emergency medicine Flashcards

Question

Septic shock

Answer 1

Background: Hypoperfusion and sepsis despite adequate fluid treatment Has greater mortality risk than sepsis alone (>40%) Associated with profound circulatory, cellular and metabolic abnormalities Diagnosis: Systolic BP <90 despite fluid resus Hyperlactatemia (>4mM) Management: Sepsis 6 pathway: give IV fluids, antibiotics and oxygen, take blood cultures, measure urine output and measure lactate levels Aggressive treatment with IV fluids to improve BP and tissue perfusion Move to HDU/ICU for treatment with inotropes like noradrenaline

Answer 2

Background: Blood poisoning An infection caused by a large amount of bacteria entering the bloodstream Presentation: Fever, fatigue Rigors SOB Diagnosis: Blood cultures ``` Management: Give IV fluids Give IV antibiotics Give oxygen Take blood cultures Take blood lactate levels Catheterise - Urine output ```

Answer 3

Background: Potentially life threatening complication of neutropenia Defined as a temperature >38 or any symptoms/signs of sepsis in a person with an absolute neutrophil count of <0.5 x 10(9) Potential fatal complication of systemic anticancer treatment with a mortality of up to 20% Pathology: Decreased neutrophil count leading to poor control of infection Aetiology: Cytotoxic chemotherapy and other immunosuppressive drugs Stem cell transplantation Infections Bone marrow disorders (aplastic anaemia and MDS) Nutritional deficiencies

Answer 4

Risk factors: All above increase the risk of infection/sepsis via prolonged or severe neutropenia Investigations/diagnosis: Systemic anticancer therapy within the last 6 weeks Vital obs - temperature Have they had a recent bone marrow transplant Are they immunocompromised? What chemotherapy are they on and when was the last treatment/tablet ABCDE approach NEWS2 scoring Urgent bloods - FBC, U+Es, LFT, CRP, blood cultures, blood gasses Consider MSU, sputum culture, throat swabs, CXR, stool sample if indicated

Answer 5

Sepsis 6: start antibiotics IV ASAP max 1 hour to initiate treatment aim for 30 mins Side room/isolate patient Antibiotics usually piperacillin-tazobactam (Tazocin) 4.5g IV/8 hours +/- gentamicin or amikacin Intra-abdominal sepsis or severe mouth ulcers - metronidazole 500mg/IV 8 hourly for 7 days added onto treatment If there is a response within 48 hours then continue until infection resolves If no evidence of infection continue for a total period of 4 days Severe neutropenia - continue treatment until >0.5 x 10(9)/L

Answer 6

Initial steps: Brief handover of patients name, DOB, age, background and reason for assessment Introduce yourself Look at the notes, obs chart, prescription chart, Pmx if available If unconscious and unresponsive start BLS ``` Airway: Can they talk? No - look for signs of compromise: see-saw breathing, cyanosis, accessory muscles, breath sounds and added sounds Open mouth to inspect for obstruction or swellings Reassess after any interventions Suction for obvious obstructions Head tilt chin lift manoeuver Jaw thrust Oropharyngeal airway Nasopharyngeal airway CPR if no signs of life ``` ``` Breathing: Respiratory rate Oxygen saturation Signs of cyanosis, SOB, cough, stridor, apnoeas, kussmaul’s respiration (metabolic acidosis) Assess tracheal position Chest expansion Chest percussion and auscultation Reassess after any interventions ABG CXR Oxygen Asthma - nebulisers, steroids COPD - nebulisers, steroids, antibiotics CPR for no signs of life ``` ``` Circulation: HR BP Fluid balance assessment General inspection - pallor, oedema Palpation - temperature, capillary refill time, pulses, JVP Auscultate for heart sounds Ankles and sacrum for pitting oedema Reassess after any interventions IV cannula fluid resus Blood tests and cultures ECG Bladder USS Urine pregnancy test Fluid output/catheterisation CPR for no signs of life ``` ``` Disability: ACVPU scale for conscioussness GCS score if time Pupil size, symmetry, direct and consensual response Drug chart review for medications which may cause neurological abnormalities Reassess after any interventions Blood glucose and ketones Imaging - CT head Maintain airway CPR for no signs of life ``` Exposure: Do they have any pain anywhere? Inspect skin for rashes, bruising, signs of infection Temperature Review any IV lines for erythema or discharge Surgical wounds for haematoma, active bleeding, infection Review urine output, surgical drain output for blood/fluid loss and infection Bleeding - estimate blood loss and rate, assess for hypovolemic shock Reassess after any interventions Swabs and samples for potential infection sources IV fluids for haemorrhage or fluid loss Bloods - FBC, coagulation, G+S Sepsis 6 for sepsis Wells score for DVT/PE CPR for no signs of life Next stages: Take thorough history Review notes, charts, recent investigations and current medications Document ABCDE assessment Discuss case with senior clinician (SBARR) Handover to anyone at end of shift if needed

