Medical emergencies symposium

Question 1

How do you know if a pt has fainted or collapsed?

Answer 1

Collapse - sudden loss of postural tone

Faint - transient loss of consciousness

Question 2

Causes of faints and collapses?

Answer 2

Neurogenic syncope
Cardiogenic syncope
Neurocardiogenic syncope including simple faint

Question 3

NICE assessment - what does it look for in relation to collapses?

Answer 3

What happened at the time it occurred
Was anything happening beforehand e.g. anxious, pain
Any shakes, jerking, urinating, biting tongue

Question 4

Examples of neurogenic syncopes?

Answer 4

Seizures/epilepsy
Sub-arachnoid haemorrhage
Not stroke

Question 5

Features of neurogenic syncope?

Answer 5

History of neurogenic problems: epilepsy
Loss of sphincter tone
Tongue biting
Prodrome
Clinical features

Question 6

Examples of cardiogenic syncope?

Answer 6

Arrhythmia: bradycardia, tachycardia
Vulvular pathology: aortic stenosis, mitral stenosis
Structural heart disease: hypertrophic cardiomyopathy (HCM)
Pulmonary embolus
Primary electrophysiological abnormalities:
- Brugada sundrome
- Long QT syndrome

Question 7

Vasovagal syncope features?

Answer 7

Commonest type of faint
Posture (upright more likely) Provoking (what happened at the time - anxious environment) Prodrome (sweating)
Transient LOC
Rapid recovery, often ongoing headache, mild nausea
Overstimulation of vagus nerve +/- sympathetic tone loss
Is there a reason to think it could be something else? - e.g. pt grabbed chest in pain

Question 8

Red flags?

Answer 8

Brain or heart cause
Call ambulance
Get ECG
Physical signs of heart failure - swelling of legs
FH of sudden cardiac death in people younger than 40 years

Question 9

How to assess and treat faints?

Answer 9

Assess airway, breathing, circulation
- Lay flat, elevate legs (if tolerated), recovery position if necessary
If occurs after an unpleasant stimulus (LA) and recovery rapid - simple faint
If any doubt - ED assessment

Question 10

Define hypogylcaemia

Answer 10

Lower than normal blood sugar

Normal blood glucose 4.7

Question 11

Symptoms of hypoglycaemia?

Answer 11

Hunger
Irritability
Headache
Altered/reduced LOC
Difficulty speaking, slurred speech
Ataxia dyscoordination (drunkenness)
Agitated
Seizures

Question 12

Causes of hypoglycaemia?

Answer 12

Too little fuel
Too much insulin (e.g. diabetics)
Excess oral diabetes drugs, beta-blockers, drug interactions
Alcohol induced hypoglycemia 
Sepsis
Insulin-secreting pancreatic tumor
Adrenal insufficiency / hypopituitarism

Question 13

How to treat hypoglycaemia?

Answer 13

Sugar
If symptoms minimal - carbohydrate (bread and sugary drink as sugary drink short acting)
With increasing symptoms - oral gel (hypostop)
IV if significant symptoms - reduced LOC/seizures
Hospital assessment focused on tx and identifying cause

Question 14

What is anaphylaxis?

Answer 14

Extreme allergy
IgE mediated
Caused by rxn to allergen

Question 15

What occurs in anaphylaxis?

Answer 15

Antigen binds to IgE antibodies on mast cells based in CT throughout body
Degranulation of mast cells with release of inflam mediators
Inflam mediators cause common symptoms f allergic rxns - itching, rash, swelling
Can cause bronchial constriction, vasodilation
Anaphylactic shock is an allergic rxn with resp symptoms and circulatory collapse

Question 16

Clinical features of anaphylaxis?

Answer 16

Resp distress - stridor, tachypnoae, wheeze, cyanosis
Circulatory signs - pallor, cool peripheries, tachycardia, hypotension
CNS - anxiety, agitation, reduced LOS
GI - abdominal pain, D&V
Skin - urticaria

Question 17

Anaphylaxis tx?

Answer 17

Remove/stop cause (e.g. LA)
Assess airway, breathing and circulation
IM adrenaline (0.5mg)
Oxygen (especially if cyanosis)
Nebulised beta agonist (salbutamol)
Remove stimuli
999 to ED

Question 18

Asthma features?

