Medical Exam

Define Infection

Invasion of the body by a harmful organism or infections agent such as a virus, parasite, bacterium or fungus

Define Colonisation

Presence of microorganisms on a body surface (such as skin, mouth, intestines or airway) that does not cause disease in the person or signs of infection

Describe the chain of infection

Infectious Agents → Susceptible Host → Portal of Entry → Mode of Transmission → Portal of Exit → Reservoir → Infectious Agents

Describe patient placement in the context of IPC

• Clear handover of information including symptoms of infection or known infections

• May prompt instigation of isolation facilities

Describe the 5 moments of Hand Hygiene in the context of IPC

• Clean hands before touching patient

• Clean hands before any ascetic procedure

• Clean hands after exposure risk to bodily fluids

• Clean hands before touching patient and patient surroundings

• Clean hands after touching patient and patient surroundings

Which coloured buckets are used for which areas?

• Red - Toilets and showers

• Blue - General areas

• Green- Kitchen and dining areas

• Yellow - Ambulances

Describe the three steps of decontaminating environments and equipment

• Cleaning

  • Involves fluid and friction, usually detergent and water to physically remove organic matter

• Disinfection

  • Process of eliminating or redacting harmful micro-organisms from surface, e.g. Clinel wipes

• Sterilisation

  • Killing all microorganisms through physical or chemical means. Not undertaken by LAS.

Describe which waste to dispose of where

• Domestic waste, recyclables and general waste - clear and black bags

• Offensive waste (non infections waste, e.g. PPE, sanitary waste, dressings) - tiger striped bag

• Infectious waste (known infections items) - orange bag

• Cat A waste (HART only, hazardous Cat A waste) - yellow bag

• Medicinal sharps - Yellow box

• Cytotoxic and cytostatic waste (Syntometrine) - Purple lid

How do you bag infectious or soiled linens?

• Infected or soiled linens should be placed in the red water-soluble bags first, then placed into clear bags before being placed in the red used linen bin

Describe the Hierarchy of IPC controls, from most effective to least effective

• Elimination (physically remove hazard)

• Substitution (replace hazard)

• Engineering controls (isolate people from the hazard)

• Administrative controls (change the way people work)

• PPE (protect worker with PPE)

What are some examples of micro-organisms spread by a contact route, and what PPE would you need?

• MRSA, CDIFF, VRE, CPE

• Gloves, Apron, Eye protection

What are some examples of micro-organisms spread by droplet transmission, and what PPE would you need?

• Influenza, Meningococcal meningitis, Bodetella pertussis

• Droplet mask, gloves, apron, eye protection (+FFP3 mask if aerosol generation procedures commenced)

What are some examples of micro-organisms spread by airborne transmission, and what PPE would you need?

• TB, Chickenpox, Rubella, Measles

• FFP3, gloves, gown, eye protection

What is the process for managing a sharps injury?

• Bleed it

• Wash it

• Cover it

• Report it

Describe the approach for Auscultation

Auscultation is the listening of sounds in the body, most commonly with a stethoscope.

You should auscultate working left to right to left again, back and forth in 6 spots on both the front and back. Press firmly and compare either side. Landmarks on the back include 6 on either side of the spine, and 2 under the shoulder blades. Landmarks on the front include 1 above each of the clavicles, three spots down along the chest and one on either side of the lateral portion of either side of the body.

What are the three categories of breathlessness?

Acute: suddenly or in minutes Subacute: over hours or days Chronic: weeks/months

How do you take a Resp rate and what is the normal adult resp rate?

Watch for chest rise and fall, measured over one minute. Can assist by placing a hand on their back or chest. Try to avoid telling your patient as they may subconsciously alter their breathing.

Normal adult resp rate range is between 12-20.

What is the ideal range for oxygen saturations in a normal healthy patient

Above 94%

What is the normal O2 saturation range for a pat with COPD?

88-92%

What is peak flow expiratory flow rate (PEFR) and how is it measured?

Peak flow is a measurement of how quickly you can breathe air out of your lungs, measured using a peak flow meter.

Explain the procedure, set to zero, get pat to hold level and exhale forcefully and quickly as much as they can. take 3 measurements and record the best. Compare on JRCALC with average for height and age. Asthma/COPD pat's may know their normal PEFR.

What is COPD, how is it diagnosed and what are the two most common diseases related to COPD?

Chronic Obstructive Pulmonary Disease (COPD) includes a range of illnesses that result in airflow obstruction. It is progressive and not fully reversible.

The two most common are chronic bronchitis and emphysema.

Diagnosed by cough and sputum production for at least 3 months in 2 consecutive years.

Describe Chronic Bronchitis, its signs and symptoms, and management.

Inflammation and increased mucus production in the bronchi/bronchioles narrows the airways, caused from long term infection and lung damage. Smoking is a huge factor affecting chronic bronchitis.

