Pt w/ Collapse Flashcards
List some important question to ask in the history of a patient presenting with collapse
BEFORE (how did they feel)
- Palpitations, dizzy, chest pain, breathlessness, headache, nausea, last time they ate or drank, any illegal drugs or alcohol, past hx of collapse, pale and clammy, weakness
DURING THE COLLAPSE
- do they remember falling or did they black out before
- did they hit their head
- did anyone else see (collateral hx)
- did they seize/shake/twitch
- how long were they unconscious for?
- did they bite their tongue?
- were they incontinent or urine or faeces
AFTER
- How did they feel after (sleepy, sick)
- How do they feel now?
- Any ongoing chest pain or breathlessness
Presenting features of an AAA
Depends very much on whether it has ruptured…
UNRUPTURED:
- usually asx
- Only known as aneurysm when increased by >50% (>3cm across)
- MAY cause abdominal or back pain
RUPTURED:
- intermittent or continuous abdominal pain that might radiate to back, iliac fossa or groin. COLLAPSE IS COMMON
Examination features of ruptured AAA
Rigid abdomen, pt in shock (tachycardia, hypotension, pale, clammy and low CRT)
Presence of PULSATILE, EXPANSIVE MASS in stomach
Where is the most common site for a AAA to form?
Just below the renal arteries (infrarenal)
What are some common causes of AAA?
Spontaneous main RF is AGE (main over 60 at high risk and are regularly screened)
Other causes include syphilis, Ehlers Danlos and Marfans
Investigations for AAA
USS is diagnostic (if already ruptured do not waste time doing this) ECG BLOODS (amylase is important and get a group and save and cross match for 10U)
Management of AAA
If you suspect rupture immediately inform theatres - will need surgical repair
- high flow O2
- IV access and give some O- blood while waiting for cross match AIM FOR SYSTOLIC <100mmHg (too high BP might rupture a contain leak)
Prophylactic METRONIDAZOLE AND CEFUROXIME
Unruptured are only repaired when they reach >5.5cm in diameter
When do symptoms of alcohol withdrawal commonly occur?
12 hours after stopping or considerably reducing the alcohol intake
What are some features of alcohol withdrawal? How quickly will they occur?
Will usually occur just 6-8 hours after alcohol withdrawal
D = Delirium, which is often worse at night T = Tremor (aka “the shakes”) S = Sympathetic overactivity (i.e. fever, tachycardia, hypertension, sweating)
H = Hallucinations (which are often visual or tactile) E = ESR (raised) L = Leucocytosis L = LFTs (impaired)
Which syndrome is suggestive of withdrawal from chronic alcohol use, when does it occur and what are its symptoms?
DELIRIUM TREMENS Usually occur 2-3 days after alcohol withdrawal PHYSICAL SIGNS: - Shaking - Sweating - Increased heart rate - Seizures - Pseudohallucinations
What investigations are important in someone with alcohol withdrawal?
Baseline bloods: FBC, U&E, Glucose (check thiamine - often deficient and can be corrected easily)
ECG
Monitor obs
ABG (monitor for metabolic acidosis)
Initial management for alcohol withdrawal
the benzodiazepine CHLORDIAZEPOXIDE (10-30mg) is very useful in the treatment of alcohol withdrawal
PABRINEX Is a thiamine-corrective solution that should also be given
What are some common cardiac causes of collapse?
COMPLETE HEART BLOCK
What is complete heart block?
Where there is incomplete or lack of conduction between the SAN and the AVN meaning the heart doesn’t beat properly and cardiac output drops
- there are many different types and degrees of heart block but complete (or third degree) heart block is the most serious and most likely to cause collapse
Why might there still be heart beat in someone with complete heart block? How will this appear on ECG
Sometimes there is some accessory pacemaker tissue that generates and conducts a signal - known as an ESCAPE RHYTHM
- will cause NARROW QRS COMPLEXES
What are some others symptoms of complete heart block?
Bradycardia
Hypotension
COLLAPSE
Haemodynamic instability
What are some common causes of complete heart block?
CORONARY ISCHAEMIA
INFERIOR WALL MI are the ones that are most likely to disturb the AVN and therefore ruin conduction and lead to heart block
What are some relevant investigations for patients with heart block and what might you find?
ECG: lack of relationship between p waves and QRS complexes - remember spotting the pattern in the relationships between the two tells us what degree of heart block it is.
Also look for LBBB as evidence of old MI
FBC, U&E, Trop
How does DKA typically present?
ALWAYS CONSIDER THIS IS THE COLLAPSED YOUNG PERSON
Can present in a large variety of ways that can be quite non specific:
- GI: nausea, vomiting, abdominal pain
- D: polyuria, polydipsia, sweet smelling breath, recent weight loss, recent fatigue, decreased skin turgor and dry mucus membranes, altered conscious state, focal neurology. HIGH BLOOD GLUCOSE
- HD: tachycardia and hypotension, hyperventilation (to blow off CO2 to compensate for metabolic acidosis)
Causes of DKA (explanation of symptoms)
Often happens in the young person who does not know they are diabetic.
Without insulin body draws of reserves of glycogen and liver breaks down fats and proteins during gluconeogenesis - breaking down fatty acids to produce glucose leads to KETONE RELEASE - ACIDOTIC
- very high levels of plasma glucose leads to diuretic osmosis and water and sodium are drawn out of cells leading to the polyuria and polydipsia
Initial management of DKA
If the patient has altered mental state consider airway preservation and breathing support etc.
FLUIDS IMPORTANT - 0.9% NaCl IV infusion over 0.5-1hr and then give constant bags until the BP is corrected
INSULIN INFUSION pump at 6U/hr
Potassium correction (insulin drives K into IC comp)
- Consider monitoring urine output (?catheter)
What condition occurs when blood glucose is high but there isn’t a considerable ketoacidosis?
HYPERGLYCAEMIC HYPEROSMOLAR STATE (HHS)
