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Internal Medicine > OHCM - Emergencies > Flashcards

OHCM - Emergencies Flashcards

1
Q

What does “1st and worst headache” mean?

A

Subarachnoid hemorrhage.

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2
Q

Thunderclap headache?

A

Subarachnoid hemorrhage.

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3
Q

Unilateral headache and eye pain?

A
  1. Cluster headache

2. Acute glaucoma

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4
Q

Unilateral headache and IPSIlateral symptoms?

A
  1. Migraine
  2. Tumor
  3. Vascular
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5
Q

Cough-initiated headache?

A

Raised ICP/venous thrombosis.

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6
Q

Worse headache in the morning or bending forward?

A

Raised ICP/Venous thrombosis.

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7
Q

Persisting headache +/- scalp tenderness in over-50s?

A

Giant cell arteritis.

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8
Q

Headache with fever or neck stiffness?

A

Meningitis

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9
Q

When a patient comes with headache, mention 2 other vital questions that should be asked.

A
  1. Where have you been? –> Malaria.

2. Might you be pregnant? –> Pre-eclampsia; especially if proteinuria and BP.

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10
Q

What headache etiology may not give any signs on examination?

A
  1. Tension headache
  2. Migraine
  3. Cluster headache
  4. Post-traumatic
  5. Drugs (nitrates, calcium-channel antagonists)
  6. CO poisoning or anoxia
  7. Subarachnoid hemorrhage
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11
Q

Cause of headache if signs of meningism?

A
  1. Meningitis (may NOT have fever or rash).

2. Subarachnoid hemorrhage (examination may be NORMAL).

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12
Q

Cause of headache if decr. conscious level or localizing signs?

A
  1. Stroke
  2. Encephalitis/meningitis
  3. Cerebral abscess
  4. Subarachnoid hemorrhage
  5. Venus sinus occlusion (focal neurological deficits)
  6. Tumor
  7. Subdural hematoma
  8. TB meningitis
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13
Q

Cause of headache if papilledema?

A
  1. Tumor
  2. Venous sinus occlusion (focal neurological deficits)
  3. Malignant HTN
  4. Idiopathic intracranial HTN
  5. Any CNS infection if prolonged (>2wks) - eg TB meningitis.
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14
Q

Acute glaucoma will give what signs?

A

Painful red eye - get pressures checked urgently.

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15
Q

Vertebral artery dissection?

A

Neck pain and cerebellar/medullary signs.

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16
Q

Mention other causes of headache.

A
  1. Cervical spondylosis
  2. Sinusitis
  3. Paget’s disease
  4. Altitude sickness
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17
Q

Emergency presentations of breathlessness: Wheezing?

A

Assess for:

  1. Asthma
  2. COPD
  3. HF
  4. Anaphylaxis
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18
Q

Emergency presentations of breathlessness: Stridor?

A

Upper airway obstruction:

  1. Foreign body or tumor
  2. Acute epiglottitis (younger patients)
  3. Anaphylaxis
  4. Trauma, laryngeal fracture
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19
Q

Emergency presentations of breathlessness: Crepitations?

A
  1. HF
  2. Pneumonia
  3. Bronchiectasis
  4. Fibrosis
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20
Q

Emergency presentations of breathlessness: Chest clear?

A
  1. Pulmonary embolism
  2. Hyperventilation
  3. Met acidosis - DKA
  4. Anemia
  5. Drugs - salicylates
  6. Shock (may cause “air hunger”)
  7. PJ pneumonia
  8. CNS causes
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21
Q

Emergency presentations of breathlessness: Others?

A
  1. Pneumothorax - pain, increased resonance, tracheal deviation (if tension pneumothorax.
  2. Pleural effusion - “stony dullness”.
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22
Q

Emergency presentations of breathlessness: Key investigations?

