PME2 Signs, Symptoms and Treatments Flashcards
2 or more of the following dictates prehospital notification for meningococcal disease
3 physiologic types of somatic sensations
mechanoreceptive somatic senses
thermoreceptive senses
(heat and cold)
pain senses
(painful stimuli)
(tactile and mechanical displacement)
What are the AAA clinical features?
ALOC
shoulder tip pain
myocardial infarction
hypotension
asymmetrical/absent distal pulses
abdo pain
palpable mass
ecchymosis (bruising around flank)
limb ischaemia
shock
(hypovolaemic)
(quality and location varies)
Where does Abdominal Aortic Dissection Occur
in the suprarenal abdominal aorta or the infrarenal aorta
most common in the infrarenal aorta
Acute Lower GI Bleed Management
IV fluids challenge
Oxygen as a supportive measure
Treat symptomatically
Transport to hospital
Acute Lower GI Bleed Clinical Features
Lightheaded
Fatigue
Anaemia
Pain +-
Mild to moderate hypovolaemia
SOB on exertion
Haematochezia
Acute Pancreatitis Management
Pain management
Antiemetic
(ondansetron)
IV fluids
(could be shocked or dehydrated)
Oxygen?
(acute respiratory failure)
Treat symptomatically
Transport to hospital
(methoxy , morphine or if contraindicated use fentanyl)
Acute Pericarditis Clinical Features
fever
sharp chest pain worsened by lying down, expiration and cough
referred pain to trapezial ridge
dyspnoea
pericardial rub
(listen with stethoscope)
perciardial effusion
ECG changes (global concave STE and PR depression, sinus tachy)
cardiac tamponade
(sinus tachy, low QRS voltage, electrical alternatives)
(bacterial or viral)
Acute Pericarditis Management
pain management
treat symptomatically
(oxygen etc)
cardiac tamponade??
Transport to hospital
(2/10 - panadol, higher consider opiates)
What is Acute Pulmonary Embolism
obstruction within pulmonary artery from thrombus (venous thromboembolsm), air emboli or fat
Acute Pulmonary Embolism Locations
Saddle of pulmonary trunk bifurcation
Lobar artery
Segmental artery
Subsegmental
Clot “in-transit”
Addison Disease Management and Treatment
treat symptomatically
Consider IV fluids to assist with hypotension and/or shock
Consider hydrocortisone (provides endocrine hormonal requirements)
Glucagon/oral glucose/glucose 10%
Salbutamol
Calcium gluconate (CCP)
Sodium bicarbonate (CCP)
Addison Disease Signs and Symptons
Skin hyperpigmentation
Hypotension (postural initially)
– Weakness
– Worsening fatigue
– Dizziness
- Crave salts
ECG – tachycardia, peaked t-waves
(& broadening QRS and 1st degree block)
Hypoglycaemia
Nausea and vomiting
Diarrhoea
Sudden pain in lower back/abdo/legs
(knees, elbows, knuckles, joints)
Additional Appendicitis Clinical Features in Children
abdominal distension
diarrhoea
difficulty walking
Anaphylaxis Management
Remove allergen if present
DO NOT WALK Patient
Appropriate posturing
(supine, legs elevated or semi recumbent)
IM adrenaline ASAP
Hypotensive? 1-2L IV fluids - Sodium Chloride 0.9%
(if hypotension doesn’t respond promptly to adrenaline within minutes)
IV Access - bilateral 16 gauge
Aortic Dissection and Aneurysm Management
Pain Management
(not hypotensive - opiate - morphine/fentanyl)
(unstable - fentanyl max 25 microg IV or 50 microg IM)
Hypotensive and Shocked
(CCP backup ASAP, IV fluids to maintain BP)
Treat Symptomatically
(nausea - ondans)
(shock - high flow oxygen)
Transport as Appropriate
Aortic Dissection Clinical Triad
sudden onset of thoracic or abdominal pain
pulse variation (absence of aproximal extremity or carotid and/or20mmHg difference in BP between Rand L arm)
mediastinal and/or aortic widening onchest radiograph
(sharp, tearing or ripping)
Aortic Dissection Clinical Features
ALOC
stroke
shoulder tip pain
chest or back pain (sharp/knife-likeor ripping/tearing)
ecg changes
hypotension/hypertension
pulse deficit
difference in bp
abdo, flank, back pain
limb paresthesia
Appendicitis Clinical Features
pain to periumbilical region followed by RLQ
rebound tenderness
positive rovsing sign
positive psoas sign
involuntary guarding
nausea/vomiting
anorexia
mild fever
tachycardia
Appendicitis Management
Pain management
Antiemetic
IV Fluids
Treat symptomatically
Transport
Are sepsis signs and symptoms the same as shock?
yes
Aspiration pneumonia Tx
Oxygenation
Paracetamol
Salbutamol if wheezes present
Antiemetic
Transport
Asthma Respiratory Assessment - Breath Sounds
Mild/Moderate - expiratory wheeze
Severe - expiratory wheeze, inspiratory wheeze
Life Threatening - expiratory wheeze, inspiratory wheeze
Asthma Respiratory Assessment - Conscious State
Mild/Moderate - alert
Severe - altered
Life Threatening - altered or unconscious
Asthma Respiratory Assessment - General Appearance
Mild/Moderate - mildly anxious
Severe - distressed, agitated
Life Threatening - exhausted, catatonic
Asthma Respiratory Assessment - O2 Saturation
Mild/Moderate - 90-94%
Severe - <90%
Life Threatening - <88%
Asthma Respiratory Assessment - Pulse Rate
Mild/Moderate - <110bpm
Severe - >110bpm
Life Threatening - hypotension/bradycardia, arrhythmia
Asthma Respiratory Assessment - Skin
Mild/Moderate - pale
Severe - pale, sweating
Life Threatening - pale, sweating, cyanosis
Asthma Respiratory Assessment - Speech
Mild/Moderate - sentances
Severe - words
Life Threatening - unable to speak
Asthma Respiratory Assessment - Ventilatory Effort
Mild/Moderate - accessory muscle use
Severe - accessory muscle use, intercostal retraction, tracheal tugging
Life Threatening - poor respiratory effort, respiratory exhaustion
Asthma Respiratory Assessment - Ventilatory Rate
Mild/Moderate - <25
Severe - pale, >25
Life Threatening - silent
Asthma Respiratory Assessment - Ventilatory Rhythm
Mild - slightly prolonged expiratory phase
Severe - marked prolonged expiratory phase
Life Threatening - marked prolonged expiratory phase, no expiratory pause
Asthmatic Arrest Management
standard cardiac arrest management:
CPR and defib as required
early back up notification
advanced airway (LMA/Igel) (adults: 6-8 vents/min) (paeds: 8-15 vents/min)
IV access and adrenaline every 3-5 mins
Autonomic Dysreflexia Description
massive stimulation of the sympathetic nervous sytem in Pts with cord lesion at T6 or above
50-70% of spinal cord injury Pts will develop symptoms of AD
Autonomic Dysreflexia Signs and Symptoms
headache (worsens as BP rises)
blurred vision
profuse sweating above the level of injury
flushing of skin above the level of injury
hypertension
bradycardia
if left untreated, intracranial haemorrhage is possible
Bacterial Pharyngitis and Tonsillitis Possible Complications
Acute rheumatic fever
Acute glumerulonephritis
Bacterial Pharyngitis and Tonsillitis Symptoms
Myalgia
fever and chills
headache
sudden onset of sore throat
painful swallowing
Obvious reddening of tonsils
Tonsillar exudate
Uvular oedema
Enlarged, painful anterior cervical lymph nodes
nausea/vomiting
Generally no rhinorrhea and cough
Bacterial Pharyngitis and Tonsillitis Tx
Treat symptomatically
fever & pain - paracetamol
dehydrated - 0.9% sodium chloride
nausea - ondansetron
Transport for further care or consider GPappointment
Blood Clot haematochezia origin
anywhere
What blood pressure characteristics define haemodynamically unstable acute pulmonary embolism?
