Management of Ventricular Tachycardia in a Patient with Ischaemic Heart Disease

When faced with a patient with a broad-complex tachycardia, it is important to consider ventricular tachycardia as the most common cause, particularly in patients with a history of ischaemic heart disease. In a haemodynamically unstable patient with regular ventricular tachycardia, the initial step is to evaluate for adverse signs or symptoms. If present, the patient should be sedated and synchronised DC shock should be administered, followed by amiodarone infusion and correction of electrolyte abnormalities. If there are no adverse signs or symptoms, amiodarone IV and correction of electrolyte abnormalities should begin immediately.

Other management options, such as primary percutaneous coronary intervention (PCI), IV magnesium, aspirin and clopidogrel, IV furosemide, and oxygen, may be indicated depending on the underlying cause of the ventricular tachycardia, but DC cardioversion is the most important step in a haemodynamically unstable patient. Diuretics are not indicated in a hypotensive patient, and improving cardiac function is the key to clearing fluid from the lungs.

Possible Diagnoses for a Pyrexial Patient with Chest Signs

A pyrexial patient with chest signs on the right-hand side may have ventilator-acquired pneumonia, which occurs due to contamination of the respiratory tract from oropharyngeal secretions. Diagnosis is based on clinical examination, X-ray, blood culture, and bronchial washings. Initial antibiotic therapy should cover anaerobes, MRSA, Pseudomonas, and Acinetobacter.

If the patient has been in the hospital for more than 72 hours, any infection that develops is likely to be hospital-acquired.

Acute respiratory distress syndrome (ARDS) presents more acutely and broncholavage samples commonly demonstrate inflammatory and necrotic cells.

Infective pulmonary edema is unlikely if there are no indications of pleural effusions or edema on clinical examination and chest radiograph.

Pulmonary hemorrhage is unlikely if there is no blood found in the bronchial aspirates.

Possible Diagnoses for a Pyrexial Patient with Chest Signs

Managing Ankle Ligament Sprains: Rest, Ice, Compression, Elevation, and Early Mobilisation

Ankle ligament sprains can be managed conservatively with rest, ice, compression, elevation, and analgesia. For minor sprains, pain-free stretching should be undertaken as soon as possible, followed by progressive weight-bearing and resistance exercises. Severe sprains or ruptures may require backslab immobilisation for ten days, followed by rehabilitation. Ankle X-rays are only required if there is pain in the malleolar zone and any of the Ottawa ankle rules findings. Orthopaedic referral is only necessary for dislocations or fractures. Prolonged immobilisation should be avoided, and passive stretches should be commenced as soon as possible.

When a patient experiences an Addisonian crisis, the first-line treatment is to administer 100 mg of hydrocortisone intramuscularly. It is important for patients with Addison’s disease to carry an autoinjector in case of emergencies. After administering hydrocortisone, fluid resuscitation should be carried out, and glucose may be added if the patient is hypoglycemic. Fludrocortisone may be used if the crisis is caused by adrenal disease. Oral hydrocortisone should not be given if the patient is vomiting. In cases of hypoglycemia, hydrocortisone should be given before glucose gel. Blood tests should be carried out urgently, and IV fluids may be necessary. Fludrocortisone may be given after hydrocortisone if the cause is adrenal disease.

Interpreting MMSE Scores and Differential Diagnosis for Confusion in an Elderly Patient

A MMSE score of 28/30 suggests no significant cognitive impairment, while a score of 18/30 indicates impairment. However, educational attainment can affect results, and the MMSE is not recommended for those with learning disabilities. Fluctuating confusion with increased impairment at night and visual hallucinations in an elderly person with an infection suggests delirium. Mild or moderate dementia is suggested if the MMSE score is over 26 in the daytime on two occasions, but confusion is at night, suggestive of delirium over dementia. Normal pressure hydrocephalus is unlikely without ataxic gait or urinary incontinence, and cerebral abscess is unlikely without persistent confusion or temperature.

Discharge and Follow-Up of Anaphylactic Patients: Recommendations and Advice

When it comes to discharging and following up with patients who have experienced anaphylaxis, there are certain recommendations and advice that healthcare professionals should keep in mind. Here are some key points to consider:

Recommendations and Advice for Discharging and Following Up with Anaphylactic Patients

– Give two adrenaline injectors as an interim measure after emergency treatment for anaphylaxis, before a specialist allergy service appointment. This is especially important in the event the patient has another anaphylactic attack before their specialist appointment.
– Auto-injectors are given to patients at an increased risk of a reaction. They are not usually necessary for patients who have suffered drug-induced anaphylaxis, unless it is difficult to avoid the drug.
– Advise that one adrenaline auto-injector will be prescribed if the patient has a further anaphylactic reaction.
– Arrange for a blood test after one week for serum tryptase, immunoglobulin E (IgE) and histamine levels to assess biphasic reaction. Discharge and follow-up of anaphylactic patients do not involve a blood test. Tryptase sample timings, measured while the patient is in hospital, should be documented in the patient’s records.
– Patients who have suffered from anaphylaxis should be given information about the potential of biphasic reactions (i.e. the reaction can recur hours after initial treatment) and what to do if a reaction occurs again.
– All patients presenting with anaphylaxis should be referred to an Allergy Clinic to identify the cause, and thereby reduce the risk of further reactions and prepare the patient to manage future episodes themselves. All patients should also be given two adrenaline injectors in the event the patient has another anaphylactic attack.

