Medical emergencies/drugs/pharmacology

Question 1

What are the signs and symptoms of hypoglycaemia?

Answer 1

* Shaking/trembling * Confusion *Aggitation *Slurring of speech * Headache *Sweating * Headache *Sweating *Aggressive behaviour *Increase in heart rate *Increase in respiratory rate

Question 2

What are the signs and symptoms of hypoglycaemia?

Answer 2

* Shaking/trembling * Confusion *Aggitation *Slurring of speech * Headache *Sweating * Headache *Sweating *Aggressive behaviour *Increase in heart rate *Increase in respiratory rate

Question 3

What actions should be taken in a case of hypoglycaemia?

Answer 3

*Reassure the patient.
*Carry out A-E assessment on patient.
*Administer up to 3 glucose tablets in the early stages where the patient is responsive, co-operative and their gag reflex still intact.
*Administer oxygen, 15 litres per minute.
*If the patient becomes unconscious dial 999 *Administer glucagon by IM on the outer aspect of the thigh (1mg adults, 0.5mg children)
*Where patient regains consciousness, administer oral glucose

Question 4

What are the signs and symptoms of syncope?

Answer 4

*Light headed. *Dizzy *Nausea *Pale *Slow heart rate *Loss of consciousness

Question 5

What actions should be taken in the event of syncope?

Answer 5

*Raise patients legs above their head
*Loosen tight clothing, keep the patient cool and ventilate the room
*Administer oxygen at 15 litres per minute
*Assess and reassure the patient

Question 6

What are the signs and symptoms of a severe acute asthma attack?

Answer 6

*Inability to complete a sentence in one breath.
*Increased heart rate.
*Increased respiratory rate.
*Audible wheeze.

Question 7

What actions should be taken in the case of a severe acute asthma attack?

Answer 7

*Reassure patient.
*Carry out A-E assessment
*Call 999
*Administer salbutamol inhaler via a spacer device for up to ten activations
*Repeat as needed.
*Administer oxygen at 15 litres per minute
*Ensure patient is in a comfortable position
*Continue to reassure and assess the patient

Question 8

What are the signs and symptoms of a cardiac emergency/ myocardial infarction?

Answer 8

*Chest pain
*Pain in neck, jaw, back, shoulders, arms
*Indigestion
*Shortness of breath
*Pale skin, sweating, clammy
*Nausea, vomiting
*Weak pulse

Question 9

What actions should be taken in the event of a cardiac emergency?

Answer 9

*Reassure the patient
*Carry out A-E assessment
*Ensure they are sitting and resting
*Administer two activations of GTN spray sublingually
*Give oxygen at 15 litres per minute
*If no improvement, dial 999
*Administer 300mg aspirin, chewed or crushed. Do not give with water
*Continually assess and reassure patient

Question 10

What are the signs and symptoms of a seizure?

Answer 10

*Vagueness
*Sudden loss of consciousness
*Patient becomes rigid and cyanosed
*Jerking movements of the limbs
*Urinary incontinence
*Frothing at the mouth

Question 11

What actions should be taken in the event of a seizure?

Answer 11

*Ensure the area is safe
*Do not restrain, support the head if possible.
*Suction in the buccal sulcus may be helpful
*Don’t place anything between the patients teeth
*Make a note of the time
*If the seizure ceases within 3 minutes, place patient in lateral position and administer oxygen at 15 litres per minute and continually assess the patient
*If seizure approaches 5 mins dial 999
*If seizure is prolonged (5 mins) or recurrent administer Midazolam buccally
*10mg adult
7.5mg 5-10 years
5mg 1-5 years

Question 12

what are the signs and symptoms of anaphylaxis?

Answer 12

*Flushing
*Sweating
*Nausea and abdominal pain
*Possible rash
*Swelling of soft tissues
*Swelling of throat and tongue
*Wheezing
*Difficulty breathing
*Increased heart rate

Question 13

What actions should be taken in the event of anaphylaxis?

Answer 13

*Reassure the patient
*Carry out A-E assessment
*Dial 999 for ambulance
*Administer oxygen at 15 litres per minute
*Raise patients legs to help restore their BP
*If symptoms are life threatening, administer IM injection of adrenaline into outer aspect of thigh
*Can be repeated after 5 minutes on opposite thigh
*0.5ml adults, 0.3ml 6-12years, 0.15ml 6mo-6yr
*Continue to assess and reassure patient

Question 14

What is an agonist?

Answer 14

Ligands or drugs that activate the receptor

Question 15

What is an antagonist?

Answer 15

Ligands or drugs that bind to and inhibit the receptor

Question 16

What is a therapeutic window?

Answer 16

The concentration range at which a drug has a positive therapeutic effect. Often drugs with a narrow therapeutic window require frequent monitoring to ensure drug concentration is maintained

Question 17

What effects do NSAIDs have on the body?

Answer 17

Anti-inflammatory, analgesic and antipyretic

Question 18

What NSAIDs are available and which are on the dental prescribing list?