SBP <90 mmHg or a drop of >40 mmHg over 15 minutes
Bowel Obstruction Management
IV fluids
antiemetic
antipyretic
(paracetamol - may do nothing due to malabsorption - probably shouldn’t be used as will likely be a complete obstruction, and associated with ischemia and necrosis)
transport
Bright red haematochezia origin
distal end of transverse colon and descending colon
Can HHS be the first presentation of type 2 diabetes?
yes
What is Cardiogenic Shock
intracardiac causes leading to decreased cardiac output and systemic hypoperfusion
Categories of lower GI bleed
Anatomic
Vascular
(ischaemic, enlargement of GI tract blood vessel, haemorrhoids)
Inflammatory
(ulcerative colitis, crohn’s disease)
Neoplastic
(abnormal cell growth, mole polyps, cancer)
Following interventions (surgery)
(diverticulitis)
Cause of aspiration pneumonia
aspirated/loss of airway patency
something harmful to airways, eg gastric reflux or lower airway issues
Cause of Cardiac Syncope
cardiomyopathy
AMI
tachy/bradyarrhythias
PE
aortic dissection
(generally don’t have prodrome)
Cause of central vertigo
cerebellar haemorrhage
cerebellar infarct
multiple sclerosis
migraine related dizziness and vertigo
post-traumatic vertigo
Cause of Medication Syncope
Nitrates
alcohol
(vasodilator)
beta-blockers
(chronotropic effects - HR can’t compensate for BP change)
diuretics
(eg GTN)
Cause of Neurally Mediated Syncope
vasovagal
carotid sinus syndrome
coughing
omiting
defecation
Cause of Orthostatic Syncope
drop of 20 mmHG SBP or 10 mmHG DBP from:
dehydration
vasodilation
Cause of Peripheral Vertigo
benign paroxysmal positional vertigo (BPPV)
acute labyrinthitis
vestibular neuritis
8th nerve lesions
meniere disease
alcohol
Causes of Addison Disease
Adrenal haemorrhage
Autoimmune destruction of the adrenal cortex
Infection – tuberculosis/fungal/HIV
Infiltrative – Amyloidosis/metastatic carcinoma
Sudden reduction/ceasing steroid medication
Trauma/surgery
(secondary to warfarin or antiplatelet drugs)
Causes of DKA - the 6 I’s of DKA
infection
infarction
insulin
illegal drugs
(includes alcohol)
infant pregnancy
idiopathic
Causes of Hyperkalaemia
Acidosis
Diet
Dialysis
IV therapy
Lysis
Renal failure
(H outside goes inside cna displaces K)
Causes of Hypokalaemia
extreme sweating
diuretic use
low food intake (extreme fasting - anorexia/bulemia)
vomiting/diarrhoea
Causes of Hypoxia
FIO2
fractured inspired oxygen
(everest/house fire)
Hypoventilation
V/Q mismatch in the form of shunt
(portion of lung shut down)
VQ mismatch in the form of dead space
(muccous plug)
Diffusion
(pneumonia)
Causes of meningitis
viral
bacterial
(mongrel bacteria)
fungal
(rare - usually immunocompromised)
spinal
(rare - infection from spine)
(most common)
Causes of Pancreatitis
Alcohol
Gallstone
Idiopathic
Morbid obesity
Smoking
Type 2 diabetic
Causes of Pericardial Effusion
Aortic Dissection
Acute Pericarditis
Chest trauma
(sharp or blunt - MVA, horse kick to chest)
Post Cardiac Surgery
(small tear creating slow bleed)
Renal failure with uremia
(urea and protein not being filtered out and creating a cascade of issues)
(ascending aorta)
Causes of Pericarditis
dissecting aneurysm
idiopathic
infectious
(viral, bacterial, fungal etc)
myocardial infarction
(post recovery)
metabolic
(uraemia, myxoedema, cholesterol pericarditis)
malignancy
trauma
(coranary intervention)
Classifications of Pancreatitis
Mild acute pancreatitis - absence of organ failure - no cytokine storm or inflammation
Moderately acute Pancreatitis - transient organ failure for up to 48 hrs
Severe acute pancreatitis - persistant organ failure for longer than 48 hours, cytokine cascade and can lead to organ failure
Clinical features of mild to moderate hypovolaemia
15% blood loss - tachycardia, orthostatic hypotension, pale, diaphoretic
40% volume loss - hypertensive and tachy in supine position, pale, diaphoretic
Clinical features of nephrolithiasis
nausea and vomiting
flank pain (moving anteriorly to abdo or inginual region)
dysuria and urgency
Clinical features of ruptured varices
generally pain free
Hx liver disease
haematemesis
ascites
melena
haemotogesia (PR) beed
possible hypovolemia
Cluster Headache Symptoms
Severere unilateral orbital, supraorbital or temporal pain
Ipsilateral (same side as pain) signs of:
eye redness
drooping eyelid
lacrimation
blocked or runny nose
Cluster Type Headaches Description
disfunction of trigeminal nerve
Lasts 15-180 minutes
clusters on daily basis for several weeks
remission from weeks to years
triggered by vasodilators (eg alcohol)
men more frequently affected
Cluster Type Headaches Management
High flow oxygen (for up to 15 minutes) is effective in up to 70% of patients
Paracetamol and Narcotics
Tx based on individual presentation
Colours of haematochezia
bright red
maroon
blood clots
malaena - dark, tarry, sticky
Common Causes of Anaphylaxis
Food
Insect stings
Medications
(Antibiotics, anaesthetic drugs, NSAID’s, opiates)
(Peanuts, tree nuts, hen’s eggs, cow’s milk, wheat, seafood, seeds)
Common causes of upper GI bleed
Mass Lesions (polyps/cancer)
Oesophagealvarices
Peptic ulcers
Portal hypertension gastropathy
Severe gastritis
Severe oesophagitis
Common Cold and Influenza Tx
PPE
Treat symptomatically
Paracetamol?
IV fluids
SARS?????
