A+E Flashcards
what are the 3 types of Acute coronary syndrome (ACS)?
Unstable Angina
ST-Elevation Myocardial infarction (STEMI)
Non-ST-elevation MI (NSTEMI)
where do the coronary arteries branch from?
the root of the aorta
what areas of the heart does the right coronary artery supply?
R Atrium
R ventricle
Inferior aspect of L ventricle
Posterior Septal area
what 2 vessels does the Left coronary artery split into?
circumflex artery
Left anterior descending (LAD)
what areas of the heart does the circumflex artery supply?
L atrium
Posterior aspect of L ventricle
curves around top, left and back of heart
what areas of the heart does the LAD supply?
anterior aspect of left ventricle
Anterior aspect of septum
travels down middle of heart
what are 6 presentations of ACS?
Central crushing chest pain radiating to jaw or arm
Nausea and vom
Sweaty and clammy
SOB
Palpitations
feeling of impending doom
How long do symptoms of ACS have to occur to be considered ACS?
> 15 mins at rest
who is at risk of silent MIs?
people with diabetes
what are 2 ECG changes seen in STEMIs?
ST segment elevation
New Left bundle branch block
what are 2 ECG changes seen in NSTEMIs?
ST segment depression
T wave inversion
what are pathological Q waves on ECG and when do they typically appear?
> 40 ms (1 mm) wide
2 mm deep
25% of depth of QRS complex
Seen in leads V1-3
Indicate deep full thickness infarction of heart (transmural)
typically appear >6 hours post symptoms
An infarct in the LCA would cause disruption in which leads?
Anterior and Lateral region =>
I
aVL
V1-6
An infarct in the LAD would cause disruption in which leads?
Septal/Anterior region =>
Leads V1-4
An infarct in the circumflex artery would cause disruption in which leads?
Lateral region
I
aVL
V5-6
An infarct in the RCA would cause disruption in which leads?
Inferior region =>
II
III
aVF
what are 5 conditions other than MI that can cause raised troponin?
CKD
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism
what are 6 investigations for ACS?
ECG
Troponin
Bloods - FBC, U+E, LFT, Lipids, Glucose
CXR - for other cause of CP
Echo - to assess damage
coronary angiogram
what causes a diagnosis of unstable angina?
symptoms of ACS with normal troponin and either a normal ECG or ST depression and T-wave inversion
What is the initial management of ACS?
MONA
Morphine - IV if needed
O2 if low sats
Nitrates - GTN
Aspirin - 300mg
Also perform ECG
what is the management of STEMI?
Percutaneous coronary intervention if available <2 hours since presentation
Fibrinolysis - if PCI unavailable <2 hours from presentation - with alteplase, streptokinase or tenecteplase
what is the medical management of NSTEMI?
Aspirin 300mg stat (MONA)
Fondaparinux if no immediate PCI
GRACE score >3%
- PCI - within 72h or immediate if unstable
- Parasugrel OR ticagrelor OR Clopidogrel OR heparin depending on bleed risk/renal impairment
GRACE score <3%
- Ticagrelor (+Aspirin DAPT)
- NO PCI
what antiplatelet should be used in NSTEMI if on DOAC?
clopidogrel
what scoring system can be used to asses risk of 6 month mortality in acs?
GRACE score
patients over what GRACE score are considered for angiography with PCI within 72 hours?
3% - medium to high risk
what is the secondary prevention for ACS?
6As
Aspirin 75mg daily for life
Another Anti-platelet - ticagrelor/clopi for 12 months
Atorvostatin 80mg OD
ACEi
Atenolol - or another beta blocker
Aldosterone - for those with clinical heart failure - eplerenone titrated to 50mg OD
what are 5 complications of MI?
DREAD
Death - most commonly due to cardiac arrest
Rupture of heart septum or papillary muscles
Oedema - heart failure
Arythmia and Aneurysm
Dressler’s syndrome and acute pericarditis
what is Dressler’s syndrome?
usually 2-3 weeks after MI
caused by localised immune response that results in inflammation of pericardium causing pericarditis symptoms
How is dresslers syndrome diagnosed?
ECG - ST elevation, T wave inversion
ECHO - pericardial effusion
raised inflammatory markers
what is the management of dresslers syndrome?
NSAIDs
Steroids - if severe
pericardiocentisis may be required with significant pericardia effusion
what are the different types of MI?
ACDC
Type 1: A- ACS type MI
Type 2: C - Cant cope MI - ischaemia secondary to to increased demand or reduced supply of O2
Type 3: D - Dead by MI
Type 4: Caused by us MI - iatrogenic
What are the 3 KDIGO criteria for AKI?
Rise in creatinine >25 micromol/L in 48 hours
Rise in creatinine >50% (1.5xbaseline) in 7 days
Urine output <0.5ml/Kg/hour in 6 hours
what are 9 risk factors for AKI?
Age >65 years
Sepsis
Chronic kidney disease
Diabetes
Heart failure
Liver disease
Cognitive impairment - reduced fluid intake
Medications - NSAIDs, Gentamicin, diuretics, ACEi
Radiology contrasts - iodine based
what are 5 medications that have nephrotoxic potential and should be stopped in AKI?
NSAIDs
Aminoglycosides - gentamicin
ACEi
ARBs
Diuretics
what are 3 medications that may need to be stopped in AKI due to increased risk of toxicity?
Metformin
Lithium
Digoxin
what are 3 pre-renal causes of AKI?
Dehydration
Shock
Heart failure
Medication - reducing BP, circulating volume, renal blood flow
Due to insufficient blood supply - hypoperfusion
what are 5 renal causes of AKI?
Toxins and drugs - antibiotics, contrast, chemo
Vascular - vasculitis, thromboembolism
Glomerulonephritis
Tubular causes - acute tubular necrosis, rhabdo, myeloma
Interstitial causes - interstitial nephritis, lymphoma infiltration
Due to intrinsic disease of kidney
what are 5 post-renal causes of AKI?
Kidney stones
Tumours
strictures
BPH
neurogenic bladder
Due to obstructed outflow leading to back-flow
what is acute tubular necrosis?
damage and death of epithelial cells of the renal tubules due to ischaemia or nephrotoxins
renal epithelial cells can regenerate - recovery usually takes 1-3 weeks
what is the most common renal cause of AKI?
acute tubular necrosis
what is seen on urinalysis in acute tubular necrosis?
muddy brown casts
renal tubular epithelial cell may also be seen
what is the management of aki?
IV fluids
withhold medications that may worsen aki
withhold/adjust medications that are renally excreted
relieve the obstruction
Dialysis
what are 3 ways to avoid aki?
avoid nephrotoxic medications
ensure adequate fluid intake
additional fluids before and after radiocontrast
what are 4 complications of AKI?
Fluid overload, heart failure, pulmonary oedema
hyperkalaemia
metabolic acidosis
uraemia - can lead to encephalopathy an pericarditis
when should people with AKI be referred to urology? (4)
pyonephrosis
obstructed solitary kidney
bilateral upper urinary tract obstruction
complications of AKI caused by urological obstruction
When should people with AKI be referred for dialysis?
Any not responding to medical management:
Hyperkalaemia
metabolic acidosis
symptoms or complications of uraemia
fluid overload pulmonary oedema
what classification system is used in AKI?
KDIGO
What is stage one aki?
creatinine rise >26 micromol in 48 hours
creatinine rise 50-99% from baseline within 7 days
urine output
<0.5ml/Kg/hour over 6 hours
what is stage 2 AKI?
100-199% creatinine rise from baseline within 7 days
Urine output
<0.5ml/kg/hour over 12 hours
what is stage 3 AKI?
