CLS201 - Intro to Medical Emergencies

Patient Assessment- Heart Auscultation: 'ALL PEOPLE ENJOY TIME MAGAZINE' (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

'ALL PEOPLE ENJOY TIME MAGAZINE' - Aortic: right 2nd intercostal space - Pulmonic: Left 2nd intercostal space - ERB's point: S1, S2 left 3rd intercostal space - Trcuspid: lower left sternal border 4th intercostal. - Mitral: Left 5th intercostal, medial to midclavicular line.

Creptitation

(1) a dry, crackling sound like that of crumpled cellophane, produced by air in the subcutaneous tissue or by air moving through fluid in the alveoli of the lungs; (2) a crackling, grating sound produced by bone rubbing against bone

Chemotherapy side effects

* Neutropenia- Low WBCs. * Thrombocytopenia- Low Platelets. * Anemia- Low RBCs.

IV Cannulation preparing equipment - EQUIPMENT NEEDED - Gauges range from 10G (larger) to 24G (smaller) : (module 1 Intravascular (IV) Cannulation)

- 16-18G for trauma / hypovolemia. - 18-20G for medical patients. - 20-22G for elderly patients - 20-24G for paediatrics - 14G may be used for needle decompression if no specialist device in use

Basic ECG Interpretation - Heart Rate (week 4 Cardiac emergencies and acute coronary Syndrome)

- 6 seconds method Count number of R waves within 6 seconds x by 10 - 300 method count number in between each large box is 300, then 150, then 100, then 75 - 1500 method count number of small boxes between R waves then divide 1,500 by that number

IV Cannulation - GENERAL RULE OF THUMB : (module 1 Intravascular (IV) Cannulation)

- A large bore cannula is preferable to a narrow bore cannula. - A shorter cannula is preferable to a longer cannula. - A larger proximal vein is preferable to smaller distal vein. - Upper limbs are preferable to lower limbs, especially in CPR

Differential Diagnosis of Chest Pain - Ischaemic Cardiovascular causes? (week 6 Module 4a Cardiac Vascular Emergencies)

- ACS (e.g acute myocardial infarction, unstable angina) - Stable angina - Severe aortic stenosis - Tachyarrhythmia (atrial or ventircular)

Cardiac arrest Definition - Typical Cause - ARRHYTHMIA (week 6 Module 4b - Cardiac Arrest)

- ACS: Coronary Thrombosis - Scarred Myocardium (previous MI) - Cardiomyopathy

ECG Rhythms to know: ORIGINATE IN THE AV JUNCTION (week 4 Cardiac emergencies and acute coronary Syndrome)

- Accelerated Junctional Rhythm - Junctional Rhythm - Junctional escape rhythm

Documentation should be

- Accurate - Legible - Timely - Complete - Professional

Differential Diagnosis-Cardiac Emergencies (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Acute Cornonary Syndromes (ACS) - Stable Angina - Severe aortic stenosis - Tachyarrhythmia (atrial or ventricular) - Aoritc dissection (tear between the layers of the wall of the aorta) and expanding aortic aneurysm - Pulmonary embolism - Pericarditis and myocarditis - Gastrointestinal causes (e.g gastro-oesophageal reflux, oesophageal spasm, peptic ulcer, pancreatitis, billary disease) - Musciloskeletal caises (e.g Costochondritis, cervical radiculopathy, fibrositis). - Pulmonary (e.g pneumonia, pleuritis, pneumothorax) - Other aietiologies (e.g sickle cell crises, herpes zoster

Possible cause of the inability to externally respirate:: unable to move oxygen and carbon dioxide from alveoli into the blood

- Acute Pulmonary Odema (APO) - Bronchitis - Pneumonia - Chronic Obstructive Pulmonary Disease (COPD) - Pulmonary Embolism (PE)

Asthma Management priorities - Severe / Life Threatening:

- Adrenaline IM - Hydrocortisone IV/IM - Ventilatory support with BVM - may have T-Piece available - Needle decompression if pneumothorax identified - Rapid transport + pre-alert - Magnesium given in some states

Assessing a Patient with Cardiac Arrhythmias (week 4 Cardiac emergencies and acute coronary Syndrome)

- Airway: Patients with ALOC face the risk of airway compromise, be sure to determine airway Status and keep checking for changes. - Breathing: Breathing complications can be common, due to cardiogenic pulmonary oedema, increased respiratory rate due to metabolic acidosis, buffer systems, due to poor perfusion. - Communication: Confusion may be present due to poor cerebral perfusion being driven by the arrhythmia, Look for other history signs if patient is confused. - Circulation: Determine if the patient has compromised perfusion, ALOC, short of breath, respiratory distress, Presence or signs of shock, cardiogenic, and chest pain/discomfort or odd feelings in the chest.

History - ANAPHYLAXIS

- Allergen exposure

Possible cause of the inability to internally respirate: inability of the blood to deliver sufficient oxygen to the cells

- Anaemia' - Carbon Monoxide Poisoning

Differing Diagnosis - Common causes of respiratory Emergencies (Module 2B week 3 respiratory emergencies)

- Anaphylaxis - Airway Obstruction - Asthma - COPD, emphysema, chronic bronchitis. - Pumonary Embolism - Pneumothorax, non-traumatic - Hyperventilation - Viral/bacterial, SARS / Corona virus - Cardiac Related

Causes of Dyspnoea - OTHER CAUSES

- Anaphylaxis - Anaemia - Viral / bacterial - SARS - Hypovolaemia - Chemicals / poisons - Diabetic ketoacidosis - Metabolic causes - Hyperventilation - Obesity - Pain

Differing diagnosis for Asthma

- Anaphylaxis - Arrhythmia - Pneumothorax - Pleural effusion - Chest infection - Anxiety

Risk factors for developing near-fatal asthma - Medical:

- Anaphylaxis - Previous Near-fatal asthma - Previous hospital admission for asthma - Presvious admission to ITU / requiring intubation - Heavy use of B2 agonist - Repeated ED attendance for asthma in last 12 months - Brittle Asthma

Differential Diagnosis for anaphylaxis

- Anxiety - Asthma - Scombridae food poisoning

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - FAMILY/PERSONAL HISTORY? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Any dysrhythmias? - Any history of sudden death in family members <45 years old (suggest Brugada's or long QT syndrome). - Any unexplained synscope? - Nocturnal agonal respiration? - Pheochromocytoma? - unxplained panic attacks?

Differential Diagnosis of Chest Pain - Non-Ischaemic Cardiovascular causes of chest pain? (week 6 Module 4a Cardiac Vascular Emergencies)

- Aortic dissection (tear between the layers of the wall of the aorta) and expanding aortic aneurysm. - Pulmonary embolism - Pericarditis and myocarditis - Gastrointestinal causes (e.g. gastro-oesophageal reflux, Oesophageal spasm, peptic ulcer, pancreatitis, biliary disease).

Systems review - Gastrointestinal

- Appetite/Weight loss - Dysphagia - Nausea / vomiting / haematemesis - Indigestion / heart burn - Jaundice - Abdominal pain - Bowels: change/constipation/diarrhoea/description of stool/blood/mucus/flatus

IV Cannulation - Preparation of patient : (module 1 Intravascular (IV) Cannulation)

- Apply tourniquet above selected site - Ask patient to make a fist and select a suitable vein - Swab site with alcohol swab using crosswise technique and allow to dry. - Maintain non-touch technique after site has been cleaned.

IV Cannulation preparing equipment - EQUIPMENT NEEDED : (module 1 Intravascular (IV) Cannulation)

- Appropriate IV catheter - Correct gauge size for task in hand.

Basic ECG Interpretation - P wave reflects atrial depolarization (week 4 Cardiac emergencies and acute coronary Syndrome)

- Are P waves present? - Are P waves regular? - Is there one P wave for each QRS complex? - Are P waves upright or inverted? - Do all P waves look a like note if they look alike sinus rhythm, if not a wandering atrial pacemaker, other cells

Causes of Dyspnoea - Pulmonary causes

- Asthma - Acute exacerbation of COPD - Pneumonia - Pulmonary embolism - Pneumothorax - Upper airway obstruction - Haemothorax - Pleural Effusion - Bronchiectasis

Differing diagnosis for Pulmonary Embolism

- Asthma - Anaphylaxis - Acute Pulmonary Oedema - Pneumothorax - Pleural Effusion - Sepsis - Pneumonia - Pleurisy - Acute Coronary Syndrome - Acute Myocardial infarction - Anxiety

Common Cause of Respiratory Emergencies

- Asthma - COPD ( emphysema, chronic bronchitis) - Pulmonary embolism - Anaphylaxis - Pnuemonia - Pneumothorax (non-traumatic) - Hyperventilation - Viral/bacterial (SARS / Corona virus) - Cardiac related

Differential Diagnosis of Chronic Obstructive Pulmonary Disease (COPD)

- Asthma - Congestive Heart Failure - Pneumonia - Pleural effusion - Pneumothorax - Pulmonary Embolism - Cardiac ischaemia - arrhythmia

Differential Diagnosis for Pleural Effusion

- Asthma - anaphylaxis - Acute Pulmonary Oedema - Pneumonia - Pneumothorax - Pulmonary Embolism - Previous lung surgery = pneumonectomy or lobectomy) - Acute Coronary Syndrome - Acute Myocardial Infarction - Anxiety

Dynamic hyperinflation or Gas Trapping can be caused by: (PPP ANZ p. 244)

- Asthma causes pressure to be exerted upon small airways, which narrow due to lack of cartilaginous support, the effect of this is that air in the terminal airways is now partially trapped, gradually leading to hyperinflation of the lungs.

Non-Shockable Cardiac Arrest Rhythms (week 6 Module 4b - Cardiac Arrest)

- Asystole - All other rhythms that look as though they should produce a pulse = Pulseless Electrical Activity (PEA).

Diagnostic Equipment -Waveform Capnography (ETCO2) (week 6 Module 4b - Cardiac Arrest)

- Attached to the end of iGel or endotracheal tube (ETT) - Displays waveforms and number - Used as a surrogate marker of cardiac output in cardiac arrest

Auscultation Sounds - FORIEGN BODY AIRWAY OBSTRUCTION (FBAO)

- Audible Stridor

Respiratory patient - Auscultation

- Auscultate over the same areas you percussed (don't forget the apices and the apex) - Ask the patient to breath through the mouth. Be wary not to let them hyperventilate - Don't miss bases or the right middle lobe (anterior) - Listen for added sounds, abnormal (adventitous) Sounds of absent sounds

Gastrointestinal emergencies: Pain is the hallmark of acute abdominal emergency - 3 Types / Classifications - CAUSE OF SOMATIC PAIN (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- Bacterial and chemical irritations of the abdomen

Cardiac arrest Definition - Typical ECG - METABOLIC / TOXIC (week 6 Module 4b - Cardiac Arrest)

- Bradycardia - Asystole - VT (ventrical Tachycardia) or - VF (Ventical Fibrillation)

Pericardial Conditions- PERICARDIAL EFFUSION- Aetiology & Pathology? (week 6 Module 4a Cardiac Vascular Emergencies)

- Build up of fluid in pericadial sac. - Secondary to Infection, malignancy, autoimmune diseases, trauma - Places pressure on the heart and decreases filling pressures.

DOLOR - Description; things to ask? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Can you describe the pain to me? - Is it the all the time or come and go? - Have you ever had this pain before? - What was it that time?

Atrial Rhythms: SVT Supraventricular Tachycardia (week 4 Cardiac emergencies and acute coronary Syndrome)

- Can't see P waves - Narrow QRS

Cardiophysiology - The Cardiac Action Potentials an Cardiac Cells (week 4 Cardiac emergencies and acute coronary Syndrome)

- Cardiac Cells: Mechanical, contractile or electrical pacemaker. - Pacemaker cells: have automaticity, spontaneously and conduct electrical impulses. - SA node has fastes automaticity rate - The cardiac AP involves Na, K+, CA++ and Cl- - AP is a rapid sequence of voltage changes across cell membrane. - Cells have a 'refractory' resting period to recover: absolute & Relative

Pericardial Conditions- PERICARDITIS- Aetiology & Pathology? (week 6 Module 4a Cardiac Vascular Emergencies)

- Caused by infection - AMI - Malignancy. - Medications - Idiopathic - can lead to tamponade

Emphysema - description

- Caused by pathological changes in lungs - Irreversible Lung disease - Long-term exposure to irritant

System review - Respiratory

- Chest pain - Shortness of breath / wheeze - Cough/Sputum/haemoptysis - Excercise tolerance

Pericardial Conditions- PERICARDITIS- Key: Signs & Symptoms? (week 6 Module 4a Cardiac Vascular Emergencies)

- Chest pain (sudden onset, persistent sharp/stabbing, worse with inspiration & cough, improves with upright/forward leaning position). - Fever - Pericardial Friction Rub - ECG: typical changes ST elevation throughout except V1 and aVR

System Review- Cardiovascular

- Chest pain/angina - Shortness of breath, including excercise - Orthopnoea - Paroxysmal nocturnal dyspnoea - Palpitations - Ankle Swelling

Pericardial Conditions- PERICARDIAL EFFUSION- Signs & Symtoms? (week 6 Module 4a Cardiac Vascular Emergencies)

- Chest pain: pressure or discomfort - Palpitations - Cough - SOB - Hoarseness - anxiety - hiccoughs - Can progress to Beck's Triad as per Pericardial Tamponade

Possible cause of the inability to ventilate adequately: unable to move air in and out of lungs and alveoli

- Choking - Asthma' - Anaphylaxis - Drug overdose - Pneumothorax - pleural effusion

Chronic Obstructive Pulmonary Disease COPD - Chronic and distinguising features / Presentations

- Chronic inflammation, mucus production, bronchospasm, and bronchiole obstructio - Patients will typically know their histroy and diagnosis - May be home O2 - Normal SpO2 can 88-92% - Consider Hypoxic drive

Chronic Bronchitis - detail

- Chronic inflammatory changes - Excess mucus production - Long-term exposure to irritants - Inflammation, swelling and thickening of the bronchi and bronchioles - Increase in number of goblet (mucus-secreting) cells in respiratory tree. Goblet cells trying to assist damaged cilia. - Production of large quantity of sputum - Alveoli not severely affected and diffussion remains normal - Gas exchange decreased because of lowered alveolar ventilation - results in hypoxia and hypercarbia. - History of frequent respiratory infections - Rhonchi: occlusion of larger airways with mucus plugs

Principles of Examination - CLOSURE

- Clarify when exam is complete - Consider modesty / allow to redress - Record findings & outline next steps

Pericardial Conditions- PERICARDIAL TAMPONADE- Signs & Symtoms? (week 6 Module 4a Cardiac Vascular Emergencies)

- Classic findings: BECKS TRIAD of hypotension, Diminished heart sounds, and JVD as evidence of elecated central venous system pressure. - Early Signs: tachycardia, mild/moderate hypotension with clear lung sounds

Ventricular Rhythms: Ventricular Fibrillation examples course and fine (week 4 Cardiac emergencies and acute coronary Syndrome)

- Coarse and fine VF

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - CARDIAC RISK FACTOR ASSESSMENT? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Cocaine; CVA? - Hypertension? - Age? - Male? - Family history? - Obese? - Lipids & Cholesterol? - Diabetes? - Smoker?

Heart Failure - Chronic (Congestive) Heart Failure - Aetiology and Pathology? (week 6 Module 4a Cardiac Vascular Emergencies)

- Compensatory mechanisms fail - Renin-angiotensin system is activated - PVR (Pulmonary vascular resistance) goes up (increased afterload in arterial system and increased venous pressures to increase preload). - NA+ and water retention also increase preload and pulmonary oedema - Leads to increased cardiac workload which with a decreased SV (stroke volume) causes reduced tissue perfusion

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - RECENT CHANGES IN PERFUSION? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Confusion or Fatigue - Postural hypotension - Changes in urinary output - Colour/cap refill/distal pulses? - Cold Extremities? - Intermittent claudication (claudication distance? changes?P

Cardiac Emergencies - Possible causes of impaired perfusion to the myocardium (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Coronary artery occlusions - Stenosis (narrowing of the artery) - Vasospasms (Prinzemetal angina) - Hypotension - tachycardia

Respiratory patient - Presenting complaint

- Cough (productive / non/productive) - Sputum - Haemoptysis - Dyspnoea (difficulty breathing - DIB) - Shortness of Breath (SOB) / unable to catch breath - Wheeze - Chest pain, discomfort, tight chest

chronic bronchitis - Signs and symptoms / appearance

- Cyanotic - Overweight - Productive Cough - Coarse rhonchi - Wheezing and Crackles - Clubbing of fingers - Signs of right sided heart failure - Difficulty breathing - Tachypnoea - Tachycardia - Tripod position - May be home oxygen

Principles of Examination - DIALOGUE

- Decide on a logical order - Explain as you go along, CONSENT, Avoid Jargon

Auscultation sounds - PNEMOTHORAX

- Decreased Breath sounds

Auscultation Sounds - ANAPHYLAXIS

- Decreased breathing sounds - Wheeze may be present

DOLOR (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Description - Onset - Location - Other signs and symptoms - Relief

Emphysema Pathophysiology

- Destruction of alveolar walls distal to terminal bronchioles. - Decreases alveolar membrane surface area, lessening area available for gas exchange - Weakening of walls of small bronchioles - When Destroyed, lungs lose capacity to recoil, air becomes trapped in lungs - Patients breathe through pursed lips, creates continued positive pressure similar to positive end-expiratory (PEEP) and prevents alveolar collapse

Patient Assessment in Cardiac Arrest (week 6 Module 4b - Cardiac Arrest)

- Determine Responsiveness /AVPU - Assess obvious life threats - Assess and manually open airway (consider C-spine) - Assess breathing (absent/irrregular) & pulse (5-10 seconds) - Determine if reasons to withhold resuscitation are present (ie: injuries incompatible with life, obvious signs of death-rigor mortis, tissue decomposition, advanced care directive).