Signs and symptoms: productive cough, dyspnoea, cyanosis, tachycardia/pnoea, accessory muscle use, high BP, reduced 02, wheeze on auscultation, slow capillary refill, oedema, reduced level of consciousness/hypoxia (extreme cases)

Management: Full history, Resp assessment, Limit O2 to 6 mins on/6 mins off, position for comfort, ask about individual care plan, baseline obs and monitor

Describe Emphysema, its signs and symptoms, and management

Distension and destruction of alveoli by enzymes called proteases, which are normally kept under control by ant-proteases enzymes but smoking for example upsets this balance. Alveoli collapse, obstructing airway, and blister like air pockets can form (bullae).

Signs and symptoms: barrel chest (air trapped due to obstruction and ribs expand), pursed lips on expiration, productive cough, dyspnoea, tachycardia/pnoea, accessory muscle use, high BP, reduced 02, wheeze on auscultation, slow capillary refill, oedema, reduced level of consciousness/hypoxia (extreme cases)

Management: Full history, Resp assessment, Limit O2 to 6 mins on/6 mins off, position for comfort, ask about individual care plan, baseline obs and monitor

Describe chest infections, signs and symptoms, and management

An infection of the lungs. Main types are Acute Bronchitis and Pneumonia.

Most bronchitis cases are caused by viruses. Most pneumonia cases are caused by bacteria. Can cause fluid buildup in lungs (consolidation), sounds like crackles

Susceptible people include the extremes of age, overweight, pregnant, immunocompromised, smokers, and others with long term health conditions

Signs and symptoms: Persistent cough, yellow/green phlegm or haemoptysis, breathlessness, dyspnoea, febrile, tachycardia, pleuritic cp or tightness, confusion or disorientation

Management: full resp assessment, establish airway, if red flags pre alert, abs, 12 lead, consider o2

Describe Asthma, its signs and symptoms, and management

Caused by irritation of lower airway and immune response producing mucus, tightening muscles around bronchi, and swelling bronchi. Obstruction overcome by inspiration but expiration delayed by narrowing of the airway. Categorised as mild, moderate, severe and life threatening. Triggers may be cold, allergies, particulates in air, exercise.

Signs and symptoms: Wheeze on expiration, tachypnoea, tachycardia, cyanoses, exhaustion, altered level of cons, arrhythmia, hypotension, dib, cannot complete full sentence, accessory muscle use, silent chest

Management: full history (prev ED or ICU attendance, annual asthma review, med compliance), analysis of triggers, full respiratory assessment, oxygen treatment, bronchodilators, PEFR (if mild-moderate).

Describe pulmonary embolism, its signs and symptoms, and management

Obstruction of pulmonary vessels causing lung tissue death. Most common cause is a DVT, where a clot breaks off and travels via femoral and iliac veins through heart and into pulmonary vessels. Commonly misdiagnosed as panic attack.

High risk factors: surgery, trauma, disabilities affecting mobility, long flights, bed bound pats.

Signs and symptoms: Dys/tachypnoea, Tachycardia, Pleuritic CP, TLOC/syncope, cough/haemoptysis, pain worse on inhalation/stabbing pain, pain/thrombus in calf,

Differentials: pleurisy, pneumothorax, cardiac CP

Management: swift transport to hospital, ABCs, position of comfort, provide O2 of required, be prepared for cardiac arrest

Describe Coronary Artery Disease (I.e. CAD or ischaemic heart disease) and the process of atherosclerosis

CAD almost always caused by atherosclerosis of coronary arteries. Tears in the Tunica intima create build up in lipids and cholesterol in Tunica media (plaques). White blood cells create fibrous caps around the plaques. Causes narrowing of artery lumen (stenosis) leading to ischaemia.

Describe Stable Angina include signs, symptoms and management

Stable Angina: insufficient oxygen reaching myocardium from significant stenosis of at east one coronary artery due to coronary artery disease.

Signs/symptoms: Chest pain (can radiate) relieved at rest, dib, sob, increased WOB, indigestion like, belching, nausea, sweating

Management: Will usually self administer own glyceryl trinitrate (GTN). Place pat at rest, avoid walking moving excessively, analgesia as required, ECG.

Describe Acute Coronary Syndrome (ACS) including how it occurs and the three conditions

Includes: Unstable Angina, non-ST-segment elevation myocardial infarction (NSTEMI), ST-segment elevation myocardial infarction (STEMI)

• Rupture of fibrous cap from atherosclerosis leads to platelet aggregation
• Thrombus (blood clot) expands the plaque (intraplaque thrombus) or thrombus itself expands (intraluminal thrombus) and can occlude artery if large enough. This causes death of heart tissue.

Above process exacerbated by vasoconstricting substances associated with platelet aggregation, constricting and narrowing vessels.

