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Chapter 4 (165-207) > . > Flashcards

. Flashcards

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
Q

Acute exacerbation of asthma - management

A

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

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26
Q

Acute exacerbation of COPD

A

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

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27
Q

Acute exacerbation of COPD/asthma ICU indications

A

Requires ventilatory support
Worsening hypoxaemia/hypercapnia/acidosis
Exhaustion
Drowsiness/confusion

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28
Q

Well’s score (PE) parameters

A

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)

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29
Q

Confirm diagnosis of PE

A

Well’s score <=4 -> d-dimer

CTPA (V/Q if contraindicated - pregnancy, allergy, renal failure)

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30
Q

Well’s score </= 4

A

D-dimer

If positive -> CTPA

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31
Q

Well’s score >/= 5

A

Treatment dose LMWH (1.5 mg/kg OD)

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32
Q

CTPA positive

A

Therapeutic anticoagulation for at least 3 months (usually 6 months)

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33
Q

Indications for thrombolysis of PE

A

Massive PE
- SBP <90 for >15 minutes
- Pulselessness
- Persistent bradycardia

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34
Q

Indications for unfractionated heparin infusion (72h)

A

Sub-massive PE
- RV dysfunction
- Myocardial necrosis
- Large clot burden (saddle embolus)

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35
Q

ACS short-term management

A

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

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36
Q

ACS assessment

A

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

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37
Q

Long-term management of ACS

A

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

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38
Q

Acute pulmonary oedema initial management

A

POD MAN
- Position (sit-up)
- Oxygen 15L
- Diuretic (IV furosemide)

  • Morphine (venodilation, reduce preload)
  • Anti-emetic
  • Nitrates in severe pul oedema (GTN infusion/spray)
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39
Q

Acute pulmonary oedema further investigations/management

A

Identify cause (PCI, surgery of aortic/mitral valves, arrhythmia management, BP management if hypertensive crisis, pericardiocentesis)

Further management: CPAP, inotropes if cardiogenic shock

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40
Q

Tachyarrhythmia and adverse sign (shock SBP<90, syncope, myocardial ischaemia, heart failure)

A

Synchornised DC cardioversion

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41
Q

Narrow complex tachycardia - supraventricular tachycardia management

A
  1. Vagal manoeuvres
  2. Adenosine (not in asthma, use verapamil)
  3. Beta blocker
42
Q

Narrow complex tachycardia - AF/flutter

A

Rate/rhythm control - bisoprolol or digoxin if heart failure
Treat cause
Therapeutic anticoagulation (CHADS2VASC score)

43
Q

Bradycardia management

A

Treat cause
If adverse signs present (shock SBP<90, syncope, myocardial ischaemia, heart failure): atropine, transvenous pacing

44
Q

Differentials of acute abdomen

A

Peritonitis/perforation
Ruptured AAA
Renal colic
Appendicitis
Gallstones
Acute pancreatitis
Gastritis/peptic ulcer
Diverticulitis
Bowel obstruction
Ectopic pregnancy

45
Q

Assessment of upper GI bleed

A

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
Q

Variceal bleed management

A

A-E
Terlipressin (splanchnic vasopressor)
Prophylactic IV antibiotics
Endoscopy - band ligation, sclerotherapy
Balloon tamponade

47
Q

Non-variceal bleed (peptic ulcer, Mallory-Weiss tear, oesophagitis) management

A

Endoscopy - adrenaline injection
IV PPI after endoscopy
Tranexamic acid if required

48
Q

Indication for platelet transfusion

A

<50 x10^9

49
Q

Warfarin reversal

A

Prothrombin complex concentrate and vitamin K

50
Q

Coagulopathic for other reasons (cirrhosis)

A

Vitamin K +/- FFP

51
Q

Low fibrinogen (<1g/L)

A

Cryoprecipitate

52
Q

Glasgow-Blatchford score

A

ADMIT OR NOT (>/= 1 admit)
Blood urea
Hb
Systolic BP
Pulse >100
History: melaena, syncope, hepatic disease, cardiac failure

53
Q

Rockall score

A

Mortality risk assessment after endoscopy

54
Q

Prevent further GI bleed

A

Varices: propranolol, banding, TIPSS, liver transplant
Peptic ulcer: PPI, H. pylori eradication, avoid NSAIDs etc

55
Q

DKA diagnostic parameters

A
  1. Blood glucose >11
  2. Acidosis pH <7.35
  3. Ketosis: blood >3 mmol/L, urinary 2+
56
Q

DKA management

A

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
Q

DKA: when to switch back to normal insulin regime

A

Corrected acid-base and capillary ketones <0.6

58
Q

HHS diagnostic parameters

A
  1. Marked hyperglycaemia without ketosis
  2. Increased serum osmolarity (>320)
  3. Hypovolaemia
59
Q

HHS management

A

IV 0.9% saline
VTE prophylaxis
Look for cause
IV insulin infusion if BG not falling
Stop metformin