Basic ECG Interpretation - QRS Complex (week 4 Cardiac emergencies and acute coronary Syndrome)

- Do all QRS complex look alike? - What is QRS duration? - Usually 0.04-0.12 second - longer than 0.12 second abnormal

Symptoms of Foreign Body Airway Obstruction (FBAO)

- Dyspnoea

Symptoms of Acute Asthma

- Dyspnoea - Cough - Unable to talk in sentances

Symptoms of Anaphylaxis

- Dyspnoea - Dysphagia - Chest tightness

Symptoms- PNEUMONIA

- Dyspnoea - Fever - Cough

signs and symptoms - Asthma

- Dyspnoea - Non-productive cough or clear sputum - Wheezing - Tachypnoea - Tachycardia - Anxiety and apprehension - Chest tightness - SPO2 <95% - Peak Expiratory Flow measure - Lower than normal

symptoms of pulmonary embolism (PE)

- Dyspnoea - Pleuritic chest pain - Cough - Possible DVT - Leg oedema

Pulmonary embolism (PE) signs and symptoms

- Dyspnoea - Pleuritic chest pain - Palpitations / tachcardia - Hypotension - Tachypnoea - Anxiety - Cough / haemoptysis - Unilateral leg Swelling - ECG Changes (supported by clinical findings)

Symptoms- PNEUMOTHORAX

- Dyspnoea - Sudden onset pleuritic chest pain

Symptoms- ACUTE HEART FAILURE

- Dyspnoea (especially on exertion) - Orthopnoea / paroxysmal nocturnal dyspnoea (PND) - Cough producing frothy white or pink phlegm

History - FORIEGN BODY AIRWAY OBSTRUCTION (FBAO)

- Eating

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - Atypical Angina? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Elderly - Female? - Diabetic? - Peripheral neuropathy?

the several infection processes that can affect the upper airway that have the potential to result in either a partial or complete occlusion (PPP ANX p. 229)

- Epiglottitis - Croup / laryngotracheobronchitis - Peritonsillar abcess - Retropharyngeal abscess

Asthma symptoms that may require ventilation:

- Extreme fatigue or exhaustion - Inability to speak - Quiet or absent breath sounds - SpO2 <90% with patient on Oxygen

HIgh Risk Factors for respiratory Disease

- Family history of Asthma, CF, TB - Sedentary lifestyle / forced immobilisation - Smoking - Occupational exposure - Obesity - Dysphagia - Weakended Chest Muscles - History of frequent RTI - Gender - Advanced Age

Heart Failure - RIGHT - KEY: Signs & Symptoms? (week 6 Module 4a Cardiac Vascular Emergencies)

- Fatigue - Increased peripheral venous pressure - Ascites - Enlarged Liver/spleen - Jugular vein distension - GI complaints - Dependent Oedema - Weight gain

System Review - General

- Fatigue/malaise - Fever/rigors/night sweats - Weight/appetite - Skin: rashes/bruising - Sleep Disturbances

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - POSSIBLE INFECTION? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Fever - rigours - Chills etc - Consider myocarditis - Consider Kawasaki's disease in children ( strawberry tongue, peeling rash on palms).

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - POSSIBLE CAUSES OF 2nd DEGREE OR TYPICAL ANGINA (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Fever (infarction) - Anaemia (bleeding or RBC production disorders). - Tachycardia (cocain, amphetamines, pain stress) - Thyrotoxicosis (excess thryroid hormone). - Hypotension (bleeding or profound fluid loss). - Hypoxaemia (CO posoning, acute pulmonary disorders).

respiratory patient - associated symptoms

- Fever (night sweats) - Hoarsness - Fatigue - Hypoventilation - Anxiety - Feeling restless / anxious - Oedema - peripheral & Sacral

Pericardial Conditions- PERICARDIAL TAMPONADE - Aetiology & Pathology? (week 6 Module 4a Cardiac Vascular Emergencies)

- Fluid in pericardial sac decreases cardiac output - Secondary to trauma/infections - Life threatening

Auscultation Sounds - PULMONARY EMBOLISM (PE)

- Focal rales may be present

Systems Review - Genito-Urinary

- Frequency/dysuria/nocturia/plyuria/oliguria - haematuria - Incontinence/Urgency - Prostatic Symptoms - Menstration (if appropriate) - Menarche ( age at onset) - Duration of Bleeding, periodicity, menorrhagia (blood loss), dysmenorrhoea, dyspareunia, menopause, post-menopausal bleeding

Systems Review

- General - Cardiovascular - Respiratory - Gastrointestinal - musculoskeletal - Central Nervous System - Genito-Urinary -Endocrine

Electrocardiograph - Key Diagnostic Tool (week 4 Cardiac emergencies and acute coronary Syndrome)

- General Impression: Take into account the context for this patient, looking at their history and clinical presentation today. - Mechanics Vs Conduction: *Consider is your patient clinically compromised or not? * Are they Haemodynamically stable or not? *Is the arryhthmia potentially the cause of this state? - Treatment: * If you treat the arrhythmia will the patient improve? * What is the safest treatment at this point? - What happens next? * Are they compensating or decompensating with cardiogenic shock? *Will the cirrent arrhythmia deteriorate into a worse arrhythmia?

Peripheral Examination

- General Impressions / end of bed assessment - Hands - clubbing, cyanosis, pulse rate, rhythem & quality - Face - inspect mouth, cyanosis, and eyes , anaemia, jaunduce. - Neck - inspect JVP (jugular vein pressure), palpate lymph nodes.

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - SYNSCOPE (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- General cardiac causes result in a sudden onset and sudden recovery, (with no confusion) whereas neurological causes result in slower recovery, with confusion. - Threatened (pre-synscope) or actual? - Any loss of consciousness? - Postural? Micturitional? (during urination), Tussive? (during Coughing), Vasovagul? (emotionally upsetting stimili?) - Rule of seizures

Respiratory patient - order of examination

- General impression - Weight & body - obesity, wasting, abnormal body shape - Hands & Nails + pulse rate, rhythm & quality - inspect - palpate - percuss - ascultate

Sepsis - Review of Systems for signs of infection (week 13 - SEPSIS)

- General: Lethargy, Fever / Rigors - Neurological: Severe headaches, new confusion, signs of meningitis or encephalitis (neck stiffness / photophobia) - Cardiovascular: Shortness of breath, shortness of breath on exertion (SOB / SOBE). - Respiratory: Pleurisy, shortness of breath, shortness of breath on exertion, cough, Sputum, haemoptysis, increased repsiratory rate or effort. - Gastrointestinal: Abdominal pain / distension, diarrhoea / vomiting. - Genito-urinary: UTI symptoms (offensive urine, frequency, dysuria), reduced urine output, abdominal / flank and back pain. - Musculoskeletal: Hot, painful joint, non-weight bearing. - Skin: Rapidly progressive cellulitis, diabetic foot & Ulcers, burns, purpuric rash / mottling. - Other: Dental problems, foreign travel, exposure ti other unwell contacts. NB: This is not an exhaustive list and clinical judgement should be used when considering whether a sign or symptom of a serious infection is present

Pharmalogical treatment - Other considerations - for Respiratory Emergencies

- Glycerine Trinitrate - Frusemide

The Electorcardiogram - ECG/EKG - Diagnostic tool (week 4 Cardiac emergencies and acute coronary Syndrome)

- Graphic record of the heart's electrical activity - Electrode: Adhesive pad on the skin detects voltage changes through wires that conduct current back to ECG machine - A lead is a record of electrical activity between two electrodes; average current flow, - The ECG machine amplifies the electrical impulses, records on them on paper and displays the waveform and the heart rate on the monitor display - Be aware of artifact: muscle tremours, shivering, movement, loose electrodes.

DOLOR - Relief; things to ask? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Has anything helped? Meds etc - Does it usually help - Deep Breaths make it worse? - Movement worse or better?

Systems Review - Central Nervous System

- Headaches - Fits/faints/loss of consciousness - Dizziness - Vision - acuity, diplopia - Hearing - Weakness - Numbness/tingling - Loss of memory/personality change -Anxiety/depression

Common Causes of Cardiovascular Emergencies (week 6 Module 4a Cardiac Vascular Emergencies)

- Heart Failure (left , Right, Chronic/Congestive). - Pericardial diseases (Pericarditis. Pericardial Effusion, Pericardia; Tamponade). - Hypertensive emergencies - Cardiogenic Shock - Aneurysm (aortic dossectopm = abdominal/thoracic) - Pulmonary embolus

Heart Failure - LEFT & RIGHT- Overview? (week 6 Module 4a Cardiac Vascular Emergencies)

- Hearts mechanical performance compromised - Cardiac output cannot meet body's needs. Note: Non-cardiogenic pulmonary can be caused by lung injury (inhalation/ARDS)

Asthma

- Hyper-responsive airways induced by Triggers - Bronchospasm, oedema, mucus in the lower airways - Reversible - Acute, Irregular, periodic attacks

Cardiac arrest Definition - Typical Cause - STRUCTURAL EXTERNAL (week 6 Module 4b - Cardiac Arrest)

- Hypovolaemia - Airway Obstruction - Tension Pneumothorax - Severe Asthma - Pericardial Tamponade - Pulmonary Embolism

Cardiac arrest Definition - Typical Cause - METABOLIC / TOXIC (week 6 Module 4b - Cardiac Arrest)

- Hypoxia - Beta of Ca+ channel blockers - Hyper/hypokalaemia - Hypomagnesaemia - TCA depressants - Digoxin Toxicity

Reversible Causes of Cardiac Arrest (Hs and Ts) (week 6 Module 4b - Cardiac Arrest)

- Hypoxia - Hypovolemia - Hypothermia - Hypo . Hyperkalaemia - Hydrogen ions - Tension pneumothorax - Tamponade Cardiac - Toxins - Thrombosis * Cardiac * Pulmonary

Ventricular Rhythms: Ventricular Tachycardia (week 4 Cardiac emergencies and acute coronary Syndrome)

- Impulse is originating in the ventricles, No P waves, Wide QRS. - Etiology: here is a re=entrant pathway looping in a ventricle, most common cause,. - Nomal rate =>100bpm - <100 = accelerated idioventricular rhythm [AIVR] or ventricular escape

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - RECENT CHANGES IN RESPIRATION? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Increase SOB? - SOBOE? - Orthopnea? ("pillow" orthopnea). - Coughing? (see next assessment) - Adventitious breath sounds

Contiguous Leads (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Indicative changes are significant when they are seen in at least two contiguous leads. - Two leads are contiguous if they look at the same or adjacent area of the heart or they are numerically consecutive chest leads

12 Lead STEMI Patterns to know (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Inferior - Septal - Anterior - Lateral - Inferolateral - Anteroseptal - Anterolateral

Pericardial Conditions- PERICARDITIS- Overview? (week 6 Module 4a Cardiac Vascular Emergencies)

- Inflammation of the pericardium (serous fluid that surrounds the myocardium) - Can also occur in myocardium, endocardium

Gastrointestinal emergencies: Pain is the hallmark of acute abdominal emergency - 3 Types / Classifications - CAUSE OF VISCERAL PAIN (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- Inflammations distention - Ischemia - Many hollow organs first cause visceral pain when distended.

Legal Issues

- Informed consent - capacity - Accountability - Negligence - Vicarious Liability - Standards of proficiency - Standards of conduct, performance & ethics

Description of Calgary-Cambridge model (1998) Patient-centred Philosophy

- Initiating the session - Gathering information - Physical examination - Explanation and planning (explain what is going to happen to the patient) - Closing the session

Patient Assessment- Key concepts of the Cardiovascular Exam (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

- Inspect Neck veins for evidence of jugular vein distention - Chest: Laboured breathing includes retractions and accessory muscle use * Crackles, Wheezes, Ronchi may indicate pulmonary congestion or pulmonary Oedema potentially caused by left ventricular failure (LVF). - Andomen: look for abdominal distention and visible pulsations. - Lower extremities: peripheral and sacral Oedema *Obvious in dependent parts (ankles/lower legs/thigs) *Classified as either pitting or non-pitting (depth of potting +1, +2, +3 etc).

The IV Cannula: (module 1 Intravascular (IV) Cannulation)

- Intravenous (IV) cannulation is a procedure where a flexible catheter is inserted into a vein via a metal needle. - Most catheters are designed with an over the needle system and will retract into a safety cover after use.

Heart Blocks: 2nd Degree Type I-Mobitz I- Wenchkebach (week 4 Cardiac emergencies and acute coronary Syndrome)

- Irregular - more Ps then QRS - PRI progressively lengthens then drops QRS - Normally at AV node

Cardiac Emergencies - Ischaemia can lead to infarction (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Ischaemia occurs when the blood supplied through an artery do not meet the demand needed to perfom proper cell function. - The injury to cells can progress to irreversible myocardial tissue death (infarction)

Differential Diagnosis of Chest Pain (week 6 Module 4a Cardiac Vascular Emergencies)

- Ischaemic Cardivascular causes - Non-Ischaemic Cardiovascular causes of chest pain - Non-Cardiovascular causes

Cardiac Emergencies - Causes of chest pain (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Ischaemic cardiovascular causes - Non- ischaemic cardiovascular causes of chest pain - Non-cardiovascular causes

History- ACUTE HEART FAILURE

- Ischemic Heart Disease (IHD) - Hypertension (HTN) - Hx of heart failure

Patient Assessmen- Cardiovascular Exam Images (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

- Jugular Venous Distension - Pulsatile Mass - Pulmonary Oedema Secretions from ETT - Pitting Oedema

Lung lobes Left Lateral View

- LUL = Left Upper Lung - LLL = Left Lower Lung

Lung lobes Posterior view

- LUL = Left upper Lung - LLL = Left Lower Lung - RUL = Right Upper Lung - RLL = Right Lower Lung

Differential Diagnosis for Choking associated with mechanical obstruction (PPP ANZ p. 232)

- Laryngeal spasm - Acute anaphylaxis

Contiguous Leads - LATERAL LEADS? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Lead I. - Lead aVL - Lead V5 - Lead V6

Contiguous Leads - INFERIOR LEADS? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Lead II - Lead III - Lead aVF

Contiguous Leads - SEPTUM? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Lead V1 - Lead V2

Contiguous Leads - ANTERIOR? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Lead V3 - Lead V4

Coronary Arteries and Coronary Perfusion Review-Back of the Heart (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Left Circumflex Artery ( supplies the left atrium and ventricle). - Left Marginal Artery ( Supplies the left ventricle). - Right Marginal Artery (Supplies the right ventrical and apex). - Posterior Interventricular Artery (Supplies the right and left ventricles and the interventricular septum) - Right Coronary Artery (Supplies the right atrium and the right ventricle)

Coronary Arteries and Coronary Perfusion Review-Front of the Heart (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Left Circumflex Artery (supplies left atrium and left ventricle - Right Coronary Artery (supplies the right atrium and the right ventricle - Right Marginal Artery ( Supplies the right ventricle and the apex_ - Left Anterior Descending Artery ( Supplies the right ventricle, left ventricle and interventricular septum) - Left Marginal Artery (supplies the left ventricle)

Heart Failure - LEFT - Aetiology and Pathology? (week 6 Module 4a Cardiac Vascular Emergencies)

- Left Ventricle (LV) fails as forward pump, causing back pressure of blood into pulmonary circulation, causes pulmonary oedema. - Pulmonary hydrostatic pressure pushes fluid (and RBC) into intersitial and avleolar spaces - May be secondary to AMI, tachydysrhythmias, valvular dysfunction, HTN

Consequences of a choking event can include: (PPP ANZ p. 227)

- Local Trauma - Aspiration - Negative Pressure Pulmonary Oedema

Pulmonary Embolism (PE) - Management

- Maintain high index of suspicion and get a good history for all SOB and chest pain complaints. - First priorities are ABCs - Establish and maintain airway. - Assist ventilations as required. - Oxygen - in accordance with Oxygen guidelines - Large pulmonary embolism may lead to cardiac arrest , perform CPR if needed

IV Cannulation -Diameter / length of the IV Cannula : (module 1 Intravascular (IV) Cannulation)

- Maximum achievable flow rate limited by the size or diameter of the IV cannula and its length - the shorter it is, the faster it will infuse fluids. - Other important factors include pressure of infusion and viscosity of fluid (e.g. saline faster than blood). - Flow is inversely proportional to the 4th power of the radius [Pouseuille's law] - small changesin cannula diameter = large changes in flow. - IV cannula size uses old wire guage system - a 20G cannula is equal to 1/20", 18G is 1/18". **Remember that when you attach a one-way valve, you are limiting the flow rate of the IV Cannula to that of the valve or bung.

Diagnostic Equipment -Waveform Capnography (ETCO2) During Cardic arrest (week 6 Module 4b - Cardiac Arrest)

- Measure ETCO2 during CPR - The higher readings correlate with better likelihood of ROSC - Can expect 20 mmHg+ with high quality CPR - ETCO2 consistently <10 mmHg associated with poor outcome - It serves as a proxy for CO and quality of CPR - Will see a significant increase in ETCOs with ROSC (before pulse is even felt).

Peak Expiratory Flow (PEF)

- Measures the rate at which a patient can breathe out (peak Flow) - Expressed in litres/min (l.min) - Asthmatics have increased resistance to exhalation - 3 attempts - take best reading as final score - Asthma patients should know their normal readings - Used to measure effectiveness of interventions - MAY NOT BE APPROPRIATE FOR LIFE- THREATENING ASTHMA

Past medical history should include

- Medical history including childhood illness# - surgical history - Obstretic / gynaecological history - Trauma - Any heart disease, epilepsy, CVA, Hypertension, diabetes, asthma/COPD, gastric, thyroid or TB, DVT/PE, rheumatic fever

Systems Review - Endocrine

- Menstrual abnormalities - Hirsutism/alopecia - Abnormal secondary sexual features - polyuria/polydipsia -Amount of sweating - Quality of hair

Cardiac arrest Definition - Typical Cause - STRUCTURAL / INTERNAL (week 6 Module 4b - Cardiac Arrest)

- Mitral Valve prolapse - Ventricular aneurysm

Differential Diagnosis of Chest Pain - Non-Cardiovascular causes? (week 6 Module 4a Cardiac Vascular Emergencies)

- Musculoskeletal causes (e.g. costochondritis, cervical radiculopathy, fibrositis). - Pulmonary (e.g. pneumonia, pleuritis, pneumothorax). - Other aetiologies (e.g. sickle cell crisis, herpes zoster).

