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Chapter 4 (165-207) > . > Flashcards

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1
Q

CPR

A

Danger
Response
CALL FOR HELP
Airway: head-tile chin lift, look for and remove obstruction
Breathing: assess for up to 10s and check carotid pulse
Begin CPR

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2
Q

Chest compressions

A

Centre of chest
Rate 100-120/minute
Depth: 5-6cm

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3
Q

4H’s and how to manage

A

Hypoxia - 15L O2
Hyperkalaemia - calcium bicarbonate, insulin/dextrose infusion, salbutamol nebulised
Hypothermia - warm
Hypovolaemia (history, drain, haemorrhage, fluid collection - expose!) - fluid resuscitation

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4
Q

4T’s and how to manage

A

Thrombosis - coronary/pulmonary (history, risk factors, DVT signs, post-surgery?) - thrombolysis if PE, cardiology if MI
Tension pneumothorax (tracheal deviation away, hyperresonance, decreased breath sounds) - cannula in 2nd intercostal space, mid-clavicular line
Tamponade (recent chest trauma/surgery, focussed US) - pericardiocentesis
Toxins (history, kardex, gather info, cap glucose) - treat

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5
Q

Shockable rhythms and how to treat

A

VT (pulseless)
VF

-> 1st shock, 2 mins CPR (8 rounds), rhythm check, 2nd shock, 2 mins CPR, rhythm check, 3rd shock, continue CPR and give IV adrenaline 1mg (1:10,000) and IV amiodarone 300mg

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6
Q

Non-shockable rhythms and how to treat

A

Pulseless electrical activity
Asystole

-> give IV adrenaline 1mg (1:10,000) ASAP, 2 mins CPR (8 rounds), rhythm check

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7
Q

Adrenaline in non-shockable rhythm

A

IV adrenaline 1mg (1:10,000) ASAP and then every 3-5 mins.

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8
Q

Adrenaline in shockable rhythm

A

IV adrenaline 1mg (1:10,000) after 3rd shock and then every 3-5 mins.

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9
Q

ROSC

A

A
B - aim 94-98%, normal PCO2,
C - 12 lead ECG
D - targeted temperature management
E - treat cause

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10
Q

When do you consider IO access

A

After 2 attempts at cannulation

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11
Q

Hyperkalaemia management

A

10 ml 10% calcium chloride/gluconate
10 units Actarapid insulin in 50ml 50% dextrose
Salbutamol nebs

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12
Q

Post-arrest investigations

A

CXR
Full bloods
12 lead ECG
Echo
ABG
Capillary glucose
Cardiac monitoring

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13
Q

Infant (<1y) CPR

A

Assess brachial pulse
5 rescue breaths first
Two fingers on sternum or encircling technique
Adrenaline 10 micrograms/kg

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14
Q

Airway

A

Patent
Not patent - GCS<8, snoring, secretions, aspiration, obstructions

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15
Q

Breathing

A

Pulse oximetry
RR
Chest exam: cyanosis, tracheal deviation, inspection of chest (accessory muscles, deformity), expansion, percussion, auscultation

Investigations: ABG, CXR
Management: 15L/min O2, non-rebreather mask, airway manoeuvres/adjuncts

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16
Q

Circulation

A

Cap refill
Pulse
BP
Exam: JVP, auscultate heart
Assess fluid balance

Investigations: 3-lead cardiac monitoring, ECG
Management: 1-2 wide-bore IV cannula, bloods, VBG, catheter to monitor UO, treat arrhythmia

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17
Q

Disability

A

Glucose
Temperature
Pupil reactivity and symmetry
GCS score including, pain

Management: CT head, analgesia (morphine if required, 10mg in 10ml)

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18
Q

Exposure

A

Bleeding, rash, injury, drain output, urine output, lines
Examine abdomen
Focussed exam of relevant systems

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19
Q

175-182

A

.

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20
Q

Acute exacerbation of asthma - life-threatening parameters

A

33, 92 CHEST
- PEFR <33% predicted
- Sats <92%
- Confusion
- Hypotension
- Exhaustion
- Silent chest
- Tachycardia

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21
Q

Acute exacerbation of asthma - severe

A

PEFR 33-50%
Cannot complete sentences
RR >25
HR >110

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22
Q

Acute exacerbation of asthma - moderate

A

PEFR <75%

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23
Q

Acute exacerbation of asthma - mild

A

PEFR >75%

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24
Q

Acute exacerbation of asthma assessment

A

History - baseline/severity, exacerbation history, ICU admissions, normal PEFR, infective symptoms, inhaler compliance, home oxygen/nebs
PEFR regularly
Investigations - ABG, CXR, bloods