Transport to hospital or refer to GP depending on Hx & Pt presentation
Common types of infection that cause sepsis
Respiratory
Abdo
(Pain, tenderness, nausea and vomiting eg pancreatitis, colicsystitis, colelithiasis)
UTI
(Frequency, Offensive odour, burning, FWT/white ccell test in hospital)
(Cough, Decreased AE, Course crackles,)
Complete Cord Injury
full disruption of spinal tracts
Cord Contusion
bruising of cord - leads to temoral loss of cord mediated functions
Cord Laceration
tearing of neural tissue
Cord Transection
severing of full cord - permanent loss
Deep Vein Thrombosis (DVT) of the Lower Limb
a blood lot (thrombus) develops in a deep vein in the leg
not all Pts symptomatic - will become symptomatic if it dislodges
Describe the Pericardium
fibrous
tough, dense connective tissue
protects heart and prevents overfilling
outer wall of heart
Diagnostic Criteria for Acute Pericarditis
must have 2 or more of:
pericarditic chest pain
pericardial rub
new widespread STE or PR Depression in ECG
pericardial effusion
(new or worsening)
Diagnostic criteria for anaphylaxis after exposure to a likely allergen
2 or more of:
sudden skin or mucosal symptoms
(generalised hives, itching, flushing, swollen lips/tongue/uvula)
sudden respiratory symptoms
(SOB, wheeze, cough, stridor, hypoxemia)
sudden hypotension or end-organ dysfunction symptoms
(hypotonia, incontinence)
sudden GI symptoms
(crampy abdo pain)
Or;
low SBP or >30% decrease in baseline BP
Diagnostic criteria for anaphylaxis when unknown
sudden onset of illness
involvement of skin, mucosal tissue or both
(generalised hives, itching, flushing, swollen lips/tongue/uvula)
and 1 of:
sudden respiratory symptoms
(SOB, wheeze, cough, stridor, hypoxemia)
sudden hypotension or end-organ dysfunction symptoms
(hypotonia, incontinence)
OR
reduced BP
(mins to hours)
DKA Management
large bore IV access
Sodium 0.9%
ECG pads
have adrenalin ready
CCP backup
transport
DKA vs HHS
Does Hyperosmolar Hyperglycaemic Syndrome (HHS) affect Type a or Type 2 diabetics?
Type 2
Does metabolic acidosis have an increased or decreased respiratory rate
increased
Does metabolic alkalosis have and increased or decreased respiratory rate
decreased
DVT Management
minimise movement
careful when palpating
pain management
(paracetamol)
transport for imaging
DVT Potential Differentials
Arthritis
Chronic Leg Oedema
Cellulitis
Postoperative swelling
Ruptured Baker Cyst
ECG Changes in DKA
prolonged PR interval
ectopic QRS
Prolonged QRS
peaked T wave
ECG Changes in Hyperkalaemia
wide, flat P wave
prolonged pr interval
decreased R wave amplitude
widened QRS
ST depression
tall, peaked T waves
ECG Changes in Hypokalaemia
formation of prominent U wave - usually bigger than T wave
T wave can flatten and become inverted
(normal biphasic T is up first - abnormal is down first)
prolonged QT interval
ectopics on back of T wave means more likely to go into VT
ECG Changes in Pulmonary Embolism
Sinus tachycardia (44% of Pts)
Complete or incomplete RBBB (18%)
Right ventricular strain pattern – T wave inversions in the right precordial leads (V1-4) ± the inferior leads (II, III, aVF). Associated with high pulmonary artery pressures (34%)
Right axis deviation (16%). Extreme right axis deviation may occur, with axis between zero and -90 degrees, giving the appearance of left axis deviation (“pseudo left axis”)
Dominant R wave in V1 – a manifestation of acute right ventricular dilatation
Right atrial enlargement (P pulmonale) – peaked P wave in lead II > 2.5 mm in height (9%)
SI QIII TIII pattern – deep S wave in lead I, Q wave in III, inverted T wave in III (20%). This “classic” finding is neither sensitive nor specific for PE
Clockwise rotation – shift of the R/S transition point towards V6 with a persistent S wave in V6 (“pulmonary disease pattern”), implying rotation of the heart due to right ventricular dilatation
Atrial tachyarrhythmias – AF, flutter, atrial tachycardia (8%)
Non-specific ST segment and T wave changes, including ST elevation and depression (50%)
ECG Changes Stage 1 Pericarditis
global STE and PR depression with reciprocal changes in aVR (first two weeks)
ECG Changes Stage 2 Pericarditis
normalisation of ST changes; generalised T wave flattening (1 to 3 weeks)
ECG Changes Stage 3 Pericarditis
flattened T waves become inverted (3 to several weeks)
ECG Changes Stage 4 Pericarditis
ECG returns to normal (several weeks onwards)
ECG Findings in Large Pericardial Effusion (by default cardiac tamponade)
Tachycardia
Low voltage in precordia leads - <5ml precordial leads and <10ml limb leads (low QRS voltage)
Electrical alternates - heart moves backwards and forwards - taller, smaller, taller, smaller QRS complexes
Function of Bile Salts
derivative of cholesterol - emulsifies fats (makes nice, smooth and more soluble) and dissolve in bile
Function of gall bladder
stores bile used for fat digestion, absorption of fatty acids, fat soluble vitamins and phospholipids
Grades of Pericardial Effusion
small = 50-100 mL
moderate = 100 - 500 mL
larger = >500 mL
Haematuria Management
Treat symptomatically
Transport to hospital
HHS Management
Sodium 0.9%
Manage airway
(Oxygen BVM)
Adrenalin
Treat symptomatically
Assess ECG for:
- Hypokalaemia
- Ectopics
- R on T (big wobbly R that hits back of T)
- Prearrest rhythms
Transport
HHS Patient Presentation
General appearance: generally ill-appearing with altered mental status
Cardiovascular: Tachycardia, orthostatic hypotension, weak and thready pulses
Respiratory Rate: Can be normal, tachypnoea might be present if acidosis is profound
Skin: Delayed capillary refill, poor skin turgor, skin tenting might not be present even in severe dehydration because of obesity
Genitourinary: Increased urine output
CNS: Focal neurological deficit, lethargy with low GCS may be comatose if severe
BGL: >33.3mmol
How do NSAIDs cause peptic ulcers?
inhibit prostaglandins
How does meningococcal disease spread?
respiratory and throat secretions
enter via upper airway
invade the meninges, blood or lungs (singularly or at same time)
How does Helicobacter pylori (H.pylori) cause peptic ulcers?
bacteria attaches to the gastric area causing release of uriase creating ammonia which releases phospholipase affecting surface tension, acid secretions then affect cells
How is pepsin formed
pepsinogen is converted to pesin by propeptide
How many mLs of urine are in the bladder when you need to urinate?
250-300mL
How much primary urine is produced per day?
170L
How much urine does the male bladder hold?
700mL
How much urine is produced per day?
1.7L
How much urine does the female bladder hold?
500mL
Hyperkalaemia Effect on Cardiovascular System
Peaked T wave
Ectopics
Heart block
Broad QRS
Bradycardia
Cardiac arrest
Hyperkalaemia Effect on Gastrointestinal System
Nausea & Vomiting
Colicky pain
Diarrhoea
Hyperkalaemia Effect on Kidneys
kidney damage
oliguria
Hyperkalaemia Effect on Nervous System
Anxiety
Numbness
Tingling
Hyperkalaemia Effect on Skeletal and Smooth Muscle
Early: hyperactive muscles
Late: weakness & flaccid paralysis
Hyperkalaemia Manifestations
Skeletal muscle cramping leading to weakness/paralysis
Smooth muscle weakness
Cardiac arrhythmias
Hypokalaemia Cardiovascular Clinical Manifestations
Arrhythmias
ECG changes (development of U wave)
Cardiac Arrest
Weak irregular pulse
Postural hypotension
Hypokalaemia Gastrointestinal Clinical Manifestations
Nausea & Vomiting
Decreased motility (peristalsis/constipation)
Distension
Decreased bowel sounds
Ileus
(temporary lack of normal intestinal muscle contractions)
Hypokalaemia Renal (kidneys) Clinical Manifestations
Water loss
Thirst
Inability to concentrate urine
Kidney damage
Hypokalaemia Managment
Treat symptomatically
Transport
IV replacement
Hypokalaemia Nervous System Clinical Manifestations
Lethargy
Fatigue
Confusion
Depression/delium
Paraesthesia
(Tingling or prickling, “pins-and-needles” sensation in arms, hands, legs or feet)
Hypokalaemia Skeletal and Smooth Muscle Clinical Manifestations
Weakness
Flaccid paralysis
(weakness or paralysis and reduced muscle tone without other obvious cause)
Respiratory arrest
Constipation
Bladder dysfunction
Cramps
Incomplete Cord Injury
some tracts still in tact - may recover
Where does an infrarenal AAA originate?
