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Phase 4 > A+E > Flashcards

A+E Flashcards

1
Q

what are the 3 types of Acute coronary syndrome (ACS)?

A

Unstable Angina
ST-Elevation Myocardial infarction (STEMI)
Non-ST-elevation MI (NSTEMI)

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2
Q

where do the coronary arteries branch from?

A

the root of the aorta

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3
Q

what areas of the heart does the right coronary artery supply?

A

R Atrium
R ventricle
Inferior aspect of L ventricle
Posterior Septal area

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4
Q

what 2 vessels does the Left coronary artery split into?

A

circumflex artery
Left anterior descending (LAD)

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5
Q

what areas of the heart does the circumflex artery supply?

A

L atrium
Posterior aspect of L ventricle

curves around top, left and back of heart

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6
Q

what areas of the heart does the LAD supply?

A

anterior aspect of left ventricle
Anterior aspect of septum

travels down middle of heart

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7
Q

what are 6 presentations of ACS?

A

Central crushing chest pain radiating to jaw or arm
Nausea and vom
Sweaty and clammy
SOB
Palpitations
feeling of impending doom

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8
Q

How long do symptoms of ACS have to occur to be considered ACS?

A

> 15 mins at rest

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9
Q

who is at risk of silent MIs?

A

people with diabetes

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10
Q

what are 2 ECG changes seen in STEMIs?

A

ST segment elevation
New Left bundle branch block

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11
Q

what are 2 ECG changes seen in NSTEMIs?

A

ST segment depression
T wave inversion

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12
Q

what are pathological Q waves on ECG and when do they typically appear?

A

> 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

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13
Q

An infarct in the LCA would cause disruption in which leads?

A

Anterior and Lateral region =>

I
aVL
V3-6

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14
Q

An infarct in the LAD would cause disruption in which leads?

A

Septal/Anterior region =>

Leads V1-4

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15
Q

An infarct in the circumflex artery would cause disruption in which leads?

A

Lateral region

I
aVL
V5-6

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16
Q

An infarct in the RCA would cause disruption in which leads?

A

Inferior region =>

II
III
aVF

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17
Q

what are 5 conditions other than MI that can cause raised troponin?

A

CKD
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism

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18
Q

what are 6 investigations for ACS?

A

ECG
Troponin
Bloods - FBC, U+E, LFT, Lipids, Glucose
CXR - for other cause of CP
Echo - to assess damage
coronary angiogram

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19
Q

what causes a diagnosis of unstable angina?

A

symptoms of ACS with normal troponin and either a normal ECG or ST depression and T-wave inversion

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20
Q

What is the initial management of ACS?

A

MONA

Morphine - IV if needed
O2 if low sats
Nitrates - GTN
Aspirin - 300mg

Also perform ECG

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21
Q

what is the management of STEMI?

A

Percutaneous coronary intervention if available <2 hours since presentation

Fibrinolysis - if PCI unavailable <2 hours from presentation - with alteplase, streptokinase or tenecteplase

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22
Q

what is the medical management of NSTEMI?

A

BATMAN

Base decision for angiography/PCI on GRACE score
Aspirin 300mg stat
Ticagrelor - 180mg stat (clopi if bleed risk, prasugrel if angiography)
Morphine
Antithrombin therapy - fondaparinux
Nitrates - GTN

Oxygen if low sats

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23
Q

what scoring system can be used to asses risk of 6 month mortality in acs?

A

GRACE score

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24
Q

patients over what GRACE score are considered for angiography with PCI within 72 hours?

A

3% - medium to high risk

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25
Q

what is the secondary prevention for ACS?

A

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

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26
Q

what are 5 complications of MI?

A

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

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27
Q

what is Dressler’s syndrome?

A

usually 2-3 weeks after MI
caused by localised immune response that results in inflammation of pericardium causing pericarditis symptoms

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28
Q

How is dresslers syndrome diagnosed?

A

ECG - ST elevation, T wave inversion
ECHO - pericardial effusion
raised inflammatory markers

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29
Q

what is the management of dresslers syndrome?

A

NSAIDs
Steroids - if severe
pericardiocentisis may be required with significant pericardia effusion

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30
Q

what are the different types of MI?

A

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

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31
Q

What are the 3 KDIGO criteria for AKI?

A

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

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32
Q

what are 9 risk factors for AKI?

A

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

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33
Q

what are 5 medications that have nephrotoxic potential and should be stopped in AKI?

A

NSAIDs
Aminoglycosides - gentamicin
ACEi
ARBs
Diuretics

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34
Q

what are 3 medications that may need to be stopped in AKI due to increased risk of toxicity?

A

Metformin
Lithium
Digoxin

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35
Q

what are 3 pre-renal causes of AKI?

A

Dehydration
Shock
Heart failure
Medication - reducing BP, circulating volume, renal blood flow

Due to insufficient blood supply - hypoperfusion

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36
Q

what are 5 renal causes of AKI?

A

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

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37
Q

what are 5 post-renal causes of AKI?

A

Kidney stones
Tumours
strictures
BPH
neurogenic bladder

Due to obstructed outflow leading to back-flow

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38
Q

what is acute tubular necrosis?

A

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

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39
Q

what is the most common renal cause of AKI?

A

acute tubular necrosis

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40
Q

what is seen on urinalysis in acute tubular necrosis?

A

muddy brown casts

renal tubular epithelial cell may also be seen

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41
Q

what is the management of aki?

A

IV fluids
withhold medications that may worsen aki
withhold/adjust medications that are renally excreted
relieve the obstruction
Dialysis

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42
Q

what are 3 ways to avoid aki?

A

avoid nephrotoxic medications
ensure adequate fluid intake
additional fluids before and after radiocontrast

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43
Q

what are 4 complications of AKI?

A

Fluid overload, heart failure, pulmonary oedema
hyperkalaemia
metabolic acidosis
uraemia - can lead to encephalopathy an pericarditis

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44
Q

when should people with AKI be referred to urology? (4)

A

pyonephrosis
obstructed solitary kidney
bilateral upper urinary tract obstruction
complications of AKI caused by urological obstruction

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45
Q

When should people with AKI be referred for dialysis?

A

Any not responding to medical management:

Hyperkalaemia
metabolic acidosis
symptoms or complications of uraemia
fluid overload pulmonary oedema

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46
Q

what classification system is used in AKI?

