CPP Res School (delete at end) Flashcards
1
Q
What are some high risk signs for sepsis in paediatrics?
A
- Capillary refill 3 seconds or longer
- Hypoglycaemia
- Moderate respiratory distress/tachypnoea
- Moderate tachycardia
- Pale or flushed/mottled/cold extremities
- Reduced urine output
- Unexplained pain or restlessness
2
Q
What are some high risk signs for sepsis in paediatrics?
A
- Capillary refill 3 seconds or longer
- Hypoglycaemia
- Moderate respiratory distress/tachypnoea
- Moderate tachycardia
- Pale or flushed/mottled/cold extremities
- Reduced urine output
- Unexplained pain or restlessness
3
Q
At what point would you consider physical management of the PPH? Outline the procedures for each method and reasoning why?
A
If blood loss over the 10 minutes of TXA administration does not improve
* External aortic compression – manual compression of the abdominal aorta against the vertebral column to restrict uterine blood flow
* Bimanual compression - invasive two-handed technique to manually compress the uterus wall - continued through to definitive care (theatre).
4
Q
Can asthmatic pts tolerate 6-8 breaths per minute adult and 8-15 breaths per minute paeds?
A
yes
5
Q
Define complete abortion
A
full loss of products of conception in the first 20 weeks gestation
6
Q
Define HELLP syndrome and how it is different to other conditions.
A
A marker for severe pre-eclampsia, where 2 of the 3 elements of Haemolysis, Elevated Liver enzymes and Low Platelets are required for a diagnosis
7
Q
Define incomplete abortion
A
partial loss of products of conception in the first 20 weeks gestation
8
Q
Define induced abortion
A
intentional termination of a pregnancy by a procedure or medication
9
Q
Define missed abortion
A
pregnancy stops developing but products of conception remain in the uterus and the cervical os is closed
10
Q
Define recurrent abortion
A
2 or more successive pregnancy losses
11
Q
Define septic abortion
A
serious uterine infection before, during or shortly after a spontaneous or induced abortion
12
Q
Define spontaneous abortion
A
natural loss of pregnancy prior to 20 weeks gestation
13
Q
Define threatened abortion
A
vaginal bleeding in the first 20 weeks of gestation
14
Q
Describe common seizure presentations in paediatric patients.
A
- Vacant stares
- Lack of gross muscle tonicity
- Fixed gaze
- Facial muscle twitching
15
Q
Describe how and why fever occurs
A
Release of pyrogens from white blood cells or pathogen triggering the hypothalamus to raise body’s set point temp. Causes physiologic changes resulting in a change to body’s set point temperature, blood vessel constriction, metabolism increase, shivering/rigors to try to generate heat
Natural defence mechanism response to infection.
16
Q
Describe the airway management in a newborn doesn’t respond to stimulation and initial IPPV?
A
- PEEP on BVM with good seal (2 person)/ETCO2
- neutral positioning with towel etc
- keep warm
- If need to suction – make sure it is brief or can stimulate reflexes and cause bradycardia
17
Q
Describe the methods to deliver effective chest compressions in the newborn?
A
- 2 fingers/or 2 thumbs
- Rotate 2 minutes
18
Q
Describe the pathophysiology of peripartum cardiomyopathy
A
hormones of late pregnancy causing endothelial dysfunction and cardiomyocyte death
19
Q
Describe the pathophysiology of peripartum cardiomyopathy
A
hormones of late pregnancy causing endothelial dysfunction and cardiomyocyte death
20
Q
Describe the pathophysiology of pulmonary embolism during pregnancy
A
hypercoagulable state and decreased blood flow from uterine veins can cause blood clots in the legs
21
Q
Describe the pathophysiology of pulmonary embolism during pregnancy
A
hypercoagulable state and decreased blood flow from uterine veins can cause blood clots in the legs which then travel through vasculature to the pulmonary arteries.
22
Q
Describe the pathophysiology of seizures.
A
abnormal neuronal activity within the brain causing random, uncontrolled neuronal depolarisation in one or more regions of the brain.
23
Q
Describe the pathophysiology of seizures.
A
abnormal neuronal activity within the brain causing random, uncontrolled neuronal depolarisation in one or more regions of the brain.
24
Q
Describe your immediate actions with a newborn that requires assistance.
A
- Initiate tactile stimulations
- Skin to skin contact
- Warm bub with skin to skin contact with mum and blanket over the top
- Suction mouth before nose
- Clamp and cut cord
- Consider: IPPV room air
25
Do asthma and anaphylaxis present similarly in some cases?
yes as pathophysiology is similar
26
How can you differentiate between syncope and seizure?
* Seizures have a post-ictal period where the patient can be drowsy, confused, have a headache and nauseous
* Ask – muscular jerking, how long did it last for
* Incontinence occurred
27
How do you instruct the mother to push when the head is crowning? Do you touch the baby?
Small pushes with contractions
Place 2 fingers against baby’s head to prevent explosive delivery of the head
28
How do you manage a focal seizure?
* Airway
* Breathing
* Circulation
* Positioning – 45 degrees to allow for cerebral drainage
* 5mg IM midazolam if required
* Backup
* Transport
29
How does oxygen administration effect patient’s with COPD?
It can cause hypoventilation due to increased blood flow to poorly ventilated alveoli, increasing V/Q mismatch dead space
30
How does the baby present in a complete breech?
hips and knees are flexed so that the foetus is sitting cross-legged, with feet beside the buttocks
31
How does the baby present in a footling breech?
