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CSI year 2 > Case 16 Emergency Medicine > Flashcards

Case 16 Emergency Medicine Flashcards

1
Q
  • What is a symptoms sieve?
A

Symptom sieve is used to get broad categories explaining pathological processes behind a condition

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2
Q
  • What does the A in the A-E assessment stand for and what does it involve looking for?
A

Airways - if compromised, treat before moving on

Verbalising intermittently

No foreign objects in mouth or excessive secretions

No snoring/stridor

No mouth or tongue swelling

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3
Q
  • What does the B in the A-E assessment stand for and what does it involve looking for?
A

Breathing

Resp rate - between 12-20
No cyanosis
No evidence of respiratory disease
Mild wheeze
Smoker
Do Arterial Blood Gas - to give info about CO2

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4
Q
  • What does the C in the A-E assessment stand for and what does it involve looking for?
A

Circulation

Blood pressure
Heart rate
Heart sounds - normal
12 lead ECG
Peripheral capillary refill brisk bilaterally < 2 seconds
Warm peripheries, flush

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5
Q
  • What does the D in the A-E assessment stand for and what does it involve looking for?
A

Disability

Blood glucose
Temperature
Confusion- GCS score
Moving four limbs normally
Pupils equal and reacting to light
Smelling of alcohol

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6
Q
  • How does the GCS (Glasgow coma score) score work?
A

Eye - 4 is max and means spontaneous eye opening

Verbal - 5 is max and means you are orientated

Motor - 6 is max and means you are obeying commands

Maximum score of 15

eg ACVPU/GCS E3 V4 M5

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7
Q
  • What does the E in the A-E assessment stand for and what does it involve looking for?
A

Exposure

No rashes
No sties of injection/track marks
No evidence trauma to head or limbs
No evidence of external bleeding
Abdominal examination

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8
Q
  • What is the most concerning part of the patients ‘circulation’ assessment and what can be done?
A

Systolic is less than 90 and so this should be intervened with by giving IV fluids to increase blood pressure

This also tells us if the BP is low due to hypovolemia (if responds)

If not treated, this could lead to hypovolemic shock

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9
Q
  • What is meant by circulatory shock?
A

Circulatory shock - used when inadequate blood flow results to damage to body tissues

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10
Q
  • What are the 4 types of circulatory shock and explain briefly what causes each of them?
A

Hypovolemic - loss of blood volume

Obstructive - physical obstruction to blood flow

Cardiogenic - due to ventricular failure

Distributive - due to vasodilation

  • Due to sepsis, anaphylaxis (allergic reaction), neurogenic
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11
Q
  • Why is altered mental state considered a sign of sepsis?
A

Decreased cerebral perfusion due to histamine and cytokine release leading to vasodilation and this can cause altered mental state

The decreased cerebral perfusion can be due to circulatory shock initiated by sepsis

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12
Q
  • What is a renal sign of hypoperfusion
  • What are 2 other signs of hypoperfusion
A

low urine output as kidneys are not receiving enough blood

Mottled skin and tachycardia also shows hypoperfusion

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13
Q
  • What is the diagnosis criteria for SIRS? (systemic inflammatory response syndrome)
A

≥2 of

Temp >38 or <36 (elderly)

Heart rate >90bpm

Resp rate >20

  • First sign of deterioration is tachypneoa

WBC Count >12x10^9 or <4x10^9/L

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14
Q
  • Other than meeting criteria for SIRS, what else is required for a sepsis diagnosis?
A

Meets SIRS criteria and evidence of infection

Blood cultures

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15
Q
  • What is needed to diagnose a patient with severe sepsis?
A

Sepsis with evidence of organ dysfunction, hypotension or hypoperfusion

Lactate, Urine output

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16
Q
  • When would someone be considered to be in septic shock?
A

Severe sepsis with hypotension despite adequate fluid resuscitation

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17
Q
  • If you suspect sepsis, you are supposed to do the Sepsis 6, what are these?
A

