Medical emergencies Flashcards
Faints and collapse of unknown cause
Collapse - sudden loss of postural tone
Faint - transient loss of consciousness
Common
Divided into several groups
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
Causes of faints and collapse
Neurogenic Syncope
Cardiogenic Syncope
Neurocardiogenic Syncope including “Simple Faint”
Neurogenic syncope causes
Seizures / Epilepsy
Sub-Arachnoid Haemoarrhage
Not stroke
Features of neurogenic syncope
History of Neurogenic problems: Epilepsy Loss of sphincter tone Tongue Biting Prodrome Clinical features
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
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
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
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
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
Hypoglycaemia
Lower than normal blood sugar
-normal blood sugar (BM) ~ 4-7
Differing thresholds for symptoms
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
Symptoms of hypoglycaemia
Hunger Irritability Headache Altered / reduced LOC Difficulty speaking, slurred speech Ataxia dyscoordination, (drunkenness) Seizures
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
Anaphylaxis
Extreme allergy
IgE mediated (anaphylactoid reactions clinically similar, but not IgE mediated)
Caused by reaction to allergen (food / drugs esp. antibiotics / NSAIDS)
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
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
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
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 & 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