One or both feet presents first, with the buttocks at a higher position.
32
How does the baby present in a frank breech?
buttocks presents first, with the legs flexed at the hip and extended at the knees, placing the feet near the ears.
33
How does the baby present in a kneeling breech?
kneeling position, with one or both legs extended at the hips and flexed at the knees.
34
How long should each shoulder dystocia manoeuvre be done for?
30 seconds
35
How quickly should the shoulders be delivered under normal circumstances?
60-90 seconds
36
How would you troubleshoot/what are your considerations in a difficult ventilation with an igel in a cardiac arrest due to underlying asthma/COPD Pt?
Bilateral decompression of chest to rule out haven’t transferred from asthmatic arrest due to bronchospasm to tension pneumothorax
37
If a patient who has just delivered a baby haemorrhages and continues to deteriorate, outline your ongoing management and justify your reasoning.
IV TXA, 1g, slow push over 10 minutes, single dose only – to assist with blood clotting
38
Outline all fours position
mum on hands and knees to alleviate SD pressure to dislodge the shoulder
39
Outline all fours running start
mum on hands and knees with one foot forward so it is near hand & apply gentle downward traction to foetus posterior shoulder or gentle upward traction to foetus anterior shoulder
40
Outline reverse wood’s screw manoeuvre
apply pressure to posterior of foetus posterior shoulder and rotate in opposite direction to Wood’s Screw manoeuvre
41
Outline rubins II manoeuvre
insert gloved hand and apply posterior pressure to anterior shoulder of the foetus to rotate shoulders to oblique diameter
42
Outline some of the services that an elderly patient could be referred to for help at home
Home care
Community transport
Social worker
Services Australia website – nationwide number for state service
Dedicated dementia lines
Geri referral team
43
Outline supra-pubic pressure
pressure superior to symphysis pubis or continuous rocking motion (back of foetus towards front) – to reduce diameter of foetal shouters and rotate anterior shoulder into oblique diameter - do with McRoberts
44
Outline the elements of the APGAR and when it is performed.
Appearance – skin colour
Pulse – count heart rate
Grimace – monitor response to stimulation
Activity – muscle tone
Respiration – count and assess resp rate
APGAR is performed at 1 and 5 minutes
45
Outline the management involved with the administration of fibrinolysis.
Complete informed consent for tenecteplase (weight based) and given in conjunction with 300mg clopidogrel and 30mg IV enoxaparin followed up at 15 mins with 1mg/kg enoxaparin subcut dose
46
Outline the McRoberts manoeuvre
mum laying supine with knees to nipples - to increase anteroposterior diameter of the pelvic inlet
47
Outline the NEXUS criteria.
* ALOC
* focal neurological deficit
* midline tenderness
* intoxication
* distracting injury
If patient is positive for at least one of the criteria, c spine precautions need to be implemented
48
Outline the normal management of the healthy newly born.
* Clean mouth and nose
* Initiate tactile stimulation
* Within 30 seconds assess heart rate and breathing status
* Apgar at 1 and 5 minutes
49
Outline the pathophysiology of anaphylaxis
Exposure to allergens where IgE sensitisation occurs and additional exposures causes crosslinking of IgE causing mast cell deregulation and release of mediators that can cause symptoms or recruit inflammatory cells continuing a chain reaction resulting in a myriad of symptoms
50
Outline the pathophysiology of anaphylaxis
Allergen exposure causes IgE sensitisation, further exposures then cause IgE crosslinking, causing a massive allergic response, activating mast cells which release inflammatory cells, cytokines white blood cells and histamines, causing wide spread vasodilation.
51
Outline the steps involved in the management of a breech delivery.
* Call for backup
* Prepare for neonatal resuscitation
* Hands off - Delivery should proceed spontaneously through gravity, maternal effort and uterine action
* Assist with delivery of legs if needed
* Perform manoeuvres if complications or failure to deliver
* Thumbs on bum
* manoeuvres if needed - Lovesets 1, Lovesets 2, Lovesets 3
* MSV maneouvre (to deliver the head)
52
Outline wood’s screw manoeuvre
place a hand on the anterior aspect of the posterior fetal shoulder and rotates the shoulder toward the fetal back
53
Outline your management for a birth at 20 weeks gestation with the foetus having gasping respirations?
* Pull over and have second assist
* Backup with second crew to assist
* No resuscitation
* Wrap baby and present to mum
* Be very supportive and ensure psychological cares
* Manage mother as post delivery – oxytocin etc
54
Q. Outline and justify management of a secondary postpartum haemorrhage.
* Fundal massage
* Patient to empty bladder
* Consider:
* Tone – fundal massage &Oxytocin
* Trauma – control external haemorrhage & Analgesia
* Tissue/temperature/Thrombin – fundal massage, inspect for membranes and pieces of placenta
* External aortic pressure
* Bimanual compression
55
Outline the important elements of the “golden hour” and the benefits that it may have.
* general management
* skin to skin contact
* delay non urgent parts of assessment
* early initiation of breast feeding
* keep bub warm
It promotes bonding and milk supply as well as the release of oxytocin in mum and bub
56
What are some risk factors for SPPH?
* Prolonged rupture of membranes
* Prolonged labour
* Emergency caesarean section
* Vaginal birth after caesarean (VBAC)
* Ragged membranes or incomplete placenta (unlikely after a caesarean section)
* Manual removal of the placenta
57
What are the signs suggestive of placental separation during labour?