Causes of Dyspnoea - CARDIAC CAUSES

- Myocardial infarction - Acute heart failure - Cardiac Tamponade - Cardiac arrythmia - Pericarditis - Ischaemic heart disease - Valvular dysfunction

Possible secondary events of an inhaled foreign body? (PPP ANZ p. 238)

- Myocardial infarction - Aspiration - Airway oedema - Negative pressure pulmonary oedema

DOLOR - Other Signs and Symptoms; things to ask? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Nausea . Vomiting? - Short of breath (SOB) - Palpitations - What came first? The pain of OSS?

Consultation Models - Patient-centred philosophy

- Neighbour (1987) - Calgary-Cambridge model (1998)

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - RECENT CHANGES IN STABLE ANGINA? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- New-onset exertional chest pain < 2 months. - New-onset increase in severity < 2 months. - Angina at rest > 20 minutes,

Basic ECG Interpretation - PR Interval (week 4 Cardiac emergencies and acute coronary Syndrome)

- Normal = 0.12-0.20 second=3-5 small boxes. - any deviation = abnormal finding. - Longer than 0.20 seconds is indicative of AV heart block.

Other signs of Ischaemia on an ECG (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Normal morphology - Hyperacute T-waves (wide & tall) - ST-elecation - Q Waves, T wave inversion - ST elevation improves - Q-waves persist, T-wave normalizes

ericardial Conditions- PERICARDIAL EFFUSION & PERICARDIAL TAMPONADE- Overview? (week 6 Module 4a Cardiac Vascular Emergencies)

- Normally have 15-50ml of pericardial fluid to facilitate heart movement - Can increase to as much as 2L with fluid, Pus, blood.

Gastrointestinal emergencies: Pain is the hallmark of acute abdominal emergency - 3 Types / Classifications - CAUSE OF REFERRED PAIN (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- Not true pain producing mechanism ie dissecting abdominal aortic artery produces referred pain felt between the shoulder blades

OPQRST - ASPN:

- Onset - Provocation / Palliation - Quality - Radiation - Severity - Timing - Associated Symptoms - Pertinent Negatives

Gastrointestinal emergencies: OPQRST-ASPN (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- Onset - Provocation / Palliation - Quality - Radiation / Region - Severity - Time - Associtated Symptoms - Pertinent Negatives

Gastrointestinal emergencies: Pain is the hallmark of acute abdominal emergency - 3 Types / Classifications - VISCERAL PAIN location (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- Originates in the walls of hollow organs (gallbladder or appendix). - In capsules of solid organs (Kidney or liver) - Or visceral peritoneum - Described as; Vague or poorly localised, dull or crampy

Pharmacological Interventions - Symptomatic tachycardias (week 4 Cardiac emergencies and acute coronary Syndrome)

- Oxygen - Adenosine= SVT - Amiodarone= VT - Both may be ICP only

Sepsis six

- Oxygen - Blood cultures - Antibiotics - Fluids - Lactate - Monitor UO

Patient Management - Pharmological Treatments (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Oxygen - aim for SP02 of 95% - Consider free radical damage in ACS - Aspirin (to reduce further thrombus formation) - Analgesia (aim to eliminate pain completely) - Glyceryl Trinitrate - Narcotics - Morphine or Fentanyl - Thrombolytic therapy (if indicated by ST elevation on ECG) - thrombolytic protocol includes for paramedics (P1s) Clopidogrel, Enoxaparin and Tenectaplase used in NSWAS - Heparin also used in some other states

Management - Sepsis - NSWA Guidelines

- Oxygen - titrated - IV antibiotics - Meningitis only - Fluids - hypovolaemia

Pharmalogical treatment for Respiratory Emergencies

- Oxygen aim for SpO2 >94% - Salbutamol (Ventolin) 5mg via neb - Ipratropium Bromide (Atrovent) 500mcg via Neb - Adrenaline (Epinephrine) 500mcg IM - Hydrocortisone 200mg IV/IM - Magnesium (not used in all states)

Pharmacological Interventions - Symptomatic bradycardias (week 4 Cardiac emergencies and acute coronary Syndrome)

- Oxygen: aim for SPO2 of 94% - Atropine: may be ICP only - Other drugs that can increase HR * ie. Slow adrenaline infusion or via IV in diluted form: typically ICP only

Cardiophysiology - ECG/EKG wave segments (week 4 Cardiac emergencies and acute coronary Syndrome)

- P wave = contraction of atria -PR Interval = start of p wave to start of QRS complex -PR Segment = finish of p wave to start of QRS complex - QRS Complex = contraction of ventricles - ST Segment = finish of S wave to start of T wave - QT Interval = start of QRS complex to finish of T wave

General Principles of Documentation

- PCR is a legal document and forms part of the patients medical record. - Avoid use of slang or medical abbreviations that are not universally accepted - Complete both the narrative and check-box sections - Pertinent Negatives - Never include slang, biased statements or irrelevant opinions. - Document any medical advice or orders you receive and the results of implementing that advice and those orders.

Cardiac arrest Definition - Typical ECG - STUCTURAL INTERNAL (week 6 Module 4b - Cardiac Arrest)

- PEA (Pulse-less Electrical Activit)

Cardiac arrest Definition - Typical ECG - STRUCTURAL EXTERNAL (week 6 Module 4b - Cardiac Arrest)

- PEA (Pulseless Electrical Activity)

Junctional Rhythms (week 4 Cardiac emergencies and acute coronary Syndrome)

- Pacemaker is in the AV junction or bundle of His region; thus the term 'Junctional Rhythm'. - Electrical impulse travels backwards to depolarise atria so if a p wave is seen, it is inverted, before or after the QRS Normal rate 40-60bpm > 60= accelerated junctional > 100 = Junctional tachycardia < 40 - junctional escape

IV Cannulation Commplications : (module 1 Intravascular (IV) Cannulation)

- Pain. - Catheter tip shear - Extravasation. - Haematoma - Air embolism - Blood Loss - Infection Risk including sepsis - Allergic reaction - Inadvertent arterial puncture - Disconnection - Phlebitis

Systems Review - Musculoskeletal

- Pain/swelling/stiffness - muscles/joints/back - Restriction of movement or function or power - able to wash and dress without difficulty? - able to climb up and down stairs?

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - RECENT CHANGES IN CHEST SENSATION? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Palpations or chest pain/discomfort

Heart Failure - LEFT - KEY: Signs & Symptoms? (week 6 Module 4a Cardiac Vascular Emergencies)

- Paroxysmal nocturnal dyspnoea - Acute and chronic pulmonary congestions ( cough, cackles, wheezes, pink/blood-tinged sputum, tachypnoea) - Restlessness - Confusion - Othropnea - Tachycardia - Exertional dyspnoea - Fatigue - Cyanosis

Causes of Dysrhythmias - Disorders of impulse conduction (week 4 Cardiac emergencies and acute coronary Syndrome)

- Partial or complete blocks caused by trauma, drugs, electrolyte disturbances, myocardial ischaemia/infarction. or - there can be reentry when an impulse continues to cycle through tissue already stimulated, caused tachy-dysrhythmias.

What are the categories of information?

- Patient details - Presenting complaint - History of presenting complaint - Allergies - Past medical History - Drug History (medical and recreational) - Social history (including sexual) - occupational history (hand dominance) - Family history - Mental health history - Vaccinations - System review

Signs- ACUTE HEART FAILURE

- Peripheral or sacral oedema - Tachycardia - Tachypnoea

Peripheral IV access: (module 1 Intravascular (IV) Cannulation)

- Peripheral venous access uses peripheral veins. - Common sites: hands & arms, may also use veins in the feet or neck (EJ) - Purpose of access determines site selection. - Simple to perform but can have complications - Peripheral veins collapse in hypervolemia or circulatory failure.

IV Cannulation - procedure Tips : (module 1 Intravascular (IV) Cannulation)

- Place the tourniquet on the patient to occlude venous flow only. - Apply above selected site, not too close nor too far! - Don't cut off a pulse either (Check distal pulses). - Select a vein that you feel you can cannulate. - Better to chose more distal if possible but important to decide based on need and size of cannula. - Prepare the site by cleansing it with and aseptic swab. - Shave around insertion site if necessary - You can use a local anesthetic i.e: 1% lignocaine. - Some services carry anesthetic cream for paediatric IV cannulation - takes 30 minutes to take effect. - Allow the site to dry - Pull the skin taut as this will anchor the vein, try to keep your thumb out of the way of the insertion - technique is all important! - Insert the cannula with bevel up at 10-30 degree angle to avoid going through the vein. - Warn patient first and consider having someone else secure their hand if you think they may pull away. - A bung is not always required, you may elect to attach an IV Line directly.

Patient Management- Pit Crew CPR (week 6 Module 4b - Cardiac Arrest)

- Position 1: Assess ABC, Start compressions, Alternate compressions and BVM - Position 2: Apply Defib pads, operate defibrillatior, assist 30.2 with P1 - Position 3: Prepare airway equip, insert adjuncts and use BVM + ECO2. - Position 4: Team Leader, rotate assist prn, family liaison, record time/interventions, follow checklist - Postion 5: IV/IO and medications: can be any of the 1,2,4 above

Patient Management - Non-Pharmological Treatments (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Positioning - Reassurance - Avoid patient exertion (avoid increasing MV02), do not walk the patient if practical - Acquire and transmit 12 lead ECG as required Transport - Percutaneous Coronary Intervention (PCI) capable facility - Pt may have Coronary Artery Bypass Graft (CABG) if PCI unsuccessful

Non-pharmalogical treatment for Respiratory Emergencies

- Positioning - Reassurance - Basic Airway Management - Advanced airway management - Avoid patient exertion - Transport (pre-alert if needed)

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - RECENT CHANGES IN COUGHING? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Precipitating factors? - Coughing subsequent to becoming surpine suggests fluid redistribution/cardiac failure. - Dry or productive - If productive what colour? * White = normal * Dark (yellow/brown/green) = infection * Red = blood (hemoptysis)

Drug History should include:

- Prescribed - Over the counter (OTC) - Herbal - Illegal / Illicit - Allergies / Sensitivities

History - ACUTE ASTHMA

- Previous asthma - Recent increase in use of inhaler - Allergen exposure

Symptoms- CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

- Progressive dyspnoea - Wheexing - Chest tightness - Cough - purulent Sputum

History - PULMONARY EMBOLISM (PE)

- Prolonged immobilisation - Recent surgery - Thrombotic disease

Sepsis - NSW Ambulance protocol for sepsis (week 13 - SEPSIS)

- Protocol M23 (NSW Amb)

Signs of impending respiratory failure

- RR >30 or <10 - SpO2 <90% - HR > 140 - Altered Mental state / Confusion - Cyanosis - Stridor - Not able to speak in sentences - Use of multiple groups of accessory muscles - Inability to lie flat - Hx of previous hospitalisation / ITU and intubation

Lung Lobes anterior view

- RUL = Right upper lung - LUL = Left Upper Lung - RML = Right medial lung - LLL = Left Lower Lung - RLL = Right lower lung (note no Left medial lung exits)

Lung lobes Right Lateral view

- RUL = Right upper lung - RML = Right Medium lung - RLL = Right Lower Lung

Auscultation sounds - ACUTE HEART FAILURE

- Rales - Creptiation's - Heart Murmur

Asthma Management priorities - Mild / Moderate

- Reassurance - Oxygen - Encourage Spacer use - Nebuliser therapy - Salbutamol, may need supplemtary Ipratropium bromide - Transport early - Reassess frequently

Management priorities - Emhysema & Chronic Bronchitis

- Reassurance - Oxygen to maintain SpO2 at 88-92% (beware hypoxic Drive) - Nebuliser therapy - Salbultomol, may need supplementary Ipratopium bromide - Ventilation support with BVM (in severe cases) - Transport early - Reassess frequently

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - MEDIASTINITIS? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Recent Esophageal infections? - Recent oropharyngeal infections? - Recent forceful emesis? - Recent endoscopy? - Recent thoracic surgery?

Heart Failure - CHRONIC (Congestive) Heart Failure- KEY: Signs & Symptoms? (week 6 Module 4a Cardiac Vascular Emergencies)

- Reduced Cardiac output ( reduced stroke volume) - Pronounced pulmonary oedema - Oedema: pulmonary, peripheral, sacral, ascites. - Confusion - angina - palpitations - Cough - Tachypnea - Frothy sputum - SOB

Heart Blocks: 2nd Degree Type II -Mobitz II (week 4 Cardiac emergencies and acute coronary Syndrome)

- Regular - More Ps then QRS - Consistent PRI - Normally Disease Bundle of His

ECG Rhythms to know: ORIGINATE IN THE SA NODE OR ATRIA (week 4 Cardiac emergencies and acute coronary Syndrome)

- Regular or normal sinus rhythm - Sinus tachycardia - Sinus bradycardia - Atrial flutter - Atrial Fibrillation - Supraventricular tachcardia

Example if IPPA respiratory Exam

- Respiration rate - Inspection: Bilateral chest expansion, Central Trachea, Wounds. - Palpation: Tenderness, Surgical emphysema. - Percussion: Resonance / dullness. - Auscultation: Breath sounds, Adventitious sounds.

Causes of Dysrhythmias (week 4 Cardiac emergencies and acute coronary Syndrome)

- Result from disorders of 1. Impulse formation 2. disorders of impulse conduction or 3. Both

Heart Failure - RIGHT - Aetiology and Pathology? (week 6 Module 4a Cardiac Vascular Emergencies)

- Right Ventricle (RV) fails as a forward pump, resulting in back pressure of blood into systemic venous circulation and venous congestion (increased preload). - May be secondary to left sided failure, COPD or Large PE - Also known as Cor Pulmonale

Cardiophysiology - Intrinsic pacemaker rates (week 4 Cardiac emergencies and acute coronary Syndrome)

- SA Node: 60-100 - Bundle of His: 40-60 - Ventricles: 20-40

Genitorinary Emergencies: Patient Management - RENAL COLIC & PYELONEPHRITIS (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- Same as UTI but will need more pain relief (ie morphine) - Ibuprofen can be effective for pain - Treat Vomiting - IV fluids to 'flush' stones if protocols allow

Assessment of Respiratory patient

- Scene Safety & PPE - Determine level of responsiveness - Rapid Primary Survey - ABCs - Critical interventions - Talking in full sentances - Any signs of hypoxia? - Obtain vital signs - SpO2, ECG, PEF - Patient History - SAMPLE, OPQRST focused - Physical examination - focused or integrated

IV Cannulation steps: (module 1 Intravascular (IV) Cannulation)

- Scene safety is considered. - Utilises ' Standard Precautions' and applies PPE appropriate to situation. - Explains procedure to patient and gains consent. - Ensures patient is in a position of comfort, ensure adequate lighting. - Tourniquet, alcohol swabs, gauze, op-site dressing, on way valve, saline flush, label. - Select appropriate sized cannnula for patient condition. - Sharps container within reach.

Principles of Examination

- Set - Dialogue - Closure

Gastrointestinal emergencies: Pain is the hallmark of acute abdominal emergency - 3 Types / Classifications - SOMATIC PAIN location (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- Sharp type of pain - travels along definite neural routes to spinal column - Pain localised to region or area

ECG Rhythms to know: ORIGIN IS ATRIA BUT PROBLEM IS AV JUNCTION (week 4 Cardiac emergencies and acute coronary Syndrome)

- Sinus Rhythm with 1st degree AV block - 2nd degree type I AV block - 2nd degree type II AV block - 3rd degree AV block

Socrates

- Site - Onset - Character - Radiation - Associated symptoms - Timing - Exacerbates / Alleviates - Severity

History- PNEUMONIA

- Smoking - Ischaemic Heart Disease (IHD)

History- CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

- Smoking > 35 years of age

What makes a 'good vein'?: (module 1 Intravascular (IV) Cannulation)

- Soft and easily palpable. - Collapsible and then refills - Visible - Large lumen (or or diameter) - Well Supported by surrounding anatomy. - Straight - No obvious valves

3 S's for Asthma

- Spasm - Swelling - Secretions

Einthoven' Triangle - frontal plane leads - Using 3 electrode locations (week 4 Cardiac emergencies and acute coronary Syndrome)

- Standard LImb: I, II, III - Augmented: aVL, AVF, aVR

IV Cannulation - Procedure : (module 1 Intravascular (IV) Cannulation)

- Stretch skin and anchor vein below site, - Warn patient and insert the cannula, bevel up at 15-30 degree angle. - When flash appears, lower insertion angle and advance needle 2-3mm. - Slide cannula off needle, without advancing the needle further into vein - avoid shearing catheter. - Loosen tourniquet. - Tamponade vein distal to tip of cannula. - Remove needle and immediately dispose of in sharps container, - attach one-way valve, secure with strip for tegaderm, flush cannula to ensure patency. - Observe for infiltration, pain or swelling along vein. - Clean insertion site and secure cannula with op-site, add label,

Respiratory Patient - Auscultation Abnormal sounds

- Stridor - Wheeze - Crackles - coarse or fine - Rales or crepitations (creps) - Pleural friction rub - Silence!

narrative writing

- Subjective part of your narrative comprises any information you elicit during your patients history, including oral statements - quote the patient. - Objective part of your narrative usually includes your general impression and any data you derive through inspection, palpation, auscultation, percussion and diagnostic testing.

Genitorinary Emergencies: Patient Management - Acute Renal Failure (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- Support ABC's - Check BSL - Watch for fluid overload (Crackles . Oedema). - Watch for Hypotension if due to shock - Give Fluid cautiously as required to maintain radial pulse (Hartmanns of NS). - Monitor ECG for dysrhythmias

Genitorinary Emergencies: Patient Management - Chronic Renal Failure (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- Support ABCs - May have altered LOC due to shock, hyperkalaemia or urea levels. - Watch for fluid overload. - Diurectics ie frusemide from ICP unlikely to be effective if no kidney function. - Monitor ECG: Peaked T waves, widening QRS, sine wave. - Cautious with fluid but give small amounts if req'd.