Describe ACS signs, symptoms and management

Signs and symptoms: Chest pain not relieved at rest, nausea and vomiting, sweating, dib, pallor, impending sense of doom. 1/3 pats present atypically - watch out for sob, abdo pain and collapse/faint especially in the young (25-40), elderly (>75), unwell diabetics and unwell female pats

Management: 12 lead ASAP, correction of major ABC problems, administer medication (O2, entonox), rapid transport to nearest appropriate hospital

Explain the Pathophysiology of Heart Failure

Abnormality in cardiac structure or function, meaning the heart cannot deliver O2 at the rate the body needs. Can be acute or chronic (stable in last month).

Can be caused by previous MI, chronic hypertension, arrhythmias, genetic heart conditions.

L Ventricular Failure: Inefficient pumping of blood out of the heart to the body causes a backlog in the L ventricle, Mitral valve, L Atrium and pulmonary vein to the lungs.

R Ventricular Failure: Blood continues to back up from the lungs, pulmonary artery, R ventricle, R atrium, Vena cava, rest of body.

Describe Heart Failure signs, symptoms and management

Signs and symptoms include SOB, DIB, Tachypnoea, Tachycardia, Crackles, Fatigue, Haemoptysis, Congestion, Peripheral oedema

Management: Management of ABCs, pat at rest, full set of obs, o2 if required (<94%), ECG

Describe Sickle Cell, signs and symptoms, and management

Genetic disease where red blood cells are shaped like sickles. Reduced oxygen carrying capacity and can create blockages leading to hypoxia and pain.

Pats usually have UCPs with treatment plans and specific hospitals.

Signs and symptoms: Pyrexia, DIB, low saturations, coughs chest pain, pallor, fatigue. Dehydration, headache, priapism

Triggers for crisis: Exercise, altitude, infection, pregnancy, dehydration, stress, cold

Management: follow UCP, pain relief, repeat obs, ECG, consider fluids, put pat at rest and use chair, convey to specialist unit unless primary survey problems take precedence (e.g. HAC, HASU)

Describe Dementia

• Disease that affects memory, thinking and daily life

• 1/14 over age of 65 have it

• Risk groups are age, genetics, lifestyle

• Controlled by medication but no known cure

• Includes Alzheimer’s

Describe Parkinson’s Disease

• Causes parts of brain to become damaged over many years

• 1/500 in UK

• Men slightly more at risk of developing, though unclear what causes condition to occur

• Treated with medication and physiotherapy

Describe Multiple Sclerosis (MS)

• Affects brain and spinal cord, stopping nerve impulses from travelling correctly

• Over 130000 in UK

• Affects mainly woman and common disability in younger adults

• Managed by medication but no cure

Describe Ataxia

• Group of disorders affecting balance, coordination, speech

• Mainly hereditary but can develop later in life

• No cure, responds well to physiotherapy and medication

Describe paralysis

• Defined as partial or complete loss of muscles function

• Other terms include

  • -plegia (paralysis)

  • -paresis (muscle weakness or incomplete loss of muscle function)

• Terms used to identify areas affected

  • Monoplegia - one limb

  • Hemiplegia - one side of body

  • Quadriplegia/tetrapelgia - all 4 limbs

  • Paraplegia - both lower limbs

What is a CVE and describe the different types and how they are differentiated

Cerebrovascular Event (CVE)

• Stroke or TIA

• Risk factors include Age, Sex, Ethnicity, Family Hx, Smoking, AF, Diabetes, Obesity, previous CVE or MI, Cholesterol, Diet, Hypertension

• Stroke

  • Blood supply to brain interrupted

  • Signs and symptoms develop rapidly, last at least 24 hours

  • Bleed or blockage

• TIA

  • Signs and symptoms of stroke but resolves within 24hrs

  • Anyone with continuing neurological signs during management - treat as stroke

• Signs and symptoms

  • Numbness

  • Weakness or paralysis

  • Slurred speech

  • Blurred vision

  • Confusion/inability to communicate

  • Severe headaches

• Management

  • FAST

  • If major ABC - nearest ED

  • If not but FAST+ HASU (If >10

Describe types of convulsions, fitting disorders and how they are managed

Convulsions are involuntary contractions and retractions of the muscles.

