Week 1: Acute emergencies (2)

Question 1

Acutely unwell child

Answer 1

Outcome of a child following cardiac arrest is poor and therefore emphasis is on early recognition of the signs of potential:

• Respiratory
• Circulatory
• Central neurological failure

Question 2

primary ABDCDE assessment and resus in child

Answer 2

Should take less than a minute. Aim is to identify life threatening problems to guide resus

Question 3

airway assessment in children

Answer 3

Airway assessment

• Look listen and feel for airway patency
• In unconscious baby or child do ‘head tilt and chin lift’
  
  • Neutral in infant
  • Sniffing position in children
• Resus
  
  • Nasopharyngeal airways and guedal airways may be appropriate
  • In conscious child, stridor or hoarse voice may indicate a compromise airwaysenior input anaesthetics

Question 4

Breathing assessment in children

Answer 4

Effort, efficacy and effect

Question 5

effort

Answer 5

• ‘how much work is going into breathing’
• Raised resp rate may be caused by airway or lung pathology or driven by metabolic acidosis (DKA)
• Normal values
• Other signs of resp distress: grunting, flaring of nostrils, tracheal tug and accessory muscle use (intercostal, subcostal and sternal recession)
  
  • Gasping is a late sign of severe hypoxia
• In cases of hypoxia with no signs of increased resp effort: child is fatigued (life-threatening asthma); neuromuscular disease e.g. muscular dystrophy, central resp depression (poisoning, head injury)

Question 6

Efficacy: ‘what are they achieving in terms of air movement and gas exchange’

Answer 6

• Observe chest expansion and auscultation for air entry
  
  • Asymmetrical air entry
  • Bronchial breathing (pneumonia)
  • Wheeze and reduced air entry (acute asthma)
  • Silent chest- extremely worrying
• Oxygen sats

Question 7

Effect: ‘what is the effect of respiratory inadequacy on the rest of the body

Answer 7

• Hypoxia will initially lead to tachycardia- h/w if prolonged will lead to bradycardia- pre-terminal sign
• Cyanosis sats <70%- pre-terminal sign
• Hypoxia and hypercapnia lead to agitation or drowsiness (may present in pts not cooperating with exam and seem very distressed or unusually quiet and withdrawn

Question 8

resuscitation in children

Answer 8

• All children with hypoxia should be given high flow oxygen (15litres/min) through oxygen mask with a reservoir bag
  
  • If inadequate resp effort, then use a bag-valve mask and consider intubation and ventilation

Question 9

choking in children

Answer 9

• In choking patient who is conscious and seems to be coughing effectively, encourage coughing
• If cough becomes ineffective: 5 back blows followed by 5 chest thrusts

Question 10

circulation in children

Answer 10

• Heart rate, pulse volume, capillary refill time and BP
  
  • Children are very good at compensating for alteration in their physiology- therefore hypotension is a late sign
• Assess effect of any circulatory inadequacy’s on other organs
  
  • Raised rep rate (met acidosis)
  • Reduced urine output
  • Mottled skin with pallor
  • Cool peripheries
  • Altered mental state

Question 11

blood volume resus in chidlren

Answer 11

• If there are signs of circulatory compromise, establish venous or intraosseous access rapidly and give 20ml/kg bolus of 0.9% sodium chloride
  
  • In DKA initial bolus is 10ml/kg due to risk of cerebral oedema
• Venous access in children can be difficult  fluid resus should not be delayed give intraosseous

Question 12

Disability (neurological assessment) in children

*

Answer 12

• AVPU or GCS
• Children may be
  
  • Floppy
  • Stiff postured suggests serious brain dysfunction
    
    • Decorticate (flexed arms, extended legs)
    • Decerebrate (extended arms and legs)
• Pupil size and response
• Blood sugar
• Consider rICP in any patient with depressed consciousness: hypertension + brady cardia= impending coning

Question 13

disability resus

Answer 13

• Consider intubation to stabilise airway in any child with conscious level graded P or U
• Treat hypoglycaemia with bolus 2ml/kg 10% glucose IV or IO, followed by glucose infusion to prevent recurrence
• In cases of suspected raised intracranial pressure consider mannitol and neuroprotective measures

Question 14

exposure children

Answer 14

A swift head to toe examination of the child may provide clues as to the aetiology of the illness, for example:

• a purpuric rash may only be noted on full exposure or surgical scars may prompt you to consider particular histories.
• Be careful to ensure exposed areas are recovered to help maintain temperature control and preserve the child’s dignity.