Genitorinary Emergencies: Patient Management - UTI (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- Support ABCs for severe cases (sepsis) - Paracetamol for fever or pain relief, if req'd. - Assume UTI as a differential dx in any new upset or worsening confusion in elderly.

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Synscope? - Recent changes in respiration? - Recent changes in coughing? - Recent changes in Chest sensation? - Recent changes in stable angina? - Possible causes of 2nd degree or atypical angina - Recent changes in perfusion - Recent changes in Weight? +/- - Possible infection. - PMHx of HTN - Family / Personal History - Cardiac Risk Factor Assessment - Prinzmetals Angina (Coronary artery vasospasm) - Atypical Angina - Mediastinitis

Signs of Pulmonary Embolism (PE)

- Tachycardia - Tachypnoea - Fever - ECG: Non-specific ST segment changes

signs of anaphylaxis

- Tachycardia - Tachypnoea - Wheeze - Erythema - Urticaria - Angiooedema

DOLOR - Location; things to ask? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Take one finger and point to the pain? - Does it go anywhere else? Radiation? - If well localised, palpate and visualise

Heart Blocks: 3rd Degree AV Block / Complete Heart Block (week 4 Cardiac emergencies and acute coronary Syndrome)

- The P waves are completely blocked in the AV junction;QRS Complexes originate independently from below the junction. - Etiology: there is complete block of conduction in the AV junction, so the atria and Ventricles form impluses independently of each other. Without impulses from the atria, the ventricles own intrinsic pacemaker kicks in at around 30-45 beats / minute

Most Common sites of infection for SEPSIS (PPP ANZ Ben Medley, p.778)

- The skin: Cellulitis, invasive medical devices). - Genitourinary tract: Urinary tract infection - Respiratory tract: pneumonia - Gastrointestinal tract: parasites, viruses)

Prinzemetal Angina aka variant angina (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- The spasm often occurs in coronary arteries that have not become hardened due to plaque build-up. -However, it also can occur in arteries with plaque build-up - These spasms are due to a squeezing of muscles in the artery wall. - They most often occur in just one area of the artery - The coronary artery may appear normal during testing, but does not function normally. - About 2% of people with angina have coronary artery spasm -

Safety IV Cannulas: (module 1 Intravascular (IV) Cannulation)

- There are varying designs. - Safety Cannulas reduce risk of needle stick injuries - Always be aware of the needle stick policy at your work place

Emphysema - Signs / Appearance

- Thin, barrel-chest appearance - Weight loss - Coughing, non-productive (not always present) - Prolonged exhaustion - Diminished Breath Sounds - Wheezing and rhonchi - Clubbing of fingers - Signs of right sided heart failure (Mod 4) - Pursed-lip breathing - Difficulty breathing - Pink complexion - Tachypnoea - Tachycardia - Diaphoresis - Tripod Position - May be on home oxygen

IV Cannulation preparing equipment - SET OUT EQUIPMENT NEEDED : (module 1 Intravascular (IV) Cannulation)

- Tourniquet. - Aseptic swab (typically alcohol or chlorhexidine). - 2 x 2 gauze pad. - Tegaderm or op-site (occlusive dressing). - One way valve. - Saline flush. - Label. - Sharps Container

History- PNEMOTHORAX

- Trauma - Previous Pnemothorax - COPD - Asthma - Smoking

Non-pharmacological Interventions - (week 4 Cardiac emergencies and acute coronary Syndrome)

- Typically only treat 'symptmatic' dysrhythmias - Valsalva Manoeuvre; involves stimulation of the vagal nerve to potentially trigger a reflex bradycardia. - Synchronised Cardioversion- a method of restoring normal cardiac rhythm in patients presenting with a rapid ventricular rate which is severely compromising cardiac output. Involves delivering a direct current counter shock, synchronised to the R-wave of the ECG. - Trancutaneous Cardiac Pacing; Works as an artificial pacemaker fir the heart, delivers repetative electrical current when the SA node is blocked or dysfunctional. Can be used after or instead of Atropine. - Continuous monitoring and transport

Central IV access: (module 1 Intravascular (IV) Cannulation)

- Utilizes veins located deep within body. - Internal jugular, subclavian, femoral, - Central IV lines placed near heart for long-term use - Also includes peripherally inserted central catheter (PICC) lines. - NOT within paramedic scope of practice except in special circumstances (ie: some air ambulance programs )

6 horizontal plane leads - V1-V6 Using 12 lead cable for chest leads (week 4 Cardiac emergencies and acute coronary Syndrome)

- V1 = 4th intercostal: right side of sternun - V2 = 4th intercostal Left side of sternum - V3 = between V2 & V4 - V4 = midclavicular: mid collarbone 5th intercostal - V5 = 5th intercotsal space: anterior axillary line - V6 = 5th intercostal space: midaxillary line

Cardiac arrest Definition - Typical ECG - ARRHYTHMIA (week 6 Module 4b - Cardiac Arrest)

- VT (Ventrical Tachycardia) or - VF (Ventrical Fibrillation)

Anatomy and physiology: Veins (module 1 Intravascular (IV) Cannulation)

- Veins have three layers with a large central lumen - Tunica Adventitia, Media & Intima. - Veins have valves that encourage one directional flow towards the heart. - Veins are collapsible and extremity locations can vary from person to person

IV access : Indications (module 1 Intravascular (IV) Cannulation)

- Venous circulation delivers medications and fluids into body. - It allows for fluid and blood replacement - it provides a route for medication administration - it also facilitates obtaining venous blodd specimens for laboratory analysis

Shockable Cardiac Arrest Rhythms (week 6 Module 4b - Cardiac Arrest)

- Ventricle Fibrillation (VF) - Pulseless Ventricle Tachycardia (VT)

ECG Rhythms to know: ORIGINATE IN THE VENTRICLES (week 4 Cardiac emergencies and acute coronary Syndrome)

- Ventricular escape/accelerated idioventricular rhythm - Ventricular tachycardia - Ventricular fibrillation

Gastrointestinal emergencies: Pain is the hallmark of acute abdominal emergency - 3 Types / Classifications (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- Visceral - Somatic - Referred

Pericardial Conditions- PERICARDIUM and PLEURAL EFFUSION? (week 6 Module 4a Cardiac Vascular Emergencies)

- Visceral Pericardium - Pericardial Cavity

Principles of examination - SET

- Warmth, dignity and privacy, NO INTERRUPTIONS - Chaperone>

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - RECENT CHANGES IN WEIGHT? +/- (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Weight changes - Belly or calves getting bigger/smaller - Pants or shoes getting tighter/looser?

History taking common pitfalls:

- Were you listening - Did you approach patient with an open mind? Did you make the findings fit the diagnosis. - was Underpinning knowledge advanced enough to appreciate the significance of obscure findings. -Were you aware of potential false positives and false negatives? - did the patient tell their story of just what they thought you wanted to hear? - is you decision making influenced by your conscious or unconscious basis? - We may hear what the patient is telling us but we interpret the information in light of our own understanding based on personal knowledge and clinical experience.

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - PMHx of HTN? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- What are their recent measurements? - Are they medicated / compliant?

Signs of Foreign Body Airway Obstruction (FBAO)

- Wheeze - Clutching at neck - Silent Cough

Signs- CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

- Wheeze - Cyanosis

Auscultation Sounds - ACUTE ASTHMA

- Wheeze - Wheeze is decreased or absent if severe

Signs of Acute Asthma

- Wheeze - tachpnoea - tachycardia - Pulsus paradoxus - Hyperresonant chest - Accessory muscle use

Basic ECG Interpretation - QRS Complex width and shape - Wide & Bizarre (week 4 Cardiac emergencies and acute coronary Syndrome)

- When an impulse originates in a Ventricle, conduction through the ventricles will be inefficient and the QRS will be more wide and bizarre

Basic ECG Interpretation - QRS Complex width and shape - Narrow (week 4 Cardiac emergencies and acute coronary Syndrome)

- When an impulse originates in the atria, SA node, Atrial Cells, AV node, Bundle of His, and then conducted normally through the venticles, the QRS will will be narrow = 0.04 - 0.12S

DOLOR - Onset; things to ask? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- When did it start? - What were you doing at the time? - Did it come on suddenly of slowly?

ST segments and ischaemia or infarction - Effects of myocardial ischaemia, Injury and infarction of ECG (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

- Zone of Ischaemia: Myocardial ischaemia causes ST segment depression with or without T wave inversion as result of altered repolarization. - Zone of injury: Myocardial injury causes ST segment elevation with or without loss of R Wave - Zone of infarction: Myocardial infarction causes deep Q waves as a result if absence of depolarization current from dead tissue and receding currents from opposite side of heart

Respiratory Patient - Red Flags

- any SOB - Cough? Productive or non-productive - any haemoptysis? - Any wheezing - Fevers or night sweats/ (TB) - Hx of Pneumonia or TB?

Patient Examination - General Impression - check before approaching patient

- any signs of respiratory distress, cyanosis, abnormal positioning. - Check environment for clues - Oxygen, nebuliser machine or mask, inhaler, GTN spray, sputum pots, PEF meters. - Other clues - cigerettes, ashtray, comit bowl

Cardiophysiology - Conductiohyhyn systems & pacemakers - Autorhythmic cells (week 4 Cardiac emergencies and acute coronary Syndrome)

- cardiac cells repeatedly fire spontaneous action potentials - Autorhyrhmic cells: the conduction system - Pace makers: * SA node= origin of cardiac excitation, fires 60-100/min * AV node * R and L bundle branches * Purkinje fibres

Respiratory Patient - Inspection of thorax

- chest shape - barrel chest, kyphosis, scoliosis - Symmentry - abnormal positioning: tripoding - Accessory muscle use / retractions - Tracheal Tug / deviation - Scars - Rashes - Breathing patterns

Description of setting the scene

- choose appropriate model for situation assess urgency! - Remember importance of communication skills - importance of dialogue - Invite the patients story - Build shared understanding

Ventricular Rhythms: Ventricular Fibrillation (week 4 Cardiac emergencies and acute coronary Syndrome)

- completely abnormal, no rhythm - Coarse and fine VF

ECG Paper and Recording (week 4 Cardiac emergencies and acute coronary Syndrome)

- each box is 1mm x 1mm = 0.4 sec - 5 boxes x 5 Boxes = 0.2 secs - 5 x large 0.2 secs = 1 sec - 30 x large boxes = 6 secs

Family history should include

- health of siblings - cause and age of death of parents or siblings - History of CHD, HTN, respiratory diseases , diabetes, cancer. - Hereditary conditions - Contagious disease - Similiar accommodation

Basic ECG Interpretation - Rhythm atrial & ventricular (week 4 Cardiac emergencies and acute coronary Syndrome)

- measure distance between all of the P Waves and the R waves 1. Regular Ie sinus rhythm 2. Irregular i. Occasionally/slightly II.Regularly irregular ie, 2nd degree type AV block III, Irregularly irregular ie AF

Risk factors for developing near-fatal asthma - Psychological / Behavioral:

- non-compliance with treatment (asthma)

Gastrointestinal emergencies: Pain is the hallmark of acute abdominal emergency - 3 Types / Classifications - REFERRED PAIN (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

- originates in a region other than where it is felt

Assess what you think of the story

- the attributes of the symptoms - Patterns of symptoms - Inclusion criteria - Exclusion Criteria - RED FLAGS

Causes of Dysrhythmias - Impulse formation (week 4 Cardiac emergencies and acute coronary Syndrome)

-Enhanced automaticity the pacemaker site, i.e SA node, is depolarising spontaneously or -a pacemake site other than the SA node increased its firing rate

Procedure of medical emergencies

-Primary Survey - History Taking - Secondary Survey - Reassessment

Signs- PNEMOTHORAX & PNEUMONIA

-Tachycardia -Tachypnoea

Heart Failure - Chronic (congestive) Heart failure- Overview? (week 6 Module 4a Cardiac Vascular Emergencies)

-Underlying structural dysfunction impairing filling/emptying or both. - Hearts reduced stroke volume causes overload of fluid in body's other tissues. - A combination of left and right failure

Performing a 12 lead ECG on a monitor/defibrillator machine (week 4 Cardiac emergencies and acute coronary Syndrome)

1. Both cables are plugged into the ECG Machine 2. Enter patients age and name into the machine, ?time of onset if ACS S&S 3. Ask the patient to try and stay still during the recording 4, Press the '12 Lead' Button 5. Wait for the print out to occur 6. Interpret the waveforms to the best of your ability 7. It is prudent to perform more than one 12 lead if the patients condition warrants it

Coronary artery occlusions and stenosis (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

1. Damaged endothelium (of coronary artery). 2. Inflammatory response -macrophages & LDLs form a 'Fatty streak'. 3. Macrophages release enzymes and toxic O2 radicals causing further damage 4. Fibrous plaque forms & can occlude or narrow the vessel (stenosis) 5. Unstable plaque may rupture and cause a haemorrhagic response which can further develop a thrombus formation (blocked artery).

Pathophysiology of Cardiac Arrest - Phases of cardiac arrest (week 6 Module 4b - Cardiac Arrest)

1. Electrical (0-4min) - myocardium still has 02 + glucose and can best respond to CPR + defib 2. Circulatory (4-10min) - myocardium using anaerobic metabolism (↑ lactic acid) and less likely to respond to defib 3. Metabolic (10min+) - H+ accumulates in myocardium, Na/K pump fails = metabolic acidosis, cells unable to produce sufficient action potentials

Basic ECG Interpretation - 5 Step Method (week 4 Cardiac emergencies and acute coronary Syndrome)

1. Heart Rate 2. Rhythm 3. P Waves 4. PR Interval 5. QRS comples

Gastrointestinal emergencies: Summary of Assessment for GI Emergencies (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies

1. Primary Survey ABCDE * Rule out Trauma * General Appearance 2. Full set of vital signs * 'Tilt test' for orthostatic hypotension * Temp (sepsis) * Cardiac monitor 3. SAMPLE * OPQRST-ASPN * Hx of alchoholism 4. Medications * NSAIDS 5. Secondary survey *focused abdominal exam

Assumed Knowledge of CLS 201 Intro to Medical Emergencies

1. Principles of Medical Ethics. 2. Professionalism & Communication. 3. History taking principles. 4. Principles of patient assessment

Wells Criteria score for Moderate Clinical probability of PE

2 - 6 points (Wells Criteria)

Accountability (Legal Issues)

3 main domains: 1. for the quality of his or her own work. 2. of health professionals within the organisations in which they work. 3. with others, as a senior member of staff, for the organisation's performance and for its provision of local services.

neutrophils, eosinophils, basophils

3 types of granulocytes

What percentage of diagnosis is made on the patient history?

90 percent. note figure rises when supported by physical examination and higher still with lab investigations.

Wells Criteria score for Low Clinical probability of PE

< 2 points (Wells Criteria)

Asthma - severity assessment >16 years old- Heart Rate = <100/min

= Mild Asthma > 16 years old (Heart rate)

Asthma - severity assessment >16 years old- Peak Expiration FLOW (PEF) = >75% predicted or best known

= Mild Asthma > 16 years old (PEF)

Asthma - severity assessment >16 years old- Talks in = Sentences

= Mild Asthma > 16 years old (Talks in)

Asthma - severity assessment >16 years old- Wheeze Intensity = Variable

= Mild Asthma > 16 years old (Wheeze Intensity)

Asthma - severity assessment >16 years old- Central Cyanosis = Absent

= Mild Asthma > 16 years old (central cyanosis)

Asthma - severity assessment >16 years old- Physical Exhaustion = NO

= Mild to moderate Asthma > 16 years old (Physical Exhaustion)

Asthma - severity assessment >16 years old- Heart Rate = 100 to 120/min

= Moderate Asthma > 16 years old (Heart rate)

Asthma - severity assessment >16 years old- Peak Expiration FLOW (PEF) = 50 to 75% predicted or best known

= Moderate Asthma > 16 years old (PEF)

Asthma - severity assessment >16 years old- Talks in = Phrases

= Moderate Asthma > 16 years old (Talks in)

Asthma - severity assessment >16 years old- Wheeze Intensity = Moderate to Loud

= Moderate Asthma > 16 years old (Wheeze Intensity)

Asthma - severity assessment >16 years old- Central Cyanosis = May be present

= Moderate Asthma > 16 years old (central cyanosis)

Asthma - severity assessment >16 years old- Oximetry on presentation = less then 90% cyanosis may be present

= Severe / Life Threatening Asthma > 16 years old (Oximetry on presentation)

Asthma - severity assessment >16 years old- Peak Expiration FLOW (PEF) = <50% predicted or best known or less than 100L/min

= Severe / Life Threatening Asthma > 16 years old (PEF)

Asthma - severity assessment >16 years old- Wheeze Intensity = Often Quiet

= Severe / Life Threatening Asthma > 16 years old (Wheeze Intensity)

Asthma - severity assessment >16 years old- Central Cyanosis = Likely to be present

= Severe / Life Threatening Asthma > 16 years old (central cyanosis)

Asthma - severity assessment >16 years old- Physical Exhaustion = YES

= Severe / Life threatening Asthma > 16 years old (Physical Exhaustion)

Asthma - severity assessment >16 years old- Talks in = Words

= Severe / Life threatening Asthma > 16 years old (Talks in)

Asthma - severity assessment >16 years old- Heart Rate > 120/min

= Severe Asthma > 16 years old (Heart rate)

Wells Criteria score for High Clinical probability of PE

> 6 points (Wells Criteria)

Granulocytes

A group of leukocytes containing granules in their cytoplasm; neutrophils, eosinophils, basophils.

continuous positive airway pressure (CPAP)

A method of ventilation used primarily in the treatment of critically ill patients with respiratory distress; can prevent the need for endotracheal intubation.