* Uterus rises in the abdomen and becomes firmer and globular
* Fresh show/trickle of blood
* Lengthening of the umbilical cord
58
What is the appropriate management for a non-pulsatile cord present in the vaginal opening?
* Assist mother to assume the knee-chest position
* Carefully attempt to push the presenting part off the cord
59
What is the appropriate management for a pulsatile cord present in the vaginal opening?
* Assist the mother into the exaggerated SIMS position
* Ask the mother to gently push the cord back into the vagina (this must be done carefully to avoid vasospasm) using a dry pad
60
What are common stroke symptoms?
* Thunderclap headache
* ALOC
* Focal neurological deficits
* Dysphasia/asphasia
* Hemiplegia
* Nausea
61
What are differentials for syncope?
Cardiac syncope
Orthostatic syncope
Reflex syncope
Seizure
62
What are high risk features of sepsis in adults?
* Deterioration in mental status (from normal)
* Respiratory rate greater than 25 breaths/min
* Needs oxygen to maintain SpO2 greater than 92%
* Systolic BP less than 90 mmHg (or a drop of greater than 40 mmHg from normal)
* Heart rate is equal to or greater than 130 beats/min
* Non-blanching rash/mottled/ashen/cyanotic
* Anuria in last 18 hours OR significantly reduced urine output
* Recent chemotherapy
63
What are some additional causes of SPPH?
* Perineal trauma / Perineal repair infection
* Uterine Abnormalities - Fibroids
* Vascular anomalies - arteriovenous malformation or pseudoaneurysm
* Caesarean section wound dehiscence / infection
* Bleeding disorders or coagulopathies
64
What are some causes for an altered level of consciousness?
* Stroke
* Inadequate cerebral perfusion
* Hypoxia
* Increased carbon dioxide levels
* Metabolic disturbances
* Drugs or toxins
* Post ictal seizure
* Intracranial pathology
* Extracranial pathology
* AEIOUTIPS
65
What are some causes of APH after 20 weeks?
* Placental abruption
* Placenta praevia
* Uterine rupture
* Loss of pregnancy
66
What are some causes of APH before 20 weeks?
* Miscarriage
* Ectopic pregnancy
* Implantation bleeding
67
What are some causes of cardiac arrest in a Pt with underlying asthma/COPD disease?
* Tension pneumothorax
* Hypovolaemia
* Arrhythmias
* Myocardial depression from prolonged hypoxia
68
What are some causes of psychosis?
* Primary psychotic disorder - Schizophrenia
* disillusion disorders
* brief psychotic disorders
* organic causes – infection, inflammatory processes
* elderly pts with UTI
* substances/medications/alcohol
69
What are some complications associated with footling and kneeling breech births?
prolapsed cord
70
What are some considerations/planning enroute to an imminent delivery patient?
* Drugs – oxytocin & TXA
* PPE maternity kit
* 2 Pts – role delineation
* CCP backup
71
What are some considerations for mandatory transport for a hypoglycaemic pt?
* Injury sustained from hypoglycaemic episode requiring further investigation
* Intentional overdose of glucose lowering agent
* Newly diagnosed diabetes
* No previous diagnosis of diabetes
* Not returned to normal mental state within 20 mins of IV glucose or incomplete recovery to normal conscious state
* Pt taking long acting oral hypoglycaemic agent that causes hypoglycaemia
* Pregnancy
* Recovered but unable to be monitored by a responsible adult for 4 hours or unable to self care
* Risk of prolonged or recurrent hypoglycaemia
* Seizure
* Severy hypoglycaemia episode within previous 48 hours
* Suspected cause of hypoglycaemia due to illness that requires further investigation
* Unable tor unwilling to consume long acting carbohydrate
* Unwitnessed onset or prolonged episode
72
What are some considerations/queries on the way to a job for third trimester pregnant patient with a headache?
Gestation
Prenatal cares
Complications with this pregnancy
In labour
73
What are some differential diagnoses of confusion in the elderly?
* Stroke/TIA
* Infection/UTI
* Sepsis
* Polypharmacy overdose
74
What are some differential diagnoses of headaches in pregnancy?
Pre-eclampsia
Eclampsia
Central venous thrombosis
Primary headache
Secondary headache
75
What are some examples of activities of daily living, and how may they be measured in the elderly?
Walking – walking frame/stick
Cleaning – cleaning themselves or having cleaners come in
Self care – showering themselves or having carers come in
76
What are some high risk for sepsis in paediatrics?
* Altered GCS/AVPU
* Severe respiratory distress/tachypnoea/apnea
* Needs oxygen to maintain SpO2 greater than 92%
* Severe tachycardia or bradycardia
* Hypothermia
* Non-blanching rash/mottled ashen/cyanotic
77
What are some intrapartum (during labour) risk factors for primary PPH?
* Expedited or prolonged second stage
* Prolonged third stage greater than 30 minutes
* Macrosomia (large baby)
* Polyhydraminos (excess amniotic fluid)
* Infection/Prolonged rupture of membranes
78
What are some maternal complications associated with shoulder dystocia?
* postpartum haemorrhage
* severe vaginal and perineal trauma
* uterine or bladder rupture
* psychological distress
79
What are some neonate complications associated with shoulder dystocia?
* Brachial plexus injuries
* humeral and clavicular fractures
* hypoxic brain injury
* stillbirth
80
What are some of your considerations going to a PV bleed in a pregnant patient?