A
  1. Baseline observations - O2 sats, pulse, temperature, peak flow.
  2. ABG if saturations <94% or concern about acidosis/drugs/sepsis
  3. ECG (signs of PE, LVH, MI)
  4. CXR
  5. Baseline bloods: glucose, FBC, U&E, consider drug screen.
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23
Q

Life threatening causes of chest pain?

A
  1. AMI
  2. Angina/coronary syndrome
  3. Aortic dissection
  4. Tension pneumothorax
  5. Pulmonary embolism
  6. Esophageal rupture
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24
Q

Mention other causes of chest pain.

A
  1. Pnemonia
  2. Chest wall pain (muscular, rib fractures, bony metastases, costochondritis)
  3. GERD
  4. Pleurisy
  5. Empyema
  6. Pericarditis
  7. Esophageal spasm
  8. Herpes zoster
  9. Cervical spondylosis
  10. Intra-abdominal: cholecystitis, peptic ulceration, pancreatitis.
  11. Sickle-cell crisis
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25
Q

What should be done before discharging patients with undiagnosed chest pain?

A

Be sure that the pain is NOT CARDIAC - dull, radiate to jaw, arm, or epigastrium, and is usually associated with exertion.

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26
Q

Key investigations in chest pain?

A
  1. CXR
  2. ECG
  3. FBC, U&E, and troponin
  4. Consider D-dimer
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27
Q

True or false? If patient’s chest wall is tender to palpation, this means that the cause is musculoskeletal.

A

FALSE

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28
Q

Give a definition of coma.

A

Unrousable unresponsiveness.

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29
Q

How do we quantify coma?

A

Using Glasgow coma scale.

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30
Q

Mention some metabolic causes of impaired conscious level/coma.

A
  1. Drugs, poisoning, eg CO, alcohol, TCAs.
  2. Hypoglycemia, hyperglycemia (ketoacidotic, or HONK)
  3. Hypoxia, CO2 narcosis (COPD)
  4. Septicemia
  5. Hypothermia
  6. Myxedema
  7. Addisonian crisis
  8. Hepatic/uremic encephalopathy
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31
Q

Mention some neurological causes of impaired conscious level/coma.

A
  1. Trauma
  2. Infection: meningitis, encephalitis (HSV, give acyclovir IV, if the SLIGHTEST suspicion), tropical (malaria), typhoid, typhus, rabies, trypanosomiasis.
  3. Tumor: 1o or 2o.
  4. Vascular: stroke, subdural/subarachnoid, hypertensive encephalopathy.
  5. Epilepsy: non-conclusive status or post-ictal state.
32
Q

What should be involved in the immediate management of a patient in coma?

A
  1. Assess Airway, Breathing, and Circulation.
  2. Check blood glucose; give 50mL 20% glucose IV stat if hypoglycemia possible.
  3. IV thiamine - for Wernicke’s
  4. IV naloxone (0.4-2mg IV) for opiate intoxication.
  5. IV flumazenil for benzodiazepine intoxication.
33
Q

Examination of a patient with impaired conscious level/coma?

A
  1. Signs of trauma
  2. Stigmata or other illnesses
  3. Skin for needle marks, cyanosis, pallor, rash (meningitis; typhus), poor turgor.
  4. Smell the breath
  5. Opisthotonus
  6. Meningism
  7. Pupils
  8. Heart/lung exam for BP, murmurs, rubs, wheeze, consolidation, collapse
  9. Abdominal/rectal
  10. Foci of infection?
  11. Any features of meningitis?
  12. Note the ABSENCE of signs - eg no pin-point pupils in a known heroin addict.
34
Q

Quick history in a patient with impaired conscious level/coma?

A
  1. From family, ambulance staff, bystanders - Abrupt of gradual onset?
  2. How found? - Suicide note, seizure?
  3. If injured, suspect cervical spine injury and do not move spine.
  4. Recent complaints - headache, fever, vertigo, depression?
  5. Recent medical history - sinusitis, otitis, neurosurgery, ENT procedure?
  6. PMH –> Diabetes, asthma, HTN, cancer, epilepsy, psychiatric illness?
  7. Drug or toxin exposure (especially alcohol or other recreational drugs? Any travel?
35
Q

What should be done if the diagnosis is unclear in a patient with impaired conscious level/coma?

