Medical emergencies Flashcards by Rachel Sladden

Faints and collapse of unknown cause

Collapse - sudden loss of postural tone
Faint - transient loss of consciousness
Common
Divided into several groups

How well did you know this?

Not at all

Perfectly

NICE assessment for faints or collapse of unknown cause: record details about

Circumstances of event
Pt’s posture immediately before LoC
Prodromal symptoms
Appearance
Presence/ absence of movement during event
Any tongue-biting
Injury occurring during event
Presence / absence of confusion during recovery period
Weakness down one side during recovery period

How well did you know this?

Not at all

Perfectly

Causes of faints and collapse

Neurogenic Syncope
Cardiogenic Syncope
Neurocardiogenic Syncope including “Simple Faint”

How well did you know this?

Not at all

Perfectly

Neurogenic syncope causes

Seizures / Epilepsy
Sub-Arachnoid Haemoarrhage
Not stroke

How well did you know this?

Not at all

Perfectly

Features of neurogenic syncope

History of Neurogenic problems: Epilepsy
Loss of sphincter tone 
Tongue Biting
Prodrome
Clinical features

How well did you know this?

Not at all

Perfectly

Cardiogenic syncope causes

Arrhythmias: Bradycardia, Tachycardia
Valvular Pathology: Aortic Stenosis, Mitral Stenosis
Structural Heart Disease: Hypertrophic Cardiomyopathy (HCM)
Pulmonary Embolus
Primary Electrophysiological Abnormalities:
-Brugada Syndrome
-Long QT Syndrome

How well did you know this?

Not at all

Perfectly

Vasovagal syncope - neurocardiogenic syncope

Commonest type of faint
3 P’s: Posture Provoking Prodrome
-prolonged standing, or similar episodes that have been prevented by lying down)
-pain or medical procedure
-sweating or feeling warm/ hot before TLoC
Transient LOC
Rapid recovery, often ongoing headache, mild nausea
Overstimulation of vagus nerve +/- sympathetic tone loss

How well did you know this?

Not at all

Perfectly

Diagnose situational syncope when

There are no features that suggest alternative diagnosis AND
Synope is clearly and consistently provoked by straining during micturition (usually whilst standing) or by coughing or swallowing

How well did you know this?

Not at all

Perfectly

NICE red flag signs - collapse or faint

Refer within 24 hrs for specialist CV assessment if TLoC and any of following:
-ECG abnormality
-heart failure
-TLoC during exertion
-family history of sudden cardiac death in people aged <40yrs and/ or inherited cardiac condition
-heart murmur
Consider referring anyone >65yrs who has experienced TLoC without prodromal symptoms

How well did you know this?

Not at all

Perfectly

Assessment and treatment of faints

Assess the Airway, Breathing and Circulation
-lay flat, elevate legs (if tolerated), recovery position if necessary
If occurs after an unpleasant stimulus (e.g. LA injection) and recovery rapid - likely ‘simple’ faint
If any doubt - emergency department assessment

How well did you know this?

Not at all

Perfectly

Hypoglycaemia

Lower than normal blood sugar
-normal blood sugar (BM) ~ 4-7
Differing thresholds for symptoms

How well did you know this?

Not at all

Perfectly

Causes of hypoglycaemia

Too little fuel
Too much insulin (e.g. diabetics)
Excess oral diabetes drugs
Alcohol induced hypoglycemia 
Sepsis
Insulin-secreting pancreatic tumor
Adrenal insufficiency / hypopituitarism

How well did you know this?

Not at all

Perfectly

Symptoms of hypoglycaemia

Hunger
Irritability
Headache
Altered / reduced LOC
Difficulty speaking, slurred speech
Ataxia dyscoordination, (drunkenness)
Seizures

How well did you know this?

Not at all

Perfectly

Treatment of hypoglycaemia

Sugar!
If symptoms minimal - carbohydrate (e.g. sandwich, sugary drink)
With increasing symptoms - oral gel e.g. “hypostop”
IV if significant symptoms (reduced LOC / seizures)
Hospital assessment focused on treatment and identifying cause

How well did you know this?

Not at all

Perfectly

Anaphylaxis

Extreme allergy
IgE mediated (anaphylactoid reactions clinically similar, but not IgE mediated)
Caused by reaction to allergen (food / drugs esp. antibiotics / NSAIDS)

How well did you know this?

Not at all

Perfectly

Pathophysiology of anaphylaxis

Antigen binds to IgE antibodies on mast cells based in CT throughout body
Degranulation of mast cells with release of inflammatory mediators
Inflammatory mediators cause common symptoms of allergic reactions, such as itching, rash, and swelling
Can also cause bronchial constriction, vasodilation
Anaphylactic shock is allergic reaction with respiratory symptoms and circulatory collapse

How well did you know this?

Not at all

Perfectly

Clinical features of anaphylaxis

Respiratory distress – stridor, tachypnoea, wheeze, cyanosis
Circulatory signs - pallor, cool peripheries, tachycardia, hypotension
CNS - anxiety, agitation, reduced LOC
GI - abdominal pain, D&V
Skin - urticaria

How well did you know this?