Give Oxygen to keep stats above 94%

Take blood cultures - sign of sepsis

Give IV Abx - if you suspect sepsis then give Abx within an hour

Give a fluid challenge - give a bit of fluid fast 250-500ml of crystalline solution within 15 mins (stat)

Measure lactate - sign of hypoperfusion

Measure urine output - sign of hypoperfusion

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18
Q
  • After seeing the patient has increased CRP, Lactate and WBC/Neutrophilia, why are these each suggestive of sepsis?
A

CRP - inflammation
- Produced by liver and produced when we have an inflammatory response

Lactate - anaerobic respiration
- Part of sepsis 6
- Vasodilation meaning hypoperfusion so no oxygen, anaerobic respiration occurs, increased lactate

WBC and neutrophila - sign of infection
- Neutrophil is suggestive of bacterial infection

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19
Q
  • Why is abnormal urea not suggestive of sepsis?
A

Not Urea - too many causes for renal injury therefore not specific for sepsis

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20
Q
  • If the patient has COPD, what sats should be aimed for and why is this different to if they didn’t have COPD?
A

Instead of aiming for sats of 98 you aim for sats of 94

they have emphysema and large alveoli and a lot of dead space

does not help with tissue perfusion so there is V:Q mismatch

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21
Q

Which BP is used for NEWS2 Score

A

Systolic Only (the first number)

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22
Q
  • Specifically in women, what could be the cause of left iliac fossa pain?
A

Violent torsion, infection in reproductive system in women could be a cause of left iliac fossa

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23
Q
  • What organ is most likely to be affected if there is left iliac fossa pain?
A

Issue with sigmoid colon as it is in the left iliac fossa

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24
Q
  • What is meant by a diverticulum
A

Diverticulum is singular out-pouching of intestine due to weakness within the wall

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25
Q
  • What group of people are diverticuli most common in and why?
A

Common in older people

Lack of fibre therefore colon does not have a lot of help to excrete faeces, contract more gets weaker, leads to outpouching

Bowel movements over time progress to diverticuli formation

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26
Q
  • Can diverticuli be present in young people as well?
  • Can diverticuli present with PR bleeding?
A

Can happen in younger people as well

Can present with PR bleeding

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27
Q
  • What is meant by diverticulosis?
  • What is meant by diverticulitis?
A

Diverticulosis - several diverticuli

Diverticulitis - inflammation of diverticuli due to lots of faeces and so more likely to be inflamed

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28
Q
  • What can airway obstruction cause if untreated?
A

Hypoxia

Risks cardiac arrest, organ damage and death

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29
Q
  • What does a GCS≤8 require?
  • Is central cyanosis a late or early sign in the airway assessment?
A

Intubation
Check for cyanosis and pallor

Late

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30
Q
  • What actions should be taken if there are abnormalities found in the airway assessment?
A

Airway opening manoeuvres - head tilt, chin lift, jaw thrust

Suction to remove debris

Simple airway adjuncts - nasopharyngeal airway, oropharyngeal airway

Supraglottic airway (e.g. iGel)

Advanced airway interventions - intubation, emergency surgical airway

Then give Oxygen At High Concentration

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31
Q
  • What would you give if a patient had anaphylactic shock?
  • If the patient’s depth or rate of breathing is insufficient or absent, what should be done?
A

Adrenaline

Use bag-mask or pocket mask ventilation to improve oxygenation and ventilation whilst calling immediately for expert help

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32
Q
  • If breathing does not improve, what may be required?
A

Non-invasive ventilation or intubation and ventilation

33
Q
  • What is a normal capillary refill time?
A

Less than 2 seconds

34
Q
  • What might a long CRT be due to?
A

Poor peripheral perfusion

Can also be due to cold surroundings and old age

35
Q
  • What might an elevated JVP indicate?
A

Heart failure or fluid overload

36
Q
  • In cardiac tamponade are are the heart sounds difficult to hear?
  • If the patient is bleeding, what would you replace the blood with instead of crystalloid fluid?
  • If BP does not improve after IV fluid resuscitation, what might they need instead?
A

Yes

Blood

Specific drug infusions

37
Q
  • What is in the right upper quadrant and what is pain in this area usually associate with?
A

Right portion of the liver, the gallbladder, right kidney, a small portion of the stomach, the duodenum, the head of the pancreas, portions of the ascending and transverse colon, and parts of small intestine.

