Presentations Flashcards
What is more important in a case of poisoning/overdose - the drug history, or the clinical assessment?
The clinical assessment - a drug history may be uunreliable as the pt may not be able to give a history, and if they truly meant to overdose, they will lie.
What are the main toxindromes that we can recognise in poisoning situations?
Sympathomimetics
Anticholinergics
Cholinergic
Opioid/sedative syndromes
What does the sympathomimetic toxindrome mimic?
The flight or fight reaction.
What drugs can cause the sympathomimetic toxindrome?
Adrenaline/NA Caffeine Methmphetamines (LSD/ritaline) Theophylline Ecstasy SSRIs Alcohol withdrawal
A patient comes in with an overdose. They are hypertensive, tachycardic, agitated, and hyperthermic. What other symptoms are common in this toxindrome?
Arrythmias Mydriasis Convulsions Rhabdomyolysis ACS/CVA/Mesenteric ischaemia
A patient comes in with an overdose. They are hypertensive, tachycardic, agitated, and hyperthermic. Which toxindrome is this?
Sympathomimetic toxindrome.
Could also be antocholinergic toxindrome.
How should sympathimimetic toxindrome be managed?
Symptomatically - cooling, sedation, hydration
What can be used to sedate a pt with sympathomimetic toxindrome?
Benzodiazepines
What are the classic symptoms of alcohol withdrawal?
Pyrexia
Tactile hallucinations, classically insects on skin
What can be given for pyrexia in sympathomimetic toxindrome?
Paracetamol
What can be given for tachycardia in sympathomimetic toxindrome?
You don’t! Benzos can sedate the patient, but DO NOT give beta blockers!
A patient comes in with overdose symptoms. They are agitated, tachycardic, dry skin, hyperthermic, in urinary retention, and complaining for palpitations. What toxindrome does this sound like?
Anticholinergic toxindrome
Which arrythmias are associated with anticholinergic toxindrome?
Long QT
Torsades de Pointes
Which drugs cause anticholinergic toxindrome in overdose?
TCAs Other antidepressants Class 1A antiarrhythmics (quinodine) Antihistamines Antipsychotics Antispasmodics Mydriatics Carbamazepine Atropine
What is found on examination of a patient with antocholinergic toxindrome? (not observations)
Dilated pupils
Urinary retention
Dry, flushed skin
Bowel sounds reduced
What bloods need to be done in an overdose?
Routine Bloods
VBG
Drug levels in the blood (depending on hospital capbility)
A patient comes in with overdose symptoms. They are agitated, tachycardic, dry skin, hyperthermic, in urinary retention, and complaining for palpitations. What is the management for this toxindrome?
Anticholinergic toxindrome:
- Magnesium sulphate for metabolic acidosis
- Bicarbonate for acidosis
-Physostigmine in ITU setting (can cause seizures and agitation)
A patient comes in with overdose symptoms. They are sweating, salivating, have watering eyes, and incontinence. What other signs would you expect from this toxindrome?
N&V Increased bronchial secretions Myosis Bradycardia Convulsions Respiratory depression
A patient comes in with overdose symptoms. They are sweating, salivating, have watering eyes, and incontinence. Which toxindrome is this?
Cholinergic toxindrome
How should cholinergic toxindrome be managed?
Atropine
Pralidoxyme
Why is atropine used to counteract cholinergic toxindrome?
It is a vagolytic
What drugs cause cholinergic toxindrome?
Pesticides
Organophosphates
Some mushrooms
When dealing with a pesticide/organophosphate overdose, why is PPE important?
Skin to skin transfer and inhalation from the patient to the HCP can occur.
A pt comes in with an overdose. They are barely breathing, have constricted pupils, reduced GCS, and are bradycardic and hypothermic. What drug overdose is likely?
Opiate or sedative overdose.
Which drugs can cause opiate/sedative oerdose?
Morphine Heroin Codeine Tramadol Hydromorphine Fentanyl Methadone Alfentanyl Hydrocodone Oxycodone Benzos Barbiturates
What is the antidote for opiate overdose?
Naloxone
What is important to remember about naloxone?
It has a short half life so will work for a little while before needing another dose.
What is the antidote for benzo overdose?
Flumazenil
What can be screened for toxins?
Blood and urine
Other than direct antidotes, what management can be used for overdoses?
- Supportive
- Prevention of absorption
- Dialysis
What can be done to prevent absorption in drug overdoses?