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25
Acute exacerbation of asthma - management
O SHITMAN Oxygen (4L through nasal cannula, +oxygen driven nebs) Salbutamol nebuliser 5mg back-to-back Hydrocortisone 100mg IV 6-hourly (or prednisolone 40mg PO once daily - oral as effective) Ipratropium 500 microgram nebulised Senior input before: Theophylline Magnesium sulphate 2g IV over 20 minutes Anaesthetist - worsening hypoxaemia/hypercapnia despite maximal therapy
26
Acute exacerbation of COPD
O SHIT Oxygen 15L if unstable, titrate to ABG result Salbutamol Hydrocortisone/prednisolone Ipratropium Theophylline Antibiotics Chest physiotherapy NIV: BiPAP Intubation if worsening hypoxaemia/hypercapnia
27
Acute exacerbation of COPD/asthma ICU indications
Requires ventilatory support Worsening hypoxaemia/hypercapnia/acidosis Exhaustion Drowsiness/confusion
28
Well's score (PE) parameters
Clinical signs and symptoms of DVT (3) PE is primary differential (3) HR >100 (1.5) Immobilisation for 3 days or surgery in past 4 weeks (1.5) Previous, diagnosed PE/DVT (1.5) Haemoptysis (1) Malignancy with treatment in past 6 months or palliative (1)
29
Confirm diagnosis of PE
Well's score <=4 -> d-dimer CTPA (V/Q if contraindicated - pregnancy, allergy, renal failure)
30
Well's score
D-dimer If positive -> CTPA
31
Well's score >/= 5
Treatment dose LMWH (1.5 mg/kg OD)
32
CTPA positive
Therapeutic anticoagulation for at least 3 months (usually 6 months)
33
Indications for thrombolysis of PE
Massive PE - SBP <90 for >15 minutes - Pulselessness - Persistent bradycardia
34
Indications for unfractionated heparin infusion (72h)
Sub-massive PE - RV dysfunction - Myocardial necrosis - Large clot burden (saddle embolus)
35
ACS short-term management
Morphine - titrate to pain Oxygen only if saturations <94% Nitrates - sublingual GTN or GTN infusion (CI if hypotensive) Aspirin - 300mg PO then 75mg OD Clopidogrel - 300-600 mg then 75 mg OD
36
ACS assessment
12 lead ECG monitoring Bloods: FBC, U&Es, LFTs, CRP, glucose, troponin (and in 12 hours), magnesium, phosphate, lipids CXR (?LVF, other causes of chest pain) All patients should have an echo
37
Long-term management of ACS
Beta blocker Ace inhibitor GTN spray Aldosterone antagonist (eplenerone) if LV dysfunction <40% CV risk reduction: aspirin (lifelong) + clopidogrel/ticargrelor (12 months), statin, BP control, lifestyle modification, cardiac rehab and smoking cessation
38
Acute pulmonary oedema initial management
POD MAN - Position (sit-up) - Oxygen 15L - Diuretic (IV furosemide) - Morphine (venodilation, reduce preload) - Anti-emetic - Nitrates in severe pul oedema (GTN infusion/spray)
39
Acute pulmonary oedema further investigations/management
Identify cause (PCI, surgery of aortic/mitral valves, arrhythmia management, BP management if hypertensive crisis, pericardiocentesis) Further management: CPAP, inotropes if cardiogenic shock
40
Tachyarrhythmia and adverse sign (shock SBP<90, syncope, myocardial ischaemia, heart failure)
Synchornised DC cardioversion
41
Narrow complex tachycardia - supraventricular tachycardia management
1. Vagal manoeuvres 2. Adenosine (not in asthma, use verapamil) 3. Beta blocker
42
Narrow complex tachycardia - AF/flutter
Rate/rhythm control - bisoprolol or digoxin if heart failure Treat cause Therapeutic anticoagulation (CHADS2VASC score)
43
Bradycardia management
Treat cause If adverse signs present (shock SBP<90, syncope, myocardial ischaemia, heart failure): atropine, transvenous pacing
44
Differentials of acute abdomen
Peritonitis/perforation Ruptured AAA Renal colic Appendicitis Gallstones Acute pancreatitis Gastritis/peptic ulcer Diverticulitis Bowel obstruction Ectopic pregnancy
45
Assessment of upper GI bleed
A-E Examination: signs of liver disease etc, PR exam for melaena Bloods: FBC, U&Es (elevated urea), LFTs (varices risk), clotting, glucose, group and save and crossmatch Catheterise CXR/AXR (once stable) OGD Observations
46