* Ectopic pregnancy
* Miscarriage
* Delicate emotional state in both mum and partner
81
What are some questions to ask parents of a seizing patient with a history of seizures?
* What has concerned mum the most in this seizure compared to other ones – length, different type of seizure?
* Has she been unwell recently?
* Do they have midazolam at home and have they given any prior to our arrival (take into drug protocol)
* Was the Pt her normal self prior to the seizure?
* How often does she have seizures?
* How long do they normally last?
* Is the buccal midazolam usually effective?
82
What are some red flags for sepsis? Why may these factors be considered red flags?
* Re-presentation to a health care professional within 48 hours – treatment not working
* Age less than 3 months OR greater than 65 years – reduced immune system
* Recent trauma or surgery/invasive procedure/wound within last 6 weeks – possible cause of infection
* Indwelling medical devices (e.g. IDC) – possible cause of infection
* Immunocompromised/unimmunised – reduced immune system
* Parental/family/health care professional concern for the patient – medical knowledge of health concern
* Aboriginal or Torres Strait Islander/Pacific Islander/Maori cultural backgrounds – reduced access to health care
83
What are some risk factors for complications during pregnancy and possible consequences that can be associated?
* Alcohol or drug abuse – cause miscarriage, defects, early labour
* Eclampsia
* Extremes of maternal age – very young or older – increased risk of complications
* Foetal growth restriction
* Gestational or preexisting diabetes – macrosomic babies, foetal death, foetal malformations and growth restriction and increased need for interventiosn during labour
* Hypertensive disorders – chronic hypertenstion, preeclampseia, help
* Older women – increased risk of complications
* Preterm – baby at risk due underdeveloped
* Previous c sections/shoulder dystocia – increased risk of shoulder dystocia
* Prior preterm delivery, prior stillbirth – increased risk in subsequent pregnancies
84
What are some risk factors for shoulder dystocia?
* Previous SD
* Macrosomia (large foetus > 4 kg)
* Maternal diabetes mellitus
* Maternal obesity (BMI > 30)
* Older maternal age
* Post term pregnancy
* Excessive weight gain in pregnancy
85
What are some risks associated with post-term delivery?
* Macrosomia
* Shoulder dystocia
* Placental breakdown
* Infection
* Stillbirth
* Maternal mortality
86
What are some signs and symptoms of anaphylaxis?
Gradual or rapid onset of:
Cutaneous – urticaria (rash), angioedema (swelling), pruritus (itch), flushed skin
Respiratory – difficulty breathing, wheeze, upper airway swelling, rhinitis (runny nose)
Cardiovascular – hypotension, dizziness, bradycardia or tachycardia, collapse
Abdominal – nausea, vomiting, diarrhoea, abdominal pain
87
What are some signs of imminent delivery?
* Loss of operculum mucous plug (bloody show) - (may have occurred days before)
* increasing frequency and severity of contractions
* with an urge to push, or open bowels
* membrane rupture (this may not occur and active membrane rupture will be required if the head has been delivered with the membrane intact)
* bulging perineum
* appearance of the presenting part at the vulva
88
What are some stroke mimics?
* Conversion disorder (results from psychological stress)
* Electrolyte derangement
* Encephalitis
* Hypoglycaemia
* Infection (particularly with fever in elderly) and sepsis
* Migrainous aura and/or hemiplegia (with/without pain)
* Space-occupying cerebral lesions
* Seizures and post-ictal periods
89
What are the benefits of active management of third stage of labour?
Speeds up the delivery of the placenta and reduces risk of post partum haemorrhage
90
What are the benefits of delayed cord clamping?
* Increases baby’s blood volume by around 80-100mls, possibly up to 300mls
* Improved iron scores at 3-6 months
* Supports transition from foetal to neonatal circulation
* Reduced risk of brain haemorrhage and ischaemic gut in premature babies
* Reduced risk of baby becoming anaemic
* Transferring blood rich in antibodies and stem cells – boosting immunity
91
What are the causes of PPH?
* Tone - Poor uterine tone (70%)
* Tissue - Retained products (10%)
* Trauma - tears of the vulva, vagina or cervix, as well as uterine rupture (20%)
* Thrombin - Coagulopathy disorders (1%)
92
What are the common signs and symptoms of severe alcohol withdrawal?
* anxiety
* insomnia
* irritability
* seizures
* fever
* visual hallucinations
* hypertension
* tachycardia
* tremor
93
What are the components of FLACC
face
legs
activity
cry
consolability
94
What are the contraindications for an acute stroke referral?
* Advanced terminal cancer with a life expectancy of less than 6 months
* Seizure/s at onset of symptoms
95
What are the elements of the paediatric assessment triangle?
Appearance – tone, interactiveness, consolability, look & gaze, speech and cry
Work of Breathing – nasal flaring, retractions, posturing, breath sounds, apnoea or gasping
Circulation to skin – pallor, mottling, cyanosis
96
What are the environmental factors that can trigger an asthma attack?
exercise
weather
infective causes
97
What are the expected vital signs of a 1 year old?
Weight: 10kg
HR: 90-150bpm
RR: 25-50rpm
SBP: 70-100mmHg
98
What are the expected vital signs of a 9 year old?
Weight: 34kg
HR: 70-120bpm
RR: 15-25rpm
SBP: 90-115mmHg
99
What are the focal seizure types?
Focal
Focal dyscognitive
100
What are the four main presentations for breech birth?
complete
footling
kneeling
frank
101
What are the generalised seizure types?
