical of high voltage electrical injury. Will scar
What is the first aid procedure for burns?
Stop burning Remove clothing Cool burn with lukewarm water Keep pt warm Cover with clingfilm Relieve pain - analgesia
What is the definitive treatment for burns?
Excision with skingrafting
Escharotomy for some full-thickness burns
What is the minimum threshold for referring burns?
> 2% TBSA in children >3% in adults
All full thickness burns
All circumferential burns
Any burns not healed in 2 weeks
What is NEWS for vital signs?
National Early Warning Score
Normal pt = 0 (unless e.g. COPD so normal could be 1)
If >0 then pt out of normal range for vitals e.g. pyrexic
What is the normal pulse rate?
Bradycardia?
Tachycardia?
Normal for a newborn
60-90bpm
<50 bpm
>100bpm
180bpm
What sites can you take a pulse from? Where would you take a pulse from if child small?
Radial pulse. Ulner pulse (weaker). Carotid pulse. Limbs = popliteal (behind knee), post-tibial (inside ankle), dorsalis pedis (on top of foot)
Small child - brachial pulse
What non-medical emergency reasons may someone be a) bradycardic b) tachycardic?
a) beta-blockers (propranolol for anxiety or atenolol for heart). Athletes
b) Anxious, caffeine, exercise
What 3 things should you say when describing a pulse?
Rate: normal, brady or tachy?
Regular or irregular e.g. atrial fibrillation (irregularly irregular pulse)
Strength: strong, weak, absent
What is the normal respiratory rate? Why would you worry if a pt is breathing too quickly?
14 breaths per min
Could be acidotic - too much CO2 in bloodstream
Describe how taking a blood pressure works
Listen over the brachial artery. Pump cuff until radial artery pulse disappears. Listen for karofkoff sounds: sound = systolic, disappears = diastolic
What does hyperdynamic circulation sound like from taking a BP and when can this happen?
Sound never fully disappears e.g. in pregnancy
What is the normal value for BP?
120/80 mm/Hg
How would you test cranial nerve I (olfactory)?
Standard smell bottles one nostril at a time
How would you test cranial nerve II (optic)?
Test acuity (ask prior if usually wear glasses) by asking them to read Test visual fields to confrontation - cover one eye and test temporal and nasal fields
How would you test cranial nerve III (oculomotor)?
Look for dilated pupil, ptosis (drooping of upper eyelid), problems with eye movements. Use a light and test reaction
How would you test cranial nerve IV (trochlear)?
Ask patient if they have double vision. Move pen in H shape and ask if double vision when following
How would you test cranial nerve V (trigeminal)?
Test sensation in all 3 nerve divisions. Start above eye L-R, below eye L-R and chin L-R
Test MOM - push on chin and ask pt to push against, clench teeth
How would you test cranial nerve VI (abducens)?
Eye is deviated towards the nose
How would you test cranial nerve VII (Facial)?
Raise eyebrows, scrunch eyes and use fingers to try to open, blow out cheeks, smile, tense neck
Look for symmetry
How would you test cranial nerve VIII (vestibulo-cochlear)?
Rinnes and Webers (air and bone conduction of sound waves)
Audiometric testing
How would you test cranial nerve IX (glossopharyngeal)?
Stick on tongue and say ahhh - need symmetry
How would you test cranial nerve X (vagus)?
Soft palate moves to the normal side on saying ahhh
How would you test cranial nerve XI (accessory)?
Test trapezius by pushing against the side of head and asking to resist or shrug shoulders
How would you test cranial nerve XII (hypoglossal)?
Tongue deviated to affected side on protrusion - stick tongue out
What are the possible problems with the olfactory nerve CNI?
Trauma
Tumour
What are the possible problems with the optic nerve CNII?
Trauma
Tumour
Multiple sclerosis
Stroke
What are the possible problems with the occulomotor nerve CNIII?
This is the motor nerve to the extrinsic eye muscles except the superior oblique.