A

KDIGO

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47
Q

What is stage one aki?

A

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

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48
Q

what is stage 2 AKI?

A

100-199% creatinine rise from baseline within 7 days

Urine output
<0.5ml/kg/hour over 12 hours

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49
Q

what is stage 3 AKI?

A

> 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

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50
Q

what are 3 unmodifiable risk factors for ACS?

A

Increasing age - peak incidence 60-70
Male
Fhx

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51
Q

What are 5 modifiable risk factors for acs?

A

smoking
diabeted mellitus
hypertension
hypercholesterolaemia
obesity

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52
Q

What is the criteria for STEMI?

A

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

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53
Q

What is the criteria for PCI in STEMI?

A

presentation <12 hours since onset of symptoms and PCI available within 120 mins

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54
Q

what is the criteria for thrombolysis in STEMI?

A

within 12 hours of symptom onset if PCI cannot be given within 120 mins of presentation

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55
Q

what antiplatelets are used prior to PCI?

A

ASPIRIN +

Parasugrel if patient not on anticoagulant

Clopidogrel if patient is on anticoagulant

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56
Q

what are 5 investigations that can be done for AKI?

A

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

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57
Q

what 5 medications should be stopped in AKI due to worsening renal function?

A

NSAIDs
Aminoglycosides
ACEi
ARBs
Diuretics

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58
Q

what 3 medications may need to be stopped in AKI due to increased risk of toxicity?

A

Metformin
Lithium
Digoxin

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59
Q

what are the 2 shockable rhythms in a pulseless patient?

A

ventricular tachycardia (VT)

Ventricular fibrillation (VFib)

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60
Q

what are the 2 non-shockable rhythms in pulseless patient?

A

pulseless electrical activity
Asystole

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61
Q

what is a narrow QRS complex?

A

<0.12s - 3 little squares

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62
Q

what are 4 causes of narrow complex tachycardias?

A

sinus tachycardia

supra ventricular tachycardia (SVT)

atrial fibrillation (AF)

atrial flutter

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63
Q

what are 4 causes of broad complex tachycardias?

A

ventricular tachycardia - regular

polymorphic ventricular tachycardia - torsades de pointes - irregular

atrial fibrillation with bundle branch block - irregular

supra ventricular tachycardia with bundle branch block

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64
Q

what is a broad QRS complex?

A

> 0.12s - 3 small squares

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65
Q

when are people with shockable rhythms who were not being monitored when they arrested shocked?

A

Single shock followed by 2 minutes of CPR

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66
Q

when are people with shockable rhythms who ARE being monitored when they arrest shocked?

A

up to 3 successive shocks THEN CPR

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67
Q

when is adrenaline given in ALS?

A

Adrenaline 1mg

ASAP - non-shockable rhythms

Shockable rhythms - after 3rd shock with chest compressions

THEN every 3-5 mins

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68
Q

when should amiodarone be given in ALS?

A

300mg after 3rd shock in shockable rhythms

PLUS 150mg after 5th shock

lidocaine can be used as alternative

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69
Q

what are 8 reversible causes of cardiac arrest?

A

4Hs and 4Ts

Hypoxia
Hypovolaemia

Hyperkalaemia,
Hypokalaemia, Hypoglycaemia, Hypocalcaemia, acidaemia and metabolic disorders

Hypothermia

Thrombosis - coronary or pulmonary
Tension pneumothorax
Tamponade, cardiac
Toxins

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70
Q

what classes as sustained VT?

A

> 30 seconds of wide complex ventricular ectopic beats

or requiring intervention due to haemodynamic compromise

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71
Q

what are 2 different types of VT?

A

Monomorphic - most commonly caused by MI

Polymorphic - torsades de points

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72
Q

what are 3 causes of VT?

A

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

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73
Q

what is brugada’s sign?

A

In ventricular tachycardia

distance from onset QRS to nadir (base) of S-wave >0.1s

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74
Q

What is usually seen in ventricular tachycardia (VT) on ECG? (6)

A

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

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75
Q

what is josephson’s sign?

A

In ventricular tachycardia

notching near nadir of S wave

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76
Q

what is the management of ventricular tachycardia?

A

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

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77
Q

what is torsade de pointes?

A

ventricular tachycardia with QRS complexes which vary in amplitude axis and duration along with long QT

Can deteriorate to Vfib

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78
Q

what should the QT interval be?

A

Men - QTc should be <440ms
Women - QTc should be <460ms

QTc should not be <350ms

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79
Q

what are 2 congenital syndromes that can cause long QT?

A

Jervell-Lange-Neilsen syndrome

Romano-ward syndrome

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80
Q

QTc over what increases risk of torsades de pointes?

A

> 500ms

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81
Q

what is the management of torsades de pointes and polymorphic VT?

A

1 - IV magnesium sulfate
2g over 10-15 mins

correct underlying cause
defibrillation if VT occurs

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82
Q

what are 3 electrolyte imbalances that can lead to long QT?

A

hypokalaemia
hyperkalaemia
hypomagnesaemia
hypocalcaemia

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83
Q

what are 6 medications that can cause long QT?

A

Antipsychotics
Citalopram and escitalopram
Flecainide
Amiodarone
Macrolide Abx
Ondansetron

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84
Q

what is atrial flutter?

A

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

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85
Q

what are 5 risk factors for atrial flutter?

A

Structural heart disease
hypertension
diabetes
Hx of AF

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86
Q

what is the appearance of Atrial flutter on ECG?

A

regular sawtooth - due to repeated P waves between QRS complexes - often 2 p waves between every QRS

Narrow complex tachycardia - around 150/min

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87
Q

what is the management of atrial flutter?

A

Medical -B blockers, Ca channel blockers, digoxin

anticoagulation - CHADSVASc

Radiofrequency ablation of accessory pathways

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88
Q

what is supraventricular tachycardia?

A

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

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89
Q

what are 6 risk factors for SVT?

A

Increased age
Female
Hyperthyroidism
Smoking, alcohol, caffeine
Stress
Meds - salbutamol, atropine, decongestants, cocaine, methamphetamines

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90
Q

what is seen on ECG with supraventricular tachycardia (SVT)?

A

narrow complex tachycardia (<0.12s)

P waves often buried in QRS complexes so not visible

Sudden onset and less variable rate than sinus tachy

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91
Q

what are 3 causes of SVT?