Answer 18

Increased airway reactivity
Atopic/non-atopic
(atopic - triad of atopic eczema, allergic rhinitis and asthma)
Various triggers
Acute attacks - wheezing, SOB, tight chest, coughing

Question 19

How to treat asthma?

Answer 19

Try and prevent - avoid precipitants
Inhaled beta-agonists - salbutamol, terbutaline (ventolin) - pts own or nebulised
Steroids if indicated - reduce airway inflam

Question 20

Ischaemic heart disease - angina/MI features?

Answer 20

Common in western world
Can be caused by coronary artery disease
Complicated pathogenesis
Risk factors (fixed and modifiable)

Question 21

Stable angina symptoms?

Answer 21

Pain on exercise, relieved by rest +/- GTN

Question 22

Unstable angina symptoms?

Answer 22

Worsening pain especially at rest, increasing freq of episodes

Question 23

MI features?

Answer 23

Symptoms, ECG changes, biomechanical markers

Question 24

Typical MI/angina symptoms?

Answer 24

Chest pain - sometimes radiates
Nausea/vomiting
Collapse
Sweating
Pallor
Anxiety

Question 25

Angina/MI tx?

Answer 25

``` GTN spray/tablet Aspirin 300mg Oxygen if indicated 999 to ED Primary PCI for AMI that meet criteria MONA: Morphine, oxygen, nitrates (GTN), aspirin ```

Question 26

What is adrenal insufficiency?

Answer 26

Inadequate production of steroid hormones Primarily cortisol May have impaired aldosterone production Several causes

Question 27

Causes of adrenal insufficiency?

Answer 27

Primary adrenal insufficiency - impairment of adrenal gland Idiopathic Autoimmune - addison's disease Congenital adrenal hyperplasia Adenoma of adrenal gland 2ndry adrenal insufficiency - impairment of the pituitary gland or hypothalamus Pituitary microadenoma Hypothalamic tumour Sheehan's syndrome (postpartum pituitary necrosis)

Question 28

Clinical features of adrenal insufficiency?

Answer 28

Weakness, tiredness, dizziness, hypotension Hypoglycaemia, dehydration, weightloss, disorientation Myalgia, nausea, vomiting, diarrhoea Hyperkalaemia and hyponatraemia Palmar crease tanning Vitiligo

Question 29

Adrenal crisis clinical features?

Answer 29

``` Lethargy, fever Abdominal pain (back and legs also) Severe D&V Hypotension Hypoglycaemia Syncope Confusion, psychosis, slurred speech ```

Question 30

Tx of adrenal crisis?

Answer 30

Avoid Modification of steroid regimen before examination/tx If signs of crisis - 999 Will need hospital assessment - steroids, fluids, observation

Question 31

Features of seizures?

Answer 31

Not always epileptic Several types of seizures Difficult to diagnose Classic seizure dramatic, but rarely problematic

Question 32

What are the types of seizures? Features?

Answer 32

Partial seizure - may have LOC (simple/complex) Generalised seizure - all have LOC (absence, tonic-clonic, myoclonic, tonic, atonic)

Question 33

Causes of seizures?

Answer 33

Epilepsy Fatigue Intracranial lesion Drug and alcohol intoxication/withdrawal Intracranial infection - encephalitis, meningitis Metabolic disturbances - hypoglycaemia, hyponatraemia or hypoxia MS

Question 34

How to manage a seizure?

Answer 34

Protect pt from injury Post-ictal phase may be distressing and prolonged Classic tonic-clonic seizure rarely more than 1-2mins If prolonged - assess airway, breathing, circulation and call 999 If more than 5 mins = benzodiazepam

Question 35

What can stress cause?

Answer 35

Cardiac events, syncope, seizures, acute adrenal insufficiency, asthma Past MH may predict events and prevention e.g. increasing steroid doses peri-surgery Assess airway, breathing and circulation 999 to ED if any concerns

Question 36

PE features?

Answer 36

Massive PE = collapse More likely SOB +/- chest pain Many risk factors