Not at all

Perfectly

Treatment of anaphylaxis

Remove / stop cause (e.g. LA injection)
Assess Airway, Breathing and Circulation
Intramuscular adrenaline (0.5mg)
Oxygen
Nebulised ß agonist (salbutamol)
999 to ED

How well did you know this?

Not at all

Perfectly

Asthma

Increased airway reactivity
Atopic / non - atopic (atopy - triad of atopic eczema, allergic rhinitis (hay fever) and asthma)
Various triggers
Acute attacks - wheezing, SOB, ‘tight chest’, coughing

Treatment of asthma

Try and prevent - avoid precipitants
Inhaled B-agonists - salbutamol, terbutaline (ventolin / bricanyl) – Patients own or Nebulised
Steroids if indicated - reduce airway inflammation
British Thoracic Society guidelines for hospital management
Others - magnesium, IV aminophylline, ventilation

Ischaemic heart disease

Angina/ MI
Common in Western world 
Coronary artery disease
Complicated pathogenesis
Risk factors (fixed &amp; modifiable)
Clinical manifestations variable

Preventative measures for ischaemic heart disease

BP control
Metabolic control
Stop smoking 
Ca xP control
Infection screnning

Pharmacological measures for ischaemic heart disease

ACE inhibitors
Statins
Aspiring
PPAR-gamma agonists
Anti-oxidants

Mechanical measures for ischaemic heart disease

By-pass surgery
Coronary angioplasty
Endarterectomy

measures for acute coronary event

Thrombolysis | Coronary angioplasty

'Stable' angina symptoms

- pain on exercise | - relieved by rest +/- GTN

'Unstable' angina symptoms

Worsening pain esp. at rest | > frequency of episodes

MI symptoms

Chest pain – sensation of pressure, tightness or squeezing in centre of chest Pain in other parts of the body – can feel as if pain is travelling from chest to arms, jaw, neck, back and abdomen -usually left arm is affected, but can affect both arms feeling lightheaded or dizzy sweating SOB Feeling sick (nausea) or being sick (vomiting) Overwhelming sense of anxiety (similar to having a panic attack) Coughing or wheezing Collapse Pallor

Signs of MI

Symptoms ECG changes Biochemical markers

Angina/ MI treatment

``` GTN spray / tablet Aspirin 300mg (chew / dispersible) Oxygen (if indicated) 999 to ED Primary PCI (STH) for AMI that meet criteria MONA ```

MONA

Morphine Oxygen Nitrates (GTN) Aspirin

Adrenal insufficiency

Inadequate production of steroid hormones Primarily cortisol May have impaired aldosterone production Several causes

Causes of primary adrenal insufficiency

``` Primary adrenal insufficiency - impairment of the adrenal glands. Idiopathic Autoimmune - Addison's disease Congenital adrenal hyperplasia Adenoma (tumor) of the adrenal gland ```

Causes of secondary adrenal insuffiency

Secondary adrenal insufficiency - impairment of the pituitary gland or hypothalamus Pituitary microadenoma Hypothalamic tumour Sheehan's syndrome (postpartum pituitary necrosis)

Clinical features of adrenal insufficiency

Weakness, tiredness, dizziness, hypotension esp. orthostatic Hypoglycemia, dehydration, weight loss, and disorientation Myalgia, nausea, vomiting, and diarrhoea Hyperkalaemia & hyponatraemia Palmar crease tanning Vitiligo

Clinical features of an adrenal crisis

``` Lethargy, fever Abdominal pain (back / legs also) Severe D&V (+/- dehydration) Hypotension Hypoglycaemia Syncope Confusion, psychosis, slurred speech ```

Treatment of adrenal crisis

Avoid! Modification of steroid regime before examination / treatment If signs of crisis - 999 Will need hospital assessment - steroids, fluids and observation

Seizures

Not always epileptic Several types of seizure Difficult to diagnose Classic seizure dramatic, but rarely problematic

Partial seizures

May have LOC (simple/ complex)

Generalised seizure

All have LOC - absence - tonic-clonic - myoclonic - tonic - atonic

Causes of seizures

Epilepsy (including drug non-compliance or interactions) Fatigue Intracranial lesion Drug and alcohol intoxication / withdrawal Intracranial infection - encephalitis or meningitis Metabolic disturbances - hypoglycaemia, hyponatraemia or hypoxia Multiple sclerosis

Treatment of seizures

Protect patient from injury Most come to no harm at all, post-ictal phase may be distressing and prolonged Classic tonic-clonic seizure rarely more than 1-2 mins If prolonged - assess Airway, Breathing and Circulation and call 999

Supraventricular tachycardia (SVT)

abnormally fast heart rhythm arising from improper electrical activity in the upper part of the heart

Ventricular tachycardia (VT)

Pulse of more than 100 beats per minute with at least three irregular heartbeats in a row -wide QRS complex

Pulmonary embolus (PE)

More common than we think... Massive PE can manifest as collapse More likely SOB +/- chest pain Many risk factors