A

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

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92
Q

what is the management of SVT?

A

1 - Vasovagal manoeuvres

2 - Adenosine 6mg IV - give centrally if pos, then 12mg, then 18mg

3 - verapamil or beta blocker

4 - synchronised DC cardioversion

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93
Q

who cannot have Adenosine?

A

ASTHMATICS

Use verapamil instead

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94
Q

what is the management of SVT in a haemodynamically unstable patient?

A

Synchronised DC cardioversion

under sedation/GA

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95
Q

what is the secondary prevention of SVT?

A

Beta-blockers
Radio-frequency ablation

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96
Q

what are the 4 different types of junctional rhythms?

A

Junctional bradycardia - <40bpm
Junctional escape rhythm - 40-60 bpm
Accelerated junctional rhythm - 60-100 bpm
Junctional tachycardia - >100bpm

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97
Q

what causes junctional rhythms?

A

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

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98
Q

what does Ventricular fibrillation look like on ECG?

A

Rapid, chaotic irregular deflections varying in amplitude without identifiable PQRST waves

rate 150-500/min

Amplitude decreases with duration eventually to asystole

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99
Q

what are 7 causes of ventricular fibrillation?

A

electric shock
ischaemia/hypoxia
electrolyte abnormality - low K+/Mg2+
altered autonomic and vagal inputs
mechanical stimuli
congenital susceptability
acquired disorders - ischaemia, hypertrophy, myocarditis

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100
Q

what is the management of V fib?

A

defibrillation - non-synchronised

Correction of cause
CPR

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101
Q

what are 5 features of hypokalaemia on ECG?

A

U waves (after T wave)
Small/absent/biphasic T waves
prolonged PR interval
ST depression
Long QT

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102
Q

what are 4 features of digoxin toxicity on ECG?

A

down sloping ST depression - reverse tick
Flattened/inverted T waves
short QT (<360ms)
Arrythmias

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103
Q

what are 5 ECG findings in hyperkalaemia?

A

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

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104
Q

what is 1st degree heart block?

A

where they is delay in AV node conduction
Every P wave followed by QRS

PR interval >0.2 seconds (200ms)

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105
Q

what is 2nd degree heart block Type 1?

A

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

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106
Q

what is 2nd degree heart block Mobitz type 2?

A

intermittent failure of conduction through AV node usually in a set ration of P waves to QRS complexes

at risk of asystole

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107
Q

what is 3rd degree heart block?

A

complete heart block
no relationship between P waves and QRS complexes

significant risk of asystole

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108
Q

what is the 1st line management of bradycardia with adverse signs?

A

Atropine 500 mcg IV

up to max 3mg

can occur with complete heart block and 2nd degree mobitz II HB

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109
Q

what is sick sinus syndrome?

A

dysfunction of SA node causing sinus bradycardia, sinus arrhythmias and prolonged pauses

often causes by idiopathic degenerative fibrosis of SA node

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110
Q

what are 4 risk factors for asystole?

A

Heart block Mobitz type 2
3rd degree Heart block
Previous asystole
Ventricular pauses longer than 3s

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111
Q

what is the management of an unstable patient at risk of asystole?

A

1 - IV atropine
2 - Inotropes

temporary cardiac pacing

permanent ICD when available

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112
Q

what are 2 options for temporary cardiac pacing?

A

Transcutaneous pacing with pads

Trans venous pacing with catheter fed though vein to directly stimulate heart

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113
Q

what is the MOA of atropine?

A

antimuscarinic that inhibits parasympathetic nervous system

Gives adrenaline like response

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114
Q

what are 4 side effects of atropine?

A

pupil dilation
dry mouth
urinary retention
constipation

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115
Q

what are 6 contraindications to adenosine?

A

Asthma
COPD
heart failure
heart block
severe hypotension
potential atrial arrhythmias with pre-excitation (WPW)

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116
Q

what is one side effect that you should ward the patient about when administering adenosine?

A

Feeling of impending doom/like dying

Passes quickly - half life only 10s

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117
Q

what is seen on ECG in left bundle branch block?

A

WiLLiaM

W in V1
M in V6

Broad QRS complexes

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118
Q

is new LBBB conserning?

A

YES - always pathological

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119
Q

what are 5 causes of LBBB?

A

MI
Hypertension
aortic stenosis
cardiomyopathy
rare - idiopathic fibrosis, digoxin toxicity, hyperkalaemia

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120
Q

what is sen on ECG in Right bundle branch block?

A

MaRRoW

M in V1
W in V6

AKA Bunny ears in V1 with larger Right ear

Broad QRS complexes

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121
Q

what are 7 causes of RBBB?

A

normal variation
right ventricular hypertrophy
cor pulmonale/chronic increased right ventricular pressure
pulmonary embolism
MI
ASD
Cardiomyopathy/myocarditis

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122
Q

what is bi-fascicular heart block?

A

RBBB with left anterior or posterior hemiblock

e.g. RBBB with left axis deviation

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123
Q

what is tri-fascicular heart block?

A

RBBB + left anterior or posterior hemi block + 1st degree heart block

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124
Q

what are 5 ECG changes in hypothermia?

A

bradycardia
J wave - small hump at end of QRS
1st degree heart block
long QT
atrial and ventricular arrythmias

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125
Q

what are the 8 reversible causes of cardiac arrest?

A

4Hs and 4Ts

Hypoxia
hypo/hyperkalaemia
Hypothermia/hyperthermia
Hypovolaemia

Tension pneumothorax
Tamponade
Thrombosis
Toxins

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126
Q

what is wolff-Parkinson-white syndrome?

A

presence of congenital accessory cardiac pathways leading to episodes of tachyarrythmia

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127
Q

what are 5 ECG signs in WPW syndrome?

A

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

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128
Q

what is the risk of WPW syndrome?

A

if concurrent AF, chaotic electrical activity may pass into ventricles leading to v-fib and posible cardiac arrest

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129
Q

what medications are contraindicated in WPW syndrome?

A

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

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130
Q

what is the management of WPW syndrome?

A

Radiofrequency ablation of accessory pathway

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131
Q

what are 4 features of AF?

A

irregularly irregular heart rate
Tachycardia
heart failure - due to impaired filling of ventricles during diastole
increased stroke risk

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132
Q

what are 5 causes of AF?

