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COTE Flashcards

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1
Q

Pressure Ulcers

Risk factors

A
  • Malnourishment
  • Incontinence
  • Immobility
  • Pain (reduction in mobility)
  • Dehydration
  • Lives alone
  • Old age
  • High BMI
  • Reduced blood supply
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2
Q

Pressure Ulcers

Pathophysiology

A
  1. Hard surface
  2. Localised external pressure on the skin causes occlusion of the capillaries and compression of the tissue
  3. Leads to reduced oxygen and nutrition to the tissue
  4. Altered soft tissue hydration as the fluid is pushed away
  5. Worsened by friction –> shears skin off
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3
Q

Pressure Ulcers

What score would you use to assess risk of developing a pressure sore?

A

The Waterlow Score

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4
Q

Overview of the Waterlow Score

A

● 10 -14: At risk
● 15 – 19: high risk
● 20: very high risk

Takes into account:
o	BMI (low)
o	Skin type (dry/oedematous/clammy/broken)
o	Sex (female)
o	Age (older)
o	Incontinence (urine/faecal/both)
o	Mobility (restless/bed or chair bound)
o	Appetite (anorexia/feeding tube)
o	Neuro deficit (diabetes/paraplegia)
o	Organ failure
o	Peripheral vascular disease
o	Anaemia
o	Smoking
o	Medication (steroids/anti-inflammatories)
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5
Q

Pressure ulcers

Grade 1

A

Grade 1:

  • Non-blanchable erythema of intact skin
  • Discolouration of skin, warmth, oedema, induration or hardness may also be used as indicators (particuarly on darker skin)
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6
Q

Pressure ulcers

Grade 2

A

Grade 2:

  • Partial thickness skin loss involving the epidermis, or dermis, or both
  • Ulcer is superficial and presents clinically as an abrasion or blister
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7
Q

Pressure ulcers

Grade 3

A

Grade 3:

  • Full thickness skin loss involving damage to or necrosis of SC tissue that may extend down to, but not through, the underlying fascia
  • Slough
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8
Q

Pressure ulcers

Grade 4

A

Grade 4:

  • Extensive destruction, tissue necrosis, damage to muscle, bone or supporting structures with or without full-thickness skin loss
  • Slough, bone/tendon/muscle seen
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9
Q

Pressure ulcers

Differentials?

A

Deep tissue injury:
- Purple localised area of discoloured intact skin, or a blood-filled blister

Moisture lesion:
- Redness or partial thickness skin loss involving epidermis, dermis or both

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10
Q

Pressure ulcers

Investigations

A 
●	CRP/ESR
●	Swab and blood cultures
●	X-Ray for bone involvement
●	Albumin (low will delay healing)
●	General exam and history
●	FBC’s (anaemia will delay healing)
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11
Q

Pressure ulcers

Management

A

SSKIN:

  • S: Support surface - pressure redistributing mattress
  • S: Skin assessment regularly
  • K: Keep them moving - repositioning regime
  • I: Incontinence and moisture - continence assessment and management
  • N: Nutrition and hydration

Stages 3-4: TVN

Dressings:
- Hydrocolloid and hydrogels

Topical antimicrobial therapy:

  • Silver, honey or iodine-impregnated dressing
  • Maggots

Last resort - debridement

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12
Q

Delirium

Risk factors

A
  • Age > 65 years
  • Background of dementia
  • Significant injury e.g. hip fracture
  • Frailty or multimorbidity
  • Polypharmacy
  • Sensory impairments
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13
Q

Delirium

Precipitating events

A
  • Infection: particularly urinary tract infections
  • Metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
  • Change of environment
  • Any significant cardiovascular, respiratory, neurological or endocrine condition
  • Severe pain
  • Alcohol withdrawal
  • Constipation
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14
Q

Delirium

Features

A
  • Memory disturbances (short term > long term)
  • Agitated or withdrawn
  • Disorientation
  • Mood changes
  • Visual hallucinations
  • Disturbed sleep cycle
  • Poor attention

Four key features:
o Disturbance of consciousness
o Changes in cognition or development of perpetual disturbance
o Disturbance develops over a short period of time and fluctuates over the course of a day
o History supports an underlying medical condition, medication withdrawal or intoxication