A

Treat the treatable:

  1. Pabrinex IV for Wernicke’s
  2. O2
  3. Naloxone
  4. Glucose (50mL of 50% IV)
  5. Septic specifics: cefotaxime 2g/12h IV (meningitis)
  6. Artemether/quinine (malaria)
  7. Aciclovir (HSV)
36
Q

Mention the steps for managing coma.

A
  1. ABC of life support.
  2. IV access
  3. Stabilize the cervical spine (vital if trauma possibility)
  4. Blood glucose (fingerprick and lab)
  5. Control seizures
  6. Treat potential causes eg IV glucose, thiamine, naloxone (if pupils small or if possible narcotic use). Other antidotes.
  7. Brief collateral history and examination. Get details later.
  8. Investigations - ABG, FBC, U&E, LFT, ESR, CRP, ethanol, tox screen, drug levels - Blood, urine culture, consider malaria - CXR, CT head.
  9. Reassess the situation and plan further investigations.
37
Q

What are the 3 types of response assessed in GCS?

A
  1. Best motor response
  2. Best verbal response
  3. Eye opening
38
Q

No response to pain + no verbalization + no eye opening gives us a GCS of?

A

3.

39
Q

What is the GCS for severe injury?

A

<8 - Consider airway protection.

40
Q

What is the GCS for moderate injury?

A

9-12

41
Q

What is the GCS for minor injury?

A

13-15.

42
Q

What signs imply damage ABOVE the level of the red nucleus in the midbrain?

A

Decorticate posture - arms bent inwards on chest, thumbs tucked in a clenched fist, legs extended.

43
Q

What signs imply damage BELOW the level of the red nucleus?

A

Decerebrate posture (adduction and internal rotation of shoulder, pronation of forearm).

44
Q

What is the role of the red nucleus?

A

Reinforces upper limb ANTI-GRAVITY flexion - when output is damaged, the unregulated reticulospinal and vestibulospinal tracts reinforcee extension tone of upper and lower limbs.

45
Q

What is the AVPU scale?

A 
A= Alert
V= responds to Vocal stimuli
P= responds to Pain
U= Unresponsive
46
Q

What is the role of the neurological exam in coma?

A

Aimed at locating the pathology in 1 of 2 places - Altered level of consciousness implies either:

  1. Diffuse, bilater, cortical dysfunction (usually producing loss of awareness with normal arousal).
  2. Damage to the ARAS located throughout the brainstem from the medulla to the thalami (usually producing loss of arousal with unassessable awareness) - Brainstem can be affected directly (eg pontine hemorrhage) or indirectly (herniation, tumor).
47
Q

Systematic examination - Level of consciousness in coma?

A

Describe using OBJECTIVE words/AVPU.

48
Q

Systematic examination of coma patient - Respiratory pattern.

A
  1. Cheyne-Stokes - Brainstem lesions or compression.
  2. Hyperventilation - Acidosis, hypoxia, rarely neurogenic
  3. Ataxic or apneustic (breath-holding) breathing - Brainstem damage with grave prognosis.
49
Q

Systematic examination of coma patient - Eyes - Visual fields?

A

In light coma, test fields with visual threat. No blink in one field suggests hemianopia and contralateral hemisphere lesion.

50
Q

Systematic examination of coma patient - Pupils?

A
  1. Normal direct and consensual reflexes present = intact midbrain.
  2. Mid-position (3-5mm) non-reactive +/- irregular = midbrain lesion.
  3. Unilateral dilated and unreactive (fixed) = 3rd nerve compression.
  4. Small reactive = pontine lesion or drugs.
  5. Horner’s syndrome = ipsilateral lateral medulla or hypothalamus lesion, may precede uncal herniation.
  6. Beware patients with false eyes or who use eye drops for glaucoma.
51
Q

Systematic examination of coma patient - extraocular movements?