Generalised convulsion

• Affect large part of cerebral cortex

• Bilateral Tonic-Clonic seizures (BTCS)

  • Tonic phase - body wide rigidity, falls, crying out, tongue biting, jaw clenching

  • Clonic phase - regular jerking movements which eventually slow and stop - sometimes accompanied by incontinence

  • Prolonged period of confusion, disorientation, sleepiness or unconsciousness after convulsion called Post-Ictal phase

Absent convulsion

• Staring/daydreaming/absent period

• May be accompanied by repetitive motions

• Last a few seconds with immediate recovery

Partial convulsion

• Affects localised part of cerebral cortex, though may progress into generalised tonic clonic

• Patient may be conscious or altered level of consciousness

• May be changes in behaviour or mood

• May be localised tonic clonic activity

Epilepsy

• Uncontrolled firing of neurons in brain

• Some well managed by medication, other struggle to manage

• Can significantly limit cognitive development in children

• Generally tonic clonic

• Can progress to Status Epilepticus

  • Continuous convulsion lasting over 5mins

  • Series of convulsions (3 or more in an hour) close together with no recovery period in between

Non-epileptic seizures

• FND (Functional Neurological Disorder) and PNES (Psychogenic non-epileptic seizures)

  • Usually last a lot longer

  • Usually triggered by psychological trauma

  • No tonic clonic period

  • Generally does not affect breathing or circulation

• Other causes for non epileptic seizures

  • Hypoglycaemia

  • Kidney failure

  • Tumour

  • Infection

  • Alcohol

  • Eclampsia

  • Stroke

Management using the Primary Survey

R - if actively consulting, put on high-flow O2 and call for paramedic backup. If reduced LOC protect from injury and recovery position

A - Jaw may be clenched (trismus), may have bitten tongue, may be impossible to assess. Do NOT use OP if actively convulsing. Attempt NP if possible.

B - administer high flow, consider Capnogrophy if ventilating

C - oximetry may be difficult but can assess skin colour, tone, cap refill

D - reassess AVPU, any improvement? Convulsion caused by head injury? Check BM now! Could be Hypoglycaemia

E - look for medic alert bracelet, signs of underlying injection, obvious injury, protect pat from injury and protect dignity

Time critical if:

• Major ABCD problem

• Serious head injury

• Status EP

• Underlying infection

Remember when attending seizures

• First, worst or longest should attend hospital

Describe meningococcal disease, symptoms of meningitis and septicaemia, and management

Bacterial infection of meninges caused by meningococcus bacteria. Presents as Meningitis, Septicaemia or combination of both. Can be fatal.

Meningitis symptoms:

• Fever, vomiting, severe headache, rash (particularly non blanching rash), stiff neck, photophobia, sleepy/vacant, confusion/delirium, seizures

Septicaemia symptoms:

• Fever/vomiting, limb/joint pain, cold and shivering, DIB, rash, sleepy/vacant, confusion/delirium

Management

• Standard primary survey approach, look particularly for rash in E (however absence of rash does not exclude meningitis)

Time critical if

• any major ABCD problem

• Non-blanching rash

• Any suspicion of meningitis/septicaemia

Describe coma and management

Coma is described as absence or loss of consciousness

• GCS of 8 or below

• May not always find cause, management is supportive

• Causes

  • Stroke, convulsion, inadequate airway, inadequate breathing, hyper/hypoglycaemia, OD, meningitis, arrhythmias, carbon monoxide etc

Time critical if any major ABCD problem

Management

• comprehensive obs, GCS, pupils

• Thorough secondary survey

• 12 lead

• Reassess

• Scene for clues, med alerts, needle marks, consider trauma

Can you definitively diagnose causes of abdominal pain pre-hospitaly?

No. Can pin-point where pain is, how it is, timeline etc but cannot find cause

What are the four quadrants of the abdomen? (For assessment)

4 Quadrants

• Left upper (contains some of liver, most of stomach, spleen, pancreas,

• Right upper (contains majority of liver, gall bladder, some of stomach, first part of duodenum, right kidney)

• Right lower (small and large intestine, appendix)

• Left lower (small and large intestine)

What are the advantages of dividing the abdomen into quadrants for assessment?

• Supports diagnosis

• Highlights red flags

• Aids documentation

What are the 9 quadrants of the abdomen? (For assessment)

What are some elements of primary survey you may pick up when someone has abdominal pain?

• Airway - may have problems with vomit, saliva, blood

• Breathing - rate may increase because of pain, may be shallow to avoid causing pain

• Circulation - rate may increase because of pain, BP may be very high (pain) or very low and weak pulse (dehydration from D&V)

• Disability - AVPU may be affected by low BP (dehydration)

What elements of your history taking are specific to abdo pain? (Using SAMLPE)

S - how they feel, any changes, ROS (resp, circ, abdomen of course)

A - allergies to medication food, any sensitivities, what normally happens when have thing you’re allergic to? (E.g. normally abdominal pain)

M - prescribed, OTC (over counter), recreational - any changes? Side effects?

P - medical and surgical, work back in time - any tests, scans, GP visits, hospital appointments? Chronic - eating disorders, alcoholic, IBD, Crohns

L - ins and outs - BO (bowls open), PU (Passing urine), D&V, diet and fluid intake

E - What led to calling 999, progression of symptoms, self care, progress

What should you consider in your review of symptoms for abdominal pain?