Variceal bleed management
A-E Terlipressin (splanchnic vasopressor) Prophylactic IV antibiotics Endoscopy - band ligation, sclerotherapy Balloon tamponade
47
Non-variceal bleed (peptic ulcer, Mallory-Weiss tear, oesophagitis) management
Endoscopy - adrenaline injection IV PPI after endoscopy Tranexamic acid if required
48
Indication for platelet transfusion
<50 x10^9
49
Warfarin reversal
Prothrombin complex concentrate and vitamin K
50
Coagulopathic for other reasons (cirrhosis)
Vitamin K +/- FFP
51
Low fibrinogen (<1g/L)
Cryoprecipitate
52
Glasgow-Blatchford score
ADMIT OR NOT (>/= 1 admit) Blood urea Hb Systolic BP Pulse >100 History: melaena, syncope, hepatic disease, cardiac failure
53
Rockall score
Mortality risk assessment after endoscopy
54
Prevent further GI bleed
Varices: propranolol, banding, TIPSS, liver transplant Peptic ulcer: PPI, H. pylori eradication, avoid NSAIDs etc
55
DKA diagnostic parameters
1. Blood glucose >11 2. Acidosis pH <7.35 3. Ketosis: blood >3 mmol/L, urinary 2+
56
DKA management
Protocol IV 0.9% saline +/- potassium IV fixed rate insulin 0.1 unit/kg/hour (Actarapid). Continue long-acting insulin Monitor BG and VBG - aim to reduce BG by 3 and ketones 0.5 Look for cause ?infection VTE prophylaxis
57
DKA: when to switch back to normal insulin regime
Corrected acid-base and capillary ketones <0.6
58
HHS diagnostic parameters
1. Marked hyperglycaemia without ketosis 2. Increased serum osmolarity (>320) 3. Hypovolaemia
59
HHS management
IV 0.9% saline VTE prophylaxis Look for cause IV insulin infusion if BG not falling Stop metformin
60
Hypoglycaemia
BG <4
61
Hypoglycaemia - able to swallow
15-30g fast-acting carbohydrate and long-acting carbohydrate
62
Hypoglycaemia - conscious but cannot swallow
GlucoJel Check cap glucose 10 minutes later
63
Hypoglycaemia - unconscious
150 ml 10% glucose IV stat Glucagon 1mg IM if no venous access Check cap glucose 10 minutes later
64
Management of stroke
CT head within 1 hour Once haemorrhage excluded -> <4.5 hours = Thrombolysis >4.5 hours = Aspirin 300 mg, Clopidogrel 75mg OD (lifelong) Transfer to stroke ward SALT assessment Early physio Protect pressure areas MDT Consider endovascular clot retrieval
65
Long-term management of stroke
Anti-hypertensives Clopidogrel 75 mg OR anticoagulation if AF - wait 2 weeks Statin - wait 48 hours
66
Informing DVLA after stroke
No driving for 4 weeks or 1y (HGV) Inform DVLA if HGV driver or residual symptoms or complications (seizures, neurosurgery or crescendo TIA)
67
TIA management
Aspirin 300 mg, Clopidogrel 75mg OD (lifelong) UNLESS on anti-platelet (continue) or in AF (start anticoagulation) Specialist review within 24 hours DVLA - same as stroke
68
TIA investigations
ECG Carotid US 24 hour tape Echo Vasculitis screen Thombophilia screen
69
Seizure management <10 minutes
4mg Lorazepam IV OR 10mg Diazepam PR Repeat within 20 minutes if required
70
Seizure management <30 minutes
IV phenytoin
71
Seizure management 1 hour
ICU for GA
72
Manage cause of seizure (hypoglycaemia, alcohol)
50 ml 50% glucose IV Pabrinex if alcohol abuse
73
DVLA after seizure
Must always inform DVLA Stop driving for 1 year (sometimes 6 months)
74
Burns - determining % body surface
Rule of 9's (head, L arm, R arm, L leg 18 R leg 18, trunk front 18, trunk back 18) Lund and Browder (most accurate, especially children) Palmar surface = 0.8%
75
Superficial burn characteristics and management
Red, dry, blanches with pressure (sunburn) Simple moisturiser
76
Partial thickness burn
Red, moist, blistered, does not blanch Systemic analgesia Cleanse with soap and water, rinse thoroughly Scrub off necrotic tissue Use non-adherent gauze and dressing. Review every 48 hours
77
Full thickness burn
White, grey, scaled, insensate, solid, dry Skin graft
78
Management of burns
A-E Fluid requirement = 4 x total burn surface area x kg (50% in first 8 hours, 50% in 16 hours) Leave blisters intact
79
Ottawa ankle rules