Diabetes
Increased intracranial pressure
What are the possible problems with the trochlear nerve CNIV?
Supplies superior oblique muscle around eye
Trauma
What are the possible problems with the trigeminal nerve CNV?
Sensory = idiopathic (numbness e.g. post viral), trauma, IDN/lingual nerve damage Motor = bulbar palsy
If there are problems with V, IX, X, XI, XII, what condition may have occured?
Bulbar palsy
What are the possible problems with the abducens nerve CNVI?
Supplies lateral rectus so an inability to look laterally
Multiple sclerosis
Stroke
What are the possible problems with the facial nerve CNVII?
LMN = bell’s palsy (idiopathic), skull fracture, parotid tumour. There will be total facial weakness on that side
UMN = stroke, tumour. This is forehead sparing weakness.
What are the possible problems with the vestibulo-cochlear nerve CNVIII?
Balance and hearing
Excess noise
Paget’s
Acoustic neuroma (Benign brain tumour pressing on nerve)
What are the possible problems with the glossopharyngeal nerve CN IX?
Trauma
Tumour
Leads to impaired gag reflex
What are the possible problems with the vagus nerve CNX?
Trauma
Brainstem lesion
What are the possible problems with the accessory nerve CNXI?
Polio
Stroke
Leads to weakness turning head away from affected side
What are the possible problems with the hypoglossal CN XII?
Trauma
Brainstem lesion
On the medical risk assessment ASA, what do the following mean?
a) ASA 1
b) ASA II
c) ASA III
d) ASA IV
e) ASA V
f) ASA VI
a) Healthy
b) Mild systemic disease e.g. well controlled asthma
c) Severe systemic disease (functional limitation)
d) Severe disease (constant threat)
e) Moribund
F) Bread dead
What should you tell the ambulance in a medical emergency?
Is the pt conscious? Is the pt breathing? Location Brief history/background Initial measures, what you've tried and if its effective
What documentation is required after a medical emergency?
Date, location and time
Action taken, patient positioning and any drugs you administered and time given
ABCDE and comment on each
Information given to team at hand-over and time of hand-over
Team debrief
How often are the emergency equipment and drugs checked?
Weekly
How do you open the airway? What airway adjuncts can you use in a medical emergency?
Head tilt chin lift or jaw thrust
Guedel Airway - put in upside down until back of throat then twist (to avoid pushing tongue back)
What position should the patient be put in if
a) Losing consciousness
b) Struggling to breathe
c) In anaphylaxis
d) If pregnant?
a) Lie flat and raise legs
b) Keep pt sitting
c) Lie flat to support circulation as go into shock more quickly otherwise
d) Left lateral position (if laid flat can go into cardiac arrest as uterus presses on inferior vena cava which is slightly to the right)
What is in the emergency drug box?
- Adrenaline 1:1000 (Epi-pen)
- Aspirin 300mg
- Glucagon 1mg (inject water into bottle shake bottle and draw up)
- GTN spray
- Oxygen
- Salbutamol inhaler (given via spacer)
- Midazolam 10mg buccal liquid
Give examples of drugs that are administered by the following routes:
a) Oral
b) Sublingual
c) Subcutaneous
d) Intramuscular
e) Inhalation
f) Rectal
g) Topical
h) Intravenous
a) Glucogel, aspirin
b) GTN
c) Glucagon - 45 degrees to skin
d) Adrenaline - 90 degrees to skin
e) Oxygen, salbutamol
f) Diazepam
g) Midazolam
h) Only if experienced
What are the signs of anaphylaxis?
Uticaria, erythema, rhinitis, conjunctivitis
Abdo pain/vomiting/diarrhoea
Flushing
Marked upper airway oedema and bronchospasm (stridor/wheeze/hoarseness)
Breathing rapid
Clammy, faint, drowsy
What are the signs of vaso-vagal syncope?
Pt feels faint, dizzy or lightheaded
Pallor and sweating
Nausea and vomiting