> 200% or more creatinine rise in 7 days
creatinine rise to 354 micromol/L or more with acute rise of 26 micromol/L or more within 48 hours or 50% or more rise within 7 days
Urine output <0.3 ml/Kg/hour for 24 hours or anuria for <12 hours
what are 3 unmodifiable risk factors for ACS?
Increasing age - peak incidence 60-70
Male
Fhx
What are 5 modifiable risk factors for acs?
smoking
diabeted mellitus
hypertension
hypercholesterolaemia
obesity
What is the criteria for STEMI?
symptoms >20 mins
ECG features in at least 2 corresponding leads
> 2.5 small squares ST elevation in V2-3 if <40 years or >2 if >40 years MALE
1.5 small squares in V2-3 in WOMEN
1 small square elevation in any other leads
new LBBB
What is the criteria for PCI in STEMI?
presentation <12 hours since onset of symptoms and PCI available within 120 mins
what is the criteria for thrombolysis in STEMI?
within 12 hours of symptom onset if PCI cannot be given within 120 mins of presentation
what antiplatelets are used prior to PCI?
ASPIRIN +
Parasugrel if patient not on anticoagulant
Clopidogrel if patient is on anticoagulant
what are 5 investigations that can be done for AKI?
Dipstick
Urine MSC
Protein:creatinine if glomerulonephritis suspected
Bloods - U+Es, FBC, CRP, Bone profile, creatinine kinase
USS
Strange bloods - ANA, ANCA, anti-GBM, complement levels, immunoglobulin levels, antistreptolysin O titre, HIV
what 5 medications should be stopped in AKI due to worsening renal function?
NSAIDs
Aminoglycosides
ACEi
ARBs
Diuretics
what 3 medications may need to be stopped in AKI due to increased risk of toxicity?
Metformin
Lithium
Digoxin
what are the 2 shockable rhythms in a pulseless patient?
ventricular tachycardia (VT)
Ventricular fibrillation (VFib)
what are the 2 non-shockable rhythms in pulseless patient?
pulseless electrical activity
Asystole
what is a narrow QRS complex?
<0.12s - 3 little squares
what are 4 causes of narrow complex tachycardias?
sinus tachycardia
supra ventricular tachycardia (SVT)
atrial fibrillation (AF)
atrial flutter
what are 4 causes of broad complex tachycardias?
ventricular tachycardia - regular
polymorphic ventricular tachycardia - torsades de pointes - irregular
atrial fibrillation with bundle branch block - irregular
supra ventricular tachycardia with bundle branch block
what is a broad QRS complex?
> 0.12s - 3 small squares
when are people with shockable rhythms who were not being monitored when they arrested shocked?
Single shock followed by 2 minutes of CPR
when are people with shockable rhythms who ARE being monitored when they arrest shocked?
up to 3 successive shocks THEN CPR
when is adrenaline given in ALS?
Adrenaline 1mg
ASAP - non-shockable rhythms
Shockable rhythms - after 3rd shock with chest compressions
THEN every 3-5 mins
when should amiodarone be given in ALS?
300mg after 3rd shock in shockable rhythms
PLUS 150mg after 5th shock
lidocaine can be used as alternative
what are 8 reversible causes of cardiac arrest?
4Hs and 4Ts
Hypoxia
Hypovolaemia
Hyperkalaemia,
Hypokalaemia, Hypoglycaemia, Hypocalcaemia, acidaemia and metabolic disorders
Hypothermia
Thrombosis - coronary or pulmonary
Tension pneumothorax
Tamponade, cardiac
Toxins
what classes as sustained VT?
> 30 seconds of wide complex ventricular ectopic beats
or requiring intervention due to haemodynamic compromise
what are 2 different types of VT?
Monomorphic - most commonly caused by MI
Polymorphic - torsades de points
what are 3 causes of VT?
Re-entry - due to two conduction pathways usually due to myocardia scaring after MI
Triggered activities - early or late after-depolarisations - torsades de pointes or digoxin toxicity
Abnormal automaticity
what is brugada’s sign?
In ventricular tachycardia
distance from onset QRS to nadir (base) of S-wave >0.1s
What is usually seen in ventricular tachycardia (VT) on ECG? (6)
Broad QRS complexes - >0.12 (usually >0.2s)
Usually uniform (monomorphic)
Brugada’s sign - distance from onset QRS to nadir of S-wave >0.1s
Josephson’s sign - notching near nadir of S wave
RSR’ Complexes - complexes with taller LEFT rabbit ears
Extreme axis deviation - northwest axis
capture or fusion beats
what is josephson’s sign?
In ventricular tachycardia
notching near nadir of S wave
what is the management of ventricular tachycardia?
Unstable - DC cardioversion up to 3x, then IV amiodarone hydrochloride
Stable
1 - amiodarone hydrochloride - initially 300mg then 150mg if required
2 - flecainide acetate, propafenone hydrochloride.
Catheter ablation can be used if indicated and non-urgent
what is torsade de pointes?
ventricular tachycardia with QRS complexes which vary in amplitude axis and duration along with long QT
Can deteriorate to Vfib
what should the QT interval be?
Men - QTc should be <440ms
Women - QTc should be <460ms
QTc should not be <350ms
what are 2 congenital syndromes that can cause long QT?
Jervell-Lange-Neilsen syndrome
Romano-ward syndrome
QTc over what increases risk of torsades de pointes?
> 500ms
what is the management of torsades de pointes and polymorphic VT?
1 - IV magnesium sulfate
2g over 10-15 mins
correct underlying cause
defibrillation if VT occurs
what are 4 electrolyte imbalances that can lead to long QT?
hypokalaemia
hyperkalaemia
hypomagnesaemia
hypocalcaemia
what are 6 medications that can cause long QT?
Antipsychotics
Citalopram and escitalopram
Flecainide
Amiodarone
Macrolide Abx
Ondansetron
what is atrial flutter?
A type of SVT with rapid regular atrial depolarisation due to reentrant circuits most commonly in the cavotricuspid isthmus of R atrium
Atrial rhythm usually around 300/min with ventricular rhythm being around 150/min
what are 5 risk factors for atrial flutter?
Structural heart disease
hypertension
diabetes
Hx of AF
what is the appearance of Atrial flutter on ECG?
regular sawtooth - due to repeated P waves between QRS complexes - often 2 p waves between every QRS
Narrow complex tachycardia - around 150/min
what is the management of atrial flutter?
Medical -B blockers, Ca channel blockers, digoxin
anticoagulation - CHADSVASc
Radiofrequency ablation of accessory pathways
what is supraventricular tachycardia?
ventricle electrical activity re-enters the atria then passes through AV node to re-enter ventricles again causing another ventricular contraction leading to a self [perpetuating loop without an end point
what are 6 risk factors for SVT?
Increased age
Female
Hyperthyroidism
Smoking, alcohol, caffeine
Stress
Meds - salbutamol, atropine, decongestants, cocaine, methamphetamines
what is seen on ECG with supraventricular tachycardia (SVT)?
narrow complex tachycardia (<0.12s)
P waves often buried in QRS complexes so not visible
Sudden onset and less variable rate than sinus tachy
what are 3 causes of SVT?
atrioventricular nodal re-entry tachycardia - most common
Atrioventricular re-entry tachycardia (due to accessory pathway - WPW)
Junctional tachycardias - abnormally generated accelerated rhythm from AV node
what is the management of SVT?
1 - Vasovagal manoeuvres
2 - Adenosine 6mg IV - give centrally if pos, then 12mg, then 18mg
3 - verapamil or beta blocker
4 - synchronised DC cardioversion
who cannot have Adenosine?
ASTHMATICS
Use verapamil instead
what is the management of SVT in a haemodynamically unstable patient?
Synchronised DC cardioversion
under sedation/GA
what is the secondary prevention of SVT?
Beta-blockers
Radio-frequency ablation
what are the 4 different types of junctional rhythms?
