Medical emergencies symposium Flashcards
How do you know if a pt has fainted or collapsed?
Collapse - sudden loss of postural tone
Faint - transient loss of consciousness
Causes of faints and collapses?
Neurogenic syncope
Cardiogenic syncope
Neurocardiogenic syncope including simple faint
NICE assessment - what does it look for in relation to collapses?
What happened at the time it occurred
Was anything happening beforehand e.g. anxious, pain
Any shakes, jerking, urinating, biting tongue
Examples of neurogenic syncopes?
Seizures/epilepsy
Sub-arachnoid haemorrhage
Not stroke
Features of neurogenic syncope?
History of neurogenic problems: epilepsy Loss of sphincter tone Tongue biting Prodrome Clinical features
Examples of cardiogenic syncope?
Arrhythmia: bradycardia, tachycardia
Vulvular pathology: aortic stenosis, mitral stenosis
Structural heart disease: hypertrophic cardiomyopathy (HCM)
Pulmonary embolus
Primary electrophysiological abnormalities:
- Brugada sundrome
- Long QT syndrome
Vasovagal syncope features?
Commonest type of faint
Posture (upright more likely) Provoking (what happened at the time - anxious environment) Prodrome (sweating)
Transient LOC
Rapid recovery, often ongoing headache, mild nausea
Overstimulation of vagus nerve +/- sympathetic tone loss
Is there a reason to think it could be something else? - e.g. pt grabbed chest in pain
Red flags?
Brain or heart cause
Call ambulance
Get ECG
Physical signs of heart failure - swelling of legs
FH of sudden cardiac death in people younger than 40 years
How to assess and treat faints?
Assess airway, breathing, circulation
- Lay flat, elevate legs (if tolerated), recovery position if necessary
If occurs after an unpleasant stimulus (LA) and recovery rapid - simple faint
If any doubt - ED assessment
Define hypogylcaemia
Lower than normal blood sugar
Normal blood glucose 4.7
Symptoms of hypoglycaemia?
Hunger Irritability Headache Altered/reduced LOC Difficulty speaking, slurred speech Ataxia dyscoordination (drunkenness) Agitated Seizures
Causes of hypoglycaemia?
Too little fuel Too much insulin (e.g. diabetics) Excess oral diabetes drugs, beta-blockers, drug interactions Alcohol induced hypoglycemia Sepsis Insulin-secreting pancreatic tumor Adrenal insufficiency / hypopituitarism
How to treat hypoglycaemia?
Sugar
If symptoms minimal - carbohydrate (bread and sugary drink as sugary drink short acting)
With increasing symptoms - oral gel (hypostop)
IV if significant symptoms - reduced LOC/seizures
Hospital assessment focused on tx and identifying cause
What is anaphylaxis?
Extreme allergy
IgE mediated
Caused by rxn to allergen
What occurs in anaphylaxis?
Antigen binds to IgE antibodies on mast cells based in CT throughout body
Degranulation of mast cells with release of inflam mediators
Inflam mediators cause common symptoms f allergic rxns - itching, rash, swelling
Can cause bronchial constriction, vasodilation
Anaphylactic shock is an allergic rxn with resp symptoms and circulatory collapse
Clinical features of anaphylaxis?
Resp distress - stridor, tachypnoae, wheeze, cyanosis
Circulatory signs - pallor, cool peripheries, tachycardia, hypotension
CNS - anxiety, agitation, reduced LOS
GI - abdominal pain, D&V
Skin - urticaria
Anaphylaxis tx?
Remove/stop cause (e.g. LA) Assess airway, breathing and circulation IM adrenaline (0.5mg) Oxygen (especially if cyanosis) Nebulised beta agonist (salbutamol) Remove stimuli 999 to ED
Asthma features?
Increased airway reactivity
Atopic/non-atopic
(atopic - triad of atopic eczema, allergic rhinitis and asthma)
Various triggers
Acute attacks - wheezing, SOB, tight chest, coughing
How to treat asthma?
Try and prevent - avoid precipitants
Inhaled beta-agonists - salbutamol, terbutaline (ventolin) - pts own or nebulised
Steroids if indicated - reduce airway inflam
Ischaemic heart disease - angina/MI features?
Common in western world
Can be caused by coronary artery disease
Complicated pathogenesis
Risk factors (fixed and modifiable)
Stable angina symptoms?
Pain on exercise, relieved by rest +/- GTN
Unstable angina symptoms?
Worsening pain especially at rest, increasing freq of episodes
MI features?
Symptoms, ECG changes, biomechanical markers
Typical MI/angina symptoms?
Chest pain - sometimes radiates Nausea/vomiting Collapse Sweating Pallor Anxiety
Angina/MI tx?
GTN spray/tablet Aspirin 300mg Oxygen if indicated 999 to ED Primary PCI for AMI that meet criteria MONA: Morphine, oxygen, nitrates (GTN), aspirin
What is adrenal insufficiency?
Inadequate production of steroid hormones
Primarily cortisol
May have impaired aldosterone production
Several causes
Causes of adrenal insufficiency?
Primary adrenal insufficiency - impairment of adrenal gland
Idiopathic
Autoimmune - addison’s disease
Congenital adrenal hyperplasia
Adenoma of adrenal gland
2ndry 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
Hypoglycaemia, dehydration, weightloss, disorientation
Myalgia, nausea, vomiting, diarrhoea
Hyperkalaemia and hyponatraemia
Palmar crease tanning
Vitiligo
Adrenal crisis clinical features?
Lethargy, fever Abdominal pain (back and legs also) Severe D&V Hypotension Hypoglycaemia Syncope Confusion, psychosis, slurred speech
Tx of adrenal crisis?
Avoid
Modification of steroid regimen before examination/tx
If signs of crisis - 999
Will need hospital assessment - steroids, fluids, observation
Features of seizures?
Not always epileptic
Several types of seizures
Difficult to diagnose
Classic seizure dramatic, but rarely problematic
What are the types of seizures? Features?
Partial seizure - may have LOC (simple/complex)
Generalised seizure - all have LOC (absence, tonic-clonic, myoclonic, tonic, atonic)
Causes of seizures?
Epilepsy
Fatigue
Intracranial lesion
Drug and alcohol intoxication/withdrawal
Intracranial infection - encephalitis, meningitis
Metabolic disturbances - hypoglycaemia, hyponatraemia or hypoxia
MS
How to manage a seizure?
Protect pt from injury
Post-ictal phase may be distressing and prolonged
Classic tonic-clonic seizure rarely more than 1-2mins
If prolonged - assess airway, breathing, circulation and call 999
If more than 5 mins = benzodiazepam
What can stress cause?
Cardiac events, syncope, seizures, acute adrenal insufficiency, asthma
Past MH may predict events and prevention e.g. increasing steroid doses peri-surgery
Assess airway, breathing and circulation
999 to ED if any concerns
PE features?
Massive PE = collapse
More likely SOB +/- chest pain
Many risk factors