A

SMITH

Sepsis
Mitral valve pathology - stenosis or regurg
Ischaemic heart disease
Thyrotoxicosis
Hypertension

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133
Q

what are 2 lifestyle causes of AF?

A

Alcohol
Caffeine

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134
Q

what is the risk of stroke in AF?

A

5x that of a normal person
Around 5% risk per year

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135
Q

what are 5 symptoms of AF?

A

Palpitations
SOB
Dizziness/syncope
Symptoms of associated conditions - stroke, sepsis, thyrotoxicosis
Chest discomfort

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136
Q

what are ventricular ectopics?

A

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

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137
Q

How do ventricular ectopics appear on ECG?

A

random isolated abnormal broad QRS complexes on otherwise normal ECG

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138
Q

what is begeminy?

A

when every other beat is a ventricular ectopic

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139
Q

How are ventricular ectopics rate dependant?

A

Usually disappear with higher heart rate e.g. during exercise

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140
Q

what is the management of ventricular ectopics?

A

reassurance in otherwise healthy individuals

refer if symptomatic

May been Beta blockers for symptom management

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141
Q

what are 3 ecg findings in AF?

A

Absent p waves
narrow QRS complex tachycardia (<100ms)
irregularly irregular ventricular rhythm

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142
Q

how long can paroxysmal AF last?

A

anywhere from 30s to 48 hours

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143
Q

what are 2 valvular pathologies that can lead to AF?

A

mitral stenosis
mechanical heart valve

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144
Q

what are 3 respiratory risk factors of AF?

A

pneumonia
smoking
obstructive sleep apnoea

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145
Q

what are 5 signs of haemodynamic compromise in AF?

A

HR >150
BP <90 mmHg
Syncope/severe dizziness
SOB
Chest pain

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146
Q

what is the 1st/2nd/3rd line management of AF?

A

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

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147
Q

when is rhythm control used in AF?

A

reversible cause for AF
New onset AF - within 48h
Heart failure caused by AF
Symptoms despite rate control

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148
Q

what are 3 medication that can be used for rhythm control in AF?

A

Beta blockers
dronedarone
amiodarone

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149
Q

when is immediate cardioversion used in AF?

A

AF present <48 hours
Life-threatening haemodynamic instability

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150
Q

what medications are used for pharmacological cardioversion in AF?

A

Flecainide

Amiodarone - 1st if structural heart disease

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151
Q

what needs to happen before delayed cardioversion?

A

Anticoagulation for at least 3 weeks

rate control while waiting

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152
Q

what 3 medications are used for long term rhythm control?

A

1 - Beta blockers

2 - Dronedarone

3 - Amiodarone - in HF

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153
Q

what medication can be used to stop AF in paroxysmal AF?

A

Flecainide

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154
Q

what are 2 options of ablation in AF if unable to control rate/rhythm?

A

Left atrial ablation
AV node ablation and permanent pace maker

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155
Q

what is an option for reducing stoke risk in AF if anticoagulation is contraindicated?

A

left atrial appendage occlusion

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156
Q

what scoring system is used to determine is risk of stroke/TIA in AF?

A

CHA2DS2-VASc

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157
Q

what medication is used for anticoagulation in AF?

A

1 - DOAC - apixaban, riveroxaban, edoxaban, dabigatran

2 - warfarin

158
Q

what is the MOA of DOACs?

A

Apixaban, riveroxaban, edoxaban - Direct inhibitors of factor Xa

Dabigatran - direct thrombin inhibitor

159
Q

what is the antidote for apixaban and rivaroxaban?

A

Andexanet alfa

160
Q

what is the antidote for dabigatran?

A

idarucizumab

161
Q

what are 3 indications for DOACs?

A

stroke prevention in AF
Tx of DVT and PE
Prophylaxis of VTE after hip/knee replacement

162
Q

what is the MOA of Warfarin?

A

vitamin K antagonist

causes increased prothrombin time

163
Q

what is the INR target for patients with AF on warfarin?

A

between 2-3

164
Q

what is the antidote for warfarin?

A

Vitamin K

165
Q

what foods can affect warfarin?

A

Leafy green veg
cranberry juice
alcohol

166
Q

what CHA2DS2-VASc score needs anticoagulation?

A

> 1 in Men
2 in Women

167
Q

what does CHA2DS2-VASc stand for?

A

Congestive heart failure
Hypertension
Age >75 (2)
Diabetes
Stroke or TIA (2)

Vascular disease
Age 65-74
Sex (female)

168
Q

what score is used to assess bleeding risk in AF patients on anticoagulation?

A

ORBIT

169
Q

what does ORBIT stand for?

A

Older age >75
Renal impairement (GFR<60)
Bleeding previously
Iron - low haemoglobin or haematocrit
Taking antiplatelets

170
Q

what orbit score is high risk of bleeds?

A

> 4

171
Q

what orbit score is medium risk of bleeds?

A

3

172
Q

what is the normal blood pH?

A

7.35-7.45

173
Q

what is normal paO2 on ABG?

A

10.7-13.3 kPa

174
Q

what is normal PaCO2 on ABG?

A

4.7-6 kPa

175
Q

what is normal HCO3 on ABG?

A

22-26 mmol/L

176
Q

which is normal base excess on ABG?

A

-2 to +2

177
Q

what is normal lactate on ABG?

A

0.5-1 mmol/L

178
Q

How do you calculate anion gap?

A

(Na + K) - (Cl + HCO3)

179
Q

what is the normal anion gap?

A

10-18 mmol/L

180
Q

what does a raised bicarbonate on ABG indicate in respiratory acidosis?

A

chronic retainer of CO2 - bicarb is being produced as a buffer

181
Q

when does respiratory alkalosis occur?

A

when a patient cannot get rid of enough CO2

182
Q

when does respiratory alkalosis occur?

A

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!

183
Q

what is the ABG picture in metabolic acidosis?

A

Low pH
Low bicarb

184
Q

what are 4 causes of metabolic acidosis?

A

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

185
Q

what is the ABG picture in metabolic alkalosis?

A

raised pH
Raised Bicarb

186
Q

what are 3 mechanisms for metabolic alkalosis?

A

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

187
Q

what are 5 causes of increased activity of aldosterone?