Even if a patient is able to sit up and talk once a foreign body has been removed from a patients away should hospital admission be considered? (PPP ANZ p. 234)

A patient should be observed in a safe environment at hospital, looking for signs of progressive airway oedema, pulmonary oedema or aspiration

McBurney's point

A point on the right side of the abdomen, about two-thirds of the distance between the umbilicus and the anterior bony prominence of the hip: Pain in RLQ with appendicitis

Troponin

A protein of muscle that together with tropomyosin forms a regulatory protein complex controlling the interaction of actin and myosin and that when combined with calcium ions permits muscular contraction

Abdominal Aortic Aneurysm (AAA)

A rapidly fatal condition in which the walls of the aorta in the abdomen weaken and blood leaks into the layers of the vessel, causing it to bulge.

cardiogenic shock

A state in which not enough oxygen is delivered to the tissues of the body, caused by low output of blood from the heart. It can be a severe complication of a large acute myocardial infarction, as well as other conditions.

Thorocatomy

A thoracotomy is a surgical procedure to gain access into the pleural space of the chest.

Cardiac Emergencies - Acute Coronary Syndromes (ACS) (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

ACS is a catch all phrase that covers sypmtoms related to myocardial ischaemia or infarction (MI) A. STE-ACS: ST Elevation ACS or STEMI B. NSTE-ACS: Non ST Elecation ACS, Unstable Angina and NSTEMI, refers to any acute coronary syndrome which does not show ST segment elecation NB: Normal Angina is not included as part of an ACS but we will still discuss this in realtion to the more sinister unstable angina for differentiating between the two

Endocrine Emergencies: Differential Diagnosis: Adrenal Glands Related: Addisons Disease - Presentation, Signs & Symptoms (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Addisonian crisis: acute stresses such as infection or trauma; potentially life-threatening emergency. May also have Congenital Adrenal Hyperplasia. Electrolyte imbalances, low blood volume, hypotension, and increased potential for cardiac arrhythmias. Confirm pre-existing diagnosis of adrenal insufficiency and worsening symptoms: nausea, high fever, mental confusion, low BP, rapid heart rate, hypoglycaemia Tx (if in scope of practice) 100mg of IV hydrocortisone

Patient Assessment- Cardio-respiratory - ADDITIONAL EXAMINATIONS (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

Additional Examinations: - Check Lower Limbs for bilateral peripheral oedema. - Check unilateral calf tenderness or swelling. - Check Distal pulses - Check Temp - Check Skin colour - Check for evidence of sacral oedema (in bed bound patients)

Patient Assessment and Diagnostic tools- A more complete Picture (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

Additional and structured history taking - questioning that broadens your clinical decision making and rationale •Allowing you to tie more together and fine tune your differential diagnoses •Focusing your clinical assessments The use of 12 leads and basic 12 lead interpretation are essential for differentiation of ACS and Angina You may think this will take longer, and it will at first, but over time you will get much faster

"Sepsis Six" interventions

Administer high flow O2 --Sepsis state will start to impair perfusion. When perfusion drops, cellular dysfunction. Draw Blood Cultures- lab tests, seeking to grow bacteria and determine what type Identify causative organism. Can take 24-48 hours though, so not instant results Start IV Fluid Resuscitation --Bring BP back up, replaces intravascular volume Initiate IV antibiotics: broad spectrum antibiotics, potent antibiotic that can kill many types of bacteria. Until we get cultures back, can't be sure of what bacteria is Check hemoglobin and lactate --Hemoglobin: worried about cellular oxygenation and perfusion. If not enough hemoglobin, may need blood --Lactate: measures lactic acid levels. Indicator of cellular hypoxia and anaerobic metabolism (high levels-confirmatory for sepsis) Measure hourly urine output Indicator of organ perfusion

Endocrine Emergencies: Differential Diagnosis: Adrenal Glands Related: Addisons Disease - Pathophysiology (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Adrenal glands fail to produce adequate amounts of steroid hormones (cortisol and aldosterone). A sudden half of steroid use; body will decrease steroid production if on steroids

Endocrine Emergencies: Differential Diagnosis: Thyroid Related: GRAVES DISEASE- Presntation, signs, Symptoms (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Agitation, emotional changeability, insomnia, poor heat tolerance, weight loss despite increased appetite, weakness, dyspnea, tachycardia (from SNS). Can cause exophthalmos (protrusion of eyeballs). Interaction of antibodies with thyroid tissue often produces diffuse goiter (enlarged thyroid gland).

IV Cannulas aim of insertion: (module 1 Intravascular (IV) Cannulation)

Aim of insertion

Airway management - anatomy of upper airway

Airway management - anatomy of upper airway

Gastrointestinal emergencies - A&P Overview- Alimentary Tract (module 6 - Gastrointestinal, Genitourinary Endocrine Emergecies)

Alimentary tract: •Oesophagus •Stomach •Duodenum •Terminal ileum •Caecum •Appendix •Ascending, transverse and descending colon •Sigmoid Colon

Uritcaria

Allergic reaction of the skin characterized by the eruption of pale red elevated patches called wheals (hives)

Needle decompression

Also referred to as a needle thoracentesis, this procedure introduces a needle or angiocath into the pleural space in an attempt to relieve a tension pneumothorax.

Endocrine Emergencies: Differential Diagnosis: Pancreas Related - HYPOGLYCAEMIA - Presentation, Signs, Symptoms (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Altered mental status sign of hypoglycaemia; inappropriate agitation or bizarre behavior. Diaphoresis and tachycardia; hypoglycemic seizure or become comatose. Can develop quickly. Look for Medic-Alert bracelet

biphasic reaction

An anaphylactic reaction that resolves and then recurs hours later without further exposure to the trigger.

Gastrointestinal emergencies: Patient Management -PHARMACOLOGICAL TREATMENTS (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies

Analgesia (IN/IM/IV) •Morphine •Fentanyl (if in scope of practice) •Ketamine (if in scope of practice) • Antiemetic •Ondansetron Metoclopramide

Hypotension secondary to (Module 2B week 3 respiratory emergencies)

Anaphylatic Shock of Sepsis may cause?

Anaphylaxis - pathophysiology

Anaphylaxis - pathophysiology

If abdominal pain or vomiting is a reaction due to injected medications or insect stings, what would be considered?

Anaphylaxis is considered if?

Auscultation sites of lung

Anterior and posterior

Subjective part of narrative writing in documentation PCR

Any information you elicit during your patients history, including oral statements - quote the patient.

Diagnostic Equipment - Monitor Defibrillator (Manual) (week 6 Module 4b - Cardiac Arrest)

As compared to an AED, paramedics must diagnose the ECG rhythm, set the joules appropriate to patient age and size, then manually deliver a shock

Pouseuille's Law

As resistance increases, flow decreases (and vice versa)

ECG Rhythms to know: (week 4 Cardiac emergencies and acute coronary Syndrome)

Asystole

Basic 12 Lead Interpretation - what do I need to learn for year 2? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

At this stage we want you to focus upon whether the ECG has ST changes or T wave changes. Are these in groups or patterns which are together in one place of the heart? •When this occurs we say they are in CONTIGUOUS leads •Contiguous means adjoining, or nearby •If this happens, it can mean that part of the heart has a problem with perfusion

Atrial Rhythms: Atrial Fibrillation (week 4 Cardiac emergencies and acute coronary Syndrome)

Atrial Fibrillation: •No organised atrial depolarisation, so no normal P waves (impulses are not originating from the sinus node). •Atrial activity is chaotic resulting in an irregularly irregular rate, R-R interval is irregular.

Atrial Rhythms: Atrial Fibrillation (week 4 Cardiac emergencies and acute coronary Syndrome)

Atrial Flutter: •No P waves. Instead flutter waves ("sawtooth" pattern) are formed at a rate of 250 - 350 bpm. •Only some impulses conduct through the AV node (usually every other impulse).

Patient Assessment- Cartiod Artery Auscultation (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

Auscultation of carotid arteries may reveal bruits (murmurs) -Sign of turbulent blood flow through vessel -Indicates partial blockage of vessel, commonly from atherosclerosis

Foreign Body Airway Obstruction, FBAO - AUSCULTATION SOUNDS (Module 2B week 3 respiratory emergencies)

Auscultation sounds of?: - Audible Stridor

Anaphyaxis - AUSCULTATION SOUNDS (Module 2B week 3 respiratory emergencies)

Auscultation sounds of?: - Decreased breath sounds - Wheeze may be present

Acute Asthma - AUSCULTATION SOUNDS (Module 2B week 3 respiratory emergencies)

Auscultation sounds of?: - Wheeze: note: decreased or absent if severe

Patient Assessment- Cardio-respiratory - AUSCULTATION (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

Auscultation: - Aucultates 6 lung fields (3 per side, posterior and anterior), using systematic pattern. - Comments on noisy breath sounds (ie. Cackles, wheezes, rhonchi). - Auscultates hear sounds (aortic, pulmonary, trucuspid, mitral) noting any abnormalities found.

Endocrine Emergencies: Differential Diagnosis: Thyroid Related: GRAVES DISEASE- Pathophysiology (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Autoimmune origin; excessive amounts of thyroid hormones (T3 and T4).

Patient Assessment- Cardiovascular - VITAL SIGNS AND AUSCULTATION (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

BP - pay close attention to widening pulse pressures, large variations in trending BP Pulse - pulsus paradoxus, weak pulses, sign of poor perfusion SPO2 - sign of poor perfusion if unable to detect, low sats = hypoxia RR - increased rate may be early sign of shock as used for respiratory buffer system JVD - sign of increased thoracic pressure, or increased venous pressure Auscultation - listening for adventitious sounds, pericardial rubs, abnormal or muffled heart sounds, carotid bruits

Endocrine Emergencies: Differential Diagnosis: Pancreas Related - HYPOGLYCAEMIA - Pathophysiology (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

BSL <4mmol/L Patient takes too much insulin, eats too little to match insulin dose, overexerts and uses almost all blood glucose. Risk: brain cells permanently damaged or killed due to lack of glucose

Pulmonary embolus

Blockage of the pulmonary artery or one of its branches due to a translocated clot

Sepsis - Patient Management - Breaking the chain of transmission (week 13 - SEPSIS)

Breaking the chain of transmission: •Hand hygiene •Standard precautions •Indwelling devices •Clean environment •Rational prescribing

aspiration / pulmonary aspiration

Breathing fluid, food, vomitus, or an object into the lungs

Brittle asthma

Brittle asthma is a rare form of severe asthma. The term "brittle" means difficult to control. Brittle asthma is also called unstable or unpredictable asthma because it can suddenly develop into a life-threatening attack two types: Type 1 difficult to control & Type 2 easier to control

Description of Neighbour (1987) Patient-centred Philosphy

Builds on other models - views consultation as a journey with 'checkpoints' along the way: -Connecting -Summarising (ie repeat what patient says) -Handing over (IMISTAMBO) -Safety netting (verbally explain what could happen, and document it) -Housekeeping (closing off consultation with crew mate, hospital staff, crew briefings

Gastrointestinal emergencies: GI (Abdominal Pain) History (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Can start with a SAMPLE history (symptoms, allergies, medications, past medical history, last oral intake, events) or use other history taking models as appropriate •Focus on 'S' for symptoms then OPQRST - ASPN •It can take a lot of time to elicit a history so be patient and organised •Last oral intake important for surgical patients

Diagnostic Equipment -Waveform Capnography (ETCO2) Canography Sampling line (week 6 Module 4b - Cardiac Arrest)

Capnograph sampling line (for handheld ETC02 or monitor/defib)

IV Cannulation - sample taping procedure : (module 1 Intravascular (IV) Cannulation)

Catheta taping procedure

Endocrine Emergencies: Differential Diagnosis: Adrenal Glands: Cushings Syndrome - Pathophysiology (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Caused by high levels of cortisol in blood. Affects middle-aged persons; women more than men. Long-term exposure to excess glucocorticoids

Mediastinum

Centrally located space between the lungs

General Impression

Check the following before approaching the patient: - Any signs of respiratory distress, cyanosis, abnormal positioning. - Check environment for other clues - Oxygen, ebuliser machine or mask, inhaler, GTN spray, sputum pots, PEF meters. - other clues

Pericardial Conditions- Chest Pain and Classic ECG in Pericarditis? (week 6 Module 4a Cardiac Vascular Emergencies)

Chest Pain - PERICARDITIS: Worse with Inspiration. AMI : No change with Breathing - PERICARDITIS: Relieved by sitting forward. AMI : No Change with Position. .- PERICARDITIS: Radiates to shoulder & back. AMI : Radiates to jaw and arm. - PERICARDITIS: Not Relieved by GTN. AMI : May be releived by GTN - PERICARDITIS: Widespread ST Elevation. AMI : Potential specific ST elevation. .

Phneumothorax

Collection of air in the pleural space / collapsed lung

Patient Assessment- Cardio-respiratory - COMPLETING THE EXAMINATION (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

Completing the Examination: - Undertake any other relevant diagnostic testing E.g 4 lead & 12 lead ECG if not already completed)

Endocrine Emergencies: Differential Diagnosis: Pancreas Related - HYPERGLYCAEMIC HYPEROSMOLAR NONKETOTIC COMA - Pathophysiology (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Complication associated with Type II diabetes Sustained hyperglycemia causes osmotic diuresis to produce dehydration; water intake inadequate to replace lost fluids Do not produce ketones as there is still some insulin to metabolise carbohydrates Mortality rate for HHNK coma higher than for ketoacidosis (40 to 70%) Primarily affects elderly

Secondary peritonitis

Complications occur frequently in the postsurgical ICU patient; "stable vital signs" does not imply clinical stability. Postoperative residual or recurrent intra-abdominal sepsis may not be clinically obvious and may not be demonstrated by a CT scan; cardiorespiratory instability should prompt a high level of suspicion. The treatment of the febrile postsurgical patient is not simply the administration of further antibiotics. The patient is very ill but may not require surgical intervention (e.g., severe pancreatitis)

Rales

Crackles; wet crackling noise in lungs made during inspiration

Crepitations are associated with?

Crepitations which are late inspiratory and unchanged with cough are typical of: Q2012 A. Pneumonia B. Lung fibrosis C. Pleural effusion D. Pulmonary edema E. Subcutaneous emphysema

Wells Criteria

Criteria for diagnosing a DVT / PE: - High > 6 points - Moderate 2-6 points - Low < 2points

oliguria

Decreased urine output

Endocrine Emergencies: Differential Diagnosis: Thyroid Related: Hypothyroidism - Pathophysiology (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Deficiency in thyroid hormone production; More common in women than men (6-10%)

Difficult to use Bag valve Mask, BVM - 'BONES' (Module 2B week 3 respiratory emergencies)

Difficult to use ....... due to - Beard - Obese - No teeth - Elderly - Sleep Apnoea . Snoring

Difficult to use Superglottal Airway Device, SGA - 'RODS' (Module 2B week 3 respiratory emergencies)

Difficult to use ....... due to: - Restricted mouth opening - Obstruction - Distorted airway - Stiff lungs or c-spine

Oesophageal varices

Dilated veins due to cirrhosis of the liver and portal hypertension

Diagnostic Equipment -Waveform Capnography (ETCO2) EMMA capnograph (week 6 Module 4b - Cardiac Arrest)

EMMA capnograph

Diagnostic Equipment -Waveform Capnography (ETCO2) EMMA capnograph on an iGel (week 6 Module 4b - Cardiac Arrest)

EMMA capnograph on an iGel

Einthoven' Triangle - (week 4 Cardiac emergencies and acute coronary Syndrome)

Einthovens triangle

Common GI Disorders and Emergencies Related to: (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Emergencies related to: •GI bleed (upper or lower) •Oesophageal varices •Bowel obstruction •Severe gastroenteritis •Mesenteric ischemia •Pancreatitis •Appendicitis •Cholecystitis •Hepatitis (ascites) •Secondary peritonitis

Heart Blocks: Sinus Rhythm with 1st Degree AV Block (week 4 Cardiac emergencies and acute coronary Syndrome)

EtiologyL Prolonged conduction delay in the AV node or Bundle of His - PR Interval =>0.20sec

Principles of Examination - Basic Principles

Examine from the patients right side: - JVP (jugular vein pressure) assessment more reliable from the right - Palpation of liver and kidney facilitated better - most examination rooms / ambulances are set up woth the bed against the left side against the wall! Universal precautions

Dysmenorrhoea

Excessive pain with menstration

Patient Assessment- Cardio-resipratory - GENERAL APPEARANCE (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

General Appearance: - Work of breathing: rate, rhythm & qualitiy - Patient position & accessory muscle use (e.g. tripod) - Presence of home O2 and respiratory meds (eg.puffers). - Presence of Cough (and Sputum) .

Patient Assessment- Cardio-resipratory (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

General Appearance: - Work of breathing: rate, rhythm & qualtiy - Patient position & accessory muscle use (e.g. tripod) - Presence of home O2 and respiatory meds (eg.puffers). - Presence of Cough (and Sputum) Inspection: - Inspect hands/nails for evidence of CO2 retention or any other abnormalities (e.g Cyanosis, clubbing, nicotine staining, splinter haemorrhages, hand flap) - Note: Skin Colour, Temp, Condition - Check pulse: Rate, Rhythm & volume (radio-radial delay or collapsing pulse?) - Inspect face, eyes an mouth and note any abnormalities found(eg, xanthelasma, corneal arcus, conjunctival pallor, poor dentition, cyanosis). - Visualises any scars (CABG/pacemaker), wounds, bruising or patches (eg. GTN). - Inspect abdomen for pulsatile mass or mottling. Palpation: - Palpates chest for pain and tenderness. Auscultation: - Aucultates 6 lung fields (3 per side, posterior and anterior), using systematic pattern. - Comments on noisy breath sounds (ie. Cackles, wheezes, rhonchi). - Auscultates hear sounds (aortic, pulmonary, trucuspid, mitral) noting any abnormalities found. Additional Examinations: - Check Lower Limbs for bilateral peripheral oedema. - Check unilateral calf tenderness or swelling. - Check Distal pulses - Check Temp - Check Skin colour - Check for evidence of sacral oedema (in bed bound patients). Completing the Examination: - Undertake any other relevant diagnostic testing E.g 4 lead & 12 lead ECG if not already completed) .