Junctional bradycardia - <40bpm
Junctional escape rhythm - 40-60 bpm
Accelerated junctional rhythm - 60-100 bpm
Junctional tachycardia - >100bpm
what causes junctional rhythms?
Reduced function of SA node causing the AV node to be the primary pace maker of the heart
Myocardial ischaemia, myocarditis, digoxin toxicity, cardiac surgery, beta-agonists, hyperkalaemia
what does Ventricular fibrillation look like on ECG?
Rapid, chaotic irregular deflections varying in amplitude without identifiable PQRST waves
rate 150-500/min
Amplitude decreases with duration eventually to asystole
what are 7 causes of ventricular fibrillation?
electric shock
ischaemia/hypoxia
electrolyte abnormality - low K+/Mg2+
altered autonomic and vagal inputs
mechanical stimuli
congenital susceptability
acquired disorders - ischaemia, hypertrophy, myocarditis
what is the management of V fib?
defibrillation - non-synchronised
Correction of cause
CPR
what are 5 features of hypokalaemia on ECG?
U waves (after T wave)
Small/absent/biphasic T waves
prolonged PR interval
ST depression
Long QT
what are 4 features of digoxin toxicity on ECG?
down sloping ST depression - reverse tick
Flattened/inverted T waves
short QT (<360ms)
Arrythmias
what are 5 ECG findings in hyperkalaemia?
Peaked/tall tented T waves (>2.5 squares in limb leads or >1.4 in chest)
Loss of P waves
Broad QRS complexes (>100ms)
Sinusoidal wave pattern
V-fib
what is 1st degree heart block?
where they is delay in AV node conduction
Every P wave followed by QRS
PR interval >0.2 seconds (200ms)
what is 2nd degree heart block Type 1?
Atrial impulses take progressively longer to get through AV node leading to increasing PR interval until P wave not followed by QRS, then returns to normal and repeats
what is 2nd degree heart block Mobitz type 2?
intermittent failure of conduction through AV node usually in a set ration of P waves to QRS complexes
at risk of asystole
what is 3rd degree heart block?
complete heart block
no relationship between P waves and QRS complexes
significant risk of asystole
what is the 1st line management of bradycardia with adverse signs?
Atropine 500 mcg IV
up to max 3mg
can occur with complete heart block and 2nd degree mobitz II HB
what is sick sinus syndrome?
dysfunction of SA node causing sinus bradycardia, sinus arrhythmias and prolonged pauses
often causes by idiopathic degenerative fibrosis of SA node
what are 4 risk factors for asystole?
Heart block Mobitz type 2
3rd degree Heart block
Previous asystole
Ventricular pauses longer than 3s
what is the management of an unstable patient at risk of asystole?
1 - IV atropine
2 - Inotropes
temporary cardiac pacing
permanent ICD when available
what are 2 options for temporary cardiac pacing?
Transcutaneous pacing with pads
Trans venous pacing with catheter fed though vein to directly stimulate heart
what is the MOA of atropine?
antimuscarinic that inhibits parasympathetic nervous system
Gives adrenaline like response
what are 4 side effects of atropine?
pupil dilation
dry mouth
urinary retention
constipation
what are 6 contraindications to adenosine?
Asthma
COPD
heart failure
heart block
severe hypotension
potential atrial arrhythmias with pre-excitation (WPW)
what is one side effect that you should ward the patient about when administering adenosine?
Feeling of impending doom/like dying
Passes quickly - half life only 10s
what is seen on ECG in left bundle branch block?
WiLLiaM
W in V1
M in V6
Broad QRS complexes
is new LBBB conserning?
YES - always pathological
what are 5 causes of LBBB?
MI
Hypertension
aortic stenosis
cardiomyopathy
rare - idiopathic fibrosis, digoxin toxicity, hyperkalaemia
what is sen on ECG in Right bundle branch block?
MaRRoW
M in V1
W in V6
AKA Bunny ears in V1 with larger Right ear
Broad QRS complexes
what are 7 causes of RBBB?
normal variation
right ventricular hypertrophy
cor pulmonale/chronic increased right ventricular pressure
pulmonary embolism
MI
ASD
Cardiomyopathy/myocarditis
what is bi-fascicular heart block?
RBBB with left anterior or posterior hemiblock
e.g. RBBB with left axis deviation
what is tri-fascicular heart block?
RBBB + left anterior or posterior hemi block + 1st degree heart block
what are 5 ECG changes in hypothermia?
bradycardia
J wave - small hump at end of QRS
1st degree heart block
long QT
atrial and ventricular arrythmias
what are the 8 reversible causes of cardiac arrest?
4Hs and 4Ts
Hypoxia
hypo/hyperkalaemia
Hypothermia/hyperthermia
Hypovolaemia
Tension pneumothorax
Tamponade
Thrombosis
Toxins
what is wolff-Parkinson-white syndrome?
presence of congenital accessory cardiac pathways leading to episodes of tachyarrythmia
what are 5 ECG signs in WPW syndrome?
Short PR interval < 120ms
Delta wave: slurring slow rise of initial portion of the QRS
Wide QRS > 110ms
Discordant ST-segment and T-wave changes (i.e. in the opposite direction to the major component of the QRS complex)
Pseudo-infarction patterns
what is the risk of WPW syndrome?
if concurrent AF, chaotic electrical activity may pass into ventricles leading to v-fib and posible cardiac arrest
what medications are contraindicated in WPW syndrome?
anti-arrhythmic medications (e.g., beta blockers, calcium channel blockers, digoxin and adenosine)
increase this risk of v-fib by reducing conduction through the AV node and promoting conduction through the accessory pathway
what is the management of WPW syndrome?
Radiofrequency ablation of accessory pathway
what are 4 features of AF?
irregularly irregular heart rate
Tachycardia
heart failure - due to impaired filling of ventricles during diastole
increased stroke risk
what are 5 causes of AF?
SMITH
Sepsis
Mitral valve pathology - stenosis or regurg
Ischaemic heart disease
Thyrotoxicosis
Hypertension
what are 2 lifestyle causes of AF?
Alcohol
Caffeine
what is the risk of stroke in AF?
5x that of a normal person
Around 5% risk per year
what are 5 symptoms of AF?
Palpitations
SOB
Dizziness/syncope
Symptoms of associated conditions - stroke, sepsis, thyrotoxicosis
Chest discomfort
what are ventricular ectopics?
benign premature ventricular beats caused by random electrical discharges outside atria - common in all age an healthy patients but more common in prev. heart conditions
How do ventricular ectopics appear on ECG?
random isolated abnormal broad QRS complexes on otherwise normal ECG
what is begeminy?
when every other beat is a ventricular ectopic
How are ventricular ectopics rate dependant?
Usually disappear with higher heart rate e.g. during exercise
what is the management of ventricular ectopics?
reassurance in otherwise healthy individuals
refer if symptomatic
May been Beta blockers for symptom management
what are 3 ecg findings in AF?
Absent p waves
narrow QRS complex tachycardia (<100ms)
irregularly irregular ventricular rhythm
how long can paroxysmal AF last?
anywhere from 30s to 48 hours
what are 2 valvular pathologies that can lead to AF?
mitral stenosis
mechanical heart valve
what are 3 respiratory risk factors of AF?
pneumonia
smoking
obstructive sleep apnoea
what are 5 signs of haemodynamic compromise in AF?
HR >150
BP <90 mmHg
Syncope/severe dizziness
SOB
Chest pain
what is the 1st/2nd/3rd line management of AF?
RATE CONTROL
1 - Beta blocker - atenolol or bisoprolol
2 - Ca Channel blocker - diltaliazem or verapamil - not in HF
3 - Digoxin - in sedentary people with persistent AF
when is rhythm control used in AF?
reversible cause for AF
New onset AF - within 48h
Heart failure caused by AF
Symptoms despite rate control
what are 3 medication that can be used for rhythm control in AF?