distal to the renal arteries
Is ETC02 high or low in hyperventilation?
low as it is not being cleared
Is ETC02 high or low in hypoventilation?
high as it is not being cleared
Is MODS a process or event?
process
Where does a juxtarenal AAA originate?
just beyond the origins of the renal arteries
Large Bowel Obstruction Abdo Pain Clinical Features
waves of periumbilical cramping every 20 mins
What is the life-threatening asthma management?
oxygen (aim for 90%+)
IPPV with PEEP
salbutamol
ipratropium bromide
hydrocortisone
adrenaline
magnesium sulphate (CCP only)
CPAP (CPP only)
CCP backup ASAP
reassess
transport
(higher sats than normal)
Features of Gall Stone Pain
RUQ - tender on palpation
may radiate to back and right shoulder
intense pain lasting at least 30 minutes reaching plataeu within hour
resolve within 6 hours
Low aldosterone can lead to…
Hyperkalaemia
Hyponatremia
Decreased blood volume
Increased Protons/High H+ (Metabolic Acidosis)
Main Aetiologies of Autonomic Dysreflexia
Urological: distended bladder, UTI
Gastrointestinal: acute abdo, rectal distension
Musculoskeletal: fractures, dislocations
Others: pregnancy or skin problems such as infections, ulceration
Major causes of haematuria
Benign Prostatic Hyperplasia
Chronic Kidney Disease
Cystitis
Prostatitis
UTI’s
Renal Calculi
Trauma
Malaena haematochezia origin
more associated with upper GI bleed - can still happen sometimes with lower bleed
Management of Autonomic Dysreflexia
Management focuses on removal of the noxious stimuli. Check for kinked catheter for example
Sit patient upright with legs dependant where possible
Loosen clothing
Consider GTN if indicated
Consider Morphine or Fentanyl if indicated
Transport to hospital
Management of Cardiac Tamponade and Pericardial Effusion
Pain management
IV Fluids (to maintain radial pulse - shock = tachy, hypotensive, poorly perfused, diaphoretic)
Treat symptomatically
(eg ondansetron for nausea etc)
Prepare for resus
(manage for cardiac arrest in PEA setting)
Transport to Hospital
(must be transported as will need pericardial centesis)
(be mindful of haemostability - morphine if stable, fentanyl if not)
Management of Cholelithiasis
Pain management
Antiemetic
IV Fluids
(250 - 500 mLs)
Antipyretic
(paracetamol, will also assist with pain)
Transport
(ibuprofen - 400mg - minimise morphine as opiates affect sphincter of oddi, increasing its pressure and worsening pain)
Management of Hyperkalaemia
IV access
Sodium chloride 0.9%
CCP backup for:
Calcium gluconate
Sodium bicarbonate 8.4%
Nebulised Salbutamol
Transport
Management of Meningococcal Disease
PPE
Consider Antiemetics
IV Fluids to Maintain a Radial Pulse
(meningococcal septicaemia pts will be severely hypotensive)
If Rash Present, Administer Ceftriaxone
Consider Analgesia/antipyretic
Management of Shock
depends on cause…
IV Fluids ???
Positioning
(lift feet, lower head)
Oxygen
(don’t rely on pulse oximeter as oxygen increases o2 in plasma and haemaglobin)
Treat the cause
(good Hx to ascertain type of shock and treat - particularly if anaphylactic)
Maroon haematochezia origin
proximal end of transverse colon or descending colon
Mean Arterial Pressure (MAP) Calculation
MAP = ((2 x DBP) + SBP) / 3
Mechanisms of Kidney Filtration
Intrinsic control (renalautoregulation)
Extrinsic control
Meningism
headache
photophobia
neck stiffness
often with nausea and vomiting
Meningococcal Septicaemia results in…
Intravascular Thrombosis
Increased Vascular Permeability
Vasoconstriction and Vasodilation
Myocardial Dysfunction
Other such as Renal Impairment
Pulmonary Issues
Migraine Aura
Develops over minutes, lasts 1 hr or so, fully reversible
Migraine Description
typically unilateral and pulsating headeach that worsens with physical activity
Migraine Management
Consider analgesia (morphine/fentanyl)
Consider antiemetic (ondansetron)
Consider IV fluids (Sodium Chloride 0.9%)
Transport as appropriate
4 phases of migraines
prodrome
aura
migraine
postdrome
Migraine Postdrome
Feeling of being drained or energetic for up to 24hrs
Migraine Prodrome
Warning symptoms up to 24 hrs prior to migraine
Migraine prodrome symptoms
neuro changes (clumsy, lethargic, yawning, difficulty finding right words)
changes in behaviour (obsessional, hyperactive, lethargic)
changes in mood
gut symptoms
Migraine Triggers
food - cheese, chocolate
blow to head
barometric pressure changes
hormones
What is the moderate asthma management?
oxygen
salbutamol
ipratropium bromide (if unresponsive to first salbutamol neb)
hydrocortisone
reassess
transport
(aim for 92%+)
What is the Modified Centor Criteria for Bacterial Pharyngitis
Helps predict the probability of streptococcal pharyngitis
Near Syncope
light headedness and impending loss of consciousness
Forms of Nephrolithiasis Formation
Calcium oxalate
Calcium phosphate
Cystine crystals
Magnesium ammonium phosphate crystals
Uric acid
Nephrolithiasis Management
Pain management
Potential IV fluids
Transport to hospital
(paracetamol/ibuprofen/morphine/midaz etc)
Obstructive Shock
extracardiac causes leading to a decrease in the left ventricular cardiac output
Order of septicemia, sepsis and septic shock
septicemia
sepsis
septic shock
Organ Systems Affected by Hyperkalaemia
skeletal and smooth muscles
nervous
cardiovascular
gastrointestinal
kidneys
Where does the Pararenal AAA Originate?
