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Week 6-12

Terms in this set (111)

Glucagon
secreted from pancreatic alpha cells and acts on the liver to increase endogenous glucose production by glycogenolysis
Adrenaline
is released from the adrenal medulla and can increase endogenous glucose production in the liver
Noradrenaline
is released from sympathetic postganglionic neurons
Diabetes insipidus
Characterised by polydipsia, polyuria, increased thirst, and hypotonic urine. Central DI is due to defective synthesis or release of arginine vasopressin
cortisol
has an inhibitory effect on insulin and causes the liver to release glucose stores into the blood; both of these actions have the net effect of increasing circulating blood glucose
Type 1 diabetes
Type 1 diabetes mellitus is a metabolic disorder characterised by hyperglycaemia due to absolute insulin deficiency.
The condition develops due to destruction of pancreatic beta cells, mostly by immune-mediated mechanisms
type 2 diabetes
Common disorder characterised by insulin resistance and relative insulin deficiency. Most patients are asymptomatic and are diagnosed through screening
Gestational diabetes
defined as any degree of glucose intolerance with onset or first recognition occurring during pregnancy. It is usually recognised at 24 to 28 weeks of gestation on the basis of abnormal glucose tolerance testing
diabetic ketoacidosis
DKA and hyperosmolar hyperglycaemic states are acute metabolic emergencies. Successful treatment includes correction of volume depletion, hyperglycaemia and ketosis/acidosis, electrolyte imbalances, and comorbid precipitating events (e.g., infection), along with frequent monitoring
what is anaphylaxis
Anaphylaxis is an acute hypersensitivity reaction that can affect multiple organ systems. This wide- spread release of inflammatory mediators results in a systemic increase in capillary permeability, smooth-muscle contraction and peripheral vasodilation.
Innate immunity
• Neutrophils "eat" pathogens and send off distress signals.
• Monocytes are triggered to turn into pathogen‐eating macrophages.
• Eosinophils attack parasites,
• Basophils contain granules filled with histamine and other compounds related to allergies.
Microphages
- Start life in the bone marrow.
- Constantly circulating in the blood.
- Cannot replicate, and live for only a few days.
- The bone marrow contains large reserves of microphages.
Macrophages
• Start as monocytes, which originate in the stem cells in the bone marrow.
• Not as numerous as microphages, no large reserves, but they live longer.
• Stationed at strategic locations: the alveoli of the lungs, the abdominal (peritoneal) and chest (pleural) cavities, under the top layer of the skin and the intestines.
aquired immunity
Immunity obtained from the development of antibodies in responce to exposure to an antigen.
humoral immunity
B cells produce antibodies after exposure to specific antigens; type of adaptive immunity
Solid organs
- Liver
- Spleen
- Pancreas
Hollow organs
- Stomach
- Gallbladder
- Duodenum
-Small Intestines
- Jejunum
- Ileum
- Cecum
- Colon
GORD
• Burning sensation in chest
• Sour taste
• Difficulty in swallowing
• Dry cough
• Sore throat
• Regurgitation of food/liquid
• "lump" in throat
Oesophageal spasms
• Similar to cardiac chest pain
• Difficulty in swallowing
• Object "stuck in throat"• Regurgitation
• Pain may subside after several minutes
• Normally have a Hx
Osophageal bleeding
Mallory‐Weiss tear(excessive vomiting)
Oesophageal varices
Gastric conditions
• Hiatus hernia • Upper GI bleed • Peptic ulcer disease
Hiatus hernia
the protrusion of a part of the stomach through the esophageal hiatus of the diaphragm
Upper GIT bleeding
• Bleeding originating proximal to ligament of Treitz
• Peptic ulcer disease• Erosive gastritis and oesophagitis
• Esophageal varices (chronic liver disease, portal hypertension)
• Mallory‐Weiss tear
• Tumors
Lower GIT conditions
- Bowel obstruction - Ischaemic Bowel - diverticular disease - Diarrhoea
diverticular disease
condition in which bulging pouches (diverticula) in the gastrointestinal (GI) tract push the mucosal lining through the surrounding muscle
Diverticulitis
inflammation of a diverticulum
liver cirrhosis
Scar tissue replaces healthy tissue causing decrease liver function and increased portal hypertension
pancreatitis
inflammation of the pancreas
Signs of pancreatitis
- Mid‐epigastric/ LUQ pain
- Pain and tenderness can include upper abdomen only or generalised (thought to be related to absence of capsule that might otherwise contain the inflammation)
- N&V, abdominal bloating
- Cullen's sign (peri‐ umbilical) - Turner's sign (flank)
Cholecystitis
inflammation of the gallbladder
cholecystitis presentation
- RUQ or epigastric pain most common, with
• back/ shoulder radiation in 1/3
• N&V in 1⁄2 of patients;
• 10‐30% jaundiced
appendicitis presentation
- Initial pain at umbilicus (visceral)