Absence
A tonic
Tonic
Myoclonic
Tonic clonic
Stays epilepticus
102
What are the indications for an acute stroke referral?
Mandatory for all Pts with symptoms suggestive of stroke who meet the following:
* Onset of stroke symptoms less than 24 hours; AND
* The patient is able to be transported to an acute stroke centre (ASC) within 60 minutes (from stroke assessment)
103
What are the indications for pre-hospital administration of fibrinolysis?
* Pt located more than 60 minutes transport time (from first STEMI 12-Lead) to a pPCI capable hospital
* GCS = 15
* Classic ongoing ischaemic chest pain less than 6 hours in duration (excluding atypical ischaemic chest pain)
* 12-Lead consistent with STEMI
104
What are the risk factors associated with the development of pre-eclampsia?
* Diabetes
* Extremes of maternal age
* Family history
* Gestational hypertension
* History pre-eclampsia
* Multiple pregnancies
* Obesity
* Renal disease
105
What are the risks associated with the administration of droperidol in a patient presenting with sepsis?
Can cause profound hypotension – especially in urosepsis
106
What are the signs and symptoms for peritonitis and sepsis?
* Fever or low body temperature/rigors
* rash
* ALOC
* Lethargy/weak/fatigue
* Thirst
* Loss of appetite
* Tachypnoea
* Hypotension
* Tachycardia
* Abdominal pain or tenderness
* Bloating or a feeling of fullness in the abdomen
* Nausea/vomiting/diarrhea
* Decreased urine output
* Not able to pass stool or gas
107
What are the signs and symptoms of ectopic pregnancy?
* abnormal vaginal bleeding
* hx of amenorrhoea (at least one missed period)
* nausea
* pelvic and/or abdominal pain
* presyncopal symptoms
108
What are the symptoms of brain hypoxia?
Loss of concentration
Poor decision making
Memory loss
Cyanosis/pallor
Coma
Seizures
Brain death
109
What are the three main priorities after administering an initial adrenaline dose in anaphylaxis?
High flow oxygen
Further appropriate doses adrenaline – appropriate time frame
Throughough head to toe – to identify any external cause
110
What are your actions with a newborn that doesn't respond to stimulation?
* IPPV room air for 30 secs (20-30 breaths)
* Reassess: sats probe on right hand, HR should be >100
111
What conditions can mimic or mask alcohol intoxication?
* other intoxications
* electrolyte imbalance (hypo or hypernatremia, hypercalcemia) – abnormal ECG
* hypoglycaemia - BGL
* hypothermia - temperature
* head injury – clinical assessments/history taking
* stroke – clinical assessments
* seizure
* encephalitis or meningitis
* sepsis
* renal failure
* encephalopathy (hepatic, HIV, Wernicke)
* hypothyroidism
112
What constitutes a normal birth?
* spontaneous onset
* low-risk at the start of labour
* remaining low-risk throughout labour and birth
* the newborn is born:
o spontaneously
o in the vertex position
o between 37 and 42 completed weeks gestation
* After birth mum and bub in good condition
113
What do each of the APGAR score ranges suggest?
* 0-3: indicates severe distress in the newborn requiring immediate resuscitation
* 4-6: indicates moderate distress that requires medical attention and extreme vigilance
* 7-10: indicates the newborn is coping well at that point in time
114
What do you look for when you inspect the placenta?
Completeness, smoothness and integrity – missing parts or ragged membranes
115
What does it mean when the baby's head fails to restitute/what is this a sign of, and why does this occur?
Shoulder dystocia as the baby’s shoulders are too wide for the pelvic inlet and the anterior shoulder impacts on the symphysis pubis
116
What does the acronym AEIOUTIPS stand for?
A - Acidosis/ Alcohol
E - Epilepsy
I - Infection
O - Overdose
U - Uremia
T - Trauma to head
I - Insulin: too little or or too much
P - Pyschogenic
S - Stroke
117
What features are present for a diagnosis of pre-eclampsia?
* systolic blood pressure (SBP) ≥ 140 mmHg and/or
* diastolic blood pressure (DBP) ≥ 90 mmHg plus one or more of:
o neurological problems
o proteinuria
o renal insufficiency
o liver disease
o haematological disturbances
o foetal growth restriction
118
What gynaecological history questions should you ask a female patient who has abdomen pain?
* Are her menses regular?
* Has she had any PV bleeding?
* Is there a possibility that she could be pregnant?
* Does she have any gynaecological Hx in general?
* Does she take contraceptives?
119
What immediate assessments indicate that the newborn requires assistance?
HR
breathing status
tone
120
What is ALOC?
reduced alertness or inability to arouse
121
What is cervical shock and what are some differential diagnoses that could contribute to presentation?
Neurocardiogenic shock form dilation of the cervix
Hypovolaemic shock
122
What is status epilepticus?
seizure activity > 5 minutes in duration or recurrent seizure activity where the patient does not recover to a GCS of 15 prior to another seizure
123
What is the age group for paediatric pad use?
under 6
124
What is the appropriate management for a pregnant female in third trimester with a severe headache?
IV access for drug administration
CCP backup for IV magnesium sulphate
Paracetamol 1g – analgesia
Morphine 2.5mg – analgesia
125
What is the appropriate management for a pregnant female in third trimester with a severe headache who is refractory to initial analgesia with increasing hypertension?