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15
Q

Delirium

Management

A
  • Treatment of the underlying cause
    • Pain –> analgesia
    • Polypharmacy –> drug review
    • Laxatives for constipation
    • Correct electrolytes
    • Antibiotics for infection
  • Modification of the environment
    • Soft lighting, involve family, clocks and calendars, sleep hygiene, mobile and active, minimize provocation (loud rooms etc)
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16
Q

Delirium

Types

A

Hyperactive:

  • Heightened arousal
  • Sensitive to surroundings
  • Verbally or physically aggressive
  • Restless
  • Carphologia (pulling at straws)
  • Wandering and disorientation
  • Unable to follow complex commands

Hypoactive:

  • Confused with depression
  • More common
  • Reduced psychomotor activity
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17
Q

Delirium

Causes

A

DELIRIUM

  • D: Drugs, Dehydration, Dementia
  • E: Electrolyte disturbances, Epilepsy
  • L: Lack of drugs (withdrawal), Low O2
  • I: Infection
  • R: Reduced sensory input, Renal failure, Retention
  • I: Intracranial damage, Injury
  • U: Unfamiliar environment, Uraemia
  • M: Myocardial/pulmonary, Metastases, Malnutrition
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18
Q

Delirium

Sedation

A
  • Haloperidol or Lorazepam

- NOT haloperidol in Parkinsons

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19
Q

Falls

What does a normal gait rely on?

A
  • The neurological system - basal ganglia and cortical basal ganglia loop.
  • The musculoskeletal system (which must have appropriate tone and strength).
  • Effective processing of the senses such as sight, sound, and sensation (fine touch and proprioception).
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20
Q

Falls

Risk factors

A
  • Female
  • Neurological disease
  • Cognitive decline
  • Visual defect/bifocals
  • Hearing problems
  • Muscle weakness
  • Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson’s disease etc)
  • Incontinence
  • > 65 yrs
  • Fear of falling
  • Postural hypotension
  • Psychoactive drugs

Mechanical:

  • Walking aids
  • Footwear
  • Home hazards
  • Polypharmacy (4+ medications)
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21
Q

Falls

Risk assessment

A
  • Where and when was the fall?
  • Did anyone see the fall? (collateral Hx)
  • What happened before, during, after?
  • Why do they think they fell
  • Have they fallen before? How many this year (>2 = significant)
  • Systems review
  • PMH - especially balance/sight/gait/cognition/continence
  • Osteoporosis RFs
  • Social history
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22
Q

Falls

Medications that can cause postural hypotensions

A
  • Nitrates
  • Diuretics
  • Anticholinergics
  • Antidepressants
  • Beta-blockers
  • L-Dopa
  • ACE-Inhibitors
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23
Q

Falls

Medications that can cause falls due to other mechanisms

A
  • Benzos
  • Antipsychotics
  • Opiates
  • Anticonvulsants
  • Codeine
  • Digoxin
  • Other sedative agents
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24
Q

Falls

Investigations

A

Bedside tests:

  • Basic obs
  • Lying and standing BP
  • Blood glucose
  • ECG
  • Urine dip

Bloods:

  • FBC- anaemia/infection
  • U&Es - dehydration, AKI, diuretic use and clearance (e.g. opioids)
  • CK - if long lie
  • Bone profile
  • LFTs/TFTs

Imaging:

  • CXR
  • XR of any injured limbs
  • CT head if indicated
  • Cardiac echo - if ejection systolic murmur
  • Tilt table testing
  • 24hr tape
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25
Falls Management
- Identify all individuals who have fallen in the last 12 months. - As per above identify why they are at risk. - For those with a falls history or at risk complete the 'Turn 180° test' or the 'Timed up and Go test'.
26
Falls Management
- Identify all individuals who have fallen in the last 12 months. - As per above identify why they are at risk. - For those with a falls history or at risk complete the 'Turn 180° test' or the 'Timed up and Go test'. Offer a multidisciplinary assessment by a qualified clinician to all patients over 65 with: - >2 falls in the last 12 months - A fall that requires medical treatment - Poor performance or failure to complete the 'Turn 180° test' or the 'Timed up and Go test' - Physiotherapy - strength and balance training - Occupational therapy - home hazards assessment - Medical review - bone profile, medication, postural hypotension, diagnose any new conditions, cataracts, cognitive screening, optimize comorbidities - Tx any consequences of fall
27
Syncope Definition
Transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery
28
Syncope 3 main types
- Cardiac syncope - Reflex syncope (neurally mediated) - Orthostatic syncope
29
Syncope Cardiac syncope Causes
Arrhythmias: - Bradycardias (sinus node disease, AV conduction defections) - Tachycardias (Supraventricular, ventricular) Structural: - MI - Valvular - Cardiomyopathy (hypertrophic) - Pericardial disease/tamponade Others: - PE - Severe pulmonary HTN - Aortic dissection Drug-Induced: - Antiarrhythmics - Antianginals - Antiemetics - Antipsychotics - Inotropes
30
Syncope Reflex syncope Definition
- Most common cause of syncope - Transient loss of consciousness due to inappropriate cardiovascular responses of vasodilation or bradycardia, cerebral hypoperfusion
31
Syncope Reflex syncope Causes
- Vasovagal: triggered by emotion, pain, stress - Situational: coughing, eating, micturition, post-exercise, weight lifting, playing wind instrument - Carotid sinus syndrome
32
Syncope Orthostatic syncope Definition
- Symptomatic systolic BP drop of 20 mmHg or diastolic BP drop of 10 mmHg within 3 mins of standing - Occurs as consequence of impaired vasoconstriction due to chronic impairment of autonomic sympathetic activity
33
Syncope Orthostatic syncope Causes
Primary autonomic failure: - Pure autonomic failure - Parkinson's disease (w autonomic failure) - Lewy body dementia - Multi-system atrophy Secondary autonomic failure: - Diabetic neuropathy - Amyloidosis - Spinal cord injury - Uraemia Drug-induced: - Diuretics - Alcohol - Antihypertensives - Vasodilators - Phenothiazines - Antidepressants Volume-depletion: - Haemorrhage - Diarrhoea - Vomiting - Dehydration
34
Carotid sinus syndrome Pathophysiology
- Disease of autonomic nervous system | - Hypersensitive baroreceptors -> causes dilation and drop in BP, bradycardia, collapse
35
Carotid sinus syndrome Diagnosis
- Diagnosis with tilt table and carotid massage | - Ventricular pause of > 3 seconds and a fall in systolic BP of > 50 mmHg following carotid sinus massage
36
Sick sinus syndrome
- Usually caused by sinus node fibrosis - Sinus node becomes dysfunctional, in some cases slowing to the point of sinus bradycardia or sinus pauses - Diagnose with history, ECG and carotid sinus massage
37
Vascular steal syndrome
- Subclavian artery stenosis - Means you can’t get blood from subclavian due to stenosis, so blood is ‘stolen’ from the circle of Willis instead - Leads to collapse
38
Define multimorbidity
The presence of two or more long-term health conditions, including: Defined physical or mental health conditions, learning disabilities, symptom complexes such as chronic pain, sensory impairments and alcohol or substance misuse
39
What is the START criteria
START suggests medications that may provide additional benefits ie proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk
40
What is the STOPP criteria
STOPP identifies medications where the risk outweighs the therapeutic benefits in certain conditions Especially consider stopping the use of medications such as NSAIDS, warfarin and aspirin in patients with peptic ulcer disease, and pay particular attention to the prescription of reno-toxic or renally cleared drugs in reduced renal function
41
Physiological markers of frailty
- Increased inflammation (increased CRP, IL6, factor VIII and fibrinogen) - Elevated insulin and glucose levels in fasting state - Low albumin - Raised D dimer and α 1-antitrypsin - Low vitamin D levels