A

conn syndrome
liver cirrhosis
heart failure
loop diuretics
thiazide diuretics

188
Q

what are 6 causes of respiratory alkalosis?

A

anxiety hyperventilation
PE
slicylate poisoning
CNS disorders
altitude
pregnancy

189
Q

what are 5 causes of respiratory acidosis?

A

COPd
decompensation of asthma/pulmonary oedema
neuomuscular disease
obesity hypoventilation syndrome
sedatives - benzos, opioid overdose

190
Q

what PaO2 is hypoxaemic?

A

<10kPa

<8kPa is severely hypoxaemic

191
Q

wha are 4 causes of a high anion gap metabolic acidosis?

A

diabetic ketoacidosis
lactic acidosis
aspirin overdose
renal failure

192
Q

what are 3 causes of a normal anion gap metabolic acidosis?

A

gastrointestinal losses of HCO3-
renal tubular disease
Addisons disease

193
Q

what is the ratio of chest compressions to ventilations in adult ALS?

A

30 compressions to 2 ventilations

194
Q

what is the 1st line delivery of drugs in cardiac arrest via?

A

IV

195
Q

what is the 2nd line method of drug delivery in cardiac arrest?

A

Intraosseous (IO)

196
Q

what medication should be given for non-shockable rhythms?

A

1mg Adrenaline ASAP

197
Q

when is adrenaline given for shockable rhythms?

A

after 3rd shock once chest compressions have started

198
Q

when should adrenaline be repeated in ALS?

A

1mg every 3-5 minutes

199
Q

what should be given in shockable rhythms after the 3rd shock?

A

amiodarone 300mg

Further 150mg after 5 shocks

200
Q

what medication can be used as an alternative to amiodarone in cardiac arrest?

A

lidocaine

201
Q

what is the skin sensitisation theory of allergy?

A

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

202
Q

What classification system is used for hypersensitivity reactions?

A

Coombs and Gell

203
Q

what is a type 1 hypersensitivity reaction and what antibody is involved?

A

IgE

trigger mast cell and basophil degranulation to release histamines and other cytokines. Causes immediate reaction - typical food allergy reaction

204
Q

what is a type 2 hypersensitivity reaction?

A

IgG and IgM mediated

complement system dependant, leads to direct damage of local cells

Haemolytic disease of the newborn and transfusion reactions

take hours

205
Q

what is a type 3 hypersensitivity reaction?

A

immune complexes accumulate and cause damage to local tissues

autoimmune conditions - SLE, RhA, Coeliac, HSP

takes days

206
Q

what is a type 4 hypersensitivity reaction?

A

T lymphocytes are inappropriately activated causing inflammation and damage to local tissues

organ transplant rejection and contact dermatitis

takes days - 12-72 hours

207
Q

what are 3 ways to test for allergies?

A

skin prick test
RAST testing - blood test for total and specific IgE
Food challenge

208
Q

what is the gold standard for diagnosing allergy?

A

food challenge

209
Q

what are 4 allergic symptoms?

A

urticaria
itching
angio-oedema - swelling around lips and eyes
Abdo pain

210
Q

what are 6 symptoms indicating anaphylaxis in allergy?

A

SOB
wheeze
swelling of larynx and stridor
Tachycardia
Lightheadedness
Collapse - hypotension

211
Q

What is the management of anaphylaxis?

A

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)

212
Q

what investigation can be used to confirm anaphylaxis?

A

serum mast cell tryptase within 6 hours

213
Q

what are 5 risk factors which may require people with non-aphylactic allergies to have epipens?

A

asthma requiring ICS
poor access to medical treatment - rural
Adolescents who are high risk
Nut or insect sting allergies
significant co-morbidities like CVD

214
Q

How are epipens administered?

A

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

215
Q

what is the management for anaphylaxis after 2 doses of IM adrenaline?

A

IV adrenaline

216
Q

what dose of adrenaline is given to babies <6 months in anaphylaxis?

A

100-150 micrograms

0.1-0.15 ml 1 in 1000

217
Q

what dose of adrenaline is given to 6 month - 6 years in anaphylaxis?

A

150 micrograms
0.15ml 1 in 1000

218
Q

what dose of adrenaline is given to 6-12 year olds in anaphylaxis?

A

300 micrograms

0.3 ml 1 in 1000

219
Q

what dose of adrenaline is given to adults and children >12 years in anaphylaxis?

A

500 micrograms

0.5ml 1 in 1000

220
Q

what are 9 non diabetic causes of hypoglycaemia?

A

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

221
Q

what is shock?

A

failure to perfuse and therefore adequately oxygenate vital organs

222
Q

what are 6 signs of shock?

A

Hypotension
Tachycardia/brady with haemorrhage
Altered conscious level
Poor peripheral perfusion - >cap refill, cool peripheries, clammy, pale
Oliguria - due to decreased renal perfusion
Tachypnoea

223
Q

what are the 4 types of shock?

A

Hypovolaemic
Cardiogenic
Obstructive
Distributive

224
Q

what is hypovolaemic shock?

A

most common type caused by insufficient circulating volume

caused by blood loss, vomiting/dehydration, burns, DKA

225
Q

what is class I haemorrhagic shock?

A

Blood loss <750ml

Normotensive, no symptoms, HR<100

226
Q

what is class II haemorrhagic shock?

A

750-1500ml blood loss

HR>100, BP normal, raised RR, urine 20-30ml, anxious

Treat with IV fluids

227
Q

what is class III haemorrhagic shock?

A

1500-2000ml blood loss

HR>120, BP decreased, RR 30-40, urine 5-15ml
confused

Fluids and packed red cells

228
Q

what is class IV haemorrhagic shock?

A

> 2000ml

HR>140, BP decreased, RR >35, urine <5ml, lethargic

Agressive IV fluids and Red cells

229
Q

what is cardiogenic shock?

A

failure of heart to pump effectively leading to inadequate organ perfusion

230
Q

what are 5 signs of cardiogenic shock?

A

distended jugular veins/increaed venous pressure
weak/absent pulse
Abnormal HR
pulsus paradoxus (often in tampenade)
reduced BP
SOB

231
Q

what are 6 causes of cardiogenic shock?

A

MI
Dysrhythmias
Cardiomyopathies/myocarditis
Congestive heart failure
Myocardiac contusion
Valvular heart disease

232
Q

what is obstructive shock?