A
  1. Observe resting position and spontaneous movement.
  2. Then test the vestibulo-ocular reflex (VOR) with either the doll’s head manoeuvre (normal if the eyes keep looking at the same point in space when the head is quickly moved laterally or vertically).
  3. Ice water calorics - normal if the eyes deviate towards the cold ear with nystagmus to the other side.
  4. If present, the VOR exonerates most of the brainstem from the VII nerve nucleus (medulla) to the III (midbrain).
  5. Don’t move the head unless the cervical spine is cleared.
52
Q

Systematic examination of coma patient - Fundi?

A
  1. Papilledema
  2. Subhyaloid hemorrhage
  3. Hypertensive retinopathy
  4. Signs of other disease (diabetic retinopathy)
53
Q

How is circulatory failure (shock) often defined?

A
  1. Systolic 2mmol/L.
54
Q

What are the two general causes of circulatory failure?

A
  1. Inadequate CO

2. Peripheral circulatory failure (loss of SVR)

55
Q

Inadequate CO, causes?

A

A. Hypovolemia:
1. Bleeding - trauma, ruptured aneurysm, GI bleed.
2. Fluid loss - vomiting, burns, 3rd space losses (pancreatitis), heat exhaustion.
B. Pump failure:
1. Cardiogenic shock, eg ACS, arrhythmias, aortic dissection, acute valve failure.
2. Secondary causes, eg pulmonary embolism, tension pneumothorax, cardiac tamponade.

56
Q

Peripheral circulatory failure, causes?

A
  1. Sepsis
  2. Anaphylaxis
  3. Neurogenic –> Spinal cord injury, epidural or spinal anesthesia.
  4. Endocrine failure –> Addison, hypothyroidism.
  5. Other –> Drugs, inability to use oxygen (cyanide poisoning)
57
Q

Assessment of shocked patient - General review:

A
  1. Cold and clammy suggests cardiogenic shock or fluid loss.
  2. Look for signs of anemia or dehydration - skin turgor, postural hypotension?
  3. Warm and well perfused + bounding pulses –> Septic shock.
  4. Any features suggestive of anaphylaxis - history, urticaria, angioedema, wheeze?
58
Q

Assessment of shocked patient - CVS?

A
  1. Usually tachycardic unless on β-blocker, or in spinal shock) and hypotensive.
  2. In the young and fit, or pregnant women, the systolic BP may remain normal, although the pulse pressure will NARROW - up to 30% blood volume depletion.
  3. Difference between arms (>20mmHg) - aortic dissection.
59
Q

Assessment of shocked patient - What else?

A

JVP/CVP –> If raised, cardiogenic shock likely.

Check abdomen –> Any signs of trauma, or aneurysm? Any evidence of GI bleed.

60
Q

Management of septic shock?

A
  1. Ideally, take cultures before antibiotics (2x peripheral blood cultures plus, urine, sputum, CSF - DO NOT DELAY treatment.
  2. Antibiotics within 1st hour - Tazocin (4.5g tds) + gentamicin + vancomycin (1g/12h IVI) if MRSA. Adjust in CKD.
  3. After fluid bolus of 20mL/kg crystalloid (or 7mL/kg colloid) repeat BP and ABG.
61
Q

Management of hypovolemic shock?

A
  1. Identify and treat undelying cause. Raise the legs.
  2. Give fluid bolus 10-15mL/kg crystalloid or 3-5mL/kg colloid, if shock improves, repeat, titrate to HR (aim 90) and UO (aim>0.5mL/kg/h).
  3. If no improvement after 2 boluses, consider referral to ICU.
62
Q

Hemorrhagic shock, management?

A
  1. Stop bleeding if possible.
  2. If still shocked, despite 2L crystalloid or present with class III/IV shock, then crossmatch blood (request O Rh- in an emergency).
  3. Give FFP alongside packed RBCs (1:1) and aim for platelets >100 and fibrinogen >1. Discuss hematology early.
63
Q

Heat exposure (heat exhaustion) - management?