- Pain moves to Mc Burney's point (somatic)
- Fever is a relatively late physical finding
- Perforation → peritonitis
Diarrhoea, 4 basic mechanisms
• Increased intestinal secretion
• Decreased intestinal absorption
• Increased osmotic load
• Abnormal intestinal motility
Crohns disease
- Chronic inflammatory disease
- Can involve any part of GI tract from mouth to anus
- Chronic abdominal pain, anorexia, weight loss, persistent diarrhoea/constipation, painful defecation, fever
ulceratice colitis
Inflammatory bowel disease Ulcerated intestinal mucosa
PR bleeds
- Haemorrhoids
- Prolapsed rectum
• Wet Sterile dressings
- Anal warts
- Anal sex- Tumor
- Other conditions higher up
Melena stools
digested blood
- black
- higher up in GI tract - iron supplement/black liquorice/ blueberries
Abdominal pain- shingles
- Pain often present several days before characteristic skin lesions appear
Visceral pain
• Deep‐seated, dull pain from hollow viscera or capsule of solid organs • Poorly localised, falls along midline
somatic pain
Pain that originates from skeletal muscles, ligaments, or joints.
Local peritonitis
• Pain over affected organ with palpitation or stretching
Generalised Peritonitis
• Blood, gastric contents or pus in peritoneal cavity causes generalised pain with any movement or palpation
Abdominal assessment peritonitis
don't use rebound tenderness, get them to cough
Appetite
obstipation
constipation
diarrhoea
Abdominal assessment
- inspection- auscultation - percussion - palpation
signs and referred pain
Kehr's sign - Splenic Rupture
McBurney's Point - Appendicitis
Murphy's Sign ‐ Gallbladder / Liver
Obturator Sign ‐ Appendicitis
Psoas Sign ‐ Appendicitis
The patient population is diverse as poisoning can be due to
- Deliberate self
-poisoning
- Accidental self
-poisoning
- Recreational drug abuse
- Occupational poisoning
- Drug toxicity build up
- Envenomation
what to take into account with overdose
- The agent
- The dose
- The time taken
- Clinical features
- Progress of the symptoms
- The individual patient factors e.g. weight, medical conditions etc
seizures in drug over dose
if present, usually generalised. If partial seizures, this indicates a focal neurological problem that requires further investigation. - Common causes - Venlafaxine, bupropion, tramadol, amphetamines - Treat with Midazolam
hypoglycaemia in over dose
- Check in all patients with altered LOC - Correct if need be
Hyperthermia in over dose
Associated with a number of drugs and associated with poor outcome. - Must be cooled. Techniques discussed in another lecture
respiratory system in over dose
- Full RSA needed.
- Intubation may be required if there is a lowered LOC.
- Secure the airway while you wait for MICA.
- Monitor ventilations regularly. Have bag mask at the ready.
circulatory system in overdose
- 12 lead ECG essential - rate, rhythm, PRI, QRS width, ST, - Some drugs will cause arrhythmias- Fluids- Monitor closely
Clinical presentation of opioid
- Lowered level of consciousness (drowsy)
- Respiratory depression leading to failure & death
- Pinpoint pupils
- Could be hypotensive
- May have vomited or be vomiting
clinical presentation of benzodiazepine OD
- Drowsiness, confusion, dizziness
- Slurred speech
- Nystagmus, blurred vision
- Hypotension
- Ataxia, weakness, lack of coordination
- Coma
- Respiratory depression - even arrest - Cardiac arrest
- Large doses - hypothermia, bradycardia, hypotension may occur
Clinical presentation of GHB
- Causes a rapid onset of CNS and respiratory depression - Other symptoms include myoclonic jerking, bradycardia, sweating, agitation, vomiting, delirium, cheyne-stokes type breathing - Recreational doses 30-40 mg/kg
Clinical presentation of alcohol OD
- CNS depression even coma - Loss of inhibition - Loss of judgement - Can add to the depressive effects of other CNS depressants - Vomiting, loss of airway protection - Increase in self-confidence - Agitation, aggression, disorientation - Slurred speech, Ataxia, nystagmus - Tachycardia, hypotension, hypothermia
Complications of long term alcohol use
Cardiovascular - Afib, cardiomyopathy, clotting problems
Gastrointestinal - liver disease, hepatitis, cirrhosis, oesophageal varices, pancreatitis, chronic gastritis, GI bleeds, enlarged liver Malnutrition, Vitamin deficiency, dehydration
Alcoholic ketoacidosis, electrolyte imbalances CNS - Memory problems (Wernicke's encephalopathy), subdural haemorrhage
withdrawal from alcohol
- Autonomic excitation - tremors, sweating, anxiety, agitation, tachycardia, N&V, hyperthermia, hypertension - Neuro-excitation - hyperreflexia, hallucinations, seizures, nightmares - Delirium tremens - severe form has 8% mortality
Methanol poisoning
Common sources of methanol
- Antifreeze preparations
- Automobile and furniture polish
- Pesticides
- Industrial products (oils, detergents)
- Paint thinners
- Methylated spirits (ethanol + methanol)