Beta blockers
dronedarone
amiodarone
when is immediate cardioversion used in AF?
AF present <48 hours
Life-threatening haemodynamic instability
what medications are used for pharmacological cardioversion in AF?
Flecainide
Amiodarone - 1st if structural heart disease
what needs to happen before delayed cardioversion?
Anticoagulation for at least 3 weeks
rate control while waiting
what 3 medications are used for long term rhythm control?
1 - Beta blockers
2 - Dronedarone
3 - Amiodarone - in HF
what medication can be used to stop AF in paroxysmal AF?
Flecainide
what are 2 options of ablation in AF if unable to control rate/rhythm?
Left atrial ablation
AV node ablation and permanent pace maker
what is an option for reducing stoke risk in AF if anticoagulation is contraindicated?
left atrial appendage occlusion
what scoring system is used to determine is risk of stroke/TIA in AF?
CHA2DS2-VASc
what medication is used for anticoagulation in AF?
1 - DOAC - apixaban, riveroxaban, edoxaban, dabigatran
2 - warfarin
what is the MOA of DOACs?
Apixaban, riveroxaban, edoxaban - Direct inhibitors of factor Xa
Dabigatran - direct thrombin inhibitor
what is the antidote for apixaban and rivaroxaban?
Andexanet alfa
what is the antidote for dabigatran?
idarucizumab
what are 3 indications for DOACs?
stroke prevention in AF
Tx of DVT and PE
Prophylaxis of VTE after hip/knee replacement
what is the MOA of Warfarin?
vitamin K antagonist
causes increased prothrombin time
what is the INR target for patients with AF on warfarin?
between 2-3
what is the antidote for warfarin?
Vitamin K
what foods can affect warfarin?
Leafy green veg
cranberry juice
alcohol
what CHA2DS2-VASc score needs anticoagulation?
> 1 in Men
2 in Women
what does CHA2DS2-VASc stand for?
Congestive heart failure
Hypertension
Age >75 (2)
Diabetes
Stroke or TIA (2)
Vascular disease
Age 65-74
Sex (female)
what score is used to assess bleeding risk in AF patients on anticoagulation?
ORBIT
what does ORBIT stand for?
Older age >75
Renal impairement (GFR<60)
Bleeding previously
Iron - low haemoglobin or haematocrit
Taking antiplatelets
what orbit score is high risk of bleeds?
> 4
what orbit score is medium risk of bleeds?
3
what is the normal blood pH?
7.35-7.45
what is normal paO2 on ABG?
10.7-13.3 kPa
what is normal PaCO2 on ABG?
4.7-6 kPa
what is normal HCO3 on ABG?
22-26 mmol/L
which is normal base excess on ABG?
-2 to +2
what is normal lactate on ABG?
0.5-1 mmol/L
How do you calculate anion gap?
(Na + K) - (Cl + HCO3)
what is the normal anion gap?
10-18 mmol/L
what does a raised bicarbonate on ABG indicate in respiratory acidosis?
chronic retainer of CO2 - bicarb is being produced as a buffer
when does respiratory alkalosis occur?
when a patient cannot get rid of enough CO2
when does respiratory alkalosis occur?
when patient has raises resp rate and removes too much CO2. High pH and Low PaCO2.
due to hyperventilation syndromes and pulmonary embolisms . In PE PaO2 will be low too!
what is the ABG picture in metabolic acidosis?
Low pH
Low bicarb
what are 4 causes of metabolic acidosis?
raised lactate - sepsis, hypoxia, shock
raised ketones - DKA, alcohol
Increased hydrogen ions - renal failure, type 1 renal tubular acidosis, rhabdo
reduced bicarb - diarrhoea, renal failure, type 2 renal tubular acidosis
Urate - renal failure
what is the ABG picture in metabolic alkalosis?
raised pH
Raised Bicarb
what are 3 mechanisms for metabolic alkalosis?
H+ loss through GI tract - vomiting
H+ loss due to increased activity of aldosterone > increased H+ excretion (Conn syndrome)
Renal loss of H+ ions - loop/thiazide diuretics, heart failure, nephrotic syndrome, cirrhosis
what are 5 causes of increased activity of aldosterone?
conn syndrome
liver cirrhosis
heart failure
loop diuretics
thiazide diuretics
what are 6 causes of respiratory alkalosis?
anxiety hyperventilation
PE
slicylate poisoning
CNS disorders
altitude
pregnancy
what are 5 causes of respiratory acidosis?
COPd
decompensation of asthma/pulmonary oedema
neuomuscular disease
obesity hypoventilation syndrome
sedatives - benzos, opioid overdose
what PaO2 is hypoxaemic?
<10kPa
<8kPa is severely hypoxaemic
wha are 4 causes of a high anion gap metabolic acidosis?
diabetic ketoacidosis
lactic acidosis
aspirin overdose
renal failure
what are 3 causes of a normal anion gap metabolic acidosis?
gastrointestinal losses of HCO3-
renal tubular disease
Addisons disease
what is the ratio of chest compressions to ventilations in adult ALS?
30 compressions to 2 ventilations
what is the 1st line delivery of drugs in cardiac arrest via?
IV
what is the 2nd line method of drug delivery in cardiac arrest?
Intraosseous (IO)
what medication should be given for non-shockable rhythms?
1mg Adrenaline ASAP
when is adrenaline given for shockable rhythms?
after 3rd shock once chest compressions have started
when should adrenaline be repeated in ALS?
1mg every 3-5 minutes
what should be given in shockable rhythms after the 3rd shock?
amiodarone 300mg
Further 150mg after 5 shocks
what medication can be used as an alternative to amiodarone in cardiac arrest?
lidocaine
what is the skin sensitisation theory of allergy?
there is a break in the infants skin that allergens from the environment cross and react with the immune system as foreign
the child doesn’t have exposure to the allergen through the GI tract so it is not recognised as safe
When the child encounters the allergen again a full immune response is launched due to being viewed as foreign
What classification system is used for hypersensitivity reactions?
Coombs and Gell
what is a type 1 hypersensitivity reaction and what antibody is involved?
IgE
trigger mast cell and basophil degranulation to release histamines and other cytokines. Causes immediate reaction - typical food allergy reaction
what is a type 2 hypersensitivity reaction?
IgG and IgM mediated
complement system dependant, leads to direct damage of local cells
Haemolytic disease of the newborn and transfusion reactions
take hours
what is a type 3 hypersensitivity reaction?
immune complexes accumulate and cause damage to local tissues
autoimmune conditions - SLE, RhA, Coeliac, HSP
takes days
what is a type 4 hypersensitivity reaction?
T lymphocytes are inappropriately activated causing inflammation and damage to local tissues
organ transplant rejection and contact dermatitis
takes days - 12-72 hours
what are 3 ways to test for allergies?
skin prick test
RAST testing - blood test for total and specific IgE
Food challenge
what is the gold standard for diagnosing allergy?
food challenge
what are 4 allergic symptoms?
urticaria
itching
angio-oedema - swelling around lips and eyes
Abdo pain
what are 6 symptoms indicating anaphylaxis in allergy?
SOB
wheeze
swelling of larynx and stridor
Tachycardia
Lightheadedness
Collapse - hypotension
What is the management of anaphylaxis?
ABCDE
Secure airway
provide O2 if required, salbutamol can help with wheeze
provide IV bolus
Lie patient flat for improved cerebral perfusion
look for flushing, angioedema, urticaria
IM Adrenaline 500micrograms (1:1000) in adults - repeat after 5 minutes
Antihistamines - chlorphenamine (4mg) or cetirizine (10mg)
what investigation can be used to confirm anaphylaxis?
serum mast cell tryptase within 6 hours
what are 5 risk factors which may require people with non-aphylactic allergies to have epipens?
asthma requiring ICS
poor access to medical treatment - rural
Adolescents who are high risk
Nut or insect sting allergies
significant co-morbidities like CVD
How are epipens administered?