the renal arteries
Causes of Bowel Obstruction
Functional obstruction
Mechanical obstruction (extrinsic or intrinsic or luminal defect)
Non-strangulating or strangulating
(strangling leads to poor perfusion ad necrosis)
(peristalsis/intestinal motility)
Peptic Ulcer Management
pain management
IV fluids
antiemetic such as metoclopramide
oxygen as required
transport
What is Percicardial Effusion
too much fluid in pericardial cavity
Peritonsillar abscess signs and symptoms
Appearing ill
Fever
Drooling
Trismus
Sore throat
(generally unilateral)
Muffled voice
(hot potato)
Dysphagia
Peritonsillar abscess Tx
Treat symptomatically
Transport to Hospital
Peritonsillar abscess on examination of the oral cavity
Inferior and medial displacement of the affected tonsil
Contralateral deflection of the uvula
Swollen red tonsil
Cervical adenopathy
May or may not display purulent exudate
Pneumonia Tx
Oxygenation
Paracetamol
Salbutamol if wheezes present
Antiemetic
Transport
Pneumonia Tx if dysregulated with signs of sepesis
Oxygenation
Paracetamol
Salbutamol if wheezes present
Antiemetic
IV access
IV fluids
Hospital notification and transport
Precipitating events for hyperosmolar hyperglycaemic syndrome (HHS)
Medications
Infection
Surgery
CVA
Cardiovascular condition
(Stroke, Angina, AMI)
(thiazides diuretics, beta blockers, glucocorticoids and some atypical antipsychotics)
Primary Headaches
Migraines
Tension headaches
Cluster headaches
Pulmonary Embolism Clinical Features
Dyspnoea
Chest Pain (pleuritic)
Cough
DVT symptoms
ECG Changes
Tachycardia
+- Hypotension
Rarely: syncope, shock, haemoptysis
Pulmonary Embolism Management
Oxygen as required
Pain relief
IV fluids……careful
(no more than 1L as failing RV, and increasing preload adds stress to a failing pump)
Back up if haemodynamically unstable
(CCP as can provide vagal pressers)
Transport to Hospital
(for anticoagulants and antithrombolysis)
Prepare for resuscitation
(may deteriorate quickly)
(titrate as per sat levels)
Pulmonary Embolism Risk Factors
Inherited
Prothrombin gene mutation
Factor V Leiden mutation
Sickle Cell Disease
Acquired
age
obese
smoking
surgery
trauma
QAS Recognition of Sepsis
Requires 2 or more of:
Temp - < 35 or > 38.5⁰C
RR - >25
HR - <40 or > 110
SBP - _<_90
AVPU - new confusion
Reftactory anaphylaxis management following 3 x IM adrenaline
Upper airway obstruction:
Nebulised adrenaline
For persistent wheezing:
Salbutamol and Hydrocortisone
For persistent hypotension/shock:
Continue IV fluids + Glucagon
Risk Factors for Aortic Dissection
age
family history
hypertension
marfan syndrome, turner syndrome
pre-existing aortic aneurysm
trauma
(most common from deceleration)
Risk Factors for Bowel Obstruction
Crohn’s disease
Hernia
Hx of foreign body ingestion
Hx of cancer
Prior abdominal surgery
Risk factors for meningococcal disease
Infants ≤5 years old, late teens and ≥ 65 years old
Hx of preceding illness
Intimate kissing
Not vaccinated
Risk Factors for Nephrolithiasis
Acidic urine
Diet
(low fluid, potasium and calcium intake, high animal protein intake)
Frequent UTI’s
Previous Hx or family Hx of renal stones
Risk factors for peptic ulcers
Helicobacter pylori (H.pylori)
NSAIDs
Physiological stress
risks in conjuction with pepsin causes ulcers
Risks of aspiration pneumonia
Dysphagia from neurologic deficits
Disorders of the upper gastrointestinal tract
Mechanical disruption of the glottic closure
Reduced consciousness
Secondary Headaches
Subrachnoid haemorrhage (SAH)
Sepsis Management
Position of patient
Oxygen
normothermia assistance where appropriate
analgesic - paracetamol
antipyretic - Paracetamol
IV access
BGL
12 lead
IV sodium chloride 0.9% in the setting of inadequate perfusion
Adrenaline
(CCP - if perfusion not maintained with fluid resuscitation)
Transport and pre-notify without delay
(auto infusion in the setting of low BP)
Sepsis Signs and Symptoms
Lethargy/Weak/Look unwell
Red discoloration or small red dots that cover large portions of the body
Mottled skin
Fever or Low body Temperature
Rigors
(feeling cold & shivering)
Altered Mental State
Hypotension
Tachycardia
Tachypnoea
Nausea, vomiting and diarrhoea
Decreased Urine Output
Sluggish cap refill
Joint & Muscular pain
Cold hands and feet
(as BP drops)
What is the severe asthma management?
oxygen
(aim for 92%+)
salbutamol
Ipratropium bromide
hydrocortisone
adrenaline
magnesium sulphate - CCP only
CPAP - CCP only
CCP backup ASAP
reassess
transport
Shock Clinical Features
diaphoretic
poorly perfused
tachycardic
hypotensive
Signs and Symptoms of Anaphylaxis
Gradual or rapid onset of localised or generalised symptoms of:
Cutaneous
angioedema (swelling)
urticaria (rash)
flushed skin
pruritus (itch)
Respiratory
rhinitis (runny nose)
wheeze
difficultly breathing
upper airway swelling
Cardiovascular
collapse
hypotension
dizziness
bradycardia/tachycardia
Abdominal
nausea and vomiting
abdominal pain
diarrhoea
Signs and symptoms of diabetic ketoacidosis (DKA)
poor skin turgor
ALOC/unconsciousness
decreasing GCS
dizziness
irritability
poor cognition
acetone breath
kussmaul breathing
Signs and Symptoms of Meningitis/Septicaemia in Older Children and Adults
General Malaise
Fever
ALOC/Moaning/Unintelligent Speech
Meningism
(headache, photophobia and neck stiffness)
Tachypnoea and Tachycardia
Vomiting
Aching/Sore muscles and Joint Pain
Cold Extremities
Petechial Rash or Purpuric Rash
(Advanced Sign)
Signs and Symptoms of Meningitis/Septicaemia in Young Children
Fever
Irritability
ALOC
Photophobia
Food refusal
Grunting/Moaning
Vomiting
Petechial Rash or Purpuric Rash
Blotchy Skin
Signs of Dehydration
dry mucous
tachycardia
orthostatic hypotension
decreased urine output
Small Bowel Obstruction Abdo Pain Clinical Features
waves of periumbilical cramping every 4-5 mins
Some Causes of Pneumonia
Bioterrorism
Emerging infections from animal sources
(Coronavirus, H5N1 avian influenza)
Haemophilus influenzae
(bacteria)
Influenza
Rhinovirus
Streptococcus pneumoniae
(inhalation anthrax)
Stanford Aortic Thoracic Dissection Classification
Type A: any involvement of ascending aorta
Type B: involves the aorta distal to the origin of the left subclavian artery
Subarachnoid Haemorrhage (SAH) Management
Consider analgesia
Consider antiemetic
Consider anticonvulsant if seizure present
Transport as appropriate
Prepare for resuscitation
Subarachnoid Haemorrhage (SAH) Symptoms/Clinical Features
Thunderclap headache
ALOC
(2/3s Pts)
Seizures
photophobia
nuchal rigidity
(stiff neck)
nausea/vomiting
(blood toxic to brain when not in vessels)
(sudden, worst headache ever, peaks in minutes)
Subarachnoid Haemorrhage Danger Signs and Considerations
Hx of intracranial bleed
Family Hx of intracranial bleed
Thunderclap headaches
Progressive headache worsening over weeks
Aura lasting longer than 60 minutes
Meningism
Anticoagulant or antiplatelet therapy
Subarachnoid Haemorrhage (SAH) Description
leak of blood from rupture of intracranial vessel lasting a few seconds but can reoccur
blood released into intracranial fluid and increases ICP
life threatening
Where does a suprarenal AAA originate?
one or more visceral arteries but does not extend into the chest
Symptomology of Influenza
Myalgia
Weakness
Fever and chills
Headache
Nasal congestion
Sore throat
Cough (non-productive)
Symptomology of the common cold
Malaise
Low-grade fever
Nasal Congestion
Rhinorrhea
Sore throat
Cough (within 24-48h)
Syncope
brief loss ofconsciousness due to hopoperfusion of brain
Syncope Management
Supine/legs elevated
determine type of dizziness, post-ictal phase?, prodrome? quick onset?
Pharmacology: Ondansetron? Sodium Chloride?