Endocrine Emergencies: Patient Management (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

General Management of Endocrine Emergencies 1.Primary survey (ABCDE) 2.Full set of vital signs (including BSL) 3.Cardiac monitor 4.Always include neurological exam for altered LOC 5.Look for S&S of dehydration, presence of ketones 6.SAMPLE, focused history 7.Medications (insulin, oral hypoglycaemic's) 8.Medical Alert bracelet, necklace, anklet

Objective part of narrative writing in documentation PCR

General impressions and any data you derive through inspection, palpation, percussion auscultation and diagnostic testing

Can you send cancer patients to an Emergency Department?

Generally patients who have cancer are not sent to ED but sent to their Cancer surgery

description of Informed consent (Legal issues)

Generally, patient must be an adult, and be able to understand, retain, use or weigh up information about the general nature and effect of the proposed medical treatment and communicate their decision. All necessary information must be provided to the patient

Endocrine Emergencies: Differential Diagnosis: Thyroid Related: Thyrotoxic Crises- Presentation, signs and symptoms (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

High fever, irritability, delirium or coma, tachycardia, hypotension, vomiting, diarrhea Pt may have goiter (see image) Tx: to block the thyroid hormone synthesis

Foreign Body Airway Obstruction, FBAO - HISTORY (Module 2B week 3 respiratory emergencies)

History of? - Eating

Acute Asthma - HISTORY (Module 2B week 3 respiratory emergencies)

History of? - Previous Asthma - Recent increase in use of inhaler - Allergen Exposure

Anaphyaxis - HISTORY (Module 2B week 3 respiratory emergencies)

History of?: - Allergen Exposure

ST segment Elevation (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

How does ST Segment Elevation occur - resting - Depolarises - repolarized

ST segment depression (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

How does ST segment Depression occur - resting - Depolarises - repolarized

Another consequence of Gas trapping/Dynamic hyperinflation? (PPP ANZ p.244).

Hyperinflated lungs and associated increase in intrathoracic pressure can occlude the vessels, such as the inferior and superior vena cava, returning blood back to the heart, being a comprimise of Central Venous Pressure (CVP) leading to a fall in cardiac output and blood pressure.

Hypotension Secondary to Anaphylactic shock or Sepsis

Hypotension Secondary to Anaphylactic shock or Sepsis

IGEL

IGEL

Anaphylaxis is considered if?

If abdominal pain or vomiting is a reaction due to injected medications or insect stings, what would be considered?

What is a sensitive indicator of laryngeal oedema? (PPP ANZ p. 233)

In conscious patients quality of voice is very sensitive indicator of

Kawasaki disease

Inflammation of blood vessels, hence the strawberry tongue, causes coronary artery aneurysms.

MCI documentation

Initial documentation done using Triage SMART cards

IPPA

Inspection Palpation Percussion Auscultation

Patient Assessment- Cardio-resipratory - INSEPECTION (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

Inspection: - Inspect hands/nails for evidence of CO2 retention or any other abnormalities (e.g Cyanosis, clubbing, nicotine staining, splinter haemorrhages, hand flap) - Note: Skin Colour, Temp, Condition - Check pulse: Rate, Rhythm & volume (radio-radial delay or collapsing pulse?) - Inspect face, eyes an mouth and note any abnormalities found(eg, xanthelasma, corneal arcus, conjunctival pallor, poor dentition, cyanosis). - Visualises any scars (CABG/pacemaker), wounds, bruising or patches (eg. GTN). - Inspect abdomen for pulsatile mass or mottling

Endocrine Emergencies: Differential Diagnosis: Pancreas Related (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Insulin is critical for normal BSL (4 - 8 mmol/L) Enables body to store energy as glycogen, protein, fat. Insufficient insulin activity to move glucose into cells causes the body to slowly switch from glucose to fat as primary energy source.

Aortic Dissection (week 6 Module 4a Cardiac Vascular Emergencies)

Intimal tear results in sub-intimal haematoma formation •Expanding hematoma separates intima and media layers •False lumen develops between layers. Dissection can extend distal and proximal •Distal extension can affect aortic valve •Proximal extension can involve branching arteries (carotid, subclavian)

Possible auscultation sound of aspiration of food or fluid into small airways (PPP ANZ p. 233)

Isolated course crackles

Sacral oedema

It accumulates in the lower back after being in bed for several hours

Pylonephritis

Kidney infection -chills, fever, flank pain,malaise,CVA tenderness

Genitorinary Emergencies: Mechanisms of non-traumatic Genitorinary Problems (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies

Kidneys retroperitoneal location protects them well against injury. •Non-traumatic disorders result from: •Inflammatory or immune-mediated disease •Infectious disease •Physical obstruction •Haemorrhage

12 lead ECG (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

Layout of outputs form a 12 lead ECG recording. Other arrangements also are used, but this is the main, routine way of showing them.

Endocrine Emergencies: Differential Diagnosis: Thyroid Related: Thyrotoxic Crises- Pathophysiology (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Life-threatening emergency; can be fatal within 48 hours if untreated. Associated with severe physiologic stress. Sympathetic response is extreme.

Social History should include

Lifestyle factors: - smoking, alcohol, diet - Domestic environment who do they live with & housing type - Social interaction & support - Hobbies - Independence, Self-sufficiency - Occupation, retired or working, effect on health? - Sexual history if appropriate

LAP =

Low Acuity Pathways

LAP

Low Acuity Patients

Hypoxia

Low oxygen saturation of the body, not enough oxygen in the blood

Common GI Disorders and Emergencies - Lower GI (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Lower GI •Diverticulosis, •Lesions, fissures •Inflammatory bowel -(Ulcerative Colitis & Crohn's disease) •Haemorrhoids Foreign body

Anaphylaxis - Primary Management - QAS (Module 2B week 3 respiratory emergencies)

Management for? (Primary or secondary) - Positioning - supine - Remove allergen - Adrenaline IM: 1:1,000 500mcg 1/2 of viale make to drawing - Oxygen: Highflow - Fluid therapy (•Rapid transport + pre-alert •Reassess frequently & repeat interventions as needed •Do not stand or walk the patient! •Beware biphasic reactions)

Anaphylaxis - Secondary Management - QAS (Module 2B week 3 respiratory emergencies)

Managemet for (primary or secondary)? - Nebulised Salbutamol - Some states advocate concurrent ipratropium bromide. - Hydrocortisone - Ventilatory Support with BVM (Bag Valve Mask) (•Rapid transport + pre-alert •Reassess frequently & repeat interventions as needed •Do not stand or walk the patient! •Beware biphasic reactions)

oximetry

Measurement of oxygen concentration in the blood

Additional Considerations should include

Mental Health Industry: - Depression - Anorexia - Suicidal thoughts - Risk Factors? Vaccination History: - Tetanus - MMR - Pertussis - Full childhood vacs

Sepsis - BETWEEN THE FLAGS - (if one Red Flag = Time Critical Emergency if one Amber flag = suspected sepsis) (week 13 - SEPSIS)

Minimum frequency of Observation of Between the flags - 5 Minute observation frequency: - Pulse Rate < 40 or > 140 - Resp Rate < 5 or > 30 - Sys BP < 90 or > 200 - BGL < 4 & LOC decreased - LOC V or P - 15 Minute observation frequency: - Pulse Rate < 50 or > 120 - Resp Rate < 10 or > 25 - Sys BP < 100 or > 180 - Temp < 35.5 or > 38.5 - BGL < 4

Causes of sepsis

Most commonly bact

Sepsis - Patient Management - NSWA Guidelines (week 13 - SEPSIS)

NSWA guidelines: •Oxygen - titrated •IV antibiotics - Meningitis only •Fluids - hypovolaemia

Gastrointestinal emergencies - A&P Overview- Non Alimentary Tract (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Non alimentary tract: •Liver •Gallbladder •Spleen •Pancreas •Kidneys

pulmonary embolism (PE)

Obstruction of Pulmonary circulation caused by: - Blood Clot - Air Embolism - Fat Particle

Genitorinary Emergencies: Chronic Renal Failure (CRF) (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Occurs with severe nephron damage and loss (70%) Metabolic and Cardiovascular instability occurs in end-stage failure •i.e. pH (metabolic acidosis), K+ regulation & urea excretion •BP regulation, heart failure d/t fluid overload •Patients need regular dialysis or kidney transplant to survive •Some patients produce little to no urine

Endocrine Emergencies: Differential Diagnosis: Pancreas Related - HYPERGLYCAEMIC HYPEROSMOLAR NONKETOTIC COMA - Presentation, signs, symptoms (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Onset slow; increased urination and increased thirst; becomes lethargic, confused, or enters frank coma The dehydration without ketones is telltale

Techniques of physical examination

Order of examination: IPPA - Inspection - "look" - Palpation - "feel" - Percussion - "sound" - Auscultation - "listen"

positive end expiratory pressure

PEEP

Patient Assessment- Cardio-resipratory - PALPATION (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

Palpation: - Palpates chest for pain and tenderness

Gastrointestinal emergencies: Out of Hospital Diagnosis (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Paramedics need a clear understanding of where organs lie in the abdomen, this way you can focus on potential diagnoses. Our focus: •obtaining a thorough history •understand the location of organs in the abdomen •perform a good assessment (including ECG) •recognise life threatening problems •differential and provisional diagnoses •manage symptoms •organised handover & documentation

Atrial Rhythms: PSVT = Paroxysmal SVT (week 4 Cardiac emergencies and acute coronary Syndrome)

Paroxysmal SVT comes on suddenly

Allergic reactions / Anaphylaxis: Pathophysiology - IMMUNE SYSTEM? (Module 2B week 3 respiratory emergencies)

Pathophysiology of what system?: - Principal Body System involved in allergic reactions - Responsible for combating infection - Components found in blood, bone marrow, lymphatic system - Goal of response: destruction or inactivation of pathogens, abnormal cells, foreign molecules such as toxins. - Cellular immunity: direct attack of foreign substance by specialised cells of ............. System. - Humoral imunity: chemical attack of invading substance. - Principal chemical agents of this attack are antibodies; immunglobins Igs - Antibodies manufactured by specialised cells of the ...........immune system called B cells. - Five classed of antibodies: IgA, IgD, IgE, IgM. - Humoral immune response begins with exposure of body to antigen. - Antigen: any substance capable of inducing immune response - Principle chemical mediator of allergic reaction is histamine: minimizes body's exposure to antigen. - Histamine: potent substance, causes bronchoconstriction, increased intestinal motility, vasodilation, increased vascular permeability.

Patient Refusal

Patients (of legal age that are competent and informed of the consequences of not receiving treatment) have the right to refuse treatment. Patients can revoke consent at any time. Must sign a release form. Most common reason for EMS lawsuits.

IV Cannulation - IV Cannula gauges : (module 1 Intravascular (IV) Cannulation)

Picture IV Cannula guages)

Endocrine Emergencies: Differential Diagnosis: Pancreas Related - DIABETIC KETOACIDOSIS - Pathophysiology (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Potentially life-threatening associated with type I (IDDM) diabetes. Profound insulin deficiency coupled with increased glucagon activity. Initially profound hyperglycemia exists because of lack of insulin (BSL >14mmol/L). Body cells cannot take in glucose. Loss of glucose in urine and loss of water through osmotic diuresis produce significant dehydration.

Endocrine Emergencies: Differential Diagnosis: Pancreas Related - DIABETIC KETOACIDOSIS - Presentation, Signs and symptoms (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Presentation, signs, symptoms Fat-based metabolism, blood level of ketones rises. 1st - signs of diuresis: increased urine production; dry, warm skin and mucous membranes; excessive hunger and thirst; progressive sense of malaise. 2nd - ketoacidosis develops, compensatory mechanism for acidosis: rapid, deep breathing pattern (Kussmaul's respirations); helps expel C02. Breath: fruity or acetone-like smell. Mental function declines and frank coma may occur.

Genitorinary Emergencies: Patient Assessment (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Primary Survey •ABCDE •Listen for crackles •Look for S&S of shock •Assess GCS •Assess for fistula/graft, port-catheter (no BP or IV on this side) Vital Signs •*No BP (or IVC) on graft arm •BSL •ECG for dysrhythmias (peaked T waves, normal K+ 3.5-5mmol/L) SAMPLE •Details re: dialysis, recent illness, whether they produce urine •Do they take diuretics and how much? (i.e. frusemide) Ask re: possibility of pregnancy as appropriate OPQRST-ASPN •Especially for UTI, renal colic, pyelonephritis •Ask re: urination S&S Secondary Survey •Include thorough abdominal assessment •Ask re: groin/genital involvement but use discretion regarding inspection •Assess for flank pain •May have indwelling urinary catheter •Look for peripheral oedema -Determine pitting or non-pitting and location

Importance of documnetation

Provides for the following: - Written record of the incident - Legal record of the incident - Clinical audit - Quality improvement - Data collection - Billing and administration

Significant negative pressures when a patient is struggling to breath can result in a (PPP ANZ p. 234)

Pulmonary Oedema can be a result of

Auscultation sounds- CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Rales

Rhonchi

Rattling noise of mucous in the lungs

Respiratory assessment Redflags (Module 2B week 3 respiratory emergencies)

Red flags for? - any signs of impending respiratory failure <10 >30 RR - SPO2 <90 - HR >140 - Altered mental state or confusion - stridor - Cyanosis - not able to speak in sentances - use of multiple groups of accessory muscles - inability to lie flat due to breathing - history of repeated hospilisations in particular those that needed to be intubated and ventilated in intensive care unit.

Genitorinary Emergencies: Renal Colic (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Renal Colic •Pain due to dilation, stretching & spasms involving renal capsule and ureter •++ visceral pain secondary to obstruction (flank) •Pts classically can't remain still •Hx of urinary frequency, pain with urination, hematuria •May also complain of N/V

Auscultation sounds- PNEUMONIA

Rhonchi

Sepsis - defination has changed previous defintion

SIRS criteria: must meet 2 of 4 criteria that signal physiologic responses to inflammation. Respiratory: RR >20 or PCO2 < 32 Temperature: >38 or <36 WBC: >12 or <4 HR > 100

Sepsis - Patient Management - SEPSIS SIX (week 13 - SEPSIS)

Sepsis Six: •Oxygen •Blood cultures •Antibiotics •Fluids •Lactate •Monitor UO

Lactate hugely important in

Sepsis if >4 level associated with death

Sepsis - DEFINITION (week 13 - SEPSIS)

Sepsis is characterised by a life-threatening organ dysfunction due to a dysregulated host response to infection.' (Sepsis-3, Singer et al) 'Septic shock is a subset of sepsis where particularly profound circulatory, cellular and metabolic abnormalities substantially increase mortality.' (Sepsis-3, Singer et al)

ETCO2 wave form in asthma, COPD, Obstruction

Shark fin

NSTE-ACS, -NSTEMI - SIgns & Symptoms and ECG (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

Signs & Symptoms - ACS S&S to varying degree. - location & size depends on vessel & site of obstruction - Transmural = Full thickness of myocardium ECG - Injury and Infarct - ST depression - Elevated troponin

STE-ACS or STEMI- SIgns & Symptoms and ECG (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

Signs & Symptoms - ACS S&S to varying degree. - location & size depends on vessel & site of obstruction - Transmural = Full thickness of myocardium ECG - Injury and Infarct - ST elevation - Elevated troponin

NSTE-ACS, UNSTABLE ANGINA- SIgns & Symptoms and ECG (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

Signs & Symptoms - S&S at rest - lasts > 20 min - Less responsive to treatment ECG - Ischaemia - Non-specific ECG changes - normal troponin - or minimal Changes

ANGINA, SIgns & Symptoms and ECG (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

Signs & Symptoms - S&S with exertion - Transient - relieved by rest & nitrates ECG - Ischaemia - May have inverted T Waves

Signs and Symptoms - MILD-MODERATE ALLERGIC REACTION (Module 2B week 3 respiratory emergencies)

Signs and Symptoms of? - Swelling of lips, face , eyes - Hives or welts - Tingling mouth - Abdominable pain* - Vomiting* * If reaction is due to injected medications or insect stings, abdominal pain and vomiting: anaphylaxis would be considered?

Signs and Symptoms - ANAPHYLAXIS (Module 2B week 3 respiratory emergencies)

Signs and Symptoms of?: (any one or more of the following) - Difficult / noisy breathing - Swelling of tongue - Swelling / tightness in the throat - Difficulty talking / horse voice - Persistent dizziness or collapse - Wheeze or persistent cough - Pale & Floppy: young children

Anaphyaxis - Signs (Module 2B week 3 respiratory emergencies)

Signs of?: - Tachycardia - Tachypnoea - Wheeze - Erythema - Urticaria - Angiooedema

Foreign Body Airway Obstruction, FBAO - SIGNS (Module 2B week 3 respiratory emergencies)

Signs of?: - Wheeze - Clutching at neck - Silent cough

Acute Asthma - SIGNS (Module 2B week 3 respiratory emergencies)

Signs of?: - Wheeze - Tachypnoea - Tachycardia - Pulsus paradoxus - Hyperresonant chest - Accessory muscle use

Sinus Rhythms: Normal Sinus. (week 4 Cardiac emergencies and acute coronary Syndrome)

Sinus rhythm is created in SA node - Etiology Electrical impulse is formed in the SA node and conducted normally

Sinus Rhythms: Sinus Bradycardia (week 4 Cardiac emergencies and acute coronary Syndrome)

Sinus rhythm is created in SA node - Etiology Electrical impulse is formed in the SA node and conducted normally

Sinus Rhythms: Sinus Tachycardia (week 4 Cardiac emergencies and acute coronary Syndrome)

Sinus rhythm is created in SA node - Etiology Electrical impulse is formed in the SA node and conducted normally

Non-conveyance

Some systems allow paramedics to utilise alternative pathways if more appropriate than Emergency Department or to discharge patients on scene

Under normal conditions, the volume of fluid and solutes reabsorbed is almost as large as the volume filtered

Starlings law of capillaries

Pulsatile mass

Strong pulse of midline abdomen, noted with palpatation, possible aortic aneurysm

Gastrointestinal emergencies: Patient Management - NON-PHARMACOLOGICAL TREATMENTS (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies

Support ABCs •Oxygen if indicated (i.e. SOB with ascites) •Treat hypotension due to dehydration/sepsis/bleeding with crystalloids •Rule out respiratory/cardiac involvement •Posture for comfort

Endocrine Emergencies: Differential Diagnosis: Thyroid Related: Hypothyroidism- Presentation, signs, Symptoms (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Symptoms include lowered metabolism, lethargy, cold intolerance, tiredness, weight gain Myxoedema which is long-standing hypothyroidism that lends to puffiness and non-pitting oedema around the eyes

Foreign Body Airway Obstruction - SYMPTOMS (Module 2B week 3 respiratory emergencies)

Symptoms of ?: - Dyspnoea

Anaphyaxis - SYMPTOMS (Module 2B week 3 respiratory emergencies)

Symptoms of?: - Dyspnoea - Dysphagia - Chest tightness

Acute Asthma - SYMPTOMS (Module 2B week 3 respiratory emergencies)

Symptoms of?: - Dyspnoea - Cough - unable to talk in sentances

Neutropenic sepsis

T > 38 C ANC < 500 -Notify MD -Start IV antibiotics (and IV antifungal/IV antiviral) within 1 hour -Look at Lactate levels

SIRS criteria

The Systemic Inflammatory Response Syndrome (SIRS) must meet 2 of 4 criteria that signal physiologic responses to inflammation. Respiratory: RR >20 or PCO2 < 32 Temperature: >38 or <36 WBC: >12 or <4 HR > 100

anerobic metabolism

The cellular process in which glucose is metabolized without oxygen.