Remove safety cap on non-needle end (blue on epipen)
Grip device in fist with needle pointing downwards (orange in epipen)
Administer injection to outer portion of mid thigh until device clicks - can be through clothes - hold in place for 3-10 seconds
remove device and massage area for 10 seconds
Phone ambulance
what is the management for anaphylaxis after 2 doses of IM adrenaline?
IV adrenaline
what dose of adrenaline is given to babies <6 months in anaphylaxis?
100-150 micrograms
0.1-0.15 ml 1 in 1000
what dose of adrenaline is given to 6 month - 6 years in anaphylaxis?
150 micrograms
0.15ml 1 in 1000
what dose of adrenaline is given to 6-12 year olds in anaphylaxis?
300 micrograms
0.3 ml 1 in 1000
what dose of adrenaline is given to adults and children >12 years in anaphylaxis?
500 micrograms
0.5ml 1 in 1000
what are 9 non diabetic causes of hypoglycaemia?
EXPLAINS H
Exogenous Drugs - diabetic drugs, alcohol, quinine, BetaB paracetamol and valporate overdose
Pituitary insufficiency/Post prandial hypoglycaemia
Liver disease
Addisons
Insulinoma/Immune hypoglycaemia/Infection
Non-pancreatic neoplasms / non-insulinoma pancreatogenous hypoglycaemia
Starvation and Malnutrition
Hypothyroidism - myxoedema coma
what is shock?
failure to perfuse and therefore adequately oxygenate vital organs
what are 6 signs of shock?
Hypotension
Tachycardia/brady with haemorrhage
Altered conscious level
Poor peripheral perfusion - >cap refill, cool peripheries, clammy, pale
Oliguria - due to decreased renal perfusion
Tachypnoea
what are the 4 types of shock?
Hypovolaemic
Cardiogenic
Obstructive
Distributive
what is hypovolaemic shock?
most common type caused by insufficient circulating volume
caused by blood loss, vomiting/dehydration, burns, DKA
what is class I haemorrhagic shock?
Blood loss <750ml
Normotensive, no symptoms, HR<100
what is class II haemorrhagic shock?
750-1500ml blood loss
HR>100, BP normal, raised RR, urine 20-30ml, anxious
Treat with IV fluids
what is class III haemorrhagic shock?
1500-2000ml blood loss
HR>120, BP decreased, RR 30-40, urine 5-15ml
confused
Fluids and packed red cells
what is class IV haemorrhagic shock?
> 2000ml
HR>140, BP decreased, RR >35, urine <5ml, lethargic
Agressive IV fluids and Red cells
what is cardiogenic shock?
failure of heart to pump effectively leading to inadequate organ perfusion
what are 5 signs of cardiogenic shock?
distended jugular veins/increaed venous pressure
weak/absent pulse
Abnormal HR
pulsus paradoxus (often in tampenade)
reduced BP
SOB
what are 6 causes of cardiogenic shock?
MI
Dysrhythmias
Cardiomyopathies/myocarditis
Congestive heart failure
Myocardiac contusion
Valvular heart disease
what is obstructive shock?
shock due to physical obstruction of great vessels in systemic or pulmonary circulation
what are 7 causes of obstructive shock?
cardiac tamponade
constrictive pericarditis
tension pneumothorax
PE
aortic stenosis
Abdominal compartment syndrome
Hypertrophic sub-aortic stenosis
what is distributive shock?
inadequate end organ perfusion due to decreased BP de to dilation of blood vessels
what are 3 types of distributive shock?
Anaphylactic
Septic shock
Neurogenic shock
what is the mechanism for shock in sepsis and anaphylaxis?
widespread release of histamine in response to infection/allergen leading to widespread vasodilation, hypotension and increased capillary permeability
what is the mechanism of neurogenic shock?
Usually due to high spinal cord injury, there is a disruption to sympathetic chain leading to loss of vascular tone causing vasodilation and absence of reflex tachycardia
what are 4 endocrine causes of shock?
Hypothyroidism - can cause reduced cardiac out put and cardiogenic shock
thyrotoxicosis - may induce reversible cardiomyopathy
Acute adrenal insufficiency
Relative adrenal insuficiency - in critically ill patients where hormone levels are insufficient to meet higher demands of illness
what marker can be used to measure severity of shock?
lactate - measures level of tissue hypoxia
what is a normal lactate?
<2
severe if >4
what are resuscitation fluids?
500ml 0.9% NaCl over <15 mins
what is compartment syndrome?
A complication following fracture or re-perfusion injury characterised by raised pressure within a closed anatomical space (fascial compartment). The raised pressure eventually compromises tissue perfusion resulting in necrosis
what are the two main fractures that cause compartment syndrome?
supracondylar fractures
tibial shaft injuries
what is the management of compartment syndrome?
fasciotomies - repeated for debridement of necrotic tissue
what are the features of compartment syndrome?
5 Ps
- Pain - excessive and especially on movement
- Paraesthesia
- Pallor
- Palaysis
- Pressure is high
NOT PULSELESS
can you diagnose compartment syndrome on X-ray?
NO!
what can be used to measure compartment pressure in suspected compartment syndrome?
Needle manometry - measures resistance to injecting saline through needle into compartment
what is the initial management of compartment syndrome?
call ortho registrar or consultant
remove external dressings/bandage
Elevate leg to heart level
Maintaining good blood pressure
what can be a complication of fasciotomy?
myoglobinuria
require aggressive IV fluids
how quickly can muscle groups die in compartment syndrome?
within 4-6 hours
surgery should be within one hour of diagnosis
what are the usual intracompartmental pressures of fascia?
Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic
what is usually the cause of an extradural haematoma and what is the epidemiology?
Trauma - falls or fights
More common in males
Peak incidence - 20-30 years
what artery is often affected in extradural haematoma?
Middle meningeal artery
what is the thin portion of skull over the temporal region that often causes extradural haematomas called?
pterion
what is the classic presentation of subdural haematoma?
patient who initially loses and briefly regains consciousness then loses it again - called lucid interval
as hematoma expands uncus of temporal lobe herniates around tentorium cerebelli and patient develops fixed dilated pupil de to compression of parasympathetic fibres of CN3
what does extradural haematoma look like on CT?
biconvex hyperdense collection limited by suture lines of skull
what is the definitive management of extradural haematoma?
craniotomy and evacuation of haematoma
what patients are at risk for subdural haemorrhage?
elderly
alcoholics
due to brain atrophy and fragile bridging veins
what is the appearance of subdural haemorrhage on CT?
sickle/crescent shaped collection not limited by suture lines
Hyperdense (light) if acute and Hypodense (dark) if chronic
Can have mass effect and cause midline shift or herniation
what is the management of subdural haematoma?
Decompressive craniotomy
Surgical decompession with burr holes
What is the epidemiology of subarchnoid haemorrhages?
F > M
peak 40-50 years
what are 4 conditions associated with berry aneurysm?
hypertension
familial polycystic kidney disease
Ehlers-danlos syndrome
coarctation of the aorta
what are 6 features of Subarachnoid haemorrhage?