• Headache, visual disturbances, appetite change, nausea/vomiting, dehydration, indigestion, belching

• SOB (?due to pain), coughing anything up, pain

• Pain, diarrhoea, constipation, urine output, BO/PU position related pain/relief

• Swollen ankles, rashes, itching, weakness, pallor, sensation

What elements of the SOCRATES should you be particularly considerate of for abdo pain?

Site - get them to point specifically

Radiates - does it move anywhere? E.g. upper flank to wards bladder may be UTI, referred pain in shoulder (may be appendicitis)

What is Acute Abdomen?

• Acute abdominal pains less than 7 days duration

• Non-specific abdominal pain after examinations and investigations

What is a bowl obstruction, signs and symptoms, causes and key questions to ask?

• Partial or complete obstruction of small or large intestine

• Causes include

  • Adhesions

  • Hernias

  • IBD

  • Tumours

  • Diverticulitis

• Signs and symptoms

  • Bile stained vomit

  • Abdsolute constipation

  • Absence of flatus/wind

  • Faecal vomiting

  • Abdominal pain

  • Nausea/vomiting

  • ‘Currant jelly stool’

  • Cause death from lack of nutrients, back up of stool leading to infection

• Key questions to ask

  • When did last open bowls? When did last pass wind?

Describe Abdominal Aortic Aneurism (AAA) and signs and symptoms

How it occurs:

• Artery wall weakens and stretches

• Aneurism expand, aorta dilates

• Increases risk of rupture

• Overall mortality is 85%

Signs an symptoms

• Pulsating mass in 50% of patients

• Low BP (faint, dizzy, collapse)

• Abdominal pain, chest pain, radiating to loin or groin

• Pallor, tachycardia

What is Aortic Dissection?

Result of AAA, tear in tunica intima of aorta allows blood flow into tunica media - blood then flows into ‘false’ lumen. Bleeding into abdominal cavity and die.

Describe Gastro-intestinal bleeds, causes, signs and symptoms and key questions to ask?

Divided into:

• Upper GI bleed (higher than the duodenum) - caused by peptic ulcers, gastritis, oesophageal varices, tumours

  • Haematemesis

  • Melaena (dark, tarry stool)

• Lower GI bleed (lower than the duodenum) - caused by covert ocular disease, IBD, Bowel Disease, Haemorrhoids, Tumours

  • Bleeding Per Rectum (BPR) - bright red or dark blood clots

• Key Questions to ask:

  • When did bleeding begin?

  • Taking aspirin/NSAIDs?

  • Taking iron tablets?

  • Food containing dye/beetroot?

  • Beta blockers/calcium channel blockers?

  • Anti coats/anti platelet therapy?

  • Bleeding disorders/liver disease/abdo surgery/alcohol abuse/syncope?

Describe appendicitis, signs and symptoms and management?

• Inflammation/infection of appendix

• Usually causes pain in lower right side of abdomen

• Signs and symptoms

  • Nausea, vomiting, loss of appetite, constipation, temperature, diarrhoea, facial flushing, dry tongue, tachycardia

• Needs urgent treatment in hospital

Describe peptic ulcer and signs and symptoms

• Erosion of lining of stomach or small intestine forming ulcer

• Pain

  • Presents in upper part of abdomen

  • May feel like burning

  • Often worse at night

Describe diverticulitis and signs and symptoms

• Inflammation/infection of diverticular (pouches that form in large intestine over time)

  • LLQ pain (sometimes LRQ)

  • Pain ++ after eating

  • Pain eases after passing wind or easing bowls

  • Constipation, Diarrhoea

  • Blood in stool

  • Bloating

Describe Hernias

• Internal part of body pushes through abdominal wall

• Becomes strangulated (Cut off from blood supply)

  • May lead to ischaemic bowl

• Causes death of that tissue

Described ulcerative colitis and signs and symptoms

Comes under IBD

• Chronic condition where colon and rectum become inflamed

• Small ulcers develop on colon’s lining can bleed and produce pus

Signs and symptoms

• Diarrhoea

• Possible pus, mucus, blood

• Abdominal pain

• Bowel opening frequency

• Fatigue

• Loss of appetite

• Weight loss

• Painful joints

• Mouth ulcers

Describe Crohn’s disease and signs and symptoms

Comes under IBD

• Chronic condition that causes gut inflammation

• Managed not cured

• Remember, ulcers are always at risk of bursting

Signs and symptoms

• Diarrhoea

• Blood or mucus in stool

• Abdominal pain

• Rectal/anal pain

• Weight loss

• Fatigue

• Loss of appetite

Describe gastroenteritis

• common condition

• Causes D&V

• Usually bacterial or viral

• D (5-7 days)

• V (1-2 days)

Obtain full history, difficult to exclude serious pathology

What are three important assessment aspects to consider when dealing with abdominal pain?