A

shock due to physical obstruction of great vessels in systemic or pulmonary circulation

233
Q

what are 7 causes of obstructive shock?

A

cardiac tamponade
constrictive pericarditis
tension pneumothorax
PE
aortic stenosis
Abdominal compartment syndrome
Hypertrophic sub-aortic stenosis

234
Q

what is distributive shock?

A

inadequate end organ perfusion due to decreased BP de to dilation of blood vessels

235
Q

what are 3 types of distributive shock?

A

Anaphylactic
Septic shock
Neurogenic shock

236
Q

what is the mechanism for shock in sepsis and anaphylaxis?

A

widespread release of histamine in response to infection/allergen leading to widespread vasodilation, hypotension and increased capillary permeability

237
Q

what is the mechanism of neurogenic shock?

A

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

238
Q

what are 4 endocrine causes of shock?

A

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

239
Q

what marker can be used to measure severity of shock?

A

lactate - measures level of tissue hypoxia

240
Q

what is a normal lactate?

A

<2

severe if >4

241
Q

what are resuscitation fluids?

A

500ml 0.9% NaCl over <15 mins

242
Q

what is compartment syndrome?

A

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

243
Q

what are the two main fractures that cause compartment syndrome?

A

supracondylar fractures
tibial shaft injuries

244
Q

what is the management of compartment syndrome?

A

fasciotomies - repeated for debridement of necrotic tissue

245
Q

what are the features of compartment syndrome?

A

5 Ps
- Pain - excessive and especially on movement
- Paraesthesia
- Pallor
- Palaysis
- Pressure is high

NOT PULSELESS

246
Q

can you diagnose compartment syndrome on X-ray?

A

NO!

247
Q

what can be used to measure compartment pressure in suspected compartment syndrome?

A

Needle manometry - measures resistance to injecting saline through needle into compartment

248
Q

what is the initial management of compartment syndrome?

A

call ortho registrar or consultant
remove external dressings/bandage
Elevate leg to heart level
Maintaining good blood pressure

249
Q

what can be a complication of fasciotomy?

A

myoglobinuria

require aggressive IV fluids

250
Q

how quickly can muscle groups die in compartment syndrome?

A

within 4-6 hours

surgery should be within one hour of diagnosis

251
Q

what are the usual intracompartmental pressures of fascia?

A

Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic

252
Q

what is usually the cause of an extradural haematoma and what is the epidemiology?

A

Trauma - falls or fights

More common in males
Peak incidence - 20-30 years

253
Q

what artery is often affected in extradural haematoma?

A

Middle meningeal artery

254
Q

what is the thin portion of skull over the temporal region that often causes extradural haematomas called?

A

pterion

255
Q

what is the classic presentation of subdural haematoma?

A

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

256
Q

what does extradural haematoma look like on CT?

A

biconvex hyperdense collection limited by suture lines of skull

257
Q

what is the definitive management of extradural haematoma?

A

craniotomy and evacuation of haematoma

258
Q

what patients are at risk for subdural haemorrhage?

A

elderly
alcoholics

due to brain atrophy and fragile bridging veins

259
Q

what is the appearance of subdural haemorrhage on CT?

A

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

260
Q

what is the management of subdural haematoma?

A

Decompressive craniotomy

Surgical decompession with burr holes

261
Q

What is the epidemiology of subarchnoid haemorrhages?

A

F > M
peak 40-50 years

262
Q

what are 4 conditions associated with berry aneurysm?

A

hypertension
familial polycystic kidney disease
Ehlers-danlos syndrome
coarctation of the aorta

263
Q

what are 6 features of Subarachnoid haemorrhage?

A

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

264
Q

what are 4 examination findings in SAH?

A

subhyaloid haemorrhages on fundoscopy
Papilloedema - uncommon due to Raised ICP
+ve Kernig’s/Brudzinskis sign
Hypertension is common, hypotension is poor prognostic sign

265
Q

what investigations should be done for SAH?

A

non-contrast CT head

LP - if CT >6 hours of onset and normal

CT intracranial angiogram

266
Q

what can be seen on LP in SAH?

A

raised xanthochromia

267
Q

when should LP be performed for SAH?

A

at least 12 hours following onset of symptoms

268
Q

what medication can be used to PREVENT vasospasm in SAH?

A

oral nimodipine 60mg every 4 hours for 21 days

269
Q

what medication can be used to TREAT vasospasm in SAH?

A

IV 0.5mg/hour or 1 mg/hour (weight dependant) increased to 2mg/hour

270
Q

what is the management of SAH?

A

angiographical coiling by interventional radiologists
Craniotomy and surgical clip ligation

271
Q

what are 5 complications of SAH?

A

re-bleeding - 10%
Hydrocephalus
Vasospasm
Hyponatraemia - due to SIADH
Seizure

272
Q

what is the scoring for the glasgow coma scale?

A

MoVE

6, 5, 4

M6, V5, E4

273
Q

what is the motor scoring for the GCS?

A

6 - obeys comands
5 - localises to pain
4 - withdraws from pain
3 - abnormal flexion to pain
2 - extending to pain
1 - no response

274
Q

what is the verbal scoring for GCS?

A

5 - orientated
4 - confused
3 - inappropriate words
2 - sounds
1 - none

275
Q

what is the eye opening scoring for GCS?

A

4 - spontaneous
3 - to speech
2 - to pain
1 - none

276
Q

what are 10 risk factors for DVT?

A

Immobilisation
Inflammatory state - vasculitis, sepsis
Malignancy
Medication - Chemo, HRT, COCP
Obesity
Pregnancy
Previous VTE/FHx
Recent surgery/trauma
smoking
varicose veins
Polycythaemia

277
Q

what is virchows triad?

A

Alteration in flow
Hyper-coagulability
Vessel wall injury/endothelial damage

278
Q

what are 4 hereditary causes of hypercoagulability? (thrombophilias)

A

factor V leiden
Anti-thrombin 3 deficiency
protein S/C deficiency
Antiphospholipid syndrome

279
Q

what are 6 features of DVT?

A

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

280
Q

what score can be used for DVT?

A

DVT Wells score

281
Q

what are 10 features of wells score?

A

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)

282
Q

what wells score signifies likely DVT?

A

> 2 inclusive

283
Q

what is the management of DVT?