Question 15

Patient with anaphylaxis

Answer 15

Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction which is likely when both of the following criteria are met:

• Sudden onset and rapid progression of symptoms.
• Life-threatening airway and/or breathing and/or circulation problems.

Question 16

classic signs of anaphylaxis

Answer 16

flushing, urticaria, angio-oedema

Question 17

aetiology of anaphylaxis

Answer 17

• Allergen reacts with specific IgE antibodies on mast cells and basophils (type 1 hypersensitivity reaction), triggering the rapid release of stored histamine and rapid synthesis of newly formed mediators, causing:
  
  • Capillary leakage
  • Mucosal oedema
  • Shock
  • Asphyxia
• Usually occur over a few minutes or occasionally biphasic (may be delayed. By a few hours)

Question 18

presentation of anaphylaxis

Answer 18

• Usually history of previous sensitivity to an allergen or recent exposure to a new drug
• Skin symptoms
  
  • Itching
  • Urticaria
  • Erythema
  • Rhinitis
  • Conjuncitivits
  • Angio-oedema
• Airway involvement
  
  • Early: Itching of the palate or external auditory meatus
  • Dyspnoea
  • Laryngeal oedema (strodros)
  • Wheezing (bronchospasm)
• General symptoms
  
  • Palpitations
  • Tachycardia
  • Nausea
  • Vomiting
  • Abdominal pain
  • Fain
  • Sense of impending doom

Question 19

Common triggers of anaphylaxis

Answer 19

• Peanuts
• Eggs
• Milk
• Venom e.g. bee sting
• Drugs
  
  • Antibitoics
  • Opioids
  • NSAIDs
  • Contrast
  • Anaesthetic

Question 20

emergency treatment of anaphylaxis

Answer 20

• Rapid assessment: A-E
• Give high flow oxygen
• Lay patient flat and raise legs
• Adrenaline IM in anterolateral aspect of the middle third of thigh
  
  • Adult 500mg IM
  • Child IM
    
    • >12 500mg
    • 6-12- 300 mg
    • <6 years 150mg
  • Should be repeated after 5 mins if no clinical improvement
• IV fluid challenge- warmed crystalloid solution e.g. Hartmanns or saline to raise BP
• Antihistamine e.g. Chlorphenamine
• Steroid e.g. Hydrocortisone
• Continuing resp deterioration  bronchodilators e.g. salbutamol
• Monitor
  
  • Pulse oximetry
  • ECG
  • BP

Question 21

investigation for anaphylaxis

Answer 21

after treatment

• Serum mast-cell tryptase  clarify diagnosis  demonstrates mast-cell degranulation

Question 22

patient with shortness of breath

Answer 22

Breathlessness is a subjective, distressing sensation of awareness of difficulty with breathing

Question 23

Breathlessness can be classified by its speed of onset as:

Answer 23

• Acute breathlessness — when it develops over minutes.
• Subacute breathlessness — when it develops over hours or days.
• Chronic breathlessness — when it develops over weeks or months.

Question 24

breathlessness can be

Answer 24

cardiac, pulmonary or other in origin

Question 25

cardiac causes of breathlessness

Answer 25

• Silent MI
• Cardiac arrhythmia
• Acute pulmonary oedema
• Chronic heart failure

Question 26

pulmonary causes of breathlessness

Answer 26

• Asthma
• COPD
• Pneumonia
• PE
• Lung cancer
• Pleural effusion

Question 27

other common causes of breathlessness

Answer 27

• Anaemia
• Diaphragmatic splinting (ascites, obesity, pregnancy)
• Psychogenic breathlessness

Question 28

Features associated with presence or risk of serious illness which generally warrant emergency hospital admission include:

Answer 28

• Stridor.
• Altered level of consciousness or acute confusion.
• Significant respiratory effort (particularly if the person is becoming exhausted).
• Elevated respiratory rate.
• Oxygen saturation less than 92%.
• Cyanosis.
• Tachycardia.
• Hypotension.
• Peak expiratory flow rate less than 50% of predicted.
• Immunosuppression or other significant comorbidity.
• Pregnancy or postnatal period.
• Elderly or very frail.
• People unable to cope at home.
• Poor or deteriorating general condition.