Inspect, Auscultation, Palpation

Inspect

• Skin colour, bruising, masses, pulsing, pallor, scars (PSHx)

Auscultation

• LRQ to confirm present of BS

Palpation

• Not recommended

• Not over areas of pain

• Very light Palpation only

• Senior clinician only

What conditions could be associated with pain in each of the abdominal quadrants?

Describe the difference between the cause of Type 1 and Type 2 diabetes

Type 1: ‘not producing insulin’

• As not producing insulin, glucose in blood cannot access cells causing increase in blood glucose

• Causing

  • Increase in urination due to increased BS

  • Blurred vision as glucose build up in eyes

  • Slow healing as glucose in blood feeding bacteria

  • Increase occurrence of thrush, UTIs

Type 2: ‘receptor sites mutates or blocked up by fatty deposits, cannot ‘unlock’ lock’

• Similar symptoms and also increasing blood glucose

• Not all blocked so some can go in

What are the functions of Insulin and Glucagon

• Insulin is the “key” to the lock of receptors on cells which allow glucose to enter cells

• Glucagon releases glycogen stores in the liver which is turned into glucose

What are treatments for Type 1 and 2 diabetes?

Type 1: Insulin pens/injectors

Type 2: Lifestyle, metformin/glycoside, Insulin pens/injectors

What are Blood Glucose Levels measured as and what are normal values for diabetic and non diabetics?

Measured as millimoles per litre (mmol/L).

Normal values:

• Non diabetic

  • 3.0 to 5.6 mmol/L

• Diabetic

  • 4.0 to 7.0 mmol/L before meal

  • 10 mmol/L one and half hours after meals

  • Around 8 mmol/L at bedtime

Describe Hypoglycaemia common causes, signs and symptoms, and management.

Common causes:

• OD insulin or oral hypoglycaemic agents

• Hepatic or Renal dysfunction

• Other illnesses including infection

• GI disturbances

• Inadequate food intake

• Increased physical activity

• Alcohol intake

• Pregnancy and breastfeeding

• Elderly

Signs and symptoms:

• Usually rapid onset

• Skin can appear pale and sweaty

• Normal or shallow respirations

• Rapid and full pulse

• Irritable, confused, uncoordinated, aggressive or anti-social behaviour

• Hunger, Headache, Dizziness, Seizures (in late stages)

Management:

Is dependent on severity

Mild (able to swallow, cooperative and alert)

• Encourage to eat fast acting carbohydrate (e.g. sugar water, sweets [not chocolate])

• Monitor till BM >4mmol/L

• Then encourage long acting carbohydrate (e.g. biscuits, toast, meal if due)

• Continually reassess

Moderate (may be combative or unable to swallow)

• As per Mild, however if not able to swallow or combative - escalate to senior clinician to administer glucose gel etc.

Severe (unconscious, fitting, severely combative or risk of choking/aspiration)

• Manage ABCs

• Escalate to senior clinician

Describe Hyperglycaemia common causes, signs and symptoms, and management

Common causes:

• Undiagnosed diabetes

• Illness

• Infection

• MI

• Medication including steroids

• Failure to administer diabetic medications

Signs and symptoms:

• Usually gradual progression (hours to days)

• Skin is dry

• Deep and sighing respiration (Kussmals respiration)

• Rapid and weak pulse (decompensating BP)

• Restless, drowsy or lethargic behaviour

• Sweet, fruity breath (Ketone breath)

• Abdominal pain

• Nausea

• Polyuria

• Polydipsia

• Polyphagia

• Rapid weight loss

Management:

• Correct ABC problems

• Measure and record BM

• ECG

• Administer O2 of hypoxaemic

• Pre-alert

Explain the process for measuring blood glucose

• Clean pat finger with alcohol swab

• Once finger dry, obtain blood sample suing capillary lancet

• Wipe away first drop of blood

• Obtain fresh test strip and insert black wide end into meter

• Wait for droplet to appear on screen

• Insert end of test strip to blood sample

• Wait approx 5 secs for rereading to appear

• Press ejector button over clinical waste bag

What are some common post operative complications?

• Fever

• Wound infections

• Embolisms

• Deep vein thrombosis

What sort of complications might you expect 0-2 days post surgery?

• Post operative fever

• Superficial infection relating to the surgery

• Haematoma

What sort of complications might you expect 3-5 days post surgery?

• Pneumonia

• Sepsis

• Wound infection

• DVT

• Phlebitis

What sort of complications might you expect 5+ days after surgery?

• Wound infection

• Urinary Tract Infection

• Chest infection

• DVT

• PE

How would you manage post operative complications?