Pain in this region is associated with infection and inflammation in the gallbladder and liver or peptic ulcers in the stomach.

38
Q
  • What is in the left upper quadrant and what is pain in this area usually associated with?
A
  • What is in the left upper quadrant and what is pain in this area usually associated with?

Left portion of the liver, part of the stomach, the pancreas, left kidney, spleen, portions of the transverse and descending colon, and parts of the small intestine.

Pain in this region is associated with malrotation of the intestine and colon.

39
Q
  • What is in the right lower quadrant and what is pain in this area usually associated with?
A

Caecum, appendix, part of the small intestines, the right half of the female reproductive system, and the right ureter.

Pain in this region is most commonly associated with appendicitis.

40
Q
  • What is in the left lower quadrant and what is pain in this area usually associated with?
A

Majority of the small intestine, some of the large intestine, the left half of the female reproductive system, and the left ureter.

Pain in this region is generally associated with colitis (inflammation of the large intestine) as well as pelvic inflammatory disease and ovarian cysts in females

41
Q
  • What is sometimes considered to be a tenth abdominal division?
A

Perineum - area beneath the hypogastric region at the bottom of the pelvic cavity

42
Q
  • What causes diverticula?
A

Lack of fibre means stool is drier, smaller and more difficult to move along

Muscles work harder, creates high pressure in parts of your gut

pushes inner lining of small area of gut through muscle wall which has been weakness and this forms a small diverticulum

43
Q
  • What is it called when diverticula cause no symptoms?
A

Diverticulosis

44
Q
  • What are some of the common symptoms of diverticula?
A

Intermittent, lower tummy pain or bloating without swelling (inflammation) or infection

Pain usually crampy and tends to come and go

Constipation or diarrhoea or mucus in stool

45
Q
  • Symptoms of diverticula that develop in a young adult are more likley to be due to what condition?
  • The symptoms of diverticular disease in older people can also be similar to what other condition?
A

IBS

Early bowel cancer

46
Q
  • How can you make a diagnosis of diverticular disease?
A

Confirming presence of diverticula - colonoscopy or sigmoid colonoscopy

Ruling out other causes of symptoms

47
Q
  • Why might diverticulitis occur?
A

Faceses gets trapped and stagnate in diverticulum

Germs in trapped faeces may then multiply and cause infection

48
Q
  • What are 5 symptoms of diverticulitis?
A

A constant pain, most commonly in the lower left side of the abdomen

High temperature (fever)

Constipation or diarrhoea

Some blood mixed with your stools

Feeling sick (nauseated) or being sick (vomiting)

49
Q
  • What are 4 possible complications of diverticulitis?
A

Obstruction of colon

Abscess in abdomen

Fistula forming to other organs such as the bladder

Perforation in wall of bowel leading to peritonitis

50
Q
  • What is usually needed to treat these serious but uncommon complications?
A

Surgery

51
Q
  • How would you describe the bleeding in diverticular disease?
  • What is the bleeding a result of?
A

Abrupt and painless

Burst blood vessel that sometimes occurs in the wall of a diverticulum and so amount of blood loss can be heavy

52
Q
  • What would a very large bleed require?
A

Emergency blood transfusion

Sometimes an operation is needed to stop bleeding

Bleeding stops on its own in 3 of 4 cases

53
Q
  • What more serious condition could be causing the rectal bleeding?
  • What is the treatment for diverticulosis?
A

Bowel cancer

Requires no treatment as there are no symptoms but a high-fibre diet can reduce risks of complications and diverticulitis in the future

54
Q
  • What else would reduce risk of developing symptoms?
A

Stop smoking

Exercise

Lose weight if you are overweight or obese

55
Q
  • How much fibre is needed each day?
  • If you suddenly increase the amount of fibre you eat, what might happen?
A