20mg/dL correlates to ocular injuries
Signs of methanol poisoning
- CNS depression
- Loss of inhibition
- Ataxia
- Nausea
- Initial severe symptoms in 12-24 hours (relates to amount ingested)
- Possibility of seizures - Vision blurring or loss - Metabolic acidosis
- Death
Stimulants and psychoactive drugs
- MDMA / Ecstasy - E, pills, caps, pingers, M&M, doopa, love drug, disco biscuits, XTC, X
- Methamphetamines -Meth, Ice, Crystal Meth, Shards, Speed, Whizz, Goey, Rock, Crack, Freebase, Base, Dexies
- Cocaine
MDMA (ecstasy)
• Enlarged pupils
• Increased heart rate and blood pressure
• Increased energy
• Feeling of euphoria
• Teeth grinding and jaw clenching
• Anxiety and panic attacks
• Overheating and dehydration
• Nausea, vomiting and dizziness
• Visual distortions
• Paranoia, Psychosis
• Serotonin syndrome
• Stroke.
Methamphetamine
Methamphetamine increases the amount of the neurotransmitter dopamine, leading to high levels of that chemical in the brain.

- Methamphetamine's ability to release dopamine rapidly in reward regions of the brain produces the euphoric "rush" or "flash" that many users experience.
Cocaine
Cocaine hydrochloride: a white, crystalline powder with a bitter, numbing taste, it is often mixed with other substances such as lactose and glucose. Normally snorted but can be rubbed into gums or added to food or drinks.

• Freebase: a white powder that is more pure with less impurity than cocaine hydrochloride. Normally smoked.