(dehydration, poor cardiac output - MAP should be > 60 mmHg)
Transport as appropriate
(increases perfusion to brain)
What are the TAA and AAA Risk Factors?
age
family history
pre-existing cerebral aneurysm
previous hx of aortic dissection
hypertension
several syndromes (marfan or turner syndrome)
trauma (more commonly from deceleration)
Tension Type Headache Description
bilateral
NOT pulsating
NOT worsend by exertion
NOT associated with nausea/vomiting
Tension Type Headaches Management
Paracetamol
Severe tension-type – Same as migraines
The 3 Causes of Venous Thrombosis
inherited hypercoagulable state
Factor V Leiden
prothrombin gene mutation
acquired hypercoagulable state
surgery
trauma
malignancy
haemoglisations
pregnancy
liver disease
combination of inherited and acquired
The two types of DVT
Proximal - popliteal up
Distal - popliteal down
(greater risk of creating embolism)
Thoracic Aneurism Locations
Ascending
Descending
Arch
Thoracoabdominal
Three most common causes of portal hypertension
Cirrhosis of the liver
Hepatic schistosomiasis
Pre/post hepatic thrombosis
To be classified as an aneurysm, the aorta must
increase in size by at least 50%
Types of Pericarditis
acute - new onset
incessent group - > 4 wks but <3 mths
chronic >3 mths
recurrent - symptom free 4-6 wks but then comes back
Typical symtpoms of complicated painful gall stones
Jaundice
Fever
Pain
Tachycardia
Urinary Retention Management
abdo palption suprabubic area
ask about Hx prostate, bladder CA, infection, fever
Pain management as required
(panadol/maybe opiates)
Transport to hospital
Variceal Haemorrhage Management
ascites
(ask about alcohol intake, emesis, melena)
IV fluids (as required - titrate to maintain radial pulse)
antiemetic
(metoclopramide)
oxygen as required
(hi flow if shocked - titrate to maintain adequate sats)
transport
(pre-notify)
Vertigo
perception of constant movment happening when not moving
subjective - I am spinning
objective - things are spinning
Vertigo Management
determine type of dizziness and if peripheral or central and duration of symptoms
Pharmacology? Ondansetron? Sodium Chloride?
(Ondans treats brain disorders and MS)
Transport as appropriate
Viral Pharyngitis and Tonsillitis Symptoms
Feeling unwell
Fever (either low or high-grade)
Headache
Rhinorrhea
Sore throat
Painful swallowing
Redness and/or drainage in throat
Vesicular/petechial pattern on soft palate and tonsils
Nausea/vomiting
Viral Pharyngitis and Tonsillitis Tx
Treat symptomatically
fever & pain - paracetamol
dehydrated - 0.9% sodium chloride
nausea - ondansetron
Transport for further care or consider GPappointment
What are peptic ulcers?
umbrella term for gastic and duodenal ulcers
What are saccular aneurysms?
Wall extrusions of blood through the thin or absent tunica media
What are the 2 types of pharyngitis and tonsillitis
viral
bacterial
What are the categories of shock?
Cardiogenic
Hypovolemic
Relative Hypovolemic
Media/layman’s
What are the components of intrinsic control of regnal autoregulation?
Myogenic mechanism
Tubuloglomerular feedback mechanism
What are the conducting passagees in the upper respiratory tract?
nasal cavity
pharynx
larynx
What are the four categories of relative hypovolaemic shock?
Anaphylactic
Burns
Neurogenic
Septic
What are the stages of shock?
Compensation stage
Decompensation stage
Refractory
What are the three steroid hormones produced by the adrenal cortex?
adrenal androgens
glucocorticoids
mineralocorticoids
What are the viruses of the common cold?
Adenovirus
Coronavirus
Influenza
Rhinovirus (most common)
What are the viruses of Influenza?
Avian Influenza A (H5N1)
Influenza A, B, C and D
Swine Flu Influenza A (H3N2)
Influenza A (H1N1) from the 2009 new outbreak
What are varices?
enlarged swollen veins in the distal esophagus or proximal stomach caused by elevated pressure in the portal venous system, typically from cirrhosis
What can cause urinary retention?
Medications
Trauma
Infection
Neurologic issues
Outflow obstruction
Inefficient detrusor muscle
What clinical variables define systemic inflammatory response syndrome (SIRS)?
temperature <35 or >38
HR <90
RR >20
PCO2 <32 mmHg
WBC <4000 or >12000
(hospital test)
What colour can haematuria be?
brown
red
(macroscopic)
clots
(macroscopic)
invisible
(microscopic)
(macroscopic)
What comprises the respiratory conducting zone?
upper respiratory tract
What comprises the respiratory end zone?
bronchioles
alveoli
What do prostoglandins do?
prostoglandins inhibit acid secretions and stimulate mucous production and bicarbonate and protect against damaging compounds
What does the conducting zone do?
cleanses air
removes dust and bacteria
humidifies air
warms air
What factors does the modified centor criteria for bacterial pharyngitis take into consideration?
age
fever
tonsillar exudate
anterior cervical LAD
(lymph node swelling)
absent cough
What happens during the compensation stage of shock?
BP drops so autonomic nervous system kicks in causing:
diaphoresis
vasoconstriction
tachypnoeic
Tachycardia
Renin angiotensin system also kicks in causing:
Vasoconstriction
Decrease urine output
What happens during the decompensation stage of shock?
HR can’t keep up causing:
blood pressure decrease
(<100 mmHg)
organ perfusion decrease
(heart and brain prioritised for blood)
What happens during the refractory stage of shock?
Low SBP causes:
Systemic Inflammatory Response Syndrome (SIRS)
(organs not getting perfused and can’t perform functions - cell rupture as sodium into cell)
Multiorgan Failure (MOF) (from SIRS)
Death
What is Anaphylactic Shock
cardiovascular collapse and respiratory distress due to bronchospasm
What is a functional bowel obstruction?
peristalsis/intestinal motility
What is a lumina defect bowel obstruction?
crohns disease, gall stones, foreign body, twisted bowel
What is acute cholecystitis?
inflammation of gall bladder secondary to gall stones
What is Acute Perciditis
inflammation of the pericardium
What is acute upper gastrointestinal bleeding?
uncontrolled haemorrhage in gastric region causing haemotemesis or melena
What is addison disease (primary adrenal insufficiency)
adrenal glands fail to release adequate hormones to meet physiologic needs, despite release of ACTH from the pituitary
Note: ACTH = Adrenocorticotropic Hormone
What is an acute lower gastrointestional (PR) bleed?
bleed that originates from the colon with an acute onset
What is an aortic dissection
a tear in the inner layer (tunica intima) of the aorta allowing blood to flow into the intima-media space
What is an extrinsic bowel obstruction?
from outside - adhesion, bulge
What is an intrinsic bowel obstruction?
from within - disease, cancer
What is anaphylactic relative hypovoleamic shock?
blood vessels vasodilate and capillary gets leaky and leaks out fluid from blood
What is anaphylaxis?
a multi-system severe allergic reaction characterised by an acute onset of cardiovascular (eg hypotension) or respiratory (eg bronchospasm) symptoms
What is appendicitis?
inflammation of the appendix
What is bowel obstruction?
lumen gets obstructed
What is burn relative hypovolaemic shock?
cell mediators cause vasodilation and capillary gets leaky and leaks out fluid from blood
What is Cardiac Tamponade
increased pericardial pressure creates cardiac dysfunction (heart can’t stretch to pump properly)
What is cardiogenic shock?
impaired cardiac output primarily caused by failure of the left ventricle
What is cholangitis?