Headache - thunderclap, worst of life, reaching peak intensity in <5 mins
N+V
Meningism - photophobia, neck stiffness
Altered consciousness
Focal neurology - CN palsy, hemiparesis or hemiplegia, speech disturbance
Seizure
what are 4 examination findings in SAH?
subhyaloid haemorrhages on fundoscopy
Papilloedema - uncommon due to Raised ICP
+ve Kernig’s/Brudzinskis sign
Hypertension is common, hypotension is poor prognostic sign
what investigations should be done for SAH?
non-contrast CT head
LP - if CT >6 hours of onset and normal
CT intracranial angiogram
what can be seen on LP in SAH?
raised xanthochromia
when should LP be performed for SAH?
at least 12 hours following onset of symptoms
what medication can be used to PREVENT vasospasm in SAH?
oral nimodipine 60mg every 4 hours for 21 days
what medication can be used to TREAT vasospasm in SAH?
IV 0.5mg/hour or 1 mg/hour (weight dependant) increased to 2mg/hour
what is the management of SAH?
angiographical coiling by interventional radiologists
Craniotomy and surgical clip ligation
what are 5 complications of SAH?
re-bleeding - 10%
Hydrocephalus
Vasospasm
Hyponatraemia - due to SIADH
Seizure
what is the scoring for the glasgow coma scale?
MoVE
6, 5, 4
M6, V5, E4
what is the motor scoring for the GCS?
6 - obeys comands
5 - localises to pain
4 - withdraws from pain
3 - abnormal flexion to pain
2 - extending to pain
1 - no response
what is the verbal scoring for GCS?
5 - orientated
4 - confused
3 - inappropriate words
2 - sounds
1 - none
what is the eye opening scoring for GCS?
4 - spontaneous
3 - to speech
2 - to pain
1 - none
what are 10 risk factors for DVT?
Immobilisation
Inflammatory state - vasculitis, sepsis
Malignancy
Medication - Chemo, HRT, COCP
Obesity
Pregnancy
Previous VTE/FHx
Recent surgery/trauma
smoking
varicose veins
Polycythaemia
what is virchows triad?
Alteration in flow
Hyper-coagulability
Vessel wall injury/endothelial damage
what are 4 hereditary causes of hypercoagulability? (thrombophilias)
factor V leiden
Anti-thrombin 3 deficiency
protein S/C deficiency
Antiphospholipid syndrome
what are 6 features of DVT?
Pain in lower leg - cramping or throbbing, exacerbated by exertion
Swelling - either calves or entire leg, pitting oedema
Skin changes - pallor, cyanosis or diffuse erythema, distended superficial veins
Increased temp
tender solid calf
Tenderness on palpation of deel veins of leg
difference in size of calves - >3cm
what score can be used for DVT?
DVT Wells score
what are 10 features of wells score?
active cancer (1)
Paralysis/immobilised (1)
Bed ridden >3 days or surgery in last 12 weeks (1)
Deep vein tenderness (1)
Entire leg swollen (1)
Calf swelling >3cm larger (1)
Unilateral Pitting oedema (1)
collateral superficial veins (1)
prev DVT (1)
Alternative diagnosis at least as likely (-2)
what wells score signifies likely DVT?
> 2 inclusive
what is the management of DVT?
if unlikely on Well’s do D-Dimer
- if raised, then for leg vein USS
If likely on Well’s - do leg vein USS <4 hours if not available then D-Dimer + anticoagulation until available
what is the 1st line treatment of DVT or PE?
Apixaban 10mg OD for 10 days then 5mg BD
Rivaroxaban - 15mg BD for 21 days then 20mg OD
for 3 months then review
what is the management of DVT/PE in renal impairment and at what Cr clearance?
LMWH for 5 days - enoxaparin
then edoxaban or dabigatran (if CrCl >30)
if Cr clearance <15 ml/min
what is the management of DVT/PE in someone with antiphospholipid syndrome?
LMWH then Warfarin
what is post thrombotic syndrome?
complication of DVT leading to painful heavy calves, pruritus, swelling, varicose veins and venous ulceration
treated with compression stockings
what is the first line treatment for DVT in pregnancy?
LMWH - enoxaparin by weight
what is budd-chiari syndrome?
obstruction to outflow of blood from liver caused by thrombosis in hepatic veins or inferior vena cava
triad of - abdo pain, hepatomegaly, ascites
diagnosis - dopper USS
Tx - LMWH + warfarin, thrombolysis or angioplasty, liver transplant
How can paracetamol overdose present?
Usually asymptomatic
Nausea and vomiting
Coma
what are 6 presentations of aspirin (salicylate) overdose?
Hyperventilation
Tinnitus
Deafness
Vasodilation
Sweating
Coma
what can be seen on ABG in salicylate overdose?
mixed respiratory and metabolic alkalosis
Early resp centre stimulation leads to resp alkalosis but later acid effect of salicylates may lead to acidosis
what are 11 symptoms of tricyclic and related antidepressants overdose?
Dry mouth
seizure
coma
cardiac conduction defects
Arrythmias
Hypothermia
hypotension
hyperreflexia
extensor plantar response
Convulsions
resp failure
May have dilated pupils and urinary retention
what are 8 presentations of SSRI overdose?
nausea + vom
agitation
tremor
nystagmus
drowsiness
sinus tachy
convulsions
serotonin syndrome
what are 5 presentations of beta blocker overdose?
bradycardia
hypotension
syncope
conduction abnormalities
Heart failure
Coma and drowsiness
what are 4 presentations of iron overdose?
Nausea, vom, diarrhoea, abdo pain
Haematemesis and rectal bleeding
Hypotension
Hepatocellular necrosis
what are 7 presentations of lithium overdose?
Apathy and restlessness
Vomiting + diarrhoea
Ataxia
Tremor
weakness
dysarthria
Muscle twitching
electrolyte derangement, dehydration, convulsions - if severe
what are 6 presentations of benzo overdose?
Drowsiness
Dysarthria
Ataxia
Nystagmus
Resp depression
Coma
what is the presentation of antimalarial overdose?
rapid onset of life threatening arrythmias and intractable convulsions
what are 4 presentations of amphetamine overdose?
excessive activity and wakefulness
hallucinations
paranoia
hypertension
convulsions
hyperthermia
exhaustion
coma
what are 9 presentations of cocaine overdose?
Agitation
Hypertension
tachycardia
Dilated pupils
Hallucinations
Hyperthermia
hypertonia
hyperreflexia
Cardiac effects
what are 4 presentations of opioid overdose?
Drowsiness
Coma
Resp depression
Pinpoint pupils
what are 6 presentations of MDMA overdose?
Neuro - agitation, anxiety, confusion, ataxia
CV - Tahcy, hypertension
Hyponatraemia
Hyperthermia
Rhabdo
what is the presentation of lead poisoning?
Abdo pain
peripheral neuropathy - mainy motor
Neuropsychiatric eatures
fatigue
constipation
Blue lines on gum margins
what can be given within 1 hour of ingesting most poisons?
Activated charcoal
what is the antidote to opioid overdoe?
Naloxone
what is the antidote to benzo overdose?
Flumazenil - carries risk of seizure
what is the management of beta blocker overdose?
glucagon - for cardiogenic shock
Atropine - for brady
what is the management of calcium channel blocker overdose?
Calcium chloride
or
Calcium gluconate
what is the management of cocaine overdose?
Diazepam
what is the management of cyanide ingestion?
Dicobalt edetate
what is the management of methanol or ethylene glycol (antifreeze) ingestion?
1 - Fomepizole
OR
Ethanol
what is the presentation of carbon monoxide poisoning?
Headache
Nausea and vom
vertigo
confusion
subjective weakness
what is normal carbon monoxide levels?
<3% - non smokers
<10% - smokers
what is the management of carbon monoxide poisoning?
100% oxygen
hyperbaric oxygen
what may reduce risk of seizures in tricyclic antidepressant overdose?
IV bicarbonate
Ultimately dialysis
what is the management of iron overdose?
Desferrioxamine
what is the management of lead poisoning?
Dimercaprol
Calcium edetate
what is the management of salicylate overdose?