• Complete full set of obs

• Senior clinician to complete differential diagnosis on presenting signs, symptoms and observations

• Senior clinician to identify appropriate care pathway OR convey to nearest ED if appropriate

Describe allergic reactions

Mild symptoms in reaction to an allergen, e.g. localised urticaria, runny nose,

• triggers include food, drugs, venom

Describe anaphylaxis and how it can develop

• Severe life threatening generalised or systematic hypersensitivity reaction

• Rapidly developing life-threatening airway/breathing/circulation problems

• How develops?

  • First exposure to allergen, body creates antibodies

  • Next time exposed, body recognises/responds quicker

  • Disproportionate immune response (histamine and WBCs)

  • Histamine gives symptoms

    • Bronchospasm and vasodilation (anaphylaxis symptoms)

What are some symptoms of anaphylaxis?

• Hypotension

• Swelling of tissues (BP crashes causes fluid to leak into tissues from blood)

• DIB wheezing due to bronchospasm

• Hypoxia (confusion)

• Tachypnoea and Tachycardia

• Nausea and vomiting

• Sweating

• Diarrhoea

• Decreased cardiac output (low BP)

How can allergens enter the body?

• Injection

• Ingestion

• Absorption (skin contact)

• Inhalation

What could be a presentation of early anaphylaxis?

• Itchy rash

• Swelling around eyes

• Prickly lips

• Dry non-productive cough

• Restlessness

What could be a presentation of acute anaphylaxis?

• Flushed skin

• Tachycardia

• Chest tightness

• Tongue and throat swelling

• Wheeze

• Hoarseness

• Dyspnoea

• Strider

• Cyanosis

• Vomiting

• Diarrhoea

How would you treat anaphylaxis?

• Oxygen 15l using non-rebreather (continued until vital signs normal)

• Paramedic intervention:

  • Salbutamol and Adrenaline

  • Advanced airway

  • IV fluids

• If time for hotel backup is too long, consider rapid transport if have EMT

• Continually monitor and pre-alert to hospital

Define poisoning

Exposure to a substance that may result in mortality or morbidity

What are the ways in which poisons may enter the body?

• Inhalation

• Ingestion

• Injection

• Absorption

Common types of poison

• Household products

• Pharmaceuticals/recreational substances

• Plants/Fungi

• Alcohol

• Chemicals

• Cosmetics

What are key considerations when assessing a poisoning patient (using medical model)?

Using Primary survey

• Danger - consider cause of poisoning. - ?attack ?suicidal/mh crisis

• Response - overdoses can alter loc

• Airway - Overdose can cause nausea/vomiting - ensure airway clear of vomit if unresponsive

• Breathing - Some overdose can cause respiratory depression -may need to oxygenate and bag

• Circulation Some overdoses can cause low BP - may not be able to feel radial pulse - Elevate limbs or fluids

• Disability - reassess AVPU

• Evaluate - reevaluate and rapid extrication if time critical patient

History taking

• Global overview - tablet packets all around? Drug paraphernalia?

• If OD - ?staggered or all at once (PCHx)

• Look at prescription history and if susceptible from PMHx

• Toxbase

What should your management principles be for poisoning?

• Identification of poison

• Specific treatment for specific poisons

• Rapid access to hospital

When should you consider carbon monoxide poisoning and how do we manage this?

• Consider if patient is in a confined space with impaired ventilation or defective boiler

  • Could by hypoxic from CO affinity to Haemoglobin

    • Disorientation

    • SOB/DIB

    • Ataxia

    • Cyanosis

    • Dizziness

    • Nausea

    • Lethargy

    • Visual problems

• Consider COMA

  • Cohabitants/companion - does anyone else feel unwell? Pets behaving abnormally?

  • Outdoors - Do you feel better if you go outside or away from property for a long time?

  • Maintenance - Are any heating appliances properly maintained?

  • Alarms - Do you have a working CO alarm? Has it activated?

• Remove patient from source

• Administer high flow O2 continuously (SPO2 monitoring has no value here)

Describe Urinary Retention, causes, signs and symptoms

• Inability to empty bladder - can. Be acute or chronic

• Acute urinary retention is a medical emergency

• Causes

  • Prostate enlargement

  • Urethral stricture from surgery

  • Urinary tract stones - blocking opening to urethra

  • Nerve problems - vaginal childbirth, spinal cord injury, pelvic injury/trauma

  • Aging - inability to empty bladder completely

• Signs and symptoms

  • Severe lower abdo pain

  • Unable to pass urine

  • Reduced flow

  • Swelling of bladder

  • Without prompt treatment, urine may pass back up into the kidneys, which may damage them

Describe Urinary Tract infections (UTIs), causes and signs and symptoms

• Develops when part of urinary tract becomes infected, usually bacterial

• Mainly occur in women

• Are far less common in me and for that reason need investigating

  • Narrowing of urethra (a stricture)