18g

You have symptoms of wind and bloating

Any increase should be gradual to prevent this and allow gut to be used to extra fibre

56
Q
  • What are the 2 classes of drugs given in diverticular disease?
A

Paracetamol - ease pain if high fibre diet or supplements do not help to ease pain

Antispasmodics - mebervine if you have persistent abdominal spasms

57
Q
  • What drugs should be avoided in diverticular disease?
A

NSAIDs and opioid medicines - can cause perforation

58
Q
  • When symptoms are not too severe, what is the treatment for diverticulitis?
A

Course of Abx - if patient feels unwell

Follow diverticulosis diet recommendations unless advised otherwise

Strong painkillers for a while

59
Q
  • What imaging tests show diverticulosis?
A

Sigmoidoscopy and endoscopy

CT or Barium X-Rays

60
Q
  • Give three examples of fibre supplements?
A

Psyllium, Methylcellulose, Polycarbophil

61
Q
  • Does diverticulosis lead to cancer?
  • What investigation can confirm a diagnosis of diverticulitis?
A

No

CT

62
Q
  • What would the investigation and treatment of an abscess involve?
A

CT to diagnose the abscess

Hospital stay and IV Abx

Drainage of abscess

63
Q
  • Repeated attacks of diverticulitis may require what?
A

Surgery to remove affected portion of colon

64
Q
  • What is the most common cause of major colonic bleeding in patients over 40?
  • If bleeding does not stop on its own, what must be done for evaluation?
A

Diverticular bleeding

Colonoscopy

65
Q
  • Why might soluble fibre be preferred over insoluble fibre?
A

Insoluble fibre can cause more wind and bloating, particularly aggravate symptoms in some people.

Soluble fibre is found mostly in fruit and vegetables.

66
Q
  • Give examples of dietary sources of soluble and insoluble fibre
A

Dietary sources of soluble fibre include oats, , nuts, flax seeds, lentils, beans, fruit and vegetables.

Insoluble fibre is chiefly found in corn (maize) bran, wheat bran, nuts

67
Q

What frequency of monitoring would you use for a NEWS2 score of
0
1-4
3 in a single parameter
5 or more
7 or more

A

12 hours
4-6 hours
1 hour
1 hour
Continuous

68
Q

What is the clinical response for a NEWS score of 0

A

Continuous routine NEWS2 monitoring

69
Q

What is the clinical response to a NEWS2 score of 1-4

A

Inform registered nurse
They decide if escalation is required

70
Q

What is the clinical response to a NEWS2 score of 3 in a single parameter

A

Tell registered nurse who informs medical team
They decide if escalation is necessary

71
Q

What is the clinical response when NEWS2 score is 5 or more

A

Move to facility with monitoring facilities
Registered nurse tells medical team
Urgent assessment by clinician or team with core competencies

72
Q

What is the clinical response to someone with a NEWS2 score of 7 and above

A

Tell a registrar
Emergency assessment by clinical with competency
Continuous monitoring facility
Transfer to ICU

73
Q

What type of response does a NEWS2 score of 0-4 call for

A

Ward based response

74
Q

What type of response does a NEWS2 score of 3 in a parameter

A

Urgent ward based response

75
Q

What type of response does a NEWS2 score of 5-6 call for

A

Key threshold for urgent response

76
Q

What type of response does a NEWS2 score of 7 or more

A

Urgent or emergency response

77
Q

What is the GCS for Eyes

A

E1- no response

E2- to pain

E3- to voice

E4- spontaneously

78
Q

What is the GCS for Verbal

A

V1- no response

V2- incomprehensible sounds

V3- incomprehensible words

V4- confused

V5- orientated to time person and place

79
Q

What is the GCS for Motor?

A

M1- no response

M2- abnormal extension

M3- abnormal flexion

M4- withdrawal from pain

M5- localised pain

M6- obeys commands

CSI year 2 (8 decks)

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