X-ray if Pain in malleolar zone PLUS any of: tenderness on medial/lateral malleolus, inability to weight bear both immediately and now
80
Ottawa foot rules
Foot XR if Pain in midfoot PLUS any of: tenderness over navicular bone or base of 5th metatarsal, inability to weight bear both immediately and now
81
Ligaments of ankle
Deltoid Lateral: anterior/posterior talofibular, calcaneofibular
82
Ankle injury assessment
Ottawa rules Palpate ligaments Palpate fibula up to knee (associated head of fibula fracture) Squeeze test (syndesmosis intact?) Test weight bearing Distal neurovascular exam
83
Lower limb ligament/meniscal injury management
Ice pack for 20 minutes if acute injury Crutches NSAIDs Rest Ice (20 mins 4 times daily) Compression Elevation for 24 hours Then mobilise and weight bear as able - it will hurt but not harm Physio if not better in 1-2 weeks
84
Fracture management
Resuscitate Reduce (displaced) - open, closed, traction Retain - fixation (external, internal), conservative immobilisation Rehabilitate - physio, ?weight-bearing
85
Other aspects of fracture management
Rest, Ice, Elevation Smoking cessation Analgesia (not NSAIDs) Antibiotic prophylaxis if open VTE prophylaxis Treat cause of fracture if necessary - osteoporosis, fall etc
86
Immediate complications of fractures
Arterial damage - haemorrhage, ischaemia Surrounding structure damage - tendons, nerves Fat embolus
87
Early (few weeks) complications of fractures
Wound/prosthesis infection Loss of position/fixation VTE Chest infection Compartment syndrome
88
Late (months-years) complications of fractures
Malunion Non-union Delayed union Osteoarthritis AVN
89
When are temporary fixations for fractures removed? And when is full fracture healing achieved?
6 weeks 12 weeks
90
Assessment of patient with suspected sepsis
Observations A-E Look for infection source Oxygen, IV fluids, IV antibiotics Blood cultures, urine output, lactate Other investigations: Bloods - FBC, U&Es, LFTs, clotting VBG Blood glucose Urinalysis and urine culture CXR Other relevant imaging
91
AKI diagnosis
Urine output <0.5 ml/kg/hr OR Creatinine >50% baseline
92
DIC diagnosis and management
Thrombocytopenia Prolonged PT Low fibrinogen High D-dimer Give blood products (red cells, platelets, FFP, cryoprecipitate), anticoagulation
93
Anaesthetic complications
Arrhythmia Hypo/hypertension Hyperthermia Breathing problems MI/stroke Allergy Teeth/lip/tongue damage
94
Early post-op complications
Dehydration Electrolyte imbalance Local infection or systemic infection Fluid collections Atelectasis DVT/PE Wound breakdown Anastomotic breakdown Pressure sores
95
Post-op pyrexia differentials
Sepsis Atelectasis (<48 hours) UTI (2-4 days) Wound infection (1 week) VTE (8-10 days) Transfusion/drug reactions (anytime)
96
Post-op hypotension differentials
Decreased intravascular volume Cardiogenic shock Sepsis - EXCLUDE Anaphylaxis Sympathetic shock (epidural analgesia)
97
Increased respiratory effort post-op differentials
Atelectasis Pneumonia PE Pulmonary oedema
98
Low urine output (<0.5 ml/kg/hr) post-op differentials
Dehydration Nephrotoxic drugs (aminoglycosides, metformin) Prostatic hypertrophy Raised intra-abdominal pressure
99
Anaphylaxis management
Remove allergen ! IM Adrenaline 0.5 mg (1:1000) A-E Admit Steroids Consider anti-histamines Monitor ECG Document event and allergy Long-term: educate, EpiPen, medic alert bracelet, allergy clinic if allergy unknown, clinical incident form if given allergic antibiotic
100
Rapid tranquillisation (last resort in agitated patient at risk to self or others)
Lorazepam 1-2 mg PO/IM OR Haloperidol 2-5 mg PO/IM (CI: Parkinson's, Lewy body dementia, alcohol withdrawal, long QT) Both repeat every 30-60 mins, up to 3 times. Takes >30 minutes to work.
101
Acute abdomen standard investigations
Bloods: FBC, U&Es, LFTs, CRP, amylase, clotting, G+S Blood culture if pyrexial Urine dip +/- culture bHCG female

Chapter 4 (165-207) (1 decks)

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