Answer 18

Ibuprofen - on DP
Aspirin - on DP
Diclofenac - on DP
Benzydamine - on DP
Choline Salicylate (topical aspirin) - on DP
Naproxen
Celecoxib

Question 19

What are the five cardinal symptoms of inflammation and describe each
`

Answer 19

1. Heat - due to pyretic effect of PGE2
2. Redness - due to vasodilatory effects of PGE1, PGE2, histamine and bradykinin.
3. Swelling - Due to actions of histamine and bradykinin which increase blood vessel permiability allowing fluid to leak out
4. Pain - Due to pain sensitising effects of histamine and bradykinin, as well as CGRP and substance P. These also transmit pain signals
5. Loss of function - due to pain and swelling

Question 20

What is COX-1

Answer 20

An enzyme permanently present in many cells in the body including endothelial cells and platelets

Question 21

What is COX-2

Answer 21

An enzyme induced in cells when inflammation occurs

Question 22

Describe histamines involvement in inflammation

Answer 22

In inflammation, histamine is released. This mediator causes increased permeability of blood vessels, vaso dilation and sensitised C fibres to pain

Question 23

Describe bradykinins involvement in inflammation

Answer 23

Bradykinin is released in inflammation, increases permiability in blood vessels, causes vavodilation and sensitises C fibres to pain

Question 24

What is the mechanism of action of NSAIDs?

Answer 24

NSAIDs act to reversibly inhibit the COX enzymes in one branch of the inflammatory cascade.
This means that fewer pro-inflammatory factors are produced and as a result the body’s response to inflammatory stimulus is lessened.

Question 25

What is the mechanism of action of aspirin and how is it used?

Answer 25

* An irreversible COX1 and COX2 inhibitor.
* Its irreversible inhibitory effect provides some useful properties when it comes to reducing platelet aggregation.
* Low dose (75mg) - antiplatelet action (inhibits COX1 in platelets with little anti-inflammatory effect)
* High dose (300mg+) - anti-inflammatory and analgesic effects. At high doses it inhibits COX1 and COX2 enzymes.
*When metabolised in the liver, aspirin is converted to the active metabolite salcylate, which also acts as an anti-inflammatory and COX inhibitor

Question 26

How do NSAIDs exacerbate asthma?

Answer 26

Inhibition of COX enzymes creates a shunt in the inflammatory cascade. This leads to an increase in the production of leukotrienes which can cause bronchospasm

Question 27

How do NSAIDs cause stomach ulcers?

Answer 27

Some prostaglandins promote mucus production in the lining of the stomach. This mucus acts as a barrier and protects the cells of the stomach wall from damage from stomach acid. Reduced prostaglandin synthesis means there is a reduction in the mucus and so the buffering capacity is reduced. NSAIDs are also direct irritants to the cells lining the stomach

Question 28

How can NSAIDs damage the kidneys?

Answer 28

NSAIDs decrease blood flow to the kidney as this is martly mediated by PGE2. PGE2 causes vasodilation in the blood vessels of the kidney. When NSAIDs block this action, there can be reduced blood flow. In certain susceptible individuals the reduced blood flow can cause acute kidney injury

Question 29

How do NSAIDs carry an increased risk of bleeding?

Answer 29

NSAIDs decrease thromboxane A2 production. Thromboxane A2 is involved with platelet aggregation. Reduced levels leads to reduced clotting

Question 30

What are the cautions and contraindications of NSAIDs?

Answer 30

* Aspirin should not be given to under 16s due to the risk of Reyes syndrome. A rare but dangerous disorder that can cause organ damage including to the brain and liver.
* Not suitable for asthmatics
* Not suitable for those with a history of GI ulcers
* Not suitable for those with uncontrolled HBP; HBP puts stress on kidneys, NSAIDs can worsen this
* Not suitable for those with renal dysfunction - risk of acute kidney injury
* Aspirin allergy - very small percentage of population but should avoid all NSAIDs
* Not suitable for use in pregnancy - inhibition of prostaglandin synthesis by doses used for inflammatory conditions can be harmful to the foetus

Question 31

What are some drugs that interact with NSAIDs

Answer 31

* Anticoagulants and antiplatelets (warfarin, clopidogrel, low dose aspirin)
* Carbamazepine (trigeminal neuralgia)
* SSRIs
* Methotrexate (immunosuppressant)
* Lithium
* Antihypertensives

Question 32

What is the mechanism of action of paracetamol?

Answer 32

Alalgesic and antipyretic
Weak COX inhibitor in the brain. Most likely has another mechanism of action but this is unclear

Question 33

Discuss paracetamol overdose

Answer 33

* Paracetamol is primarily metabolised in the liver
* A small percentage of paracetamol is metabolised into NAPBQI, which is toxic
* At therapeutic doses this metabolite is detoxified and causes no harm
* In overdose, the detoxification pathway is overwhelmed, leading to a build up of NAPBQI and cell death
* Patients who have ingested 75mg/kg+ within 24 hours are at risk of hepatotoxicity and should be referred to hospital
* Overdose is treated with acetylcysteine up to 24 hours after the event

Question 34

Former smoker with history of ischemic heart disease c/o central crushing pain across chest and down left arm. What is the most likely diagnosis, how would you manage? (assume pt is conscious)

Answer 34

Myocardial infarction
2 x sublingual sprays GTN spray
15 litres oxygen
300mg chewed aspirin