• Crack: crystals ranging in colour from white or cream to transparent with a pink or yellow hue. Normally smoked
Clinical symptoms on CNS stimulants
- Tachycardia and hypotension is common but hypertension and tachycardia also possible (adrenergic effect)
- Dilated pupils (myadrisis) -adrenergic effect
- Dysrhythmias
- Diaphoresis - adrenergic effect
- Agitation (adrenergic), hallucinations and paranoia
- Dry mucous membranes - adrenergic effect
- Fever, hyperthermia
- Seizures, tremors, hyper-reflexia
- Poly-pharmacy must always be considered with CNS stimulant use
- Ingestion by children is potentially lethal
- Known teratogenic effects, leading to miscarriage and fetal demise
Cardiovascular effects on CNS stimulants
Toxicity results from sympathomimetic, vasospastic and sodium channel blocking effects (cocaine).
- Vasospasms also means poor myocardial perfusion as well as promotion of platelet aggravation
- Blocking of fast sodium channels results in dysrhythmias
- Increased vascular dissection
Major complications of CNS stimulants
Hyperthermia - Can result from excited delirium (cocaine) or excessive exercise (MDMA) - Further exacerbated by the environment they are in e.g. hot night club
- Can also be a sign of severe serotonin syndrome

Hyperthermia leads to:
- Rhabdomyolysis
- Impaired consciousness,
- DIC (disseminated intravascular coagulation) - and multi-organ failure
serotonin syndrome
Is due to too much serotonin in the brain and peripherally - through either its release or the blocking of its reuptake. Caused by drugs that affect the level of serotonin -CNS stimulants , SSRIs
serotonin syndrome S&S
- Confusion, hallucinations
- Agitation or restlessness, anxiety, apprehension
- Dilated pupils
- Headache- Changes in blood pressure and/or temperature
- Nausea and/or vomiting, diarrhoea
- Rapid heart rate, hypertension, increased RR
- Tremor, seizures
- Loss of muscle coordination or twitching muscles
- Shivering and goose bumps
- Heavy sweating, flushing
- Increased muscle tone, rigidity, hyper-reflexia
S&S of TCA toxicity
- drowsiness
- tachy
- slurred speech
- hyperreflexia
- ataxia
- mild hypertension
dry mucous membrane

severe:
- coma
- PC's
- SVT
- VT
-hypotension
- seizures
Hallucinogen drugs
Hallucinogens (also known as 'psychedelics') can make a person see, hear, smell, feel or taste things that aren't really there or are different from how they are in reality (hallucinations).

Types of hallucinogens:
- LSD - (Lysergic acid diethylamide)
- Magic mushrooms
- psilocybin
- Mescaline
- peyote cactus
LSD
is a white odourless powder. However, it usually comes in squares of gelatine or blotting paper that have been dipped or soaked in LSD. LSD is also sometimes sold as a liquid, in a tablet or in capsules.
- potent hallucinogens
- low abuse potential
Psilocybin
natural hallucinogen found in certain mushrooms
Ketamine
Ketamine is used by medical practitioners and veterinarians as an anaesthetic. It is sometimes used illegally by people to get 'high
organs and glands of the endocrine system
- Hypothalamus
- Pituitary Gland
- Pineal Gland
- Thyroid Gland
- Parathyroid Glands
- Thymus
- Pancreas (Pancreatic Islets)
- Adrenal Glands
- Gonads
Hyperthyroidism
is an overproduction of thyroid hormones.
Hyperthyroidism (Graves' Disease) can be caused by:

Thyroid Stimulating Hormone (TSH) immunoglobulin antibodies that bind to TSH receptors, which may develop as a result of autoimmune reaction against thyroid tissue.
S&S of hyperthyroidism
- Intolerance to heat - Fine, straight hair
- Bulging eyes - Facial flushing
- Enlarged Thyroid - Tachycardia
- Increased systolic BP - Breast enlargement
- Weight loss - Muscle wasting
- Localised edema - Finger clubbing
- Tremors - Diarrhoea
- Menstrual Changes
Thyroid storm
is an exaggerated or florid state of thyrotoxicosis, it is a life threatening sudden onset of thyroid hyperactivity.
Thyroid storm may occur in 1% of patients with hyperthyroidism which may be precipitated by:
- Surgery
- Trauma
- Infection
- Thyroxine ingestion
Hypothyroidism
s an underproduction of Thyroid Hormones.
It may result from:
- Autoimmune reaction that destroys the gland;
- Iodine deficiency (goiter) where uninhibited TSH production leads to increase in precursor molecule (thyroglobulin) but without iodine T3 and T4 cannot be formed
S/S of hypothyroid
- Intolerance to cold - Receding hairline
- Facial and eyelid edema - Dull-blank expression
- Extreme fatigue - Thick tongue
- Slow speech - Anorexia
- Brittle nails and hair - Menstrual disturbances
- Hair loss - Apathy
- Lethargy - Dry skin
- Muscle aches and weakness - Constipation
Addisons disease
is caused by insufficient amounts of hormones from your adrenal glands.

- Primary cause is autoimmune destruction (Addison's Disease).
- Secondary adrenocortical insufficiency from ACTH deficiency from pituitary and hypothalamic disease
S&S of Addisons disease
- Bronze pigmentation to skin - Changes in distribution of body hair
- GI disturbances - Hypoglycemia
- Postural hypotension - Weight loss
- Pre-hospital

Treatment:- Supportive care. - Oxygen if required- Fluids- Some systems - Hydrocortisone / dexamethasone
Cushings syndrome
is caused by high levels of the hormone cortisol.
Cause of raised cortisol levels
- Tumour
- Steroid use side effect
S&S of cushings syndrome
- Personality changes - Moon face
- Increased susceptibility to infection
- Males - gynecomastia
- Fat deposits on face and back of shoulders - Osteoporosis
- Hyperglycemia - CNS irritability
- NA and fluid retention (edema) - Thin extremities
- GI distress
- Females - Amenorrhea, hirsutism- Thin skin with purple striae
- Bruises and petechiaePrehospital Treatment

- Supportive care, manage symptoms, transport, rarely an emergency.
Phaechromocytoma
is caused by benign tumour releasing hormones in an adrenal gland
S&S of Phaechromocytoma
- Persistent hypertension - Severe headache - Diaphoresis - Tachycardia - Palpitations - Pallor - Nausea and vomiting - Epigastric / chest pain
Hyperpituitarism
Hyperpituitarism causing overproduction of pituitary hormones.
Caused by Pituitary adenoma (benign tumour)

Gigantism - young - epiphyseal / grown plates open > enlarged long bones
Acromegaly - older - epiphyseal / grown plates fussed > enlarged face, hands & feet.
Hypopituitarism
Caused by low levels of certain hormones made by the pituitary gland.
S&S of hypopituitarism
- Fatigue - weight loss - sensitivity to cold - decreased appetite - facial puffiness - anemia - irregular or no periods - short stature in children
Thyroid physiology
Tyroid gland secretes thyroxine (T4) and triiodothyronine (T3), under the influence of TSH.

- Both have a significant effect on metabolism
- lack of thyroid secretion can reduce basal metabolic rate by 50%,
- whereas increased levels of hormone can increase metabolism by 100%
Adrenal physiology
- Medulla - adrenaline/noradrenaline
- Cortex - corticosteroids: Mineralocorticoids (aldosterone) Cause the conservation of sodium, secretion of potassium, increased water retention, and increased blood pressure.
What is a seizure
A seizure is a transient alteration of brain function due to uncontrolled depolarisation of cerebral neurons
status epilepticus
some instances a seizure may not resolve either spontaneously or with treatment and the condition is described as status epilepticus
epilepsy
Epilepsy is a condition encompassing a broad range of seizure disorders and is diagnosed in patients suffering recurrent seizure
febrile convulsion
are the most common seizure type in young children. Febrile convulsions are defined as those occurring in children aged between 6 months and 5 years with a febrile illness.