Answer 7

Airway problems: anaesthetist Breathing problems: medical registrar or critical care team Circulation problems: medical registrar, critical care team, specialist of pathology Disability: medical registrar on call, anaesthetist if airway threatened (GCS <8), specialist of pathology Exposure: medical registrar, specialist of pathology

Answer 8

Fluids: have you given a fluid challenge? Measure urine output and consider catheter Gas: check ABG or VBG; when does it need to be repeated? Haematology: lab tests taken and sent? Imagine: order any X-rays, CT’s etc. and review them? Jobs: have you allocated jobs appropriately? Can nursing staff help? (YES THEY ALWAYS CAN) K (ECG): look, interpret and compare to previous Location: does the patient need to be moved e.g. to ICU Monitoring: how often is it needed? Any need for neurological obs? Next of kin: has anyone informed the NoK? Do they need to be informed? Oh, shit: stop, think, are you ok? Do you need help? (probably yeah) Plan: document your plan and inform nursing staff Questions: does the patient have any questions about what’s happened or about the plans put in place?

Answer 9

Allergies Medications Past medical history and last relevant treatments Last ate and drank Events leading up to admission (recent infections, presentation etc.)

Answer 10

A legal document that formalises decision-making about whether an individual should be treated with CPR in the event of a cardiac arrest Key consideration in the management of patients with progressive life limiting illnesses, those approaching the end of life and significantly frail patients It is a clinical decision, you have a duty to determine the chance of survival using CPR once the heart has stopped and it does not relate to any other medical decisions or affect any other treatments regarding current treatments It is also your clinical duty to explain the reasoning and procedures for this decision to the patient and family It is appropriate for when the potential benefits outweigh the risks - less than 20% of patients survive in-hospital cardiac arrests, survival for elderly and frail patients is much less. It is important to consider each decision on a case by case basis based solely of comorbidities It is an anticipatory decision and should be made in advance of when it is needed to be applied

Answer 11

A discussion about DNACPR may be appropriate in a wide variety of contexts including: as part of advance care planning in the community with a well patient whilst discussing treatment and prognosis with a patient with a chronic disease in an acute setting with a patient who is deteriorating When explaining it is crucial to put across that this conversation does not imply that you expect them to rapidly decline nor does it change any efforts or managements to sustain their life and treat them. It should ideally be held in the presence of family or other individuals important to the patient to help them all understand why this is important and everyone is aware and has a good understanding of future management If not possible the family should be informed at the next available opportunity Explaining: Do not ask them to sign or ask direct consent as this can confuse them as to how the decision is made Introduce yourself Confirm patients identity Explain purpose of the conversation - wish to discuss resuscitation in the event of a cardiac arrest Gain consent and ensure they are willing to have the conversation, come back another time if too distressed Establish if there is anyone else they would live to have present Explain what is meant by a cardiac arrest: “As your illness progresses, you may become so unwell that your heart stops beating, this is called a cardiac arrest”. Explain what is meant by CPR and what it involves including chest compressions, ventilation, defibrillation, and intravenous drugs. It is important to emphasise it is an invasive process and to explain this in non-medical terms. Explain what a DNACPR is, and why it is appropriate for this patient Important information to convey includes: CPR is likely to be futile It is likely to lead to poor outcomes for the patient Explain that a DNACPR means that in the event of a cardiac arrest, CPR would not be administered. It is important to emphasise it is specific to CPR as a treatment and does not apply to other interventions or treatments. Patients may interpret a DNACPR as “giving up” on them – if a patient expresses this concern it is crucial to reassure them otherwise. Explain that a DNACPR is a standard part of advance care planning – this helps the patient to understand that the discussion is a normal part of care, rather than something exceptional about their treatment. Finalising the discussion Check the patient’s understanding of the conversation. Invite the patient to ask any further questions. Summarise the conversation. If the patient, next of kin or carers object to or disagree with the decision, you should listen to their concerns and attempt to address them through a further explanation. If they continue to disagree, the guidance from the GMC is to escalate to a senior for a second opinion rather than continue to try to convince the patient otherwise. Thank the patient for their time and check how they are feeling emotionally, as they may want to discuss the matter further with either yourself, another member of the team, or their family or carers.

Answer 12

In a scenario in which a patient does not have capacity, this discussion should instead be had with their next of kin, or the person nominated to have decision-making power on their behalf (such as a medical Lasting Power of Attorney). The same principles apply – it is not this person who is able to make this decision, but the rationale for it should be fully explained. If a representative for the patient is not available, then a DNACPR form can be completed without having had this discussion – although the patient’s next of kin or a representative should be informed of the decision at the nearest available opportunity.

Answer 13

Wind - respiratory infection like pneumonia or atelectasis Wound - surgery site infection Water - UTI Walking - VTE like PE or DVT Wonder drugs - antibiotics or sulfur drugs as well as IV line inflammation/phlebitis Withdrawal - alcohol withdrawal Wonky glands - thyrotoxicosis and adrenal insufficiency

emergency medicine Flashcards

(37 cards)