A+E Flashcards
(32 cards)
Typical picture of salycilate overdose
- A key concept for the exam is to understand that salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis.
- Early stimulation of the respiratory centre leads to a respiratory alkalosis
- Following this, a metabolic acidosis develops along side the respiratory alkalosis due to the direct acid effects of salicylates (combined with acute renal failure).
- In children metabolic acidosis tends to predominate.
Features
* hyperventilation (centrally stimulates respiration)
* tinnitus
* lethargy
* sweating, pyrexia*
* nausea/vomiting
* hyperglycaemia and hypoglycaemia
* seizures
* coma
treatment of salicylate overdose
- general (ABC, charcoal)
- urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine
- haemodialysis
Indications for haemodialysis in salicylate overdose
- serum concentration > 700mg/L
- metabolic acidosis resistant to treatment
- acute renal failure
- pulmonary oedema
- seizures
- coma
child abuse presentations:
- where do they present
- how might they present physically
Children may disclose abuse themselves. Other factors which point towards child abuse include:
story inconsistent with injuries
repeated attendances at A&E departments
delayed presentation
child with a frightened, withdrawn appearance - ‘frozen watchfulness’
Possible physical presentations of child abuse include:
bruising
fractures: particularly metaphyseal, posterior rib fractures or multiple fractures at different stages of healing
torn frenulum: e.g. from forcing a bottle into a child’s mouth
burns or scalds
failure to thrive
sexually transmitted infections e.g. Chlamydia, Gonorrhoea, Trichomonas
testicular torsion signs and sx
- pain is usually severe and of sudden onset
- the pain may be referred to the lower abdomen
- nausea and vomiting may be present
- on examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened
- cremasteric reflex is lost
- elevation of the testis does not ease the pain (Prehn’s sign) [positive in epididymitis]
testicular torsion Mx
treatment is with urgent surgical exploration
if a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.
acute DKA management
- fluid resus - saline
- fixed rate insulin [ 0.1 unit/kg/hour] whilst continuing regular injected long-acting insulin but stopping short actin injected insulin [if pt is known diabetic]
- later add in potassium according to their initial levels on presentation
DKA diagnostic criteria
glucose > 11 mmol/l or known diabetes mellitus
pH < 7.3
bicarbonate < 15 mmol/l
ketones > 3 mmol/l or urine ketones ++ on dipstick
DKA resolution is defined as:
pH >7.3 and
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L
what extra care should children and young adults get after treatment for DKA
they are at greater risk of cerebral oedema t4
1:1 nursing to monitor neuro-observations, headache, irritability, visual disturbance, focal neurology etc. It usually occurs 4-12 hours following commencement of treatment but can present at any time. If there is any suspicion a CT head and senior review should be sought
Complications may occur from DKA itself or the treatment:
- gastric stasis
- thromboembolism
- arrhythmias secondary to hyperkalaemia/iatrogenic hypokalaemia
- iatrogenic due to incorrect fluid therapy: cerebral oedema*, hypokalaemia, hypoglycaemia
- acute respiratory distress syndrome
- acute kidney injury
a child presents to A+E with no signs of life - how do you proceed
5 rescue breaths then 15 chest compressions to every 2 ventilation breaths
- For a child under 1, the two-thumb encircling or two-finger techniques should be used.
- For a small child, the one-handed technique should be used.
- For a larger child, the two-handed technique can be used (as for adults).
define hypothermia
unintentional reduction of core body temperature below the normal physiological limits
- Mild hypothermia: 32-35°C
- Moderate or severe hypothermia: < 32°C
hypothermia risk factors
Risk factors:
- General anaesthesia
- Substance abuse
- Hypothyroidism
- Impaired mental status
- Homelessness
- Extremes of age
Signs of hypothermia include:
- shivering
- cold and pale skin. Frostbite occurs when the skin and subcutaneous tissue freeze, causing damage to cells.
- slurred speech
- tachypnoea, tachycardia and hypertension (if mild)
- respiratory depression, bradycardia and hypotension (if moderate)
- confusion/ impaired mental state
ECG signs of hypothermia
As the core temperature approaches 32°C to 33°C, acute ST-elevation and J waves or Osborn waves may appear
hypothermia investigations
- Temperature. Special low-reading rectal thermometers or thermistor probes are preferred for measuring core body temperature. The patient’s temperature should be tracked over time, to check for improvement.
- 12 lead ECG. As the core temperature approaches 32°C to 33°C, acute ST-elevation and J waves or Osborn waves may appear
- FBC, serum electrolytes. Haemoglobin and haematocrit can be elevated (due to haemoconcentration). Platelets and WBCs are low due to sequestration in the spleen. Monitoring potassium is advised as hypothermic patients can be hypokalaemic due to a shift of potassium into the intracellular space.
- Blood glucose. Stress hormones are increased, and the body can have more peripheral resistance to insulin.
- Arterial blood gas
- Coagulation factors
- Chest X-ray
T/F
rapid rewarming is the best treatment option for hypothermic pts
FALSE
this can lead to peripheral vasodilation and shock
who should be treated with acetylcysteine in paracetmol OD
- the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity
- there is a staggered overdose or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or
- patients who present 8-24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available
- patients who present > 24 hours if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal
- acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated whilst seeking specialist advice
how is acetylcysteine administered + why
IV infusion over 1 hour as it can cause anaphylactic reactions when given over shorter periods
management of PE
HAEMODYNAMICALLY STABLE PTs
- DOACs first line for most people, including cancer patients. [apixaban or rivaroxiban]
- 2nd line = LMWH –> dabigatran or edoxaban or warfarin.
- low risk patients are managed as outpatients and higher risk are admitted.
- PE severity index score [PESI] is used to determine risk.
- anti-coagulate for at least 3 months [provoked PE’s]
- treat for 3 extra months for unprovoked PEs and active cancer pts.
HAEMODYNAMICALLY UNSTABLE PTs
- thrombolyse.
- massive PE presents with haemodynamic instability, particularly hypotension.
Well’s score features
Clinical probability simplified score
DVT likely: 2 points or more
DVT unlikely: 1 point or less
DVT Mx based on wells score
signs of a PE on ECG
S1 Q3 T3
- a prominent S wave in lead I, a Q wave in lead III, and a T wave inversion in lead III
- indicates right heart strain which is associated with PE
- can be seen in other conditions causing right ventricular strain, such as acute bronchospasm, pneumothorax, and other acute lung disorders t4 NOT specific
- not always seen in PE t4 not sensitive
- used alongside clinical features
what are the 3 determining factors for how you approach AF management
- haemodynamic in/stability
- unstable pts are electrically cardioverted
- stable pts, see below.
- how acute the AF is:
- <48 hours; give rhythm control
- > 48 hours OR uncertain time frame; give rate control
- anticoagulation - all pts require anticoagulation usually with a DOAC [1st line] or warfarin [2nd line]