Simple febrile seizures are generalised, last less than 15 minutes and occur no more than once in 24 hours. They represent the majority of febrile seizures and carry few risks. Complex febrile seizures last longer than 15 minutes, occur more than once within 24 hours and may display a focal component
partial seizure
Begin focally in a (unilateral) cortical site- Affect part of body controlled by part of brain Main causes: • Stroke• Tumour• Head injury
partial simple seizure
No alteration in LOC
• Involve involuntary limb movement (stiffening)
• Déjà vu feeling
• Unpleasant smell/taste
• Stomach sensations (nausea, "butterflies")
• Can remember what happens
• Lasts a few minutes
• May have an aura
partial complex seizure
associated with altered LOC
- Starts in temporal/frontal lobe
- Pt appears confused/dazed
- Pt may do strange things, e.g. play with clothes, chewing
- Lasts up to several minutes
- Pt appears confused/drowsy minutes/hours after with no recall of incident (before or after)
- Can be mistaken for drug/alcohol/psych behaviour
- May have an aura
Gerneralised seizure
- Absence seizure
- Atonic seizure
- Myoclonic seizure
- Tonic seizure
- Tonic-Clonic seizure
- Secondary generalised seizures
Absense seizure
- Awareness and responsiveness are impaired
- Pt simply stare, eyes may roll back/eyelids flutter, may be hand movements.
- Start suddenly & cannot be interrupted - Last a few seconds then stop suddenly
- continue with activity
- Last < 10 seconds
- Can occur many times during day
atonic seizure
- Known as "drop attacks"
- affect muscle tone => Pt collapses to ground
- usually remains conscious
- can cause head/facial/other injury => unprotected fall
- Recovery quite quick
myoclonic seizure
- Brief, shock‐like jerks of a muscle/group of muscles
- Lasting a second or two
- Can be one, sometimes many will occur within a short timeframe
tonic seizure
- muscle tone is greatly increased
- body, arms, or legs make sudden stiffening movements
- often occur in clusters during sleep, but can occur when Pt awake => "heavy" fall
- duration < 20 sec
- remain conscious
Tonic clonic seizure
- body stiffens & fall to the ground( tonic phase)
- may cry/groan (air forced past the vocal cords)
- tongue/cheek may be bitten => bloody saliva
- limbs begin to jerk in strong, symmetrical, rhythmic movements (clonic phase)
- Pt may dribble from the mouth, facial cyanosis/red, loss of bladder and/or bowel control
- Tonic‐clonic seizures generally last 1 to 3minutes
Secondary generalised seizure
- Seizure activity spreads from focal point across to both sides of brain => initially a partial seizure
- Episode so brief Pt has no recall or recognises it
- Lasts 1‐3 minutes
- Similar to primary generalized seizures
- Occur in 30% of Pts with partial seizures
preictal phase
Period just before seizure. May involve aura, restlessness, nervousness, wandering.
Ictal phase
- Seizure period (eg tonic/ clonic) lasting a few seconds to minutes.
postictal
- Period after seizure (disorientation, confusion, salivation, unresponsiveness, incontinence).
status epilepticus
Is a neurological emergency characterised by a series of convulsions, rapidly repeated without intervals of consciousness, which if untreated may lead to hypoxia, hyperthermia, cerebral damage and death.

Definition - > 5 minutes of seizure activity or multiple seizures (of any duration) without full recovery of consciousness between seizures.
Anticonvulsants
Benzodiazepines Diazepam or midazolam are commonly used as first line treatment of status.
Benzodiazepine effects
- Anxiolytic
- Muscle relaxant
- Anticonvulsant
- Hypnotic
- Memory impairment
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