60
Q

Hypoglycaemia

A

BG <4

61
Q

Hypoglycaemia - able to swallow

A

15-30g fast-acting carbohydrate and long-acting carbohydrate

62
Q

Hypoglycaemia - conscious but cannot swallow

A

GlucoJel
Check cap glucose 10 minutes later

63
Q

Hypoglycaemia - unconscious

A

150 ml 10% glucose IV stat
Glucagon 1mg IM if no venous access
Check cap glucose 10 minutes later

64
Q

Management of stroke

A

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
Q

Long-term management of stroke

A

Anti-hypertensives
Clopidogrel 75 mg
OR anticoagulation if AF - wait 2 weeks
Statin - wait 48 hours

66
Q

Informing DVLA after stroke

A

No driving for 4 weeks or 1y (HGV)
Inform DVLA if HGV driver or residual symptoms or complications (seizures, neurosurgery or crescendo TIA)

67
Q

TIA management

A

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
Q

TIA investigations

A

ECG
Carotid US
24 hour tape
Echo
Vasculitis screen
Thombophilia screen

69
Q

Seizure management <10 minutes

A

4mg Lorazepam IV
OR
10mg Diazepam PR

Repeat within 20 minutes if required

70
Q

Seizure management <30 minutes

A

IV phenytoin

71
Q

Seizure management 1 hour

A

ICU for GA

72
Q

Manage cause of seizure (hypoglycaemia, alcohol)

A

50 ml 50% glucose IV
Pabrinex if alcohol abuse

73
Q

DVLA after seizure

A

Must always inform DVLA
Stop driving for 1 year (sometimes 6 months)

74
Q

Burns - determining % body surface

A

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
Q

Superficial burn characteristics and management

A

Red, dry, blanches with pressure (sunburn)

Simple moisturiser

76
Q

Partial thickness burn

A

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
Q

Full thickness burn

A

White, grey, scaled, insensate, solid, dry

Skin graft

78
Q

Management of burns

A

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
Q

Ottawa ankle rules

A

X-ray if
Pain in malleolar zone
PLUS any of: tenderness on medial/lateral malleolus, inability to weight bear both immediately and now

80
Q

Ottawa foot rules

A

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
Q

Ligaments of ankle

A

Deltoid
Lateral: anterior/posterior talofibular, calcaneofibular

82
Q

Ankle injury assessment

A

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
Q

Lower limb ligament/meniscal injury management

A

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
Q

Fracture management

A

Resuscitate
Reduce (displaced) - open, closed, traction
Retain - fixation (external, internal), conservative immobilisation
Rehabilitate - physio, ?weight-bearing

85
Q

Other aspects of fracture management

A

Rest, Ice, Elevation
Smoking cessation
Analgesia (not NSAIDs)
Antibiotic prophylaxis if open
VTE prophylaxis
Treat cause of fracture if necessary - osteoporosis, fall etc

86
Q

Immediate complications of fractures

A

Arterial damage - haemorrhage, ischaemia
Surrounding structure damage - tendons, nerves
Fat embolus

87
Q

Early (few weeks) complications of fractures

A

Wound/prosthesis infection
Loss of position/fixation
VTE
Chest infection
Compartment syndrome

88
Q

Late (months-years) complications of fractures

A

Malunion
Non-union
Delayed union
Osteoarthritis
AVN

89
Q

When are temporary fixations for fractures removed? And when is full fracture healing achieved?

A

6 weeks

12 weeks

90
Q

Assessment of patient with suspected sepsis

A

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
Q

AKI diagnosis

A

Urine output <0.5 ml/kg/hr
OR
Creatinine >50% baseline

92
Q

DIC diagnosis and management

A

Thrombocytopenia
Prolonged PT
Low fibrinogen
High D-dimer

Give blood products (red cells, platelets, FFP, cryoprecipitate), anticoagulation

93
Q

Anaesthetic complications

A

Arrhythmia
Hypo/hypertension
Hyperthermia
Breathing problems
MI/stroke
Allergy
Teeth/lip/tongue damage

94
Q

Early post-op complications

A

Dehydration
Electrolyte imbalance
Local infection or systemic infection
Fluid collections
Atelectasis
DVT/PE
Wound breakdown
Anastomotic breakdown
Pressure sores

95
Q

Post-op pyrexia differentials

A

Sepsis
Atelectasis (<48 hours)
UTI (2-4 days)
Wound infection (1 week)
VTE (8-10 days)
Transfusion/drug reactions (anytime)

96
Q

Post-op hypotension differentials

A

Decreased intravascular volume
Cardiogenic shock
Sepsis - EXCLUDE
Anaphylaxis
Sympathetic shock (epidural analgesia)

97
Q

Increased respiratory effort post-op differentials

A

Atelectasis
Pneumonia
PE
Pulmonary oedema

98
Q

Low urine output (<0.5 ml/kg/hr) post-op differentials

A

Dehydration

Nephrotoxic drugs (aminoglycosides, metformin)

Prostatic hypertrophy
Raised intra-abdominal pressure

99
Q

Anaphylaxis management

A

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
Q

Rapid tranquillisation (last resort in agitated patient at risk to self or others)

A

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
Q

Acute abdomen standard investigations

A

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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