infection of the liver’s bile ducts - fever, jaundice and pain)
What is cirrhosis of the liver
dead cells replaced by connective tissue, restricting blood flow
caused by hep B and C, alcoholics, non alcoholic fatty disease
What is complicated gallstone disease?
biliary colic (pain) with the any of the following:
Acute cholecystitis
Cholangitis
Gallstone pancreatitis
What is diabetic ketoacidosis (DKA)?
build up of ketones in the blood from breaking down fat for energy when the body doesn’t have enough insulin to process blood sugar into energy
What is gall stone disease?
when gall stones cause symptoms
What is gallstone pancreatitis?
affects pancreatic duct or obstructs hepatopancreatic ampula
What is Haematuria
blood in urine - symptom not a condition
What is hyperosmolar hyperglycaemic syndrome (HHS)?
also known as non-ketotic hyperglycaemic hyperosmolar syndrome (NKHS)
profound hyperglycaemia BGL >33.3 mmol/L where fluid is drawn into the blood vessels through osmotic pull causing severe dehydration from excessive urination
What is hypokaleamia?
low potassium levels in the blood
What is hypovolaemic shock?
decreased intravascular volume due to fluid loss from traumatic blood loss or;
internal fluid shifts (severe dehydration, edema, or ascites)
What is Hypovolemic Shock
decreased intravascular volume and increased systemic venous assistance
What is primary urine?
Filtrate - 1st pass
nutrients, iron, water
What is media/layman’s shock?
term used by media to describe highly stressed state - catatonic, delirious etc
What is meningococcal disease?
Illness caused by Neisseria meningitidis bacteria in the meninges, spinal cord (meningitis) and bloodstream.
What is meningococcal septicaemia
infection in blood stream and going septic and affects integrity of blood vessels causing bleeding into organs
What is Metabolic Acidosis?
low bicarbonate levels
What is Multiple Organ Dysfunction Syndrome (MODS)
the development of a potentially reversible physiologic derangement involving two or more organ systems not involved in the initial cause of the physiological derangement (extension of SIRS)
What is neurogenic relative hypovolaemic shock?
spinal injury causing vasodilation - particularly above T4 level
What is normal blood pH?
7.35 - 7.45 pH
What is pancreatitis?
inflammation of the pancreas from large pooling of pancreatic juices in the pancreas
What is pneumonia?
acute infection of pulmonary paranchema (alveoli and bronchioles)
What is portal hypertension?
portal system gets to pressure >10mmHg
What is rabdomyolysis?
myoglobin protein in the blood caused by muscle breakdown and death due to overexertion trauma, toxins or disease
What is refractory anaphylaxis?
symptoms continue post adrenaline x 3
What is relative hypovolaemic shock?
third spacing of fluids eg bowel obstruction; ascites; loss of blood volume into a fracture site; burns
What is Respiratory Acidosis?
ETCO2 levels over 45 mm
What is Respiratory Alkalosis?
ETCO2 levels below 35mm
What is Sepsis?
life-threatening organ dysfunction caused by a dysregulated host response to infection
What is septic relative hypovolaemic shock?
cell mediators cause vasodilation and capillary gets leaky and leaks out fluid from blood
What is Septic Shock?
a subset of sepsis in where intense circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone
What is Septicemia?
a serious bloodstream infection that occurs when a bacterial infection in another part of the body, such as the lungs or skin, enters the bloodstream
What is shock?
the inadequate perfusion of tissues to meet the metabolic demands at that time and effectively remove the tissues metabolic wastes (heart not pumping enough blood to sustain life or perform functions)
What is SIRS termed as when caused by infection?
sepsis
What is splanchnic circulation?
splantnic circulation feeds abdomen
What is Systemic Inflammatory Response Syndrme (SIRS)?
systemic inflammation and widespread tissue injury caused by trauma, thermal injury, pancreatitis, autoimmune disorders, and surgery
How much blood passess the the kidneys per day?
1700L
What is the main vehicle for excreting cholesterol?
bile
What is the myogenic mechanism of Intrinsic control (renal autoregulation)?
Responds to BP - vasoconstricts to reduce flow if BP increases and dilates if BP drops to increase flow
What is the neural control of extrinsic control in renal filtration?
SNS shunts blood to vital organs, adrenalin and noradrenalin to smooth muscles affecting efferent arterioles and causing vasoconstriction
What is the normal ETCO2 range?
35 - 45 mm
respiratory rate increases with ETCO2 increase
What is the role of the appendix?
immunity - has lymphoid tissue and stores bacteria to replenish the gut when required
What is the role of the large intestine/bowel?
a little bit of digestion through good bacteria
absorption - water and electrolytes - sodium chloride and some vitamins
What is the role of the small intestine/bowel?
digestion and absoprtion
What is the Tubuloglomerular feedback mechanism of Intrinsic control (renal autoregulation)?
macular densa cells monitor flow and osmolarity
will promote vaso dilation to increase flow if too slow
will constrict if flow or osmomolarity is too high
What is the vestibular Occular Reflex
connections between the brainstem, cerebellum and parietal lobes and occulomotor nuclei
What is uncomplicated gallstone disease?
biliary colic - pain with no related complications
What is V/Q Mismatch Dead Space?
the portion of the respiratory system where tidal volume doesn’t participate in gas exchange: it is ventilated but not perfused.
What is variceal haemorrhage?
slow leak or full rupture of varices
mortality rate of up to 60%
ascites/alcholism can be an indicator
What is Metabolic Alkalosis?
Increased bicarbonate levels
What is Biphasic anaphylaxis?
less common
Has 2 phases:
spontaneously recover - asymptomatic in 1-24 hours
return of some symptoms approx 16-48 hours later
(may not be the same ones)
What is choledocholithiasis?
gall stones within common bile duct
What is Cholelithiasis?
gall stones in the gall bladder that causes pain when the gall bladder constricts
What is Hepatic schistosomiasis?
group of 5 paracites creating immune response and irreversible fibrosis
What is Nephrolithiasis?
kidney and ureteral stones - painful renal colic
What is Protracted (persistent) anaphylaxis?
less common, lasts hours to days without completely self resolving
What is Uniphasic anaphylaxis?
80-90% - peak within minutes to hours, may spontaneously self resolve within a few hours
Who are high risk Pts for sepsis?
Underlying Malignancy/Chemotherapy/Radiation Therapy
Autoimmune
Elderly _>_65 yrs
Infants < 3 mths
Haemodialysis
Alcoholism
Diabetes
Why does jaundice occur?
pooling of bile pigments (yellow) making way through blood and into the skin
Why is glomerular filtration rate crucial?
too fast - nutrients and iron not reabsorbed
too slow - waste products reabsorbed with nurients
What are ketones and ketoacids?