- Gastric lavage (not v. popular)
- Activated charcoal
Which drugs are absorbed by activated charcoal?
Theophylline Aspirin Paracetamol Phenobarbitol Modified release drugs
Which overdose most commonly requires dialysis?
Ethylene glycol (anti-freeze)
How common is chest pain as a presentation to A&E?
5% of A&E visits as well as 40% of admissions to hospital
What causes of chest pain are there (by system)?
- Cardiac - ischaemic and non-ischaemic
- Respiratory
- MSK
- GI
- Breast disease
- Skin disease
- Psychiatric
- Sickle cell
What ischaemic cardiac causes of chest pain are there?
Angina ACS Coronary vasospasm Cardiomyopathy Aortic stenosis
What non-ischaemic cardiac causes of chest pain are there?
Arrythmias
Aortic dissection
Pericarditis
Mitral valve disease
What are the acute respiratory causes of chest pain?
Pneumothorax PE Pneumonia Pleuritis Lung cancer (not acute, but can cause acute pain)
What are the MSK causes of acute chest pain?
Costochondritis Trauma Rib pain Radicular pain Fibromyalgia
What are the GI causes of acute chest pain?
GORD Oesophageal rupture/spasm Peptic ulcer disease Cholecystitis Pancreatitis Gastritis
What old results are useful for acute chest pain assessment?
Old ECGs
Old chest x-rays
Describe the typical chest pain for ACS.
Central, crushing/stabbing. Radiates to jaw/arm Assoc. with sweating, N&V \+/- SoB Timing - 15 minutes plus GTN spray helped (if used)
What is the difference between a STEMI and NSTEMI/unstable angina?
STEMI causes cardiac muscle death -> ST elevation on ECG.
NSTEMI/unstable angina -> cardiac muscle damage
What is the classic presentation of chest pain for pericarditis?
Positional pain - wrose on leaning forwrad. Sharp, central, retrosternal Worsens on deep inspiration Low grade fever Pressing on oesophagus -> reflux
How do pericarditis and myocarditis differ in presentation?
They are very similar, but myocarditis may also have symptoms of LVHF.
What are the symptoms of cardiogenic pulmonary oedema?
Chest pain
SoB
Tachycardia
Arrythmias
A pt presents with pleuritic chest pain and SoB, with haemoptysis. What is the top differential?
Pulmonary embolism
A pt with pleuritic chest pain and SoB has an episode of syncope and is cyanosed. What is the top differential?
A Massive PE
What can we use to determine assessment and management of a PE?
Wells score
What are the elements of the wells score?
S/S of DVT PE likely diagnosis HR >100 Immobilisation or recent surgery PMH of dvt/pe Haemoptysis Malignancy
A pt presents with chest pain. They describe it as a tearing pain that radiates to the back, and they had an episode of syncope when it first started. What is the most important differential?
Aortic dissection
A pt with HTN in their PMHx has sudden onset back pain and a postural drop. What is the top differential?
AAA
How can MSK be distinguished from other types of chest pain?
It is reproducible on palpation, and most often follows physical activity
What are the classic symptoms of pneumonia?
Chest pain
SoB
Increased work of breathing
Fever
When a young pt has an MI, what do we need to think about?
Cocaine use
What are the acute causes of cardiac shortness of breath?
Pulmonary oedema Acute MI Cardiac arrythmia Pericarditis Pericardial effusion
What are the acute causes of respiratory shortness of breath?
Pneumonia Pneumothorax PE Asthma Acute exaccerbation of COPD ARDS Large airway obstruction
Other than cardiac and respiratory causes of SoB, what can cause shortness of breath acutely?
Pain DKA Drugs e.g. aspirin overdose Trauma Anxiety Thyrotoxicosis Sepsis
What is a primary pneumothorax?
A pneumothorax that occurs where there is no underlying lung disease.
Who are primary pneumothoraces most common in?
Young (teen), tall males.
What is a secondary pneumothorax?
A pneumothorax that occurs in the presence of underlying lung disease.
What is the classic sign of a tension pneumothorax?
Deviated trachea
Where should the needle be inserted to decompress a tension pneumothorax?
2nd intercostal space, midclavicular line
Use a large bore cannula.
After decompression, further management is needed to resolve the problem.
What bloods should be done to investigate chest pain and shortness of breath?
FBC U&Es LFTs CRP Clotting Cultures A/VBG Troponins as appropriate D-dimers as appropriate
Why is analgesia so good for both chest pain and shortness of breath?
