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Teachingseries3: A–Eassessmen t -Electrolyte imbalanceandpoisoning DelivereDr Arwa Ali- FY1 Kettering General Hospital Deliver: Dr Momna Raja- SFP doctor- FY1 Kettering General HospitalQuick introduction Dr Arwa Ali FY1 Kettering General Hospital Arwa.ali4@nhs.net Dr Momna Raja SFP doctor FY1 Kettering General Hospital Momna.raja@nhs.netDisclaimerLearning objections •Conduct an A-E •Manage electrolyte disturbances •Manage acute poisoning Case 1 • You are a medical F1 in A&E. Mr John Smith has presented with abdominal pain, weakness and confusion. He is currently being investigated for lung cancer • NEWS; RR = 18bpm, Sats = 99% on air, HR = 84bpm, BP = 156/90, temp = 36.9oC. • How did you proceed? Airway • Patent • Patient is speaking in full sentences. BREA THING • Look: • Peripheral or central cyanosis – none • Feel • Trachea- central • chest expansion.- equal and symmetrical • Percussion – resonant • Listen: • Normal air entry • Obs: RR = 18bpm, Sats = 99% on air • Any Investigations?• [2]RIPE ABCDE • R - rotation • I - Inspiration • P - Picture • E - Exposure • A - Airway • B - Breathing C – Circulation • • D - Diaphragm • E – Everything else • [2] CIRCULA TION • Look: • No Peripheral or central cyanosis, JVP = not raised • Feel • Temperature = warm peripherally • CRT < 2seconds • Pulse : Regular Listen: • • HS I + II + 0 • Obs: HR= 85bpm, BP = 162/50 What investigations would you like now? •[3] DISABILITY •Assessment •Pupils – equal and reactive •AVPU – Alert but confused •Temperature = 36.9 oC •Investigations: BM – 5.2 mmol/L EXPOSURE + EVERYTHING ELSE • Abdominal examination : soft, non-tender with no palpable masses Exposure (rash, bleeding, drains, catheter ) • • Squeeze calves • Gather information -> full clinical Hx, collateral Hx, patient notes, drug chart. Once complete - Repeat A-EBloods test results • Hb: 99 (135-175) Na 142 (137-144) • • K 4.5 (3.5-5.3) • U 4.3 (2.5-7.0) • Cr 196 (60-110) • eGFR 40 (>60) Ca 4.8 (2.2-2.6) •Diagnosis? Diagnosis? Hypercalcemia of malignancyHypercalcemia • Causes? Primary and tertiary hyperparathyroidism, cancer, multiple myeloma, sarcoidosis, TB, Paget’s disease, Thiazide diuretics • ECG changes: Prolonged QT – primarily ST segments. T wave remains unchanged Mnemonic for symptoms Painful ‘bones’ Bone pain, Fragility fracture Renal ‘stones’ Back pain, Hematuria, AKI Abdominal ‘groans’ Abdominal pain, nausea, vomiting, constipation, indigestion Psychiatric ‘moans’ Lethargy, fatigue, memory loss, psychosis, depressionTreatment Medical emergency 1)IVF: 0.9% Saline 1L over 4 to 6 hours (Aim: 1-3L in 24h) 2)IV Bisphosphonate: Zoledronic acid (Pamidronate 2 line) 3)Admit and monitor Symptomatic control: Laxatives, Anti-emetics Others: Calcitonin, Furosemide, Dialysis Case 2 • A 54-year-old man with a history of end-stage renal disease department because of a sudden chest pain and inability to move his limbs. •How will you proceed? Airway •Speaking in full sentences •No additional airway sounds BREA THING • Look: • End of bed – accessory muscle use, • Peripheral or central cyanosis – yes • Feel • Trachea- central • chest expansion.- equal, symmetrical but reduced • Percussion – resonant • Listen: • Reduced air entry at the bases Obs; RR = 17 bpm, Sats = 99% on air •ABG • Ph – 7.28 pCO2 – 4.26 kPa • • pO2 – 13.2 kPa • HCO3 – 12.8 mmol/L • Na - 133 • K – 8.9mmol/LABG • Ph – 7.28 • pCO2 – 4.26 kPa • pO2 – 13.2 kPa HCO3 – 12.8 mmol/L • • Na - 133 • K – 8.9mmol/L Metabolic acidosis with hyperkalemia CIRCULA TION • Look: • No Peripheral or central cyanosis, JVP = 9cm • Feel • Temperature = warm peripherally • CRT < 2seconds • Pulse : Regular Listen: • • HS I + II + Ejection systolic murmur • Obs: HR= 45bpm, BP = 145/90 Investigations? •[4]Diagnosis? Diagnosis? HyperkalemiaSerum Potassium Typical ECG appearance Possible ECG abnormalities A. Mild (5.5-6.5) Peaked T wave Prolonged PR segment Moderate (6.5 – 8) Loss of P wave Prolonged QRS complex [5] ST segment elevation Ectopic beats and escape rhythms Severe (>8) Progressive widening og QRS complex Sinus wave Ventricular fibrillation Asystole Axis