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CARDIOVASCULAR > Medical Emergencies Symposium > Flashcards

Medical Emergencies Symposium Flashcards

1
Q

What is the difference between a faint and a collapse?

A

Can collapse without fainting

Collapse - sudden loss of postural tone

Faint - transient loss of consciousness

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2
Q

What do you do if a patient faints, record wise?

A

Gather information about the faint

  • what pt was doing when they collapsed
  • did they have symptoms
  • appearance throughout - important for seizures
  • were they moving
  • was there tongue biting
  • how long did it last
  • did they come round quickly
  • any other symtpoms?
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3
Q

What are the main causes of faints and collapses? (3)

A

—Neurogenic Syncope - caused by problem with brain and NS

—Cardiogenic Syncope - problem with heart

—Neurocardiogenic / Vasovagal Syncope including “Simple Faint”

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4
Q

What can be classed as a neurogenic syncope?

What causes it?

A

—Seizures / Epilepsy are included in neurogenic syncopes

—Caused by a sub-Arachnoid Haemoarrhage

—Not stroke

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5
Q

What are features to suggest the faint was neurogenic?

A

—History of Neurogenic problems: Epilepsy

May have symptoms - funny smells / seeing things

—Loss of sphincter tone

—Tongue Biting

—Prodrome

—Clinical features

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6
Q

What are some different causes of cardiogenic syncope?

A

—Arrhythmias: Bradycardia (heart blocks - reduced perfusion to brain), Tachycardia

—Valvular Pathology: Aortic Stenosis, Mitral Stenosis (valves thicken)

—Structural Heart Disease: Hypertrophic Cardiomyopathy (HCM)

—Pulmonary Embolus

—Primary Electrophysiological Abnormalities: Brugada Syndrome, Long QT Syndrome - increase the risk of cardiac arrest

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7
Q

What are the symptoms of vasovagal syncope?

What is the timescale like?

A

—Commonest type of faint

—Symptoms: 3 P’s:

Posture (standing up too long) Provoking (bereavment, seeing blood, etc) Prodrome (pale, sweating

—Transient loss of consciousness (30 seconds)

—Rapid recovery, often ongoing headache, mild nausea

—Overstimulation of vagus nerve +/- sympathetic tone loss

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8
Q

What is situational syncope?

A

Pts may faint when they strain / go to the toilet

There are no features that suggest an alternative diagnosis.

Not usually a concern

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9
Q

What are red flag signs? Who needs referring once theyve fainted?

A
  • Anyone who collapses and has an ECG abnormality
  • breathlessness
  • heart murmur
  • family history of sudden cardiac death
  • heart failure
  • transient loss of consciousness
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10
Q

How do you assess and treat faints?

A

—Assess the Airway, Breathing and Circulation

  • Lay flat, elevate legs (if tolerated), recovery position if necessary

—If occurs after an unpleasant stimulus (e.g. LA injection) and recovery rapid - it is likely a ‘simple’ faint

—If any doubt - ED assessment

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11
Q

—72 year old man with hypertension, stable ischaemic heart disease and type 2 diabetes on insulin attends for dental treatment. His appointment is at 1030 but the surgery is running late. He starts to become agitated and aggressive in the waiting room and staff become very concerned. He tries to punch the receptionist and this is very out of character.

What is he experiencing?

A

Hypoglycaemia

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12
Q

What is hypoglycaemia?

A

—Lower than normal blood sugar

—Normal blood sugar (BM) ~4 - 7

—Differing thresholds for symptoms

DEFG = Don’t Ever Forget Glucose

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13
Q

What are some symptoms of hypoglycaemia?

A

Symptoms get worse as blood sugar decreases

—Hunger, irritability, headache, altered / reduced LOC, difficulty speaking, slurred speech, Ataxia dyscoordination, (drunkenness), seizures

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14
Q

What are some causes of hypoglycaemia?

A
  • —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
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15
Q

How do you treat hypoglycaemia?

A
  • —Sugar!
  • If symptoms minimal - carbohydrate (e.g. sandwich, sugary drink)
  • With increasing symptoms, use oral gel e.g. “hypostop”
  • IV if significant symptoms (reduced LOC / seizures)
  • Hospital assessment focused on treatment and identifying cause
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16
Q

—24 year old man with severe dental pain attends an emergency dental clinic. He takes some pain killers a friend recommends as he arrives. Whilst waiting, he starts to become agitated, feeling he can’t breathe and that his throat is tight.

Diagnosis?

A

Anaphylaxis

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17
Q

What is anaphylaxis?