Sepsis - Patient Management - SEPSIS SIX STATISTICS (week 13 - SEPSIS)

The mortality rate for adult patients with septic shock has been shown to increase by 7.6% for every hour of delay after the onset of hypotension, in commencing antibiotic therapy (Kumar et al, 2006; Clinical Excellence Commission (CEC). Sepsis Program Implementation Guide for NSW Healthcare Facilities. 2013 Sydney: CEC)

tunica adventitia

The outer layer of tissue of a blood vessel wall, composed of elastic and fibrous connective tissue.

Sepsis definition

The presence of a systemic inflammatory response with a confirmed infectious process (Vinvent & Korkut, 2008 - chap 44 page 778 Ben Medley, paramedic principles and practice)

respiratory drive

The tonic stimulation of respiratory centers that maintains some steady level of respiration.

Single sign of sepsis? (PPP ANZ p: 778)

There is no single sign of sepsis (PPP ANX p> 778)

Patient Management- Withholding CPR (week 6 Module 4b - Cardiac Arrest)

These are general guidelines - ambulance service providers will differ: 1. Signs of rigor mortis or post-mortem lividity 2. A clear advanced directive not to receive resuscitation for cardiac arrest 3. Scenarios where resuscitation is either futile or clearly not in the best interest of the patient. i.e. asystole and unwitnessed cardiac arrest patient with no bystander CPR was performed

Genitorinary Emergencies: Common Genitourinary Emergencies (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies

Though the renal system is very complex, there are a limited number of 'emergencies' that paramedics encounter out of hospital. •Urinary tract infections •Renal colic •Pyelonephritis •Acute renal failure •Chronic renal failure •Dialysis related -Hyperkaelmia -Hypotension or fluid overload

contiguous leads

Two or more ECG leads that are anatomically close together and that cover the same general area of the heart; specifically, the walls of the left ventricle.

Endocrine Emergencies: Differential Diagnosis: Pancreas Related - (type I & II diabetes) TYPE I (*Formerly IDDM) and TYPE II (*formerly NIDDM) Old terminology: (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Type I (formerly IDDM) •Juvenile onset •Type I diabetes mellitus: b-cell destruction; very low production of insulin; in many cases, no insulin at all. •Insulin-dependent diabetes mellitus (IDDM): regular insulin injections to maintain glucose homeostasis. Type II (formerly NIDDM) •Adult onset •Moderate decline in insulin production accompanied by deficient response to insulin present in body (insulin resistance). •Non-insulin-dependent diabetes mellitus (NIDDM); some type II patients may require insulin. •Initial therapy: diet & exercise

Genitorinary Emergencies: Dialysis - Peritoneal (PD) - Typical complications (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Typical complications: •Hyperkalaemia (ECG dysrhythmias) if K+ levels rise •Hypotension post dialysis if too much fluid removed •Fluid overload if dialysis missed or delayed •Altered LOC if urea levels too high

Patient Assessment and Diagnostic tools- Additional Considerations for Assessment and History Taking - PRINZMETALS ANGINA (Coronary artery Vasospasm)? (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

Typical factors: - Young. - Female - Japanese - Onset at rest - Onset whilst smoking - Hx of connective tissue disease - Recent or ongoing infection.

Genitorinary Emergencies: Urinary Tract Infection (UTI) (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies

UTI •Elderly are especially susceptible •Present with cloudy, foul smelling urine •May have pain with urination, hematuria •*Typical presentation in elderly is new onset or worsening confusion caused by undiagnosed UTI

Common GI Disorders and Emergencies - Upper GI (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Upper GI •Peptic ulcer disease •Oesophagitis •Gastritis •Oesophageal Varices Mallory-Weiss tear

Haematemesis

Vomiting of pure blood or blood mixed with stomach contents

Endocrine Emergencies: Differential Diagnosis: Adrenal Glands Related: Cushings Syndrome - Presentation, Signs & Symptoms (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

Weight gain, trunk of body, face, neck; "moon-faced" appearance develops. Fat on upper back - "buffalo hump." Skin changes, fragile, infection prone. Mood swings and impaired memory or concentration.

Wells Criteria Clinical Feature for a score of 3 points

Wells Criteria score for: - Clinical Signs and symptoms of DVT - Alternative diagnosis is less likely than PE

Wells Criteria Clinical Feature for a score of 1 point

Wells Criteria score for: - Haemoptysis. - Malignancy (on treatment, treated in the last 6 months or palliative)

Wells Criteria Clinical Feature for a score of 1.5 points

Wells Criteria score for: - Heart Rate > 100 bpm - Immobilisation or surgery in the previous 4 weeks - Previous DVT/PE

Aneurysm, (aortic shock) - AETIOLOGY & PATHOLOGY? (week 6 Module 4a Cardiac Vascular Emergencies)

What are these the AETIOLOGY & PATHOLOGY of? - Aneurysm is localised weakness of arterial wall - causing bulge and altered blood flow, predisposed to thrombus, embolization or rupture. - Fusiform - whole diameter - Sacculated - one side - Pseudoaneurysm - intimal layer

Hypertensive emergency - Malignant Hypertension- AETIOLOGY & PATHOLOGY? (week 6 Module 4a Cardiac Vascular Emergencies)

What are these the AETIOLOGY & PATHOLOGY of? - Non-compliance with meds, - llicit drug use. - Renal disease. - Pre-eclampsia.

Cardiogenic shock - AETIOLOGY & PATHOLOGY? (week 6 Module 4a Cardiac Vascular Emergencies)

What are these the AETIOLOGY & PATHOLOGY of? - Inability of heart to pump forward or when rate/rhythm are compromised, causing impaired myocardial contraction. - Most common cause is AMI - directly related to extent of myocardial damage and resultant pump failure (i.e. >40% of LV). Backflow to lungs causes hypoxia and acidosis.

Hypertensive emergency - Malignant Hypertension- OVERVIEW? (week 6 Module 4a Cardiac Vascular Emergencies)

What are these the OVERVIEW of? - Either cardiac output or PVR is elevated, complications include stroke.

Aneurysm, (aortic shock) - OVERVIEW? (week 6 Module 4a Cardiac Vascular Emergencies)

What are these the OVERVIEW of? Dissection can occlude any artery branching off aorta.

Cardiogenic shock - OVERVIEW? (week 6 Module 4a Cardiac Vascular Emergencies)

What are these the OVERVIEW of? Reduced systemic blood flow affecting renal and cerebral perfusion. Inability of heart to deliver sufficient blood flow to meet metabolic demands.

Hypertensive emergency - Malignant Hypertension- SIGNS & SYMPTOMS? (week 6 Module 4a Cardiac Vascular Emergencies)

What are these the Signs & Symptoms of? - Diastolic >120mmHg with complications: i.e. - altered LOC, - headache, - CV compromise, - chest pain, - renal failure

Cardiogenic shock - SIGNS & SYMPTOMS? (week 6 Module 4a Cardiac Vascular Emergencies)

What are these the Signs & Symptoms of? - Pulmonary oedema, - hypotension, - Increased SVR causes pallor, cold/clammy skin. - Progressively worsening of symptoms - Leads to death if not reversed.

Aneurysm (aortic dissection)- SIGNS & SYMPTOMS? (week 6 Module 4a Cardiac Vascular Emergencies)

What are these the Signs & Symptoms of? - Tearing, sharp or ripping pain - shock - Reduced or absent carotid - femoral pulses (may be unilateral) - Dx by chest xray (widened mediastinum)

Anaphylaxis - CAUSES (Module 2B week 3 respiratory emergencies)

What can these cause?: - Allergens enter body through: oral ingestion, inhalation, topically, injection, or envenomation. - Majority of reactions result form injection or envenomation. - Parenteral penicillin injections most common cause of fatal reactions. - Insect stings second most frequent cause of fatal reactions eg; Fire ants, Wasps, Yellow jackets, Honets , Honey Bees - Nut allergies also becoming increasingly common, can be from ingestion or being in same room. - Occurs when specific allergen injected into circulation. - When allergen enters circulation, it is distributed widely though-out body. - Principle body systems affected = Cardiovascular, Respiratory, Gastrointestinal systems, integumentary the skin. - Histamine causes widespread peripheral vasodilation. - Increased permeability of capillaries results in marked loss of plasma from circulation. - People sustaining..................reactions can actually die from circulatory shock

Allergic reaction versus Anaphylaxis - ALLERGIC REACTION (Module 2B week 3 respiratory emergencies)

What type: Allergic Reaction or Anaphylaxis?: - Exaggerated response by immune system to foreign substance. - Can range from mild skin rashes to

Allergic reaction versus Anaphylaxis - Anaphylaxis (Module 2B week 3 respiratory emergencies)

What type: Allergic Reaction or Anaphylaxis?: - Most severe type of allergic reaction - is life-threatening emergency; advanced life support measures often mean difference between life and death. - Can develop within seconds and cause death just minutes after exposure to offending agent

Description of Negligence (Legal Issues)

Whenever a clinician breaches their duty of care in connection with provision of clinical service to their patients . It mostly involves serious errors in judgement, decision making and treatment which a competent doctor would have not made. It is a liable offence!

Pheochromocytoma

a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine

pericardial effusion

a collection of fluid between the pericardial sac and the myocardium

description of capacity (legal issues)

a functional term that refers to the mental of cognitive ability to understand the nature and effects of one's acts.

Parinfluenza

a group of viruses that causes an infection in the respiratory system and closely resembles the common cold. Often a cause of CROUP in young childrem

Description of competence (Legal Issues)

a legal term that can be defined as being 'duly qualified: having sufficient, capacity, ability or authority'.

aneurysm

a localized weak spot or balloon-like enlargement of the wall of an artery

quinsy

a painful pus-filled inflammation of the tonsils and surrounding tissues also know as peritonsillar abscess

septic shock

a serious condition that occurs when an overwhelming bacterial infection affects the body - also when sepsis induced hypotension is not receptive to adequate fluid resusitation ( Anderson et el, 2002. PPP ANX Ben Meadley p. 778)

What approach is critical to good history taking

a structures approach is required in consultation models and it is vital the health care professionals possess excellent communication skills (Listen to answers and ask the right questions).

Eosinophils

a white blood cell containing granules that are readily stained by eosin.

Abdominal quadrants: (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

a. Abdominopelvic regions: - Right hypochindriac region - Epigastric region - Left hypochondriac region - Right Lumber Region - Umbililcal Region - Left Lumber Region - Right illiac Region - Hypogastric region - Left illiac region. b. Abdominopelvic Quandrants: - Right upper quandrant (RUQ) - Let Upper Quandrant (LUQ) - Right Lower quandrant (RLQ) - Left Lower quandrant (LLQ)

cerebrovascular accident (CVA)

a.k.a. "Stroke". Lack of blood supply to the brain causing brain damage

AAA

abdominal aortic aneurysm

orthopnea

ability to breathe only in an upright position - difficulty breathing when lying down

ascites

abnormal accumulation of fluid in the abdomen

pleural effusion

abnormal accumulation of fluid in the pleural space

Scoliosis

abnormal lateral curvature of the spine

diverticulosis

abnormal outpouchings in the intestinal wall of the colon

PEEP (Positive End Expiratory Pressure)

affects exhalation, maintains alveoli open to increase surface area available for gas exchange. Mechanical maintenance of pressure in the airway at the end of expiration to increase the volume of gas remaining in the lungs.

pneumothorax

air in the pleural cavity caused by a puncture of the lung or chest wall

Hyperresonant

amp: louder pitch: lower quality: booming duration: longer location ex: (normal) child's lung (abnormal) adult's lungs = increased air in emphysema

Descriptions of 'Standards of proficiency' (Legal Issues)

are required to be met by every clinical/registrant in order to become registered, and they must continue to meet in these to continue to maintain their registration.

paroxysmal nocturnal dyspnea

awakening from sleep with SOB (Shortness of Breath) and needing to be upright to achieve comfort

pulsus paradoxus

beats have weaker amplitude with respiratory inspiration, stronger with expiration

orthopnoea

breathlessness when lying down

Transient Ischemic Attack (TIA)

brief episode of loss of blood flow to the brain, usually caused by a partial occlusion that results in temporary neurologic deficit (impairment); often precedes a CVA

Cullen's sign

bruising in the skin around the umbilicus (seen with pancreantitis

aortic aneurysm

bulging or swelling of the aorta, due to a weakened aortic wall

Lactate

by product of anerobic metabolism

Marfan's syndrome

caused by a defect in fibrillin, a glycoprotein that forms a sheath around elastin

CVA

cerebrovascular accident (stroke)

Stable angina

chest pain that occurs when a person is active or under severe stress

unstable angina

chest pain that occurs while a person is at rest and not exerting himself

Cholecystitis/Cholelithiasis

cholelithiasis- gallstones Cholecystitis - obstruction of the bile duct-colicky epigastric RUQ pain, right shoulder; after fat meal

fusiform aneurysm

circumferential enlargement of a vessel with tapering at both ends

thyrotoxicosis

condition caused by the exposure of body tissue to excessive levels of thyroid hormone

CPAP

continuous positive airway pressure

pleural friction rub

continuous, dry grating sound caused by inflammation of pleural surfaces and loss of lubricating pleural fluid

Possible auscultation sound of negative pressure pulmonary oedema (PPP ANZ p.233)

crepitations

Peritonsillar abscess

deep infection in the space between the soft palate and tonsil collection of puss or fluid around tonsil. Also known as quinsy.

Neutropenia

deficiency of neutrophils

Starlings law of the capillaries (PPP ANZ p. 234)

descibes the forces moving fluid out of a capillary: Under normal conditions, the volume of fluid and solutes reabsorbed is almost as large as the volume filtered

Neutraphils

destroys bacteria and viruses

Aortic dissection

diagnosis in which the arterial wall splits apart

Grey Turner's sign

discoloration over the flanks suggesting intra-abdominal bleeding.

peripheral neuropathy

disorder of the peripheral nerves that carry information to and from the brain and spinal cord

Description of Vicarious Liability (Legal Issues)

doctrine of English tort law that imposes strict liability on employers for the wrongdoings of their employees. Generally, an employer will be held responsible for any tort committed while an employee is conducting their duties.

diplopia

double vision

pleura

double-layered membrane surrounding each lung

tilt test

drop in the systolic blood pressure of 20 mmHg or an increase in the pulse rate of 20 beats per minute when a patient is moved from a supine to a sitting position; a finding suggestive of a relative hypovolemia.