deviation Treatment: Three Steps A. Protect the heart: 10ml of 10% Calcium gluconate in 10 mins B. Shift K+ into cells: i. Salbutamol nebs ii. 10 units of actrarapid with Dextrose (25g of glucose) C. Remove K+ from the body: i. Calcium resonium ii. Loop diuretics iii. ITU: Dialysis Consider Medication review Bed with ECG monitoringEmergency Hypokalemia • Potassium chloride 0.3% solution, 1000ml over 4h • Symptoms/signs: Metabolic alkalosis, arrhythmias, muscle weakness, reduced reflexes, constipation • ECG changes: ‘In hypokalaemia U have no Pot (K )or no T but a long PR and a long QT’ • Always check Magnesium! Case 3 • You are a medical F1 on call. A nurse asks you to review Ms Susan James who is presenting with drowsiness and bradypnoea. • NEWS; RR = 10bpm, Sats = 88% on air, HR = 81bpm, BP = 110/50, temp = 36.4oC. • How did you proceed? Airway • Patent • Patient is speaking in full sentences. BREA THING • Look: • Peripheral cyanosis • Feel • Trachea- central • chest expansion.- reduced • Percussion – resonant • Listen: • Normal air entry • Obs: RR = 10bpm, Sats = 88% on air • Any Investigations?ABG • Ph – 7.28 • pCO2 – 6.7 kPa (high) • pO2 – 7.8 kPa (low) HCO3 – 12.8 mmol/L • • Na - 140 • K – 4mmol/L Type 2 respiratory failure CIRCULA TION • Look: • Peripheral cyanosis, JVP = not raised • Feel • Temperature = cold peripherally • CRT < 2seconds • Pulse : Regular Listen: • • HS I + II + 0 • Obs: HR= 85bpm, BP = 110/40 What investigations would you like now? •Bloods test • FBC • U&Es - impaired renal func on can result in the accumula on of opiates). • CRP • Lactate - to screen for evidence of reduced end-organ perfusion. • Coagula on studies • Toxicology screen - to screen for other drugs which may have been taken as part of a mixed overdose DISABILITY •Assessment •Pupils – pin-point pupils, pupillary reflexes present but reduced •AVPU – Alert but drowsy •Temperature = 36.5 oC Drug Chart Review • •Investigations: BM – 4.3 mmol/L EXPOSURE + EVERYTHING ELSE • Abdominal examination : soft, non-tender, decreased bowel sounds Exposure (rash, bleeding, drains, catheter ) • • Squeeze calves • Gather information -> full clinical Hx, collateral Hx, patient notes, drug chart. Once complete - Repeat A-E Diagnosis? Acute Opioid Overdose Decreased MOVE • (pupil diameter)s, miosis • O - Opioid • V - Vitals (RR, Pulse, Temp, BP) • E - Enteric sounds (bowel) (1)Management 1)Airway 2)Naloxone is used to treat opioid-induced respiratory depression. 3)Administer naloxone as per the BNF: • Administer an ini al dose of 400 micrograms of naloxone intravenously. • If there is no response, administer 800 micrograms for up to 2 doses, at 1-minute intervals (if there is no response to the preceding dose). • Further doses may be required if respiratory func on subsequently deteriorates as naloxone has a short half-life. • Naloxone rapidly reverses the effects of opioids and as a result, it can precipitate symptoms of opioid withdrawal, including pain, Consider involving the drug and alcohol team to discuss appropriate opiate replacement therapy to treat symptoms of opiate • withdrawal 4)For chronic opioid users the dose of naloxone differsReferences 1.https://scottsdaleazdetox.com/how-to-spot-an-oversose/ 2.Diagnostic ECG-the 12-lead (Clinical Essentials) (Paramedic Care) part 7 (no date) whatwhenhow RSS. Available at: http://what-when-how.com/paramedic-care/diagnostic- ecgthe-12-lead-clinical-essentials-paramedic-care-part-7/ (Accessed: November 17, 2022). 3.Buttner, R., Burns, E. and Burns, R.B.and E. (2022) Hyperkalaemia, Life in the Fast Lane • LITFL. Available at: https://litfl.com/hyperkalaemia-ecg-library/ (Accessed: November 18, 2022). 4.Pluijmen, M. J., & Hersbach, F. M. (2007). Sine-wave pattern arrhythmia and sudden paralysis that result from severe hyperkalemia. Circulation, 116(1), e2-e4. 5.Diagnostic ECG-the 12-lead (Clinical Essentials) (Paramedic Care) part 7 (no date) whatwhenhow RSS. Available at: http://what-when-how.com/paramedic-care/diagnostic- ecgthe-12-lead-clinical-essentials-paramedic-care-part-7/ (Accessed: November 17, 2022).FOR FEEDBACK AND QUERIES: Email @ info@bidasw.com