It prevents pain (duh), decreases anxiety, relaxes patient, causes vasodilation which can reduce symptoms depending on the cause.
A child comes in with breathing difficulties. What respiratory symptoms might they be exhibiting?
SoB
Cough
Stridor/wheeze
Chest pain
A child comes in with breathing difficulties. What non-respiratory symptoms might they be exhibiting?
Poor feeding
Abdo pain
Hypotonia
Change in colour of LoC
How can respiratory effort be assessed in a child?
- RR
- Recessions
- Noises
- Grunting
- Accessory muscle use
- Nostril flaring
- Gasping
Where can recessions be seen on a child who has increased respiratory effort?
Intercostal
Subcostal
Sternal
Suprasternal
How can respiratory efficacy be assessed in a child?
- Chest expansion
- Auscultation
- Pulse oximetry
- ABG
Why do children in respiratory distress become hypotonic?
Hypoxic cerebral depression
How should a child with respiratory distress be managed in A&E?
ABCDE
Airway manoeuvres, adjuncts, and oxygen.
Find the possible cause and start to treat accordingly.
Pathology in which areas can cause respiratory distress in a child?
- Upper airway
- Lower airway
- Lungs
- Area around the lungs
- Respiratory muscles
- Below the diaphragm
- Changes to respiratory drive
What common upper airway pathologies can cause respiratory distress in a child?
- Croup
- Epiglottitis
- FB
What common lower airway pathologies can cause respiratory distress in a child?
- Tracheitis
- Asthma/viral wheeze
- Bronchiolitis
What common lung pathologies can cause respiratory distress in a child?
- Pneumonia
- Pulmonary oedema
What common pathologies affecting the areas around the lungs can cause respiratory distress in a child?
- Pneumothorax
- Pleural effusion/empyema
- Rib fractures
What group of disorders may cause respiratory distress due to their effect on the respiratory muscles?
Neuromuscular disorders
What pathologies can cause increased respiratory drive in children?
DKA
Shock
Poisoning
Anxiety
What pathologies can cause decreased respiratory drive in children?
Coma
Convulsions
RICP
Poisoning
What is the most common cause of stridor in children in the UK?
Croup!!
How can the severity of croup be assessed?
CROUPRHL (catchy innit?)
Cyanosis Recessions O2 sats UPper airway obstruction RR HR LoC
What management is used for croup in A&E?
According to croup pathway:
- Dexamethasone 0.15mg/kg PO or IV as appropriate
- Nebulised budesonide 2mg
- Nebulised adrenaline 0.5ml/kg
Call for senior help, get ITU involved as necessary.
What management is used for asthma in A&E?
Via guidelines based on severity of attack:
- Salbutamol (inhaler/ nebulised/IV as appropriate)
- Prednisolone/Hydrocortisone (PO/IV as appropriate)
- Ipatropium bromide
- MgSO4 IV
- Aminophylline IV
Call for help/ITU involvement as appropriate
What is shock?
A state of acute cellular oxygen deficiency
What are the 3 stages of shock?
- Compensated
- Uncompensated
- Irreversible
What are the 5 classes of causes of shock?
- Hypovolaemic
- Distributive
- Obstructive
- Cardiogenic
- Dissociative
What is a burn?
An injury caused by thermal, chemical, electrical, or radiation energy.
Who are burns most common in?
Those under 5 and over 75.
What is the most common mechanism of injury for burns?
Burns or scalding related to the kitchen/cooking.
Why are toddlers at higher risk of burns and scalds?
They pull hot beverages/pans over themselves, and are more likely to touch hot irons/hair straighteners/hobs as they don’t realise the danger yet.
How should a burn be assessed?
As per primary survery - ABCDE, with prevention of hypothermia, and appropriate fluid resus.
Assess for other injuries at the same time as per trauma primary survery.
If a burn has occured in an enclosed space, what other kind of injury should be considered?
Inhalation injury
How can the surface area of a burn be measured?
By the rule of nines.
What is the rule of nines?
Each anatomical area on the adult body is 9% of surface area, or a multiple of this:
- 9% each for each upper limb, and head.
- 18% of each lower limb, front of trunk, and back of trunk.
- Genitalia is 1%
What surface area does the size of the hand represent?
Roughly 1% of total body surface area
How can the depth of a burn be described?