ETCO2

end-tidal carbon dioxide

Extravasation

escape of fluid from a blood vessel into surrounding tissue

hirsutism

excessive body hair

hypercarbia / hypercapnia

excessive level of carbon dioxide in the blood

kyphosis

excessive outward curvature of the spine, causing hunching of the back. - Hunch back / Hump back

polyuria

excessive production of urine

polydipsia

excessive thirst

nocturia

excessive urination at night

apices of lungs

extend 3-4 cm above the inner 3rd of the clavicles

synscope

fainting or sudden loss of consciousness caused by lack of blood supply to the cerebrum

Pericardial tamponade

filling of the pericardial sac with fluid, which in turn limits the filling and function of the heart.

indewling catheter

for short to long term bed ridden, blood clots, bladder issues

Description of 'Stansards of Conduct, performance and ethics' (legal Issues)

framework within which an accredited/registered clinician must work. The registering body sets these for all clinical professionals on their register and they state in broad terms, the expectations of the behaviour and conduct of registered clinicians.

glycerol trinitrate

glyceryl trinitrate (GTN) is prescribed for chest pain associated with angina. Tablet and spray formulations are referred to as short-acting preparations. This is because the effect of the medicine lasts for around 20-30 minutes. They are used to provide rapid relief from the pain as and when it happens. They can also be used for when the pain is expected to happen, such as before exercise that is likely to cause chest pain (for example, before climbing stairs). Other formulations which contain GTN are skin patches and ointment. These are longer-acting nitrates, as the medicine in these preparations works for a longer period of time. They are often referred to as transdermal nitrates. They are prescribed to prevent the pain from developing.

malignant

harmful

urtucaria

hives

urticaria

hives / itchy wheels caused by a reaction

HTN

hypertension (high blood pressure)

Beck's triad

hypotension, JVD, muffled heart sounds

aphagia

inability to swallow

dynamic hyperinflation aka Gas Trapping

increase in functional residual capacity above the elastic equilibrium volume of the respiratory system

phlebitis

inflammation of a vein

fibrositis

inflammation of fibrous connective tissues, especially in the muscle fascia

chronic bronchitis

inflammation of the bronchi persisting over a long time

costochondritis

inflammation of the cartilage that connects a rib to the sternum

Cholecustitis

inflammation of the gallbladder

mediastinitis

inflammation of the mediastinum

myocarditis

inflammation of the myocardium

pancreatitis

inflammation of the pancreas

pleuritis

inflammation of the pleura (also called pleurisy)

pericarditis

inflammation of the sac surrounding the heart

conjunctival pallor

inside of the lower eyelid appears pale

percutaneous coronary intervention (PCI)

interventional procedures used to treat coronary artery disease (CAD) performed at the time of cardiac catheterization in a specialized laboratory setting (or "cath lab") instead of the traditional operating room

agonal breathing

irregular, gasping breaths that precede apnea and death

Polycythaemia

is a disease state in which the hematocrit and/or hemoglobin concentration are elevated in peripheral blood

Scombridae food poisoning

is a food borne illness that typically results from eating spoiled fish. Symptoms may include flushed skin, headache, itchiness, blurred vision, abdominal cramps, and diarrhea. Onset of symptoms is typically 10 to 60 minutes after eating and can last for up to two days. Rarely, breathing problems or an irregular heartbeat may occur. It's treatment is antihistamines however treatment should be consistant with anaphylaxis as presentation different to separate in a pre hospital setting - one clue would be a number of patients at same time who had eaten fish,

hypoxic drive

is a form of respiratory drive in which the body uses oxygen chemoreceptors instead of carbon dioxide receptors to regulate the respiratory cycle. Normal respiration is driven mostly by the levels of carbon dioxide in the arteries, which are detected by peripheral chemoreceptors, and very little by the oxygen levels. An increase in carbon dioxide will cause chemoreceptor reflexes to trigger an increase in respirations. However in cases where there are chronically high carbon dioxide levels in the blood such as in COPD patients, the body will begin to rely more on the oxygen receptors and less on the carbon dioxide receptors. In this case, when there is an increase in oxygen levels, the body will decrease the respirations.

PCR Document

is a legal document and forms part of the patient record

severe aortic stenosis

is a narrowing of the aortic valve opening.

angiooedema

is an area of swelling of the lower layer of skin and tissue just under the skin or mucous membranes. The swelling may occur in the face, tongue, larynx, abdomen, or arms and legs. Often it is associated with hives, which are swelling within the upper skin. Onset is typically over minutes to hours.

Intraosseous IO access: (module 1 Intravascular (IV) Cannulation)

is now a common practiced skill that compliments peripheral IV access when challenges occur

Retropharyngeal abscess

life-threatening infection in the lateral pharyngeal space that has the potential to occlude the airway; most commonly occurs in children

SEPSIS is now not using SIRS Criteria

look at sepsis if organ dysfunction when not responding to medication

Frusemide

loop diuretic used in the treatment of congestive heart failure and edema

alopecia

loss of hair

Sepsis Six Approach

maintain adequate oxygenation fluid resuscitation obtain blood cultures start antibiotics monitor lactate hourly urine

MCI

mass casualty incident

NSAIDs

medication that exerts analgesic and anti-inflammatory actions

Ventilation

movement of air in and out of the lungs

cervical radiculopathy

nerve pain caused by pressure on the spinal nerve roots in the neck region

PVR (pulmonary vascular resistance)

o Afterload/resistance in the RIGHT side of the heart pumping to the lungs o Normal PVR = <250 dynes/sec/cm(-5) o High PVR (>250 dynes/sec/cm-5) - pulmonary hypertension

pulmonary embolism (PE)

occlusion in the pulmonary circulation, most often caused by a blood clot

menarche

onset of menstruation

Corneal arcus

opaque white ring about corneal periphery, seen in many individuals older than 60 years of age. This is due to deposit of lipids in the cornea or to hyaline degeneration. May indicate a lipid disorder, most commonly type II hyperlipidemia if present before the 40 years of age (if seen in younger people, it is called arcus juvenilis).

integummentary system

organs making up the skins

Murphy's sign

pain with palpation of the RUQ during inspiration, (Gall bladder) indicative of cholecystitis

claudication

pain, tension, and weakness in a leg after walking has begun, but absence of pain at rest

dyspareunia

painful sexual intercourse

dysuria

painful urination

PND

paroxysmal nocturnal dyspnea

chronic obstructive pulmonary disease (COPD)

permanent, destructive pulmonary disorder that is a combination of chronic bronchitis and emphysema

erythematous

pertaining to redness of the skin

Scoliosis & Kyphosis

picture of Scoliosis & Kyphosis

peep

positive end expiratory pressure

positive end-expiratory pressure (PEEP)

positive pressure maintained by the ventilator at the end of exhalation (instead of a normal zero pressure) to increase functional residual capacity and open collapsed alveoli; improves oxygenation with lower fraction of inspired oxygen

Haematuria

presence of blood in the urine

CPAP (continuous positive airway pressure)

pressurized air delivered to lungs to keep them expanded during exhalation

erythema

redness of the skin due to capillary dilation

biliary disease

refers to diseases affecting the bile ducts, gallbladder and other structures involved in the production and transportation of bile. Bile is a fluid ...

lobectomy

removal of a lobe of a lung

Pseudoaneurysm

results from leakage of blood into soft tissues abutting the punctured artery with fibrous encapsulation and failure of the vessel wall to heal

cor pulmonale

right ventricular hypertrophy and heart failure due to pulmonary hypertension

pericardial friction rub

scraping or grating noise heard on auscultation of the heart; suggestive of pericarditis

pleuretic chest pain

sharp, abrupt pain associated with deep breathing

Pores of Kohn

small openings in the alveolar walls that allow gases and macrophages to travel between the alveoli

Xanthelasma

soft, raised yellow plaques occurring on the skin at the inner corners of the eyes

malignancy

state of being malignant

SV

stroke volume

paroxysmal nocturnal dyspnea

sudden awakening from sleeping with shortness of breath

Transient loss of consciousness

syncope (Fainting)

Tachy dysrhythmias

tachydysrhythmia is a condition of the heart where the heart rate is more than 100 beats per minute.

acute myocardial infarction

the condition in which a portion of the myocardium dies as a result of oxygen starvation; often called a heart attack by laypersons

intrathoracic pressure

the pressure in the pleural space; also known as intrapleural pressure

pneumonectomy

the surgical removal of all or part of a lung

sacculated aneurysm

the yielding of a weak area on one side of the vessel not involving the entire circumference appears as a bulging, sac-like dilation.

JVD (jugular vein distention)

this is bulging of the external jugular vein which indicates increased blood volume and usually congestive heart failure (CHF)

Roving's sign

this is the same as for rebound tenderness but push fingers into the LEFT SIDE in the same place as McBurney's point; abruptly remove fingers pain on the right side indicates peritoneal inflammation or appendicitis; even though we press on left side, it will cause pain on the right

apex of the lung

tip or uppermost portion of the lung. An apex is the tip of a structure.

TIA =

transient ischemic attack

TLOC

transient loss of consciousness

antimetic drugs

treats nausea, vomiting, and motion sickness

idiopathic

unknown cause

atypical

unlike the typical

UO

urinary output

herpes zoster

viral disease affecting the peripheral nerves, characterized by painful blisters that spread over the skin following the affected nerves, usually unilateral; also known as shingles

purulent sputum

yellowish or greenish sputum

Sepsis - EPIDEMIOLOGY (week 13 - SEPSIS)

•2nd highest cause of mortality •5,000 deaths (Australia) / 52,000 deaths (UK) •Up to 60% mortality rate •70% admitted to ICU •$628 million (Australia) / £2.3 billion (UK) •Vulnerable populations •Increased incidence

Sepsis - VULNERABLE GROUPS (week 13 - SEPSIS)

•< 1 year •> 75 years or frail •Immunocompromised - neutropenic sepsis •Recent surgery •Breach in skin integrity •Misuse of IV drugs •Indwelling lines or catheters • •Pregnant women •Newborn babies

Genitorinary Emergencies: Dialysis - Peritoneal (PD) (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

•Abdominal peritoneum used as a membrane for filtration •Done at home daily •Indwelling PD catheter in abdomen Risk of peritonitis

Patient Management- Commencement of CPR & Cessation of CPR (week 6 Module 4b - Cardiac Arrest)

•Advocate a 'pit crew' approach •Perform High Quality CPR:(100-120/min, 5cm deep, allowing recoil, resps 10-12/min & delivered over 1 sec, change after 2min) •Prioritise searching for a shockable rhythm & defib asap (safely) with immediate compressions post defib •Consider the use of automatic CPR devices (i.e. LUCAS) when appropriate •Use CPR feedback device if available Basic airway + 30:2 or asynchronous •Cessation requires good clinical judgement •Must follow your local CPGs (i.e. time frames for CPR with no ROSC) •Consider CPGs around transporting with CPR in progress

Sepsis - Patient Management - Care bundles (week 13 - SEPSIS)

•Care bundles are where groups of individual elements are applied as they are proven to more effective when implemented in combination than in isolation (Robb et al, 2010). •Promote standardisation of care •Audited for compliance • *Sepsis Six - 1st line (pre-hospital & ED)

Patient Assessment- Cardiovascular - PEEP and CPAP (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

•Continuous Positive Airway Pressure, is a form of Non-Invasive Positive Pressure Ventilation (NIPPV). •Helps avoid intubation but can cause hypotension (covered more in BMS317) •Positive End Expiratory Pressure, affects exhalation, maintains alveoli open to increase surface area available for gas exchange •Typically applied via PEEP valve to a BVM and used with PPV - contraindicated in hypotension

Patient Assessment and Diagnostic tools- The next level of thinking about decision making for ACS (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

•Despite suggestions that a good mnemonic based assessment will help identify ACS, such as OPQRST, DOLOR or CHEST PAIN (1), the reported patient history on its own has consistently demonstrated a very poor ability to allow a paramedic to rule out ACS (2-5) and there is no support for the effectiveness of any of the commonly used assessment mnemonics. •Therefore, paramedics require an evidence-based approach to the assessment of the acute, non-traumatic chest-pain patient. •Any aid memoir such as DOLOR is helpful, but WILL NOT give you the complete picture, so use with caution. •Open your eyes, see the bigger picture, and try to look outside the mnemonic. This is good practice for year 3!

Endocrine Emergencies: Overview (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

•Endocrine system is closely linked to the nervous system •Controls body through hormones •8 endocrine glands produce one or more hormones - Hypothalamus - Pituitary gland - Thyroid gland - Parathyroid glands - Thymus - Pancreas - Adrenal glands - Gonads

Gastrointestinal emergencies: Focused Abdominal Exam - RED FLAGS (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

•Expose and visually inspect abdomen •Distention of abdomen ominous sign: Caused by buildup of free air due to obstruction of bowel or haemorrhage •Signs of fluid loss: peri-umbilical ecchymosis (Cullen's sign) and ecchymosis in flank (Grey Turner's sign) •Signs of possible appendicitis (Rovsing's sign - pain in RLQ (at Mcburney's point) with palpation of RLQ) or cholecystitis (Murphy's sign - pain at right costal margin with inspiration) •Note scars, ostomy bags, masses, bulging

Gastrointestinal emergencies - A&P Overview (module 6 - Gastrointestinal, Genitourinary Endocrine Emergecies)

•GI tract one long tube •Converts food into nutrients that cells can use; excretes solid wastes from body.

Patient Assessment- Heart Auscultation (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

•Heart examined from four classic auscultation sites: aortic, pulmonic, mitral, tricuspid •S1, S2 and possibly S3 or S4 •Murmurs can typically indicate mitral valve regurgitation or aortic stenosis

Sepsis - Challenges with vital signs (week 13 - SEPSIS)

•Heart rate •Respiratory rate •Temperature •BP • •Impact on mortality rates?

Gastrointestinal emergencies: Oesophageal Varices (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies

•High mortality rates •Associated with alcohol abuse •Can be precipitated by severe vomiting

Endocrine Emergencies: Differential Diagnosis: Thyroid Related: (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

•Hyperthyroidism: excess thyroid hormones. •Thyrotoxicosis: prolonged exposure of body organs to excess thyroid hormones, with resultant changes in structure and function (caused by Graves' disease). •Hypothyroidism: inadequate thyroid hormones. Myxedema: long-term exposure to inadequate levels of thyroid hormones; resultant changes in structure and function

Pathophysiology of Cardiac Arrest (week 6 Module 4b - Cardiac Arrest)

•In ventricular fibrillation many impulses are traveling in all directions with no coordinated electrical flow and therefore no effective myocardial contraction •Over time the voltage of each depolarisation weakens as VF or pVT deteriorates to asystole •CPR will extend the phases but alone will not reverse dysrhythmias (VF/pVT) •Defibrillation is needed to depolarise all myocardial cells and allow for an organized rhythm to emerge

Sepsis - SUMMARY (week 13 - SEPSIS)

•Increase awareness •Prompt recognition •Early intervention •Time-critical • •Reduce mortality!

Genitorinary Emergencies: Anatomy review (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies

•Kidneys •Ureters •Bladder •Urethra

Genitorinary Emergencies: Key functions of the GU System (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies

•Maintains water and blood volume, pH (acid base balance) •Removes toxins from blood (i.e. ammonia in the form of urea) •Regulates blood pressure •Controls RBC development

Contiguous Leads - Reason for right side and posterior ECGs (week 4 Module b Cardiac emergencies and acute coronary Syndrome)

•Note that neither the right ventricular wall (X) nor the posterior wall of the left ventricle (Y) is well visualized by any of the usual six chest leads. •This is why we should also take right sided and posterior ECGS. You will learn about this more in CLS300. •For CLS201 will concentrate on the standard 12 lead and what it means when parts of the 12 lead have ST/T changes.

Genitorinary Emergencies: Renal Failure (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

•Often secondary to diabetes or HTN •Can be acute (ARF) or chronic (CRF) •ARF onset is sudden or over a few days

Patient Assessment- Cardiovascular -PHARMACOLOGICAL TREATMENTS (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

•Oxygen - aim for SP02 of 95% •Consider PEEP if oxygenation is not improving •The goal in APO is to reduce preload and afterload •Glyceryl Trinitrate (GTN) for pulmonary oedema (and chest pain). Some services may give it for hypertensive crisis •Diuretics (i.e. frusemide) - not used often but still in some services •Narcotics - Morphine or Fentanyl small doses for anxiety from PEEP or for chest pain in suspected pericarditis •May have to also treat underlying or associated ischaemic chest pain or dysrhythymias

Genitorinary Emergencies: Pyelonephritis (Kidney Infection) (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

•Pain due to infection & inflammation of kidney •Typically secondary to UTI •Hx of urinary complaints, general flank/groin pain, hematuria &/or cloudy urine •Pain can be referred to neck/shoulder •N/V, fever, chills •Can become septic

Endocrine Emergencies: Review Adrenal Glands (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

•Paired, superior surface of kidneys •Secretes catecholamine hormones (adrenaline; noradrenaline) •Produce steroid hormones - cortisol and aldosterone

Patient Assessment- ECG as a Diagnostic tool- CONDITIONS THAT MAY DISPLAY ECG CHANGES (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

•Pericarditis - could be unchanged or show widespread concave upward ST elevation •Cardiac tamponade - low voltage QRS complexes - not diagnostic •RVF - ST depression, T wave inversion most often pronounced in lead III •LVF - possible MI patterns, common cause of LVF, pulsus paradoxus •CHF - decreased amplitude of QRS and P wave, shortened QRS complex and QT interval •Cardiogenic shock - arrhythmias can be present •Aneurysms (thoracic) - non-specific results, but possible ST depression and T wave changes •Aneurysms (abdominal) - widened pulse pressure is a better sign

Sepsis - Common Infections (week 13 - SEPSIS)

•Pneumonia (50%) •Urinary tract (20%) •Abdomen (15%) •Skin, soft tissue, bone or joint infection (10%) •Endocarditis (1%) •Device-related infection (1%) •Meningitis (1%) Other (2%)

Patient Assessment- Cardiovascular - NON-PHARMACOLOGICAL TREATMENTS (week 6 Module 4a Cardiac Vascular Emergencies- Part 2 patient assessment and diagnostic tools)

•Positioning (i.e. for pulmonary oedema) •Reassurance •Avoid patient exertion (avoid increasing MV02) •Acquire and transmit 12 lead ECG as required •Transport •Early notification to the hospital •PEEP or CPAP for pulmonary oedema •An anti-anxiolytic may be helpful with PEEP if in scope of practice •May consider small amounts of IV fluid in some cases - i.e. cardiogenic shock (Frank Starling's Law) or severe shock in AAA

Endocrine Emergencies: Review Pancreas (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

•Upper retroperitoneal space behind stomach •Composed of both endocrine (islets of Langerhans) and exocrine tissues (secrete digestive enzymes) Pancreas Endocrine cells in islets of Langerhans: alpha (α), beta (β), delta (Δ). Each produces and secretes different hormone. Alpha cells produce hormone glucagon. Glycogenolysis: glucagon stimulates breakdown of glycogen. Gluconeogenesis: glucose from nonsugar sources. Both processes contribute to homeostasis, raising blood glucose level. Beta cells produce hormone insulin. Insulin antagonist of glucagon: Lowers blood glucose level. Promotes energy storage by increasing synthesis of glycogen, protein, fat. Delta cells produce somatostatin. Inhibits secretion of glucagon and insulin. Retards nutrient absorption fromintes

Genitorinary Emergencies: Dialysis - Haemodialysis (HD) (module 6 - Gastrointestinal, Genitourinary Endocrine Emergencies)

•Use a fistula, graft, port-catheter •Done at home or in hospital - 3x/week

Sepsis - PATHOPHYSIOLOGY OF SEPSIS (week 13 - SEPSIS)

•Vasodilation •Respiratory rate: elevated •Hypotension or relative hypotension (SBP>40mmHg lower than normal) •Heart rate: elevated •Oliguria: decreased urine output (<0.5ml/kg/hr)