A

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

284
Q

what is the 1st line treatment of DVT or PE?

A

Apixaban 10mg OD for 10 days then 5mg BD

Rivaroxaban - 15mg BD for 21 days then 20mg OD

for 3 months then review

285
Q

what is the management of DVT/PE in renal impairment and at what Cr clearance?

A

LMWH for 5 days - enoxaparin

then edoxaban or dabigatran (if CrCl >30)

if Cr clearance <15 ml/min

286
Q

what is the management of DVT/PE in someone with antiphospholipid syndrome?

A

LMWH then Warfarin

287
Q

what is post thrombotic syndrome?

A

complication of DVT leading to painful heavy calves, pruritus, swelling, varicose veins and venous ulceration

treated with compression stockings

288
Q

what is the first line treatment for DVT in pregnancy?

A

LMWH - enoxaparin by weight

289
Q

what is budd-chiari syndrome?

A

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

290
Q

How can paracetamol overdose present?

A

Usually asymptomatic

Nausea and vomiting
Coma

291
Q

what are 6 presentations of aspirin (salicylate) overdose?

A

Hyperventilation
Tinnitus
Deafness
Vasodilation
Sweating
Coma

292
Q

what can be seen on ABG in salicylate overdose?

A

mixed respiratory and metabolic alkalosis

Early resp centre stimulation leads to resp alkalosis but later acid effect of salicylates may lead to acidosis

293
Q

what are 11 symptoms of tricyclic and related antidepressants overdose?

A

Dry mouth
seizure
coma
cardiac conduction defects
Arrythmias
Hypothermia
hypotension
hyperreflexia
extensor plantar response
Convulsions
resp failure

May have dilated pupils and urinary retention

294
Q

what are 8 presentations of SSRI overdose?

A

nausea + vom
agitation
tremor
nystagmus
drowsiness
sinus tachy
convulsions
serotonin syndrome

295
Q

what are 5 presentations of beta blocker overdose?

A

bradycardia
hypotension
syncope
conduction abnormalities
Heart failure

Coma and drowsiness

296
Q

what are 4 presentations of iron overdose?

A

Nausea, vom, diarrhoea, abdo pain
Haematemesis and rectal bleeding
Hypotension
Hepatocellular necrosis

297
Q

what are 7 presentations of lithium overdose?

A

Apathy and restlessness
Vomiting + diarrhoea
Ataxia
Tremor
weakness
dysarthria
Muscle twitching

electrolyte derangement, dehydration, convulsions - if severe

298
Q

what are 6 presentations of benzo overdose?

A

Drowsiness
Dysarthria
Ataxia
Nystagmus
Resp depression
Coma

299
Q

what is the presentation of antimalarial overdose?

A

rapid onset of life threatening arrythmias and intractable convulsions

300
Q

what are 4 presentations of amphetamine overdose?

A

excessive activity and wakefulness
hallucinations
paranoia
hypertension

convulsions
hyperthermia
exhaustion
coma

301
Q

what are 9 presentations of cocaine overdose?

A

Agitation
Hypertension
tachycardia
Dilated pupils
Hallucinations
Hyperthermia
hypertonia
hyperreflexia
Cardiac effects

302
Q

what are 4 presentations of opioid overdose?

A

Drowsiness
Coma
Resp depression
Pinpoint pupils

303
Q

what are 6 presentations of MDMA overdose?

A

Neuro - agitation, anxiety, confusion, ataxia
CV - Tahcy, hypertension
Hyponatraemia
Hyperthermia
Rhabdo

304
Q

what is the presentation of lead poisoning?

A

Abdo pain
peripheral neuropathy - mainy motor
Neuropsychiatric eatures
fatigue
constipation
Blue lines on gum margins

305
Q

what can be given within 1 hour of ingesting most poisons?

A

Activated charcoal

306
Q

what is the antidote to opioid overdoe?

A

Naloxone

307
Q

what is the antidote to benzo overdose?

A

Flumazenil - carries risk of seizure

308
Q

what is the management of beta blocker overdose?

A

glucagon - for cardiogenic shock
Atropine - for brady

309
Q

what is the management of calcium channel blocker overdose?

A

Calcium chloride
or
Calcium gluconate

310
Q

what is the management of cocaine overdose?

A

Diazepam

311
Q

what is the management of cyanide ingestion?

A

Dicobalt edetate

312
Q

what is the management of methanol or ethylene glycol (antifreeze) ingestion?

A

1 - Fomepizole
OR
Ethanol

313
Q

what is the presentation of carbon monoxide poisoning?

A

Headache
Nausea and vom
vertigo
confusion
subjective weakness

314
Q

what is normal carbon monoxide levels?

A

<3% - non smokers
<10% - smokers

315
Q

what is the management of carbon monoxide poisoning?

A

100% oxygen
hyperbaric oxygen

316
Q

what may reduce risk of seizures in tricyclic antidepressant overdose?

A

IV bicarbonate

Ultimately dialysis

317
Q

what is the management of iron overdose?

A

Desferrioxamine

318
Q

what is the management of lead poisoning?

A

Dimercaprol
Calcium edetate

319
Q

what is the management of salicylate overdose?

A

Urinary alkalinization with IV sodium bicarbonate

Haemodialysis

320
Q

what medication is given in paracetamol overdose?

A

n-acetylcysteine

321
Q

who should be given n-acetylcysteine in paracetamol overdose?

A

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

322
Q

how quickly is NAC transfused?

A

1 hour

323
Q

what is 1 adverse effect of NAC?

A

non-IgE mediated anaphylactoid reaction

324
Q

what criteria can be used to assess need for liver transplant with paracetamol overdose?

A

King’s college criteria for acetaminophen toxicity

325
Q

what are the 4 King’s college criteria for liver transplant?

A

Arteria pH <7.3 24 hours after ingestion
PT Time >100s
Creatinine >300
grate III/IV encephalopathy

326
Q

what are 6 features of organophosphate poisoning (insecticide)?

A

SLUD
Salivation
Lacrimation
urination
Defecation/diarrhoea

CV - hypotension. bradycardia
Small pupils and muscle fasiculations

327
Q

what is the management of organophosphate poisoning?

A

Atropine

328
Q

what is the triad of DKA?

A

Hyperglycaemia
Acidosis
Ketonaemia

329
Q

what are 7 risk factors for diabetic ketoacidosis?

