ILLNESS SCRIPTS

Myocardial Ischaemia

When the tissue in the heart becomes ischaemic due to lack of oxygen

Timeline MI

Can be a sudden or gradual onset over hours/days

Clinical Signs for STEMI

More than or equal to 2mm of ST elevation in two or more leads from V1-V3, or more than 1mm in leads V4-6, I, II, III, aVl or aVf, or V7-9. Or a new known left bundle branch block.

Clinical signs for NSTEMI

ST depression of 0.05mm in 2 adjacent leads. ST depression of 0.1-0.2mV in single lead. Other signs may include T-wave inversions.

Symptoms of MI

Chest pain, could radiate down left arm, up to jaw or in both arms can even radiate to the back or epigastric region. SOB, diaphoresis, nausea, pain associated with exertion, palpitations, dizzy.

What went wrong in MI

blockage due to thrombosis, global ischaemia. Either causes lack of oxygen in heart muscle causing pain and cell death.

Treatment at EMT level for MI

for a STEMI - DO NOT WALK THEM. 300mg Aspirin PO, 0.4mg of GTN with caution, withhold if signs of poor perfusion. For NSTEMI 300mg Aspirin PO, 0.4mg of GTN repeat every 5 minutes if needed. Call for Paramedic backup.

Differentials for MI

PE - also causes chest pain and SOB, but it is pinpoint chest pain and doesnt show ECG changes. Non-cardiac pain (usually sharp, positional, not associated with exertion, and not associated with ECG changes

Ashtma Timeline

Episodic, Pmx of Ashtma, Acute SOB

Asthma Signs and Symptoms

SOB, tripod position, distressed, cannot speak full sentences, widespread bilateral wheeze, high resp rate, access muscle use. prolonged expiratory phase

Asthma What went wrong

immune cells encounter a pathogen creating an inflammatory response, bronchoconstriction, mucus production, bronchial wall oedema. Usually set off by a trigger

Asthma Differentials

anaphylaxis(all airways multisystem), arrhythmia (excluded by ECG), pneumothorax (unilateral, trauma, lung disease, tissue disorder), pleural effusion (unilateral localised), chest infection (fever productive cough), anxiety (no airway narrowing so no wheeze), ACPO (worsens over days, lower sounds, hypertensive) COPD (not symptom free between attacks)

Asthma Treatment

Salbutamol via MDI (1 puff, 6 breaths 6 times), or Nebulised Salbutamol 5mg repeated as required and 0.5mg Ipratropium once. 40mg prednisone, 0.5mg Adrenaline IM if not helped with salbutamol.

Pleural Effusion Timeline

Complication of other disease

Pleural Effusion Signs and Symptoms

sharp pleuritic pain, cough, SOB, viral aetiology can be idopathic (PE, Pneumonia, surgery, cancer) diminished sounds and vocal resonance unilaterally

Pleural Effusion What went wrong

accumulation of excess fluid in pleural cavity, caused by rubbing of pleura instead of smooth gliding

Pleural Effusion Differentials

ACPO (bilateral crackles, Pneumonia (fever), pneumothorax (trauma), PE (pinpoint pain

Pleural Effusion Treatment

symptomatic, positioning O2, analgseia

Pneumonia Timeline

Develops on its own or after viral infection, slow onset

Pneumonia Signs and Symptoms

SOB, pleuritic chest pain, fatigue, productive cough (from lung), ache, tempurature, crackles and wheeze unilaterally

Pneumonia What went wrong

infection in the lung commonly caused by bacteria

Pneumonia Differentials

COPD (chronic), HF/ACPO (bilateral crackle), pneumothorax (sudden/trauma), PE (pinpoint and thigh/calf pain)

Pneumonia Treatment

symptomatic, O2 analgesia

Anaphylaxis

Allergic reaction involving 2 or more body systems

Anaphylaxis Sgins and symptoms

2 or more systems, swelling of upper airway, sneeze, stridor, nausea, diarrhoea, vomiting, vasodilation, tachycardia, flushing, rash, itch

Anaphylaxis What went wrong

2nd exposure to an allergen

Anaphylaxis Differentials

Asthma (only one system usually has history will tell you if it feels similar treatment is same) Sepsis (fever)

Anaphylaxis Treatment

0.5mg Adrenaline, every 5min if not improving. Loratadine if systemic signs are gone for a rash. O2 if needed

ACPO Timeline

Left ventricular enlargement and deterioration over time. can be chronic build up of fluid or acute

ACPO Signs and Symptoms

SOB, Tachypnoea, Tachycardia, bilateral inspiratory crackles, pink white froth, low SpO2 not fixed with oxygen therapy, hypertensive

ACPO What went wrong

Blood left in left ventricle as cardiac output decreases from heart failure, build up travels back up into the lungs causing change in the orthostatic pressure pushing fluid across into the lungs

ACPO Differentials

Asthma (wheeze and normotensive) chest infection/pneumonia (unilateral crackles) PE, (pinpoint pain), pleural effucion (unilateral crackles)

ACPO Treatment

0.8mg (two sprays of GTN every 5 min if not improving 10 if caution is present. Backup if severe respiratory distress for CPAP. PEEP at 10cm

PE Timeline

can be nonspecific, asymptomatic, subacute (days or weeks)

PE Signs and Symptoms

usually subtle, normal lung sounds, diminished breath sounds or pleural friction rub, pleuritic chest pain, SOB, calf/thigh pain, Tachypnoea/cardia, fever, pinpoint chest pain

PE What went wrong

emboli (usually DVT) travels to heart then lungs, large emboli associated with haemodynamic compromise

PE Differentials

Pleural effusion (unilateral localised diminished vocal resonance)

PE treatment

symptomatic and analgesia

Hypoglycaemia Timeline

Acute emergency develops in hours

Hypoglycaemia Clinical signs

BGL <3.5mmol/L or what a patient says is their low

Hypoglycaemia Symptoms

altered LOC, headache, syncope, diaphoresis, cold clammy, weak, rapid pulse, tremors, seizure

Hypoglycaemia What went wrong

missed meal, infection, stress, alcohol

Hypoglycaemia Differentials

intoxication, infection, epilepsy (pt not on insulin or oral meds and known.)

Hypoglycaemia Treatment

10-20g glucose PO if they can swallow safely. 1mg Glucagon IM, followed by meal with complex carbs

COPD

Chronic Obstructive Pulmonary Disorder - physiological changes to the airways causing obstructed airflow

COPD Timeline

Chronic disease, slow development. Has acute exacerbations

COPD Signs and Symptoms

accessory muscle use, shortness of breath, diaphragmatic breathing, worsening or central cyanosis, peripheral oedema. Wheeze on auscultation

COPD What went wrong

Long term exposure to a toxic irritant. L/URTI can exacerbate COPD

COPD Differentials to rule out

Heart failure ACPO (also causes shortness of breath - rule out by pink white froth/ACPO has low bilateral crackles and pitting oedema), Pneumonia (rule out by fever, localised chest pain and rhonci) PE (rule out with no pinpoint chest pain) Pleural effusion (rule out by unilateral localised wheeze or crackles)

COPD Treatment

Allow physiologically favourable position. Maintain SpO2 levels with O2 between 88-92% usually with nasal prongs. Salbutamol 5mg and Ipratropium 0.5mg nebulised on medical air. check patients blue card and action plan, 40 mg of prednisone