Morphine 2.5mg IV – analgesia
Position of comfort and quiet environment - consult for GTN for hypertension
126
What is the cause of acute febrile illness headaches?
Pneumonia, URTI, viral infections or UTIs
127
What is the definition for hypertension during pregnancy?
Systolic blood pressure >140 mmHg
Diastolic blood pressure >90 mmHg
Severe
Systolic blood pressure >160 mmHg
Diastolic blood pressure >110 mmHg
128
What is the definition for hypertension during pregnancy?
Systolic blood pressure >140 mmHg
Diastolic blood pressure >90 mmHg
Severe
Systolic blood pressure >160 mmHg
Diastolic blood pressure >110 mmHg
129
What is the definition of anaphylaxis?
An allergic response with skin features of urticaria or erythema/flushing and/or angioedema WITH:
respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms; OR
acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is possible, even without skin features
130
What is the definition of primary postpartum haemorrhage?
Blood loss of greater than 500 mls from birth canal within the first 24 hours following birth
131
What is the definition of secondary postpartum haemorrhage?
Abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks following birth, usually defined as more than one heavily soaked pad per hour
132
What is the definition of sepsis?
Life-threatening organ dysfunction caused by a dysregulated host response to infection
133
What is the definition of septic shock?
subset of sepsis with profound circulatory, cellular, and metabolic abnormalities that are associated with a greater risk of mortality
134
What is the definition of TIA and can it be differentiated from stroke?
stroke signs and symptoms caused by a temporary occlusion, that self resolve within 60 minutes to 24 hours.
It can’t be differentiated at the time of treatment by paramedics.
135
What is the difference between active management of the third stage and physiological management of the third stage?
active management is the process of cord clamping, oxytocin and active cord traction
physiological management is all maternal effort
136
What is the drug flixotide and what is it used for?
corticosteroid
asthma and allergies
137
What is the drug salbutamol taken for?
asthma
COPD
138
What is the drug tiotropium bromide taken for?
asthma
COPD
139
What is the estimated weight of a newly born and expected vital signs?
* Weight: 3.5kg (CPG says 3-5)
* Heart rate: 100-160 bpm
* Respirations: 25-50 rpm
* Systolic blood pressure: 60-70 mmHg
* SPO2: low post delivery and increases over 10 minutes
140
What is the management for stroke?
* Position Pt with 45 degree head elevation
* Consider:
IV Access
IV fluids
Oxygen
Analgesia
Antiemetics
Midazolam
* Repeat stroke assessment to trend condition
* Rapid transport to appropriate facility
141
What is the pathophysiology of a cardiac arrest with an underlying asthmatic disease process?
Air trapping causing obstructive shock, increasing intrathoracic pressure and compressing inferior vena cava, stopping blood flow to right side of heart. Right ventricle depends on preload forcing contraction.
142
What is the pathophysiology of a cardiac arrest with an underlying asthmatic disease process?
Air trapping causing obstructive shock, increasing intrathoracic pressure and compressing inferior vena cava, stopping blood flow to right side of heart. Right ventricle depends on preload forcing contraction.
143
What is the pathophysiology of a focal seizure?
abnormal neuronal activity originates and is limited to one hemisphere of the cerebral cortex
144
What is the pathophysiology of a focal seizure?
abnormal neuronal activity originates and is limited to one hemisphere of the cerebral cortex
145
What is the pathophysiology of a generalised seizure?
abnormal neuronal activity in both hemispheres of the cerebral cortex (absence, atonic, tonic, myoclonic and tonic/clonic)
146
What is the pathophysiology of a generalised seizure?
abnormal neuronal activity in both hemispheres of the cerebral cortex (absence, atonic, tonic, myoclonic and tonic/clonic)
147
What is the pathophysiology of a haemorrhagic stroke?
blood vessel within the brain ruptures and bleeds into surrounding tissue and possibly subarachnoid space, causing hypoxia in downstream brain tissue and increasing ICP
148
What is the pathophysiology of a haemorrhagic stroke?
blood vessel within the brain ruptures and bleeds into surrounding tissue and possibly subarachnoid space, causing hypoxia in downstream brain tissue and increasing ICP
149
What is the pathophysiology of an acute asthma attack?
Response to allergen or environmental factors releasing endogenous irritant and inflammatory mediators causing reversible airway obstruction and narrowing from airway smooth muscle constriction
150
What is the pathophysiology of an acute asthma attack?
Reversible, obstructive respiratory disease, characterised by chronic airway inflammation, bronchial hyuperresponsiveness, airway narrowing, mucous production and mucous plugging.
151
What is the pathophysiology of an ischaemic stroke?
intracranial or peripheral artery occluded by a thromboembolism from within the brain or one which has travelled from the heart or distal limb which causes hypoxia in downstream brain tissue
152
What is the pathophysiology of an ischaemic stroke?
intracranial or peripheral artery occluded by a thromboembolism from within the brain or one which has travelled from the heart or distal limb which causes hypoxia in downstream brain tissue
153
What is the pathophysiology of placenta praevia?
The embryo implants in the lower part of the uterus causing the placenta to grow close to or over the cervical os
154
What is the pathophysiology of placenta praevia?
The embryo implants in the lower part of the uterus causing the placenta to grow close to or over the cervical os
155
What is the pathophysiology of placental abruption?
Rupture of the vessels in the pregnancy modified endometrium causing the placenta to separate partially or completely from the uterine wall.
156
What is the pathophysiology of placental abruption?