  • Previous STI

  • Bladder stones

  • Problem with prostate gland

• Can be lower (bladder and urethra) or upper (kidney and ureters)

  • Upper UTIs are potentially more serious than lower UTIs because of risk of kidney damage

• Signs and symptoms

  • Pain/burning sensation when urinating

  • Cramping pain in lower abdomen or back

  • Dysuria - burning sensation

  • Increased frequency of urination

  • Confusion in the elderly

  • Strong smelling urine

  • Haematuria - cloudy urine or frank blood

  • ? Kidney infection: temp >38, rigors, vomiting

  • Nausea and vomiting

Describe Kidney Stones (renal calculi), causes, signs and symptoms

• Stone-like lumps that can develop in one or both kidneys

• Move down ureters and stretches the wall

  • Small stones may be passed out painlessly in urine and go undetected

  • Fairly common for stone to block part of urinary system

• Signs and symptoms

  • Vomiting, nausea

  • Persistent ache in lower back/groin/side of abdo

  • Periods of intense pain in back/side of abdomen, lasting minute or hours (renal colic)

  • Feeling restless and unable to lie still

  • Need to urinate more often

  • Pain when urinating

  • Blood in urine

  • Can lead to UTI

Describe Acute Kidney Injury (AKI), causes, signs and symptoms and management

• Sudden episode of kidney failure or damage that happens within a few hours or days

• Range from minor loss of kidney function to complete kidney failure

• AKI causes a build-up of wast products in blood making it hard for kidneys to maintain right balance of fluid within the body

• Essential that AKI is detected early and treated promptly. Without quick treatment, abnormal levels of salts and chemicals can build up in body, affects ability of other organs to work properly

• Signs and symptoms

  • Nausea/vomiting

  • Less than 100ml urine excretion in 24hrs

  • Diarrhoea

  • Dehydration

  • Hypertension

  • Confusion

  • Drowsiness

  • Abdominal pain/back ache

Causes

• Reduced blood flow caused by low blood volume, heart pumping less blood than normal, problems with vessels, certain medicines

• AKI can be caused by problems with kidney itself or result of blockage affecting drainage of kidneys such as:

  • Enlarged prostate

  • Tumour in pelvis

  • Kidney stones

Management (Depends on severity and cause)

• Increasing intake of fluids

• Antibiotics if infection

• Stop taking certain medicines

• Urinary catheter if bladder blockage

Serious complications:

• High potassium in blood

• Fluid in lungs

• Acidic blood

Describe Chronic Renal Failure/Chronic Kidney Disease (CKD), causes, signs and symptoms and management

• Long term condition where kidneys don’t function normally

• Common with elderly

• Signs and symptoms

  • Tiredness

  • Swollen ankles, feet or hands

  • SOB

  • Nausea

  • Haematuria

  • Vomiting Hypertension

• Caused by

  • Hypertension

  • Diabetes

  • High cholesterol

  • Kidney infections

  • Glomeluronephritis

  • Polycystic kidney disease

  • Blockages in flow of urine

  • Long-term regular use of certain medicines

• Treatment depends on cause and severity

  • Lifestyle changes

  • Medicines to control associated problems

  • Dialysis

  • Kidney transplant

• Management

  • Oxygen if indicated

  • Entonox to relieve pain

  • Constant Obs

  • Consider sepsis guidelines

  • 12 lead

  • Transfer to further care

Define Sepsis and how it may present

• Dysregulated host response to infection, causing life-threatening organ dysfunction

• Can have an identifiable source of infection (Hx)

• Causes BP to dilate, BP drops, organs cannot get oxygen → causes organ dysfunction

• Hypertension also causes tachycardia and tachypnoea, high temperature as part of immune response

• Dilation of vessels causes them to become ‘leaky’ - fluid leaking in tissues

• Hypoxia can cause confusion

• As organs start to die, blood becomes acidic

What is suspected sepsis?

• Signs and symptoms, observations are indicative of sepsis but cannot identify source

What population are you more likely to see sepsis in?

• Elderly

• Immunocompromised

• Chemotherapy treatments

• Diuretics, Ace inhibitors, Metformin, NSAIDs (DAMN drugs)

• Surgery in past 6 weeks

• Lines/catherters

• IV drug use

• Breach of skin (burns, blisters, skin infection)

• Pregnant women (DONT use NEWS2)

• Recent birth

• Children under 1

What is septic shock?

• When BP crashes and rapid decline in condition

What is Disseminated Intravascular Coagulation (DIC)

• Inflammation causes abnormal clotting in vessels (DIC)

• Over active clotting blocks blood flow, causes organ damage

• Platelets used up, meaning body cannot stop bleeding, presenting as ‘petechia’ rash

How should we treat sepsis?

• 15l of 02

• Fluids

• Rapid transport