A

—Extreme allergy

—This is IgE mediated (anaphylactoid reactions clinically similar, but not IgE mediated)

—Caused by reaction to allergen (food / drugs esp. antibiotics / NSAIDS)

You need to have had exposure to the allergen in the past to be able to produce an anaphylactic response

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18
Q

What is the pathophysiology of anaphylaxis?

A

—The antigen binds to IgE antibodies on mast cells (immune cells), which are based in connective tissue throughout the body

This makes a complex which activates the mast cell.

—Degranulation of mast cells with a huge release of inflammatory mediators (histamines, cytokines, IL3, IL4)

—These inflammatory mediators cause common symptoms of allergic reactions, such as itching, rash, and swelling

—Can also cause bronchial constriction (causes wheeze), vasodilation (lip/eye swelling, epiglottis swelling causing stridor)

—Anaphylactic shock is an allergic reaction with respiratory symptoms and circulatory collapse

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19
Q

What are the clinical features of anaphylaxis?

A
  • —Respiratory distress – stridor (gasping for air), tachypnoea, wheeze, cyanosis (turning blue)
  • Circulatory signs - pallor, cool peripheries, tachycardia, hypotension
  • CNS - anxiety, agitation, reduced LOC
  • GI - abdominal pain, diarrhoea, vomiting
  • Skin - urticaria (skin rash and swelling)
20
Q

How do you treat anaphylaxis?

A
  • —Remove / stop cause (e.g. LA injection)
  • ABC: Assess Airway, Breathing and Circulation
  • Intramuscular (into arm or thigh) adrenaline (0.5mg)
  • Oxygen (15L high flow)
  • Nebulised ß agonist (salbutamol)
  • 999 to ED
21
Q

What are the effects of adrenaline?

A

Increases sympathetic NS (fight or flight). Brings all blood flo back to heart, increases HR and BP.

Acts on receptors in lungs and smooth muscle in bronchioles - they dilate and get more air flow

BVs constrict - makes blood flow get directed back to heart

22
Q

What other medications can be given for anaphylaxis?

A

High flow oxygen

IV fluid

Chlorphenamine 10mg

Hydrocortisone 200mg

Can give salbutamol (used in asthmatics usually but helps open up airways)

Give these as close together as possible all at once.

23
Q

What is asthma caused by?

What are the 2 types of asthma?

What are the symptoms of an acute attack?

A

—Caused by increased airway reactivity and getting inflamed. This causes a reversible airway obstruction

—Atopic / non - atopic (atopy - triad of atopic eczema, allergic rhinitis (hay fever) and asthma)

Atopic - an allergic IgE mediated reaction to allergens

Non-atopic - not very well understood

—Various triggers = pollen, dust, cigarette smoke, pet fur

—Acute attacks - wheezing, SOB, ‘tight chest’, coughing

24
Q

What is the treatment for a pt having an asthma attack?

A

—Try and prevent contact with allergens

—Treat with inhaled B-agonists - salbutamol, terbutaline (ventolin / bricanyl) – Patients own or Nebulised

—Steroids if indicated to treat an acute flare of asthma- reduce airway inflammation

—Others - magnesium, IV aminophylline, ventilation

25
Q

How to manage acute asthma?

Use the pneumonic

A

Oxygen - mainstay of treatment

Salbutamol - works on beta receptors in bronchioles - increases air flow

Hydrocortisone

Ipratropium

Theophylline/aminophylline

Magnesium

Escalate care

26
Q

—82 year old lady with diabetes, peripheral vascular disease and hypertension is undergoing some complex protracted dental treatment. During this she complains of central chest pain that radiates to her left arm. She starts to feel dizzy and sick.

Diagnosis?

A

ischaemic heart disease

27
Q

What are some features of ischaemic heart disease?

A

—Big umbrella term which covers a lot of heart problems (like angina and myocardial infarction)

Common in Western world

—Coronary artery disease - narrowing of the blood vessels supplying the heart

—Complicated pathogenesis

—Lots of risk factors (fixed & modifiable) - old males with family history of heart problems

—Clinical manifestations variable

28
Q

What does ischaemic mean?

A

starved of oxygen

29
Q

What are the 3 things we look for in a patient with suspected myocardial infarction?

A

3 things: symptoms, ECG changes and biochemical markers

If pt has 2 of these symptoms they will most likely have MI

30
Q

What is stable and unstable angina?

A

—‘Stable’ angina - pain on exercise, relieved by rest +/- GTN

—‘Unstable’ angina - worsening pain esp. at rest, increasing frequency of episodes. Not relieved by GTN

GTN = Glyceryl trinitrate

31
Q

What are the symptoms of angina / MI?

