Simulation cases

Question 1

autonomic features of hypoglycaemia

Answer 1

1. sweating
2. palpitations
3. tremor
4. hunger

Question 2

neurological features of hypoglycaemia

Answer 2

1. confusion
2. drowsiness
3. behavioural changes
4. speech abnormalities
5. incoordination

Question 3

other symptoms of hypoglycaemia can include

Answer 3

nausea

headache

Question 4

normal reference range for fasting plasma glucose

Answer 4

4 - 5.8mmol/l

Question 5

what defines hypoglycaemia

Answer 5

plasma glucose of less than 3mmol/l

in hospitalised patients <4.0 mmol should be treated if patient is symptomatic

Question 6

SBARR handover

Answer 6

Situation
- who, where, when, what aspect of patients management you need advice on, current working diagnosis

Background
- relevant pmh, surgical hx, medication, allergies, investigation results

Assessment
- vitals, clinical examination, overal clinical impression

Recommendations
- suspected diagnosis, what needs to happen, time frame

Response and review

Question 7

AIRWAY (hypoglycaemic patient)

Answer 7

can the patient talk !?

no:
- airway compromise: cyanosis, see-saw breathing, accessory muscle use, diminished breath sounds

• open mouth and inspect: secretions or foreign body

Question 8

how would you open airway?

Answer 8

head-tilt-chin-lift manoeuvre

Question 9

what would you do in airway if patient has suffered significant trauma with potential spinal involvement ?

Answer 9

jaw thrust

Question 10

other interventions for airway?

Answer 10

• nasopharyngeal airway

- oropharyngeal airway (Guedel)

Question 11

breathing assessment for hypoglycaemic patient

Answer 11

• resp rate

- patients with severe hypoglycaemia may develop slow, irregular pattern of breathing

Question 12

investigations for hypoglycaemic patient

Answer 12

• arterial blood gas to quantify degree of hypoxia

- CXR if abnormalities are heard on x-ray

Question 13

pulse and blood pressure: hypoglycaemia patient

Answer 13

• tachycardia in the context of hypoglycaemia

bradycardia is a late sign often precedes cardiac arrest

Question 14

investigations and procedure hypoglycaemia patient:

Answer 14

intravenous cannula

blood tests:

• fbc (anaemia and infection)
• U&Es to assess renal function and electrolyte levels
• CRP to screen for evidence of infection
• serum glucose

ECG

Question 15

interventions for hypoglycaemia patient

Answer 15

if patient conscious:
- glucose gel by mouth

• repeat capillary blood glucose 10-15mins after
• if still hypoglycaemic administer more

if patient unconscious

• intravenous glucose
• when consciousness regained then oral glucose
• IV access not possible then do IM glucagone

Question 16

disability assessment of hypoglycaemic patient

Answer 16

AVPU

• alert
• verbal
• pain
• unresponsive

Question 17

The Cushing’s triad

Answer 17

• bradycardia
• irregular respirations
• hypertension

physiological response tor raised ICP , attempts to improve perfusion

Question 18

what Is coning?

Answer 18

herniation of cerebellar tonsils through foramen magnum

compression of brainstem

Question 19

when does the classical ‘blown pupil’ appearance occur in traumatic brain injury patients

Answer 19

• herniation of uncus of temporal lobe
• through tentorial notch
• leads to compression of oculomotor nerve
• blown pupil appearance

Question 20

primary brain injury

Answer 20

• initial injury caused to brain tissue

- skulls fractures, haematoma formation

Question 21

secondary brain injury

Answer 21

• indirect damage to brain injury post primary insult

- inadequate perfusion of brain

Question 22

interventions for hypoxia and hypercapnia

Answer 22

• try and maintain oxygen sats 94-98%

- intubation in patients unable to protect their airway

Question 23

intervention for patients who have hypotension and are hypovolaemic

Answer 23

• resus with fluids or blood products

- vasopressors

Question 24

intervention for patients with cerebral oedema and raised ICP

Answer 24

• avoid tight c-spine collars
• position 30 degrees to aid venous drainage
• mannitol or hypertonic saline to reduce ICP
• intubation and hyperventilation strategies

Question 25

intervention for expanding haematoma

Answer 25

• reverse clotting abnormalities
• tranexamic acid if 3hrs since injury
• neurosurgical intervention

Question 26

intervention for hypoglycaemic patient or hyperglycaemic patient

Answer 26

• maintain bg within normal range

- with insulin or dextrose

Question 27

imaging for head injuries

Answer 27

• CT head scan
• pathologies: intracranial bleeds, EDH, SDH, SAH, ICH
• brain contusion
• skull fractures
• cerebral oedema

Question 28

if opiod toxicity is suspected as cause for patients reduced level of consciousness then what intervention should be given

Answer 28

naloxone

Question 29

Exposure : traumatic head injury

Answer 29

Active bleeding

• estimate total blood loss
• rate of blood loss
• hypovolaemic shock: hypotension, t.cardia, presyncope and syncope
• temperature

Question 30

intervention for haemorrhage

Answer 30

• if actively bleeding seek senior input
• need for blood products
• 2 large bore iv access
• bloods

Question 31

typical symptoms of opiod overdose include:

Answer 31

• nausea
• vomiting
• confusion
• drowsiness

Question 32

clinical signs of opiod overdose

Answer 32

• decreased level of consciousness
• respiratory depression
• pin point pupils

Question 33

what is the initial dose of naloxone given iv in opiod toxicity patients?

Answer 33

• 400 micrograms

Question 34

as naloxone rapidly reverses effects of opioids, it can precipitate symptoms of:

Answer 34

• opiod withdrawal

- including pain, confusion and agitation

Question 35

key components of unconscious patients:

Answer 35

• GCS
• pattern of breathing
• size and reactivity of pupils
• eye movement, oculovestibular response s
• motor responses (tone, reflexes and posturing)
• meningism

Question 36

what is antepartum haemorrhage?

Answer 36

• bleeding from or into genital tract

- occurring from 24 weeks of pregnancy

Question 37

most important causes of antepartum haemorrhage are

Answer 37

• placenta praaevia

- placental abruption

Question 38

initial assessment in patient with antepartum haemorrhage

Answer 38

• weigh blood loss
• maternal examination: vitals, gentle abdominal palpation, assess pain, rigidity and foetal presentation, size and movement

Question 39

foetal surveillance in antepartum haemorrhage

Answer 39

• CTG