alternative fuels for the body that are made when glucose is in short supply
Clinical features of peripheral vertigo
diaphoresis
spinning
nystagmus
nausea and vomiting
Clinical features of central vertigo
incoordination
headache
diplopia
nystagmus - main objective sign
slurred speech
limb weakness
Migraine aura signs and symptoms
generally visual
Less commonly affects speech or sensation
(dark spots, flashing lights)
Migraine signs and symptoms
Scalp may or may not be tender
photophobia
phonophobia
nausea/vomiting
Symptoms not entirely sensitive
(can be bilateral for instance)
TAA clinical features
pain
hoarseness of voice
(due to pressure on laryngeal nerve)
dysphagia
(compression of oesophagus)
wheezing
(compression of tracheal bronchial tree)
cough
(compression of tracheal bronchial tree)
haemoptysis
(compression of tracheal bronchial tree)
dyspnoea
(compression of tracheal bronchial tree)
(generally asymptomatic, pain will be in chest and back)
Clinical features of DVT
Pain
leg swelling
warmth
erythema
(dull ache/tight feeling, generally in calves, can be across whole leg depending on thrombus location, felt on palpation)
Clinical features of pericardial effusion and cardiac tamponade
Fatigue
fever
(pericarditis)
distended jugular veins
(increased pressure - poor ejection fraction backs up blood)
dyspnoea
(cardiac tamponade)
chest pain
(cardiac tamponade)
tachycardia
pulsus paradoxus (BP drop of 10mmHg or more between expiration (highest) and inspiration)
hypotension
(late stage)
obstructive shock (decompensating)
PEA cardiac arrest
(can’t physically pump anymore)
(poor ejection fraction as heart is restricted)
Pneumonia clinical features
fever
ALOC
cough
(dry or productive)
SOB
(may have crackles, decreased breath sounds or other consolidated sounds)
pleuritic chest pain
nausea and/or vomiting
diarrhoea
(chills 40-50%, ribals 15%)
Acute pancreatitis clinical features
fever
jaundice
ecchymotic discoloration
tachypnoea
tachycardia
hypotension
epigastric pain
(radiates to back 50%, may localise to RHS & eased when lean forward)
nausea and vomiting
Bowel obstruction clinical features
Sudden onset of abdo pain
Nausea
(more common in small)
Vomiting
(more common in small)
Abdominal distention
Obstipation
(no movement of gas or stool)
Fever (with ischemic bowel or necrosis)
dehydration
(hallmark of small bowel obstruction)
(sm - periumbilical cramping waves every 4-5 mins, lg - periumbilical waves every 20 mins)
Acute urinary retention clinical features
restless
acute change of mental status
(esp elderly pts with cognitive impairment)
abdominal pain
ack pain
nil/extremely decreased urine output
Peptic ulcers clinical features
potential hypovolemia
hematemesis
heartburn
epigastric pain - may radiate to back
nausea
bloating/fullness
melena
What simple procedure can you do to help someone having a panic attack?
5 senses
De Bakey Aortic Thoracic Dissection Classification
Type I: ascending aorta; involves all portions of the thoracic aorta
Type II: ascending aorta only, stops before the innominate artery
Type III: almost always involves the descending thoracic aorta only, starting distal to the left subclavian artery; can propagate proximally into the arch
Extent I Thoracoabdominal Aortic Aneurysm Classification
arises from above the sixth intercostal space near left subclavian artery
includes the origins of the celiac axis and superior mesenteric arteries
renal arteries can be involved
Extent II Thoracoabdominal Aortic Aneurysm Classification
arises above the sixth intercostal space
may include ascending aorta
extends distal to include the infrarenal aortic segment often to the level of the aortic bifurcation.
Extent III Thoracabdominal Aortic Aneurysm Classification
arises in the distal half of the descending thoracic aorta below the sixth intercostal space
extends into the abdominal aorta
Extent IV Thoracoabdominal Aortic Aneurysm Classification
involves the entire abdominal aorta from the level of the diaphragm to the aortic bifurcation
Extent V Thoracabdominal Aortic Aneurysm Classification
arises in the distal half of the descending thoracic aorta below the sixth intercostal space
extends into the abdominal aorta but limited to the visceral segment
Key components of HHS
Gradual onset
BGL >33.3mmol
Coma
ALOC
Impaired cognitive state
Seizures (25%)
Severe dehydration
Cellular dehydration
Decreased cellular function
Polyuria
Postural Hypotension
Hypokalaemia
(also low magnesium and calcium)
What is the AAA treatment?
Consider:
oxygen
IV access
analgesia
antiemetic
IV fluids
blood
transport
pre-notify as appropriate
What is
What is the Modified Wells Criteria:
A set of scored criteria which indicates the Pt’s likelihood to have a pulmonary embolism
What is the Modified Wells criteria assessment score >4.0?
PE likely
What is the Modified Wells criteria assessment score <4.0?
PE unlikely
What is a transient ischaemic attack (TIA)?
short lived stroke, with signs and symptoms that spontaneously resolve within 24hrs
What is a cerebrovascular accident (CVA)?
acute interruption to cerebral perfusion causing brain injury
What are the two types of cerebrovascular accidents (CVAs)?
- lschaemia (80°/o ): CVA due to a blockage or loss of cerebral perfusion
- Haemorrhage (20°/o ): CVA due to a cerebral bleed
What are the two types of cerebrovascular accidents (CVAs)?
- lschaemia (80°/o ): CVA due to a blockage or loss of cerebral perfusion
- Haemorrhage (20°/o ): CVA due to a cerebral bleed
Can hyHypoperfusion and reduced CPP cause a CVA?
yes
What can raised intracranial pressure may progress to?
brain/cerebral herniation
What are the underlying causes of ischaemic stroke?
- Arterial thromboembolism
- Cardioembolism (clot from heart)
- Carotid/vertebral artery/intracranial atheroma (build up of materials)
- Gas embolism (from pneumothorax)
- Hypercoagulopathy
- Hypotension
- Severe vascular stenosis (narrowing of blood vessels)
What are the underlying causes of haemorrhagic stroke?
- Amyloid angiopathy (protein build up in arteries)
- Anticoagulant therapy or coagulopathy
- Aneurysm
- Arteriovenous malformations (AVM)
- Hypertensive crisis (massive spike in BP)
- Secondary haemorrhage from cerebral lesion (poorly formed blood vessels, tumour)
What are some of the differential diagnoses for stroke?
- Conversion disorder (results from psychological stress)
- Electrolyte derangement
- Encephalitis
- Hypoglycaemia
- Infection (particularly with fever in elderly) and sepsis
- Migrainous aura and/or hemiplegia (with/without pain)
- Space-occupying cerebral lesions
- Seizures and post-ictal periods
What are stroke (CVA including TIA) risk factors?
- Age >60 years
- Diabetes mellitus
- Excess alcohol consumption
- Heart disease
- Hyperlipidaemia
- Hypertension
- Oral contraceptives
- Previous vascular event, e.g. STEMI, DVT
- Race: Afro-Caribbean > Asian > Caucasian
- Smoking
What assessment should you do to determine stroke?
- Questioning of Pt and witness
- National Institute of Health Stroke Scale (NIHSS-8)
- 12-lead ECG (stroke can cause dysrhythmias)
- Head-to-toe:
- Motor and sensory function
- Rashes, piloerection
- Colour & temperature changes
- Chest auscultation (listen for oedema)
- Urinary retention (distended bladder)
- Injuries sustained during collaps
What is the National Institutes of Health Stroke Scale (NIHSS)?
a systematic, quantitative assessment tool to measure stroke-related neurological deficit
What are the National Institute of Health Stroke Scale (NIHSS) components?
- Level of consciousness
- Questions (age, month)
- Commands (eyes, grip)
- Gaze tracking
- Facial palsy
- Speech (clear or slurred)
- Motor arm (drift downwards)
- Extinction and inattention (of affected side)
What is the stroke (CVA) treatment plan?
- Reassurance and non-pharmacological relief
- Position patient with 45° head elevation
- Life-threatening/haemodynamically unstable?
- Seizures to be managed in the standard way
- IV fluids (large-volume replacement or permissive hypotension?)
- Consider oxygen, analgesia, anti-emetics
- Repeat stroke assessments to trend condition
- Rapid transport to appropriate receiving facility