By following these recommendations and providing patients with the necessary information and resources, healthcare professionals can help ensure the best possible outcomes for those who have experienced anaphylaxis.

Treatment Options for Acute Mountain Sickness

Acute mountain sickness (AMS) is a common condition that can occur when ascending to high altitudes without proper acclimatization. Symptoms include nausea, headache, difficulty breathing, and dizziness. Here are some treatment options for AMS:

Administer oxygen and acetazolamide: Low-flow oxygen and acetazolamide can effectively relieve symptoms of AMS. Dexamethasone is also an alternative to acetazolamide.

Antiemetics and a dose of prophylactic antibiotics: These can help relieve symptoms in mild cases, but are not sufficient for moderate to severe cases.

Nifedipine: This medication may be effective in treating high-altitude pulmonary edema, but has no role in treating AMS.

Non-steroidal anti-inflammatory drugs (NSAIDs) and bed rest: NSAIDs can provide symptomatic relief, but cannot cure the underlying cause of AMS.

Transfer the patient immediately to a location at lower altitude: Descent is always an effective treatment for AMS, but is not necessary unless symptoms are intractable or there is suspicion of illness progression.

Treatment Options for Acute Mountain Sickness

Treatment for Paracetamol Overdose: NAC, Naloxone, and Activated Charcoal

Paracetamol overdose is a serious medical emergency that requires immediate treatment. The mainstay of treatment is intravenous (IV) N-acetylcysteine (NAC), which replenishes depleted glutathione reserves in the liver and protects liver cells from NAPQI toxicity. NAC should be started if the overdose occurred less than 10-12 hours ago, there is no vomiting, and the plasma paracetamol level is above the concentration on the treatment line. If the overdose occurred more than 8-24 hours ago and there is suspicion of a large overdose, it is best to start NAC and stop if plasma paracetamol levels fall below the treatment line and if INR/ALT return to normal. Naloxone is the mainstay of treatment for opioid overdose, while activated charcoal may play a role in gastrointestinal decontamination in a patient presenting less than 4 hours since an overdose. It is important to monitor observations and treat if deterioration occurs. A plasma paracetamol measurement should be taken to direct treatment, with NAC treatment started immediately if the time of ingestion is more than 8 hours ago and the amount ingested is likely to be more than 75 mg/kg. If the time of ingestion is within 8 hours, the paracetamol level should be checked first and treatment guided accordingly.

Diagnosing Delirium in an Elderly Patient: UTI vs. Dementia vs. Pyelonephritis

When an 89-year-old woman presents with waxing and waning consciousness, punctuated by ‘sun-downing’, it is important to consider the possible causes of delirium. In this case, the patient has normal cognitive function but is experiencing acute global cerebral dysfunction. One possible cause of delirium in the elderly is a urinary tract infection (UTI), which can present with symptoms such as frequency and confusion.

However, it is important to rule out other potential causes of delirium, such as vascular dementia or Alzheimer’s dementia. In these conditions, cognitive decline is typically steady and progressive, whereas the patient in this case is experiencing waxing and waning consciousness. Additionally, neither of these conditions would account for the patient’s new urinary symptoms.

Another possible cause of delirium is pyelonephritis, which can present with similar symptoms to a UTI but may also include pyrexia, renal angle tenderness, and casts on urinalysis. However, in this case, the patient does not exhibit these additional symptoms.

Finally, pseudodementia is unlikely in this scenario as the patient does not exhibit any affective signs. Overall, it is important to consider all possible causes of delirium in an elderly patient and conduct a thorough evaluation to determine the underlying condition.

Managing a Patient with Bradycardia and Airway Obstruction: Priorities and Interventions

When faced with a patient who is unresponsive and has both an obstructed airway and bradycardia, the first priority is to address the airway obstruction. After calling for help, the airway can be maintained with a jaw thrust and delivery of 15 l of high-flow oxygen via a non-rebreather mask. Monitoring the patient’s oxygen saturation is important to assess their response. If bradycardia persists despite maximal atropine treatment, second-line drugs such as an isoprenaline infusion or an adrenaline infusion can be considered. Atropine is the first-line medication for reversing the arrhythmia, given in 500-micrograms boluses iv and repeated every 3-5 minutes as needed. While a second iv access line may be beneficial, it is not a priority compared to maintaining the airway and controlling the bradycardia. Re-intubation may be necessary if simpler measures and non-definitive airway interventions have failed to ventilate the patient.