Urinary alkalinization with IV sodium bicarbonate
Haemodialysis
what medication is given in paracetamol overdose?
n-acetylcysteine
who should be given n-acetylcysteine in paracetamol overdose?
Plasma conc above treatment line
Staggered overdose
Presentation 8-24 hours after ingestion of >150mg/kg
Presentation >24h after ingestion with symptoms of hepatic impairment
how quickly is NAC transfused?
1 hour
what is 1 adverse effect of NAC?
non-IgE mediated anaphylactoid reaction
what criteria can be used to assess need for liver transplant with paracetamol overdose?
King’s college criteria for acetaminophen toxicity
what are the 4 King’s college criteria for liver transplant?
Arteria pH <7.3 24 hours after ingestion
PT Time >100s
Creatinine >300
grate III/IV encephalopathy
what are 6 features of organophosphate poisoning (insecticide)?
SLUD
Salivation
Lacrimation
urination
Defecation/diarrhoea
CV - hypotension. bradycardia
Small pupils and muscle fasiculations
what is the management of organophosphate poisoning?
Atropine
what is the triad of DKA?
Hyperglycaemia
Acidosis
Ketonaemia
what are 7 risk factors for diabetic ketoacidosis?
Infection
Stopping insulin therapy
MI
Physiological stress - Trauma/surgery
Hypothyroid, Pancreatitis
Undiagnosed diabetes
Drugs - corticosteroids, diuretics, salbutamol
what is the pathophysiology of diabetic ketoacidosis?
No/reduced insulin => reduced glucose entry into cells => lipolysis => Elevated Free Fatty acids => oxidised in liver => ketone bodies => ketoacidosis
what are 7 presentations of diabetic ketoacidosis?
Acetone smelling breath (pear drops)
Polydipsia + polyurea
Nausea and Vomiting
Weight loss
Dehydration and hypotension
Altered consciousness
Kassmoul’s respiration (deep fast breathing)
What is the criteria for a diagnosis of DKA?
Hyperglycaemia BG >11 mmol/L
Ketosis - blood ketones >3 mmol/L or +++ urine dip
Acidosis - pH <7.3 or Bicarb <15 mmol/L
what is the dose of insulin infusion in DKA?
0.1 units/kg/h
what are 6 blood results that might be seen in DKA?
Acidotic
Hyperglycaemia
Ketonaemia
Low Bicarb
raised creatinine
raised potassium
what are 2 key complications of rapid correction of DKA?
Cerebral oedema
Arrythmia due to hypokalaemia
what is the management for cerebral oedema?
slowing IV fluids
IV mannitol
IV hypertonic saline
what is mild DKA?
pH 7.2- 7.29 or bicarbonate < 15 mmol/L. Assume 5%
dehydrationwh
what is moderate DKA?
pH 7.1-7.19 or bicarbonate < 10 mmol/L. Assume 7%
dehydration
what is severe DKA?
pH less than 7.1 or serum bicarbonate < 5 mmol/L.
Assume 10% dehydration
what fluids should be used in DKA?
0.9% sodium chloride
with 20 mmol potassium chloride in each 500ml
bag once insulin has started
what bolus should be given to clinically dehydrated (NOT SHOCKED) children in DKA?
10 ml/Kg 0.9% NaCl over 30 mins
ONLY ONE
Subtract fluid boluses from deficit in replacement
what bolus should be given to shocked children in DKA?
10 ml/kg 0.9% NaCl in <10 minutes
Do not subtract from total fluid deficit
when should 10% dextrose be added in DKA management?
Blood Glucose <14 mmol/L
when should potassium be replaced in DKA?
if between 3.5-5.5 (normal) due to insulin driving potassium into cells
what is the max infusion rate of potassium chloride?
20 mmol/hour
what is the maximum concentration of potassium chloride in an infusion?
No more than 40 mmol per 1L of solute
what rate should potassium be given in children?
0.2 mmol/kg/hour
MAX 20 mmol/hour
what is classed as DKA resolution?
pH >7.3
Blood ketones <0.6 mmol/L
Bicarb >15 mmol/L
what are 7 complications of DKA?
Gastric stasis
thromboembolism
Hypokalaemia
Arrythmias
Cerebral oedema
Hypoglycaemia
ARDS
AKI
How do you manage regular insulin in DKA?
continue long acting insulins
Discontinue short acting
How often should glucose, pH, bicarb, ketones and electrolytes be measured in DKA?
hourly (to 2 hourly)
what is the fluid bolus in shock in children?
10-20 ml/kg NaCl over <10 minutes
How are maintenance fluids calculated in children?
Holliday-segar formula - max 75kg
100ml/kg/day first 10kg
50 ml/kg/day 2nd 10 kg (10-20kg)
20 ml/kg/day >20kg
How are neonatal maintenance fluids calculated?
Day 0-1 = 50-60 ml/kg/day
Day 2 = 70-80 ml/kg/day
Day 3 = 80-100 ml/kg/day
Day 4 = 100-200 ml/kg/day
Day 5-28 = 120-150 ml/kg/day
what is the rate of adult maintenance fluids?
25-30 ml/kg/day
what is mild hypothermia?
32-35 degrees
what is moderate-severe hypothermia?
<32 degrees
what are 6 risk factors for hypothermia?
General anaesthesia
Substance abuse
hypothyroidism
impaired mental status
homelessness
extremes of age
what are 6 signs of hypothermia?
Shivering
Cold and pale skin, frostbite
Slurred speech
Tachypnoea, tachycardia, hypertension - mild
Respiratory depression, bradycardia, hypotension - Severe
Confusion and impaired mental state
what are 5 ECG changes seen in hypothermia?
Bradycardia
J-waves - small hump at end of QRS complex
1st degree heart block
Long QT
Atrial and ventricular arrythmias
what type of thermometers are used to measure core temperature?
Low reading rectal thermometers
Thermistor probes
what electrolyte disturbance can be caused by hypothermia?
hypokalaemia
what can be seen on FBC in hypothermia?
Elevated Hb and haematocrit
Low platelets and WBCs due to splenic sequestration
what is the initial management of hypothermia?
remove from cold environment and remove wet/cold clothing
warm with blankets
secure airway and monitor breathing
Warmed IV fluids or forced war air
what can rapid rewarming in hypothermia lead to?
peripheral vasodilation and shock
what is severe hyperthermia?
> 40 degrees
how can hyperthermia be managed?
surface cooling with water sprays, ice packs, coolign garments
Cold IV fluids
Paracetamol
Neuromuscular blockade if toxological cause (serotonin syndrome) or increased muscular activity (seizure)
what is the first aid management of a temperature burn?
Irrigate with cold water for 10-30 mins
Cover in layered cling film
How do you assess % of body affected by burns?
Wallace’s rule of 9s
Head and neck = 9%
1x arm = 9%
1x Anterior or Posterior leg = 9%
Anterior/posterior chest = 9%
Anterior/posterior abdo = 9%
what is the appearance of a superficial epidermal (1st degree) burn?
red and painful
Dry
no blister
what is the appearance of a partial thickness superficial dermal (2nd degree) burn?
Pale pink
Painful
Blistered
slow cap refill
what is the presentation of a partial thickness deep dermal (2nd degree) burn?
White
may have patches of non-blanching erythema
Reduced sensation
Painful to deep pressure
what is the presentation of a full thickness burn?
white - waxy
brown -leathery
black
no blisters
no pain
who with burns should be referred to secondary care?
All dermal and full thickness burns
superficial dermal burns more than 3% TBSA in adults or 2% in children
Burns involving face, hands, feet, perineum, genitalia, flexures or circumferential burns
Inhalation injuries
Electrical or chemical burns
Suspension of NAI
what is the initial management of superficial dermal burns?
cleanse wounds
leave blisters intact
non-adherent dressing
avoid creams
review in 24 hours
what is the management of suspected airway burns or smoke inhalation airway oedema?