A
  • —Chest pain +/- radiation (crushing sensation - could spread into arm, jaw and teeth)
  • Nausea / vomiting
  • Collapse
  • Sweating
  • Pallor
  • Anxiety
32
Q

What is the treatement of angina / MI?

A
  • —GTN spray / tablet (glyceryl trinitrate)
  • Aspirin 300mg (chew / dispersible)
  • Oxygen (if indicated) - only if oxygen saturation is <94%
  • 999 to ED
  • Primary PCI (STH) for AMI that meet criteria
  • MONA: M=Morphine O=Oxygen N=Nitrates (GTN) A = Aspirin
33
Q

—62 year old woman with very longstanding rheumatoid arthritis treated with steroids for many years has tooth ache and has been vomiting after taking antibiotics for 2 days.

—She attends your surgery for dental treatment but is feeling very unwell, weak, dizzy and vomiting.

Diagnosis?

A

Adrenal insufficiency

34
Q

What do the adrenal glands do?

List the zones of the cortex?

A

—Adrenal glands sit just above the kidneys - responsible for producing all stress hormones required if you become unwell. Central part (medulla) produces adrenaline/noradrenaline

Cortex - 3 zones

Zona glomerulosa (outer) - produces catecholamines (aldosterone and corticosterone)

Zona fasciculata - produces glucocorticoids (cortisol + cortisone)

Zona reticularis (inner) - oestrogens and testosterone

35
Q

What is adrenal insufficiency?

A

—Inadequate production of steroid hormones

—Primarily cortisol

—May have impaired aldosterone production

—Several causes

36
Q

What are the causes of adrenal insufficiency?

A
  • —Primary adrenal insufficiency - impairment of the adrenal glands.
  • Idiopathic
  • —Autoimmune - Addison’s disease
  • Congenital adrenal hyperplasia
  • Adenoma (tumor) of the adrenal gland
  • Secondary adrenal insufficiency - impairment of the pituitary gland or hypothalamus
  • Pituitary microadenoma
  • Hypothalamic tumour
  • Sheehan’s syndrome (postpartum pituitary necrosis)
37
Q

What are the clinical features of adrenal insufficiency?

A
  • —Weakness, tiredness, dizziness, hypotension esp. orthostatic
  • Hypoglycemia, dehydration, weight loss, and disorientation
  • Myalgia, nausea, vomiting, and diarrhoea
  • Hyperkalaemia & hyponatraemia
  • Palmar crease tanning
  • Vitiligo
38
Q

What are the features of adrenal crisis (not making any steroid)?

A
  • Lethargy, fever
  • Abdominal pain (back / legs also)
  • Severe D&V (+/- dehydration)
  • Hypotension
  • Hypoglycaemia
  • Syncope
  • Confusion, psychosis, slurred speech
39
Q

What is the treatment of adrenal crisis?

A

Avoid treatment

Modify steroid regime before treatment (usually double the dose)

If signs of crisis - 999

Will need hospital assessment - steroids, fluids and observation

40
Q

—83 year old man with degree of dementia and a previous stroke is about to undergo a check up. He starts to get uncontrolled twitching of his left hand which then progresses to involve his whole arm before he collapses to the floor jerking violently.

Diagnosis?

A

Seizure

41
Q

Are seizures always epileptic?

A

Not always

Several types of seizure and they’re difficult to diagnose

Classic seizures are dramatic but rarely problematic

42
Q

What are the different types of seizures?

A

—Focal seizures - may have loss of consciousness (simple / complex)

—Generalised seizure - all have LOC (absence, tonic-clonic, myoclonic, tonic, atonic).

43
Q

What are the causes of seizures?

A
  • —Epilepsy (including drug non-compliance or interactions)
  • Fatigue
  • Intracranial lesion
  • Drug and alcohol intoxication / withdrawal
  • Intracranial infection - encephalitis or meningitis
  • Metabolic disturbances - hypoglycaemia, hyponatraemiaor hypoxia
  • Multiple sclerosis
44
Q

How do you deal with seizures?

A

—Protect patient from injury

—Most come to no harm at all, post-ictal phase may be distressing and prolonged

—Classic tonic-clonic seizure rarely more than 1-2 mins

—If prolonged - assess Airway, Breathing and Circulation and call 999

45
Q

Why is it important to time seizures?

What 2 drugs are commonly used for seizures?

A

Because they may need intubation and hospitalisation if:

Their seizure lasts more than 5 mins or if they have 2 seizures in quick succession.

Buccal midazolam or rectal diazepam (benzodiazepenes)

CARDIOVASCULAR (3 decks)

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