42
Stress incontinence Definition
- Sphincter weakness - Detrusor pressure > closing pressure of the urethra - Involuntary leakage on effort and exertion
43
Stress incontinence Causes
- Menopause (low oestrogen levels) - Radiotherapy - Pelvic surgery - Congenital weakness - Pregnancy/vaginal delivery
44
Stress incontinence Presentation
- Cough - Laugh - Lifting - Exercise - Movement
45
Stress incontinence Management - conservative
- Encouraged to lose weight - PELVIC FLOOR MUSCLE TRAINING - 3 months - Vaginal cones
46
Stress incontinence Management - pharmacological + MoA
- Duloxetine (SSRI) - A combined noradrenaline and serotonin reuptake inhibitor - Mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction
47
Stress incontinence Management - surgical
- Restore pressure transmission - Support/elevate urethra: - TVT (tension-free vaginal tape) - Sling
48
Urge incontinence (overactive bladder) Definition
- Involuntary detrusor muscle contractions during the filling phase - May be spontaneous or provoked (e.g. by coughing) - Urgency +/- urge incontinence
49
Urge incontinence (overactive bladder) Causes
Usually idipathic
50
Urge incontinence (overactive bladder) Presentation
- Urgency - Frequency - Nocturia - Key in door - Hand wash - Sexual intercourse - Stress incontinence - Childhood enuresis is common - Urine diary will show frequent passage of small volumes of urine, particularly at night - Examination is often normal but may find incidental cystocoele
51
Urge incontinence (overactive bladder) Management - conservative
- Bladder drill retraining - min of 6 weeks - Reduced fluid intake if excessive - Avoid caffeine etc
52
Urge incontinence (overactive bladder) Management - pharmacological + MoA
``` Anticholinergics/antimuscarinics: Suppress the detrusor muscles (parasympethetic nervous system - M2 and M3 acetylcholine-activated receptors) - Oxybutynin - Solifenacin - Tolterodine ``` Mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients Others: - Oestrogens - Botulinum toxin A
53
Overflow incontinence Definition
Due to bladder outlet obstruction, e.g. due to prostate enlargement
54
Initial investigations of incontinence
- Bladder diaries for a minimum of 3 days - Vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles - Urine dipstick and culture - Urodynamic studies
55
Hypothermia Definition
Unintentional reduction of core body temperature below the normal physiological limits - Mild = 32-35 - Moderate or severe = < 32
56
Hypothermia Epidemiology
- Most common during winter - Elderly are particularly susceptible - Many occur indoors due to poor heating etc
57
Hypothermia Causes
- Exposure to cold in the environment - Inadequate insulation in an operating room - Cardiopulmonary bypass - Newborn babies
58
Hypothermia Risk factors
- General anaesthesia - Substance abuse - Hypothyroidism - Impaired mental status - Homelessness - Extremes of age
59
Hypothermia Signs and symptoms
- Shivering - Cold and pale skin. Frostbite occurs when the skin and subcutaneous tissue freeze, causing damage to cells. - Slurred speech - Tachypnoea, tachycardia and hypertension (if mild) respiratory depression, bradycardia and hypothermia (if moderate) - Confusion/ impaired mental state Newborn: may look healthy but may be limp, quiet and refuse to feed
60
Hypothermia Investigations
- Temp (low-reading rectal thermometers if available) - ECG: J WAVES, acute ST elevation, Osborn waves - FBC, serum electrolytes: - Low platelets and WBCs - High Hb and haematocrit - May have hypokalaemia - Blood glucose - ABG - Coagulation factors - CXR
61
Hypothermia Management
- Removing the patient from the cold environment and removing any wet/cold clothing, - Warming the body with blankets - Securing the airway and monitoring breathing, - If the patient is not responding well to passive warming, you may consider maintaining circulation using warm IV fluids or applying forced warm air directly to the patient's body + rapid re-warming can lead to peripheral vasodilation and shock - In severe cases, be prepared to conduct CPR. IV drugs should be avoided if possible, as the patient is more likely to have a drastic response to the drug.
62
Hypothermia What NOT to do
Don't put the person into a hot bath. Don't massage their limbs. Don't use heating lamps. Don't give them alcohol to drink.
63
Common features of frontotemporal dementia
Onset before 65 Insidious onset Relatively preserved memory and visuospatial skills Personality change and social conduct problems
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