Rupture of the vessels in the pregnancy modified endometrium causing the placenta to separate partially or completely from the uterine wall.
157
What is the pathophysiology of sepsis?
Infection enters bloodstream causing dysregulated inflammation response and overwhelms body by release of anti-inflammatory mediators increasing vascular permeability causing fluid shifts and cellular hypoxia. Fluid loss into interstitium causes increase in peripheral vascular resistance worsening tissue ischemia and increasing lactate resulting in circulatory dysfunction and DIC
158
What is the pathophysiology of sepsis?
Sepsis is a life threatening complication of infection occuring when chemicals are released within system circulation, triggering inflammtory response throughout the body, causing a chain reaction leading to organ failure.
159
What is the pathophysiology of uterine rupture?
A spontaneous tearing of the uterus usually from trauma, genetic uterine wall weakness, prolonged labour augmentation or stretching of the uterine wall
160
What is the pathophysiology of uterine rupture?
A spontaneous tearing of the uterus usually from trauma, genetic uterine wall weakness, prolonged labour augmentation or stretching of the uterine wall
161
What is the pharmacology of refractory anaphylaxis drugs?
Persistent wheeze
* NEB Salbutamol - affects B2 receptors causing bronchodilation
* NEB Ipratropium bromide - promotes bronchodilation by inhibiting cholinergic bronchomotor tone
* IV Hydrocortisone – stabilises mast cells
Persistent hypotension/shock
* Glucagon – increases accessory pathway of cyclic amp to increase myocardium calcium release, increasing hr and contractility via non adrenergic pathway
* Fluid for hypotension – end goal of return of radial pulse
Upper airway obstruction
* Neb adrenaline – providing localised vasoconstriction to target tissues in larynx and airways reducing capillary leakage and airway oedema
162
What is the presentation of placenta praevia?
* no pain, other than that associated with contractions
* a soft, non-tender uterus
* several small warning bleeds
* bright red blood
* significant blood loss, which may lead to hypovolaemic shock
163
What is the presentation of placental abruption?
* Constant pain in the abdomino-pelvic region
* Fundal height may increase due to expanding intrauterine haemorrhage
* Tetanic uterine contractions
* Uterine hypertonicity – feels rigid on palpation
* Bleeding may range from absent to profuse, occurring in waves as the uterus contracts
* Signs of maternal shock
164
What is the presentation of uterine rupture?
* abnormal labour or failure to progress
* severe localised abdominal pain
* non-reassuring foetal heart patterns
* uterine tenderness
* loss of intrauterine pressure or cessation of contractions
* vaginal bleeding
* maternal hypovolaemic shock
165
What is the purpose of the shoulder dystocia interventions?
To increase the functional size of the bony pelvis and change the relationship between the size of the bony pelvis and the foetus and to reduce biacromial diameter of the foetus or to rotate foetus into oblique diameter
166
What is the treatment for an anaphylaxis patient and the mechanism of management?
appropriate dose adrenaline IM – sympathomimetic agent alpha and beta adrenergic receptor antagonist that makes the heart beat faster and harder due to alpha 1 causing peripheral vasoconstriction and beta 1 increasing ventricular irritability, contractile force, conductivity and AV node. Beta 2 stabilises mast cells to negate their deregulatory effect
167
What is the treatment for refractory anaphylaxis and why?
Persistent wheeze
* NEB Salbutamol – appropriate dose, PRN, no max dose – affects B2 receptors causing bronchodilation
* NEB Ipratropium bromide - promotes bronchodilation by inhibiting cholinergic bronchomotor tone
* IV Hydrocortisone – appropriate dose, single dose only, slow push over 1 minute (dilute with 2 ml sodium chloride, then discard 0.24 ml) – stabilises mast cells
Persistent hypotension/shock
* Glucagon – increases accessory pathway of cyclic amp to increase myocardium calcium release, increasing hr and contractility via non adrenergic pathway
* Fluid for hypotension – end goal of return of radial pulse
Upper airway obstruction
* Neb adrenaline – if persistent stridor – providing localised vasoconstriction to target tissues in larynx and airways reducing capillary leakage and airway oedema
168
What is your airway management for a pregnant patient with suspected pre-eclampsia who begins to convulse?
Suctioning the airway for 10-20 seconds
NPA if unable to open mouth due to trismus
Oxygen via non-rebreather mask – 15L minute
169
What is your definition of asthma?
Reversible lower airway obstruction characterised by chronic airway inflammation, bronchospasm causing wheeze and intermittent airway narrowing, +/- excess mucous production and mucous plugging
170
What is your management if the newborn’s pulse drops below 60?
* Place on flat surface
* CPR: 3:1 (Compressions:breath)
* Paeds pads on
* If shockable rhythm, shock at 4joules/kg – manual defib setting
* IV access
* 50 mics (0.5ml) adrenaline every 3-5 mins (using 1:10,000 (100mic/1ml) ampoule)
171
What is your pharmacological management for a pregnant patient with suspected pre-eclampsia who begins to convulse?
5mg IM midazolam, repeated every 10 mins, max 20 mg; OR if have IV access;
5mg IV every 5 minutes, max 20 mg
No as it will not correct the underlying cause of peripheral vasoconstriction and increased tone
172
What occurs in the first stage of labour?
gradual effacement and dilation of the cervix through regular contractions up to 10cm dilation
173
What occurs in the second stage of labour?
full dilation of the cervix and birth of the baby
174
What occurs in the third stage of labour?
delivery of the placenta
175
What other steps can be taken to assist with uterine contractions/haemorrhage control post delivery?