Question 29

management of shortness of breath

Answer 29

Need to determine need for emergency admission by assessing the persons:

• BP
• Pulse
• RR
• Temp
• Level of consciousness
• Peak expiratory flow rate
• O2 sats
• ECG

Question 30

emergency admission in pt with breathlessness when

Answer 30

• Oxygen sats <94%
  
  • Oxygen should be given and oxygen saturation levels continuously monitored while awaiting transfer to hospital, provided they are not at risk of hypercapnia
• ECG suggestive of arrhythmia or MI
• Sepsis
• Rapid onset
• Symptoms of heart failure
• PE or pneumo
• Asthma attack
• CURB greater than 0

Question 31

silent MI summary

Answer 31

• Risk factors — coronary artery disease, smoking, high blood lipid levels, hypertension, obesity, diabetes, family history.
  
  • Atypical presentations of myocardial infarction such as isolated breathlessness are more common in the elderly, in women and in people with diabetes, chronic renal disease and dementia.
• Symptoms — breathlessness, general malaise, sudden collapse, upper body discomfort, nausea.
• Signs — breathless (sometimes), abnormal pulse rate, sweating, reduced peripheral perfusion, hypotension.
• Electrocardiogram (ECG) — features suggestive of acute MI include ST depression with T-wave inversion, persistent ST elevation, or new left bundle branch block. Q-waves do not give an indication of the age of an MI as remain permanent following infarction.

Question 32

cardiac arrhythmia and breathlessness summary

Answer 32

• Risk factors — heart failure, valvular heart disease, ischaemic heart disease.
• Symptoms — palpitations, breathlessness, chest pain, syncope (or near syncope).
• Signs — bradycardia or tachycardia.
• ECG — diagnosis of arrhythmia relies on ECG obtained during the arrhythmia.
  
  • Typical ECG features of supraventricular tachycardia (SVT) include regular narrow QRS complex tachycardia and a rate greater than 100bpm. Wide complex tachycardias may have a supraventricular or ventricular origin.

Question 33

acute pulmonary oedema summary

Answer 33

• Risk factors — chronic heart failure, ischaemic heart disease, valvular heart disease.
• Symptoms — severe breathlessness, orthopnea, coughing (rarely with frothy blood-stained sputum).
• Signs — elevated jugular venous pressure, gallop rhythm, inspiratory crackles at lung bases, and (occasionally) wheeze. Peripheral circulation is shut down.

Question 34

cardiac tamponade summary

Answer 34

• Risk factors — trauma, autoimmune disease, malignancy, myxoedema, myocardial infarction.
• Symptoms — breathlessness, collapse.
• Signs — tachycardia, pulsus paroxodus, engorgement of neck veins and face peripheral cyanosis shock.

Question 35

chronic heart failure summary

Answer 35

• Risk factors — trauma, autoimmune disease, malignancy, myxoedema, myocardial infarction.
• Symptoms — breathlessness, collapse.
• Signs — tachycardia, pulsus paroxodus, engorgement of neck veins and face peripheral cyanosis shock.

Question 36

asthma summary

Answer 36

• Risk factors — personal history of rhinitis or eczema, or family history of atopy or asthma.
• Symptoms — wheeze, breathlessness, chest tightness, cough. Symptoms are variable (often worse at night, first thing in the morning, and upon exercise or exposure to cold or allergens, or after taking nonsteroidal anti-inflammatory medication or beta-blockers).
• Signs — during an acute episode, the respiratory rate is increased, and wheeze is usually present.
• Peak expiratory flow rate (PEFR) is reduced during an acute episode.
• Acute asthma is:
  
  • Life-threatening — when PEFR is less than 33% of predicted, or any of the following are present: oxygen saturation of less than 92%, hypotension, cyanosis, poor respiratory effort, a silent chest, exhaustion, arrhythmia or impaired level of consciousness.
  • Severe — when PEFR is 33–50% of predicted, or any of the following are present; respiratory rate of 25 breaths per minute or greater, a heart rate of 110 beats per minute or greater, or an inability to complete full sentences.
  • Moderate — when PEFR is 50%-75% of predicted, without any features of severe or life-threatening acute asthma.

Question 37

COPD summary

Answer 37

• History — typically, the person is older than 35 years of age, is a smoker (or past smoker) and reports slowly progressive breathlessness.
• Symptoms — persistent progressive exertional breathlessness that is often associated with wheezing and a cough (productive of sputum). Acute exacerbations of symptoms are common, and are frequently caused by respiratory tract infection. Frequent winter ‘bronchitis’ may be described.
• Signs — there may be no abnormal signs but wheeze, hyperinflated chest, purse lip breathing or cachexia may be present. There may be signs of right-sided heart failure in people with severe disease, including swollen ankles and increased jugular venous pressure (JVP). New-onset cyanosis and/or peripheral oedema, marked dyspnoea, tachypnoea, purse lip breathing, accessory muscle use and acute confusion are suggestive of a severe exacerbation. Crackles may be present when exacerbation is infective.