Intubation
at what total body SA burns do children require IV fluids?
10%
at what total body SA burns do adults require IV fluids?
15%
what calculation is used to calculate how much fluid to give in burns?
Parkland formula for fluid requirements in 24 hours
total body SA of burn X weight (kg) X 4
Give 50% in first 8 hours then 50% in next 12 hours
what are 8 complications of extensive burns?
Haemolysis due to erythrocyte damage by heat
Plasma leakage
Hypovolaemic shock
Protein loss
Secondary infection
ARDS
Curlings ulcer - acute peptic stress ulcer
Compartment syndrome
what are 6 manifestations of dehydration?
Thirst
Dry mucous membranes
Hypotension
tachycardia
decreased skin turgor
altered mental status
what is sepsis?
life threatening organ dysfunction due to dysregulated host response to an infection
what is the pathophysiology of sepsis?
macrophages, lymphocytes and mast cells recognise pathogens and release cytokine, interleukin and TNF leading to systemic inflammation and NO release
Cytokines cause endothelial lining to be permeable leading to oedema and reduced circulating volume
coagulation system is also activated leading to thrombi formation and platelet/clotting factor consumption - DIC
there is inadequate perfusion leading to anaerobic respiration of cells and eventual lactic acidosis
what criteria can be used to assess severity of organ dysfunction in sepsis?
sepsis-related organ failure assessment SOFA
what parameters does the SOFA assessment look at?
Hypoxia
Increased O2 requirements
requiring mechanical ventilation
low platelets
reduced GCS
Raised bilirubin
Reduced BP
Raised creatinine
what does the quick SOFA assessment take into consideration?
qSOFA
RR >22
Altered mentation
Systolic <100 mmHg
heightened risk >2
what are 10 red flags for sepsis?
Respond only to pain/voice/unresponsive
Acute confusion
Systolic <90
HR >130
RR >25
SpO2 <92%
Non-blanching rash, mottled, ashen, cyanotic
Not passing urine last 18h
Lactate >2
Recent Chemo
what are 10 amber flags for sepsis?
relatives concerned about mental status
acute deterioration in functional status
immunosuppression
trauma/surgery/procedure past 6 weeks
RR 21-24
Systolic 91-100 mmHg
HR 91-130
Not urinated last 12-18h
Temp <36 degrees
Clinical signs of wound, device or skin infection
what are the sepsis 6?
Give 3
- O2
- IV fluids
- Abx
Take 3
- Lactate
- Blood cultures
- Urine output (catheterise)
what are 6 risk factors for sepsis?
extremes of age
chronic conditions - COPd, diabetes
Chemo, immunosuppression or steroids
Surgery, recent trauma or burns
pregnancy and childbirth
indwelling medical devices - catheters or central lines
what are 9 medications that can cause neutropenic sepsis?
chemotherapy
clozapine
hydroxychloroquine
methotrexate
sulfasalazine
carbimazole
quinine
infliximab
rituximab
what are 3 characteristic features of shaken baby syndrome?
subdural haemorrhage
retinal haemorrhage
encephalopathy
what are 4 factors that point towards non-accidental injury??
story inconsistent with injuries
repeated A+E attendance
Delayed presentation
Frightened, withdrawn child
what are 6 possible presentation of child abuse?
bruising
fractures - metaphyseal, posterior rib, multiple fractures at different stages of healing
torn frenulum
burns or scalds
failure to thrive
sexually transmitted infections
what are 6 possible features of neglect?
severe persistent infections
parents not administering or obtaining treatment
parents who fail to attend appointments
failure to dress child in suitable clothing
animal bite on inadequately supervised child
Smelly and dirty child
what are 7 features of childhood physical abuse?
serious or unusual injury without suitable explanation
cold injuries and hypothermia
oral injury
bruising, lacerations or burns in non-mobile child
human bite mark not by young child
Fractures of different ages or occult fractures
retinal haemorrhages
what are 10 risk factors for abuse?
domestic violence
prev. abused parent
mental health problems
emotionally volatile household
social, psychological or economic stress
disability in child
learning disability in parents
alcohol misuse
substance misuse
non-engagement with services
what are 4 causes of hypernatraemia?
Ds
Dehydration
Drips - excessive saline
Drugs - effervescents with lots of sodium
Diabetes insipidus
what rate should hypernatremia be corrected?
no more than 0.5 mmol/h
what is mild hyponatraemia?
130-135
what is moderate hyponatraemia?
125-129
what is severe hyponatraemia?
<125 mmol/L
what are 5 causes hypovolaemic hyponatraemia?
Medication - thiazides
Endocrine - Primary adrenal insufficiency
Cerebral salt wasting
Severe diarrhoea/vomiting/sweating
3rd space losses
what are 3 causes hypervolemic hyponatraemia?
Heart failure
liver disease - cirrhosis with ascites
Kidney disease - AKI/CKD/nephrotic
what are 4 causes of euvolemic hypernatraemia?
Drugs - SSRIs, thiazide diuretics
SIADH
Endocrine - secondary adrenal insufficiency, hypothyroid (rare)
Psychogenic polydipsia
what are 5 causes of SIADH?
SIADH
Small cell lung cancer
Infection
Abscess
Drugs - carbamezapine, antipsychotics
Head injury
what can aid diagnosis in hyponatraemia?
urinary sodium
what is normal urinary sodium?
20
what causes high urinary sodium?
renal losses - diuretics, addisons, SIADH, hypothyroidism
what causes low urinary sodium in hyponatraemia?
extrarenal losses (D+V), burns
Psychogenic polydipsia
Nephrotic syndrome
what is classes as acute hyponatraemia?
onset <48h
what are 8 symptoms of hyponatraemia?
headache
lethargy
nausea and vom
dizziness
confusion
muscle cramps
seizure
coma
what is the management of hypovolaemic hyponatraemia?
0.9% saline - can give as trial => if sodium increases then hypovolaemic
If sodium falls => SIADH
what is the management of euvolemic hyponatraemia?
fluid restrict 500-1000ml /day
Consider - demeclocycline, vaptans - vasopressin/ADH receptor antagonists
what is the management of hypervolaemic nyponatraemia?
Fluid restrict 500-1000ml/day
Consider -
Loop diuretics
Vaptans - vasopressin/ADH receptor antagonists
what can be used in ITU to correct acute severe or symptomatic hyponatraemia?
Hypertonic saline (3%)
what is one serious complication of hyponatraemia treatment?
osmotic demyelination syndrome (central pontine myelinolysis)
how quickly can sodium levels be increased per day?
4-6 mmol/L in a 24h period
what are 6 features of osmotic demyelination syndrome?
dysarthria
dysphagia
paraparesis/quadriparesis
seizure
confusion
coma
what are 7 causes of hypomagnesaemia?
Drugs - diuretics, PPIs
TPN
Diarrhoea
Alcohol
Hypokalaemia
Hypercalcaemia
Metabolic disorders - Gitleman’s, Bartter’s
what are 7 features of hypomagnesaemia?
paraesthesia
tetany
seizure
arrythmias
decreased PTH secretion
ECG features similar to hypokalaemia
Exacerbates digoxin toxicity
what is the management of mild hypomagnesaemia?
> 0.4 mmol/L
Oral magnesium salts - 10-20 mmol PO divided doses
what is one side effect of oral magnesium salts?
diarrhoea
what is the management of severe hypomagnesaemia?
<0.4 mmol/L
IV magnesium - 40 mmol mag sulphate over 24h
what is the ECG presentation of a posterior MI?
Reciprocal changes in V1-3
Horizontal St depression
Tall broad R waves
upright T waves
dominant R wave in V2