* Stimulate endrogenous oxytocin release by the commencement of breastfeeding
* Have mum urinate
176
What questions may be asked in the assessment of a child?
Gestational age at birth
NICU stay after birth
Pregnancy complications
Is child hydrated – wet nappies, bottle feeding appropriately, solids
Sick siblings
Going to school
Sickness at school
177
What risks are associated with cord prolapse?
* Foetal blood supply occluded, leading to hypoxia and death
* Vasospasm when manoeuvring the umbilical cord
178
What should you consider when deciding on medication doses in the elderly?
Decreased kidney function and ability to metabolise drugs
179
What should you do if you notice ongoing bleeding post delivery and why?
Fundal massage until firm and central – increases uterine tone, expresses clots and reduces haemorrhage
180
What tools can be used to identify Sepsis?
QAS sepsis criteria:
Temperature
AVPU
Respiration rate
Heart rate
Systolic BP
181
What would you consider appropriate analgesia for a pregnant patient with abdo pain and PV bleed?
2.5mg IV morphine, or
3ml methoxyflurane
182
Where do you clamp and cut the cord?
10cm, 15cm and 20cm
Cut between 15cm and 20cm
183
Why can asthmatic Pts tolerate low resp rates in ROSC?
to prevent air trapping, and build up of intrinsic PEEP
184
Why do you administer antiemetics to stroke patients?
to prevent vomiting and further increase in ICP
if haemorrhagic stroke as blood is toxic to the brain when not in blood vessels
185
Why is it important to guard the uterus when applying cord traction?
To prevent uterine inversion
186
Why is rapid transport for a stroke patient essential?
for urgent stroke testing
187
What are the symptoms of anaphylaxis?
Skin: rash, itchiness, swelling of lips, mouth, tongue and eyes
Respiratory: chest tightness, wheezing, SOB
Cardiovascular: hypotension, tachycardia, dizziness, syncope
GI: abdo pain, nausea vomiting diarrhoea
188
What is the pathophysiology of a MI?
An occlusion of a coronary artery by a thrombus, decreasing blood flow distal to the occlusion causing ischemia and cell death.
189
What is ACS?
Acute coronary syndrome is a term that describes a range of conditions related to sudden, reduced blood flow to the heart.
190
What are some conditions of ACS?
APO
Angina - stable and unstable
MI
STEMI
STEMI mimic
NSTEMI
191
Glyceryl trinitrate (GTN) Pharmacology
decreases preload and afterload, dilates blood vessels to allow blood through the coronary veins and arteries and pools blood in peripheral veins
192
Hydrocortisone Pharmacology
Inhibit the inflammatory action of the phospholipase A2 enzyme and used for multiple reasons for infections in a variety of setting for long term disease processes
193
Morphine Pharmacology
Narcotic analgesic that acts on CNS by binding with opioid receptors altering pain perception processes and emotional response to pain. Causes respiratory depression, vasodilation, decreases gag reflex and slows AV node conduction.
194
Ondonsetron Pharmacology
Serotonin 5-HT3 antagonist which inhibits the vagus nerve and blocks serotonin receptors in the chemoreceptor trigger zone
195
Paracetamol pharmacology
A p-aminophenol derivative that exhibits analgesic and antipyretic activity. It does not possess significant anti-inflammatory activity
196
Salbutamol Pharmacology
Acts on B2 adrenoreceptors causing bronchodilation, inotropic and chronotropic actions. It stimulates the sodium/potassium ATPase pump, increasing intracellular K+ and reducing serum K+.
```
inotropic = heart contractility
chronotropic = increased HR
```
197
Oxytocin Pharmacology
Stimulates uterine contractions by altering calcium concentrations within the uterine muscle cells increasing it tonicity
198
Fentanyl Pharmacology
synthetic narcotic analgesic that acts on the central nervous system by binding with the opioid receptors
199
Glucagon Pharmacology
Hyperglycaemic agent that mobilises hepatic glycogen which is released into the blood as glucose with inotropic and chronotropic effects not mediated through beta-receptors
200
Aspirin Pharmacology
prevents platelets from aggregating to exposed collagen fibres at the site of vascular injury
201
Glucose 10% Pharmacology
A sugar that is the principal energy source for body cells, especially the brain
202
Adrenaline pharmacology in asthma
sympathomimetic agent that is an alpha and beta adrenergic receptor antagonist that makes the heart beat faster and harder due to alpha 1 causing peripheral vasoconstriction and beta 1 increasing ventricular irritability, contractile force, conductivity and AV node. Beta 2 stabilises mast cells to negate their deregulatory effect
203
Atropine Pharmacology
* 1. Anticholinergic action inhibits vagus innervation of the heart
* 1. loss of parasympatheic tone resulting in increased heart rate and contractility
204
What is the pathophysiology of acute pulmonary oedema?
Accumulation of fluid in the lung alveoli leading to impaired gas exchange between the air in the alveoli and pulmonary capillaries and a diluting of surfactant, reducing alveoli compliance.
205
How does oxygen administration effect patient’s with COPD?
It can cause hypoventilation due to increased blood flow to poorly ventilated alveoli, increasing V/Q mismatch dead space
206
What is the pathophysiology of COPD?
Chronic desease that restricts airflow causing breathing difficulty due to dead space within the lungs, chronic inflammation and extensive mucous production which impairs gas exchange/vq mismatch