Question 38

pneumonia summary

Answer 38

• Symptoms — cough associated with at least one other symptom of breathlessness, sputum production, wheeze, or pleuritic pain.
• Signs — any focal chest sign (such as dull percussion note, bronchial breathing, coarse crackles, or increased vocal fremitus/resonance) plus at least one systemic feature (such as fever/sweating or myalgia), with or without a temperature greater than 38°C. There may be signs of an associated pleural effusion- may be asymptomatic in elderly

Question 39

pleural effusion summary

Answer 39

• Causes — heart, liver, or renal failure, pneumonia, pulmonary embolism, cancer (including mesothelioma), tuberculosis, pleural infection (empyema), and autoimmune disease.
• Symptoms — progressive breathlessness, pleuritic pain and symptoms of the underlying condition.
• Signs — reduced chest wall movements on the affected side, stony dull percussion note, diminished or absent breath sounds, decreased tactile vocal fremitus/vocal resonance and bronchial breathing just above the effusion. There may be signs of the underlying condition.

Question 40

lung/lobar collapse summary

Answer 40

• Causes — airway compression (for example by enlarged lymph nodes caused by cancer or tuberculosis) or blockage (secondary to pneumonia or an inhaled foreign body).
• Symptoms — breathlessness, cough.
• Signs — reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds, reduced or absent vocal resonance, mediastinal displacement towards the lesion.

Question 41

bronchiectasis summary

Answer 41

• History — suspect in people with a history of recurrent or chronic productive cough, especially if they do not smoke.
• Symptoms — cough with daily sputum production (present in 75–100% of adults), progressive breathlessness (72–83%), haemoptysis (51–45%), non-pleuritic chest pain between exacerbations (31%).
• Signs — coarse crackles during early inspiration that are heard in the affected areas, usually in the lower lung fields (70% of adults). Others include wheeze (34%) and large airway rhonci (44%). Finger clubbing occurs infrequently.

Question 42

interstitial lung disease

Answer 42

• Causes — include idiopathic pulmonary fibrosis, sarcoidosis, pneumoconioses, ILD associated with drug therapy, ILD associated with connective tissue disease, and hypersensitivity pneumonitis/extrinsic allergic alveolitis (following sensitization to inhaled environmental allergens; for example from birds, hay, or mushrooms).
• Symptoms — cough and slowly progressive breathlessness. When it is caused by extrinsic allergic alveolitis there may be a history of recurrent episodes of flu-like illness following exposure to the responsible allergen. There may be symptoms of the underlying cause (for example joint pains when the ILD is associated with connective tissue disease).
• Signs — there may be none in sarcoidosis. When present, there may be fine end-inspiratory crepitations (indicative of fibrosis), finger clubbing, cyanosis, and signs of right heart failure.

Question 43

lung or pleural cancer summary

Answer 43

• Risk factors — smoking, asbestos exposure.
• Symptoms — cough, shortness of breath, haemoptysis, chest pain, weight loss, appetite loss, fatigue, hoarseness, persistent chest infections, symptoms relating to bone or brain metastases.
• Signs — chest examination is often normal but there may be unilateral wheeze, decreased breath sounds, or signs of pleural effusion. Other signs include finger clubbing, and supraclavicular or cervical lymphadenopathy.

Question 44

anaemia summary

Answer 44

• Symptoms — mild anaemia may be asymptomatic or cause mild fatigue. As it progresses, faintness/dizziness, exertional breathlessness, palpitations and chest pain can occur. Rapid blood loss may present with collapse.
• Signs — paleness (for example of the conjunctiva or palms). More severe anaemia may lead to tachycardia or cardiac failure.

Question 45

diaphragmatic splinting summary

Answer 45

(due to ascites, obesity or pregnancy)

• Symptoms — chronic breathlessness that develops in association with increasing abdominal size. There are no symptoms to suggest other causes of chronic breathlessness.
• Signs — ascites (shifting dullness and fluid thrill) or obesity. There are no clinical features of other causes for chronic breathlessness.

Question 46

anxiety related breathlessness summary

Answer 46

• History — there may be a history of anxiety, panic or phobia.
• Symptoms — breathlessness is often described at rest rather than being exertional in nature. Other symptoms, such as palpitations, paraesthesia, dizziness, chest pain and choking sensation may occur. Anxiety and feelings of fear may accompany breathlessness.
• Signs — no signs of a physical cause for breathlessness. Hyperventilation accompanied by sighing, tachycardia and raised blood pressure (which settles) may occur.