A

Infection
Stopping insulin therapy
MI
Physiological stress - Trauma/surgery
Hypothyroid, Pancreatitis
Undiagnosed diabetes
Drugs - corticosteroids, diuretics, salbutamol

330
Q

what is the pathophysiology of diabetic ketoacidosis?

A

No/reduced insulin => reduced glucose entry into cells => lipolysis => Elevated Free Fatty acids => oxidised in liver => ketone bodies => ketoacidosis

331
Q

what are 7 presentations of diabetic ketoacidosis?

A

Acetone smelling breath (pear drops)
Polydipsia + polyurea
Nausea and Vomiting
Weight loss
Dehydration and hypotension
Altered consciousness
Kassmoul’s respiration (deep fast breathing)

332
Q

What is the criteria for a diagnosis of DKA?

A

Hyperglycaemia BG >11 mmol/L
Ketosis - blood ketones >3 mmol/L or +++ urine dip
Acidosis - pH <7.3 or Bicarb <15 mmol/L

333
Q

what is the dose of insulin infusion in DKA?

A

0.1 units/kg/h

334
Q

what are 6 blood results that might be seen in DKA?

A

Acidotic
Hyperglycaemia
Ketonaemia
Low Bicarb
raised creatinine
raised potassium

335
Q

what are 2 key complications of rapid correction of DKA?

A

Cerebral oedema
Arrythmia due to hypokalaemia

336
Q

what is the management for cerebral oedema?

A

slowing IV fluids
IV mannitol
IV hypertonic saline

337
Q

what is mild DKA?

A

pH 7.2- 7.29 or bicarbonate < 15 mmol/L. Assume 5%
dehydrationwh

338
Q

what is moderate DKA?

A

pH 7.1-7.19 or bicarbonate < 10 mmol/L. Assume 7%
dehydration

339
Q

what is severe DKA?

A

pH less than 7.1 or serum bicarbonate < 5 mmol/L.
Assume 10% dehydration

340
Q

what fluids should be used in DKA?

A

0.9% sodium chloride

with 20 mmol potassium chloride in each 500ml
bag once insulin has started

341
Q

what bolus should be given to clinically dehydrated (NOT SHOCKED) children in DKA?

A

10 ml/Kg 0.9% NaCl over 30 mins

ONLY ONE

Subtract fluid boluses from deficit in replacement

342
Q

what bolus should be given to shocked children in DKA?

A

10 ml/kg 0.9% NaCl in <10 minutes

Do not subtract from total fluid deficit

343
Q

when should 10% dextrose be added in DKA management?

A

Blood Glucose <14 mmol/L

344
Q

when should potassium be replaced in DKA?

A

if between 3.5-5.5 (normal) due to insulin driving potassium into cells

345
Q

what is the max infusion rate of potassium chloride?

A

20 mmol/hour

346
Q

what is the maximum concentration of potassium chloride in an infusion?

A

No more than 40 mmol per 1L of solute

347
Q

what rate should potassium be given in children?

A

0.2 mmol/kg/hour

MAX 20 mmol/hour

348
Q

what is classed as DKA resolution?

A

pH >7.3
Blood ketones <0.6 mmol/L
Bicarb >15 mmol/L

349
Q

what are 7 complications of DKA?

A

Gastric stasis
thromboembolism
Hypokalaemia
Arrythmias
Cerebral oedema
Hypoglycaemia
ARDS
AKI

350
Q

How do you manage regular insulin in DKA?

A

continue long acting insulins

Discontinue short acting

351
Q

How often should glucose, pH, bicarb, ketones and electrolytes be measured in DKA?

A

hourly (to 2 hourly)

352
Q

what is the fluid bolus in shock in children?

A

10-20 ml/kg NaCl over <10 minutes

353
Q

How are maintenance fluids calculated in children?

A

Holliday-segar formula - max 75kg

100ml/kg/day first 10kg
50 ml/kg/day 2nd 10 kg (10-20kg)
20 ml/kg/day >20kg

354
Q

How are neonatal maintenance fluids calculated?

A

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

355
Q

what is the rate of adult maintenance fluids?

A

25-30 ml/kg/day

356
Q

what is mild hypothermia?

A

32-35 degrees

357
Q

what is moderate-severe hypothermia?

A

<32 degrees

358
Q

what are 6 risk factors for hypothermia?

A

General anaesthesia
Substance abuse
hypothyroidism
impaired mental status
homelessness
extremes of age

359
Q

what are 6 signs of hypothermia?

A

Shivering
Cold and pale skin, frostbite
Slurred speech
Tachypnoea, tachycardia, hypertension - mild
Respiratory depression, bradycardia, hypotension - Severe
Confusion and impaired mental state

360
Q

what are 5 ECG changes seen in hypothermia?

A

Bradycardia
J-waves - small hump at end of QRS complex
1st degree heart block
Long QT
Atrial and ventricular arrythmias

361
Q

what type of thermometers are used to measure core temperature?

A

Low reading rectal thermometers
Thermistor probes

362
Q

what electrolyte disturbance can be caused by hypothermia?

A

hypokalaemia

363
Q

what can be seen on FBC in hypothermia?

A

Elevated Hb and haematocrit
Low platelets and WBCs due to splenic sequestration

364
Q

what is the initial management of hypothermia?

A

remove from cold environment and remove wet/cold clothing
warm with blankets
secure airway and monitor breathing
Warmed IV fluids or forced war air

365
Q

what can rapid rewarming in hypothermia lead to?

A

peripheral vasodilation and shock

366
Q

what is severe hyperthermia?

A

> 40 degrees

367
Q

how can hyperthermia be managed?

A

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)

368
Q

what is the first aid management of a temperature burn?

A

Irrigate with cold water for 10-30 mins

Cover in layered cling film

369
Q

How do you assess % of body affected by burns?

A

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%

370
Q

what is the appearance of a superficial epidermal (1st degree) burn?

A

red and painful
Dry
no blister

371
Q

what is the appearance of a partial thickness superficial dermal (2nd degree) burn?

A

Pale pink
Painful
Blistered
slow cap refill

372
Q

what is the presentation of a partial thickness deep dermal (2nd degree) burn?

A

White
may have patches of non-blanching erythema
Reduced sensation
Painful to deep pressure

373
Q

what is the presentation of a full thickness burn?