By degree - first, second, and third OR
- Epidermal
- Superficial dermal
- Deep dermal
- Full thickness (third degree)
- Fourth degree (inc. subcut tissues)
What additional assessment needs to be made if a burn is circumferential?
Status of distal circulation:
- cyanosis
- pulses
- cap refil
- neurological signs
What bloods are important to ask for during primary survery of a burn pt?
- FBC
- G&S/crossmatch
- Carboxyhaemoglobin (ABG)
- Glucose
- U&Es
What monitoring can show if a burn pt is becoming hypoxic or has a metabolic derrangement?
ECG - an arrythmia may be the first sign of an abnormality
How can we stop the burning process?
- Remove clothing
- Brush dry chemical powders from wound
- Rinse involved areas with tap water
How can a minor burn be managed?
- Run under cold fresh water for 20 minutes
- Debride wound
- Leave small blisters in tact, aspirate larger/awkwardly placed blisters.
- Non adhesive dressing, or biological dressing.
- Re-examine after 48 hours
Ensure adequate analgesia
How should an acute inhalation injury be managed?
May need endotraceal intubation and mechanical ventilation.
Transfer to burn centre once stable.
What a burn from flames, what might need to be considered on the B of ABCDE?
Breathing in CO -> give 100% oxygen until baseline carboxyhemoglobin is obtained
What is the formula used for fluid replacement in burns?
The Parkland formula for the total fluid requirement in 24 hours is as follows: 4ml x TBSA (%) x body weight (kg).
50% given in first eight hours; 50% given in next 16 hours
What urine output is aimed for in burned pts who are:
a) adults
b) children
a) 0.5-1 ml/kg/hour
b) 1-2 ml/kg/hour
What 2 things are very important to remember when managing a burns patient?
Analgesia and preventing hypothermia
What specific complication can occur secondary to electrical burns?
Rhabdomyolysis
What is the primary survery?
Initial assessment and management of a trauma patient, performed to detect and treat imminent life threats and prevent complicaitons.
How does a primary survery compare to standard ABCDE?
Major haemorrhage comes first
A - includes C spine control
B - Full expose, percuss, ascultate, palpate!! Basically do everything more thoroughly but quickly.
C
D - GCS, pupils, blood glucose as per.
E - palpate everything|! Log roll for full assessment
Very important to reassess as you go along.
How should Cspine be protected?
Immobilise with hands initially, then place collar and blocks to prevent pt from mobilising C spine.
What immediately life threatnening things might be found on primary survery on the B section?
- Tension pneumothorax
- Massive haemothorax
- Open pneumothorax
- Flail chest
- Ruptured diaphragm
If IV cannula insertion isn’t an option e.g. on a shocked pt, what is a good alternative for access?
Inserting an intraosseous line
How should fluids be given to a trauma patient?
They should be warmed before administration
Who is head trauma more common in?
a) men or women?
b) children under 15 or adults 15-75?
a) men
b) children under 15
What is the most common common factor in adult head injuries?
Alcohol
Other than alcohol, what risk factors are common in head injuries?
Falls, assaults, and RTCs.
How should a pt with GCS of 14/15 be assessed following head injury?
- Hx and obs
- Neurological examination
- Examine for other injuries
- CT head if indicated by guidelines
How should a pt with GCS of 13 or less be assessed following head injury?
Resus and get them scanned within an hour (CT head)
What are the indications for a CT head following head injury in adults?
- GCS less than 13 at first assessment or less than 15 2 hours after injury
- Suspected open or depressed skull fracture
- ?Basal skull fracture
- Post-traumatic seizure
- > 1 discrete episode of vomiting
- Focal neurological deficit
- Amnesia
- Anticoagulation or coagulopathy
What are the signs of a basal skull fracture?
- Panda eyes
- Battle sign
- CSF otto/rhinorrhoea
- Haemotympanum
How do the guidelines for CT head following injury differ for children compared to adults?
Includes:
- ?NAI
- Tense fontanelle
- Aged <1 withbruise, swelling, or laceration >5cm on head.
- Witnessed LoC
- Dangerous mechanism of injury
- Abnormal drowsiness
Differences:
- GCS <14 initially
- 3+ episodes of discrete vomiting
How should a suspected C-spine injury be investiagted?
- C spine x ray
- CT C spine if xray not adequate
What are the possible complications of head injury?
- Amnesia
- RICP
- Cerebral herniation
- CSF leak
- Meningitis
- Intracranial haemorrhage
- Skull fracture
- Seizures
- Concussion