A
  1. Tepid sponging + fanning - avoid ice and immersion.
  2. Resuscitate with high-sodium IVI, such as 0.9% saline +/- hydrocortisone 100mg IV.
  3. Dantrolene seems ineffective.
  4. Chlorpromazine 25mg IM may be used to stop shivering.
  5. Stop cooling when core temperature <39C.
64
Q

Systemic inflammatory response syndrome (SIRS) definition?

A

Presence of 2 or more of the following:

  1. Temp >38C or 36C.
  2. Tachycardia >90bpm.
  3. RR > 20, PaCO2 12x10^9 or <4x10^9, or 10% immature (band) forms.
65
Q

SIRS-related syndromes:

A
  1. Sepsis - SIRS occurring in the presence of infection.
  2. Severe sepsis - With evidence of organ hypoperfusion, eg hypoxemia, oliguria, lactic acidosis, or altered cerebral function.
  3. Septic shock - Severe sepsis with hypotension (systolic <60) DESPITE adequate fluid resuscitation, or the requirement for vasopressors/inotropes to maintain BP.
66
Q

What was the usage of the term”septicemia”?

A

Was used to denote the presence of multiplying bacteria in the circulation, but has been replaced with other definitions.

67
Q

Anaphylactic shock - Definition?

A

Type I IgE-mediated HSR.

68
Q

Anaphylactoid reaction?

A

Results from direct release of mediators from inflammatory cells, without involving antibodies, usually in response to a drug, eg acetylcysteine.

69
Q

Examples of precipitants of anaphylactic shock?

A
  1. Drugs eg penicillin, contrast media in radiology.
  2. Latex
  3. Stings, eggs, fish, peanuts, strawberries, semen (rare).
70
Q

Signs and symptoms of anaphylactic shock?

A
  1. Itching, sweating, diarrhea, vomiting, erythema, urticaria, edema.
  2. Wheeze, laryngeal obstruction, cyanosis.
  3. Tachycardia, hypotension.
71
Q

Mimics of anaphylaxis?

A
  1. Carcinoid
  2. Pheochromocytoma
  3. Systemic mastocytosis
  4. Hereditary angioedema
72
Q

Steps in management of anaphylaxis.

A
  1. Secure airway - give 100% O2.
  2. Intubate if respiratory obstruction imminent.
  3. Remove the cause; raising the feet may help restore the circulation.
  4. Give adrenaline IM 0.5mg.
  5. Repeat every 5min, if needed as guided by BP, pulse, respiratory function, until better.
  6. Secure IV access.
  7. Chlorphenamine 10mg IV and hydrocortisone 200mg IV.
  8. IVI (0.9% saline, eg 500mL over 1/4h up to 2L may be needed - Titrate against BP.
  9. If wheeze, treat for asthma - may require ventilatory support.
  10. If still hypotensive, admission to ICU and an IVI of adrenaline may be needed +/- aminophylline and nebulized salbutamol. Get expert help.
73
Q

Further management of anaphylaxis?

A
  1. Admit to ward. Monitor ECG.
  2. Measure mast cell tryptase 1-6h after suspected anaphylaxis.
  3. Continue chlorphenamine 4mg/6h PO if itching.
  4. Suggest a “MedicAlert” bracelet naming the culprit allergen.
  5. Teach about self-injected adrenaline (eg 0.3mg Epipen) to prevent fatal attacks.
  6. Skin-prick tests showing specific IgE help identify allergens to avoid.
74
Q

How is adrenaline given?

A

IM and NOT IV, unless the patient is severely ill, or has no pulse.
IV dose is different - 100μg/1min - titrating with response.
If on a beta-blocker –> salbutamol instead of adrenaline.

75
Q

What is the vast majority of headaches?

A

Benign.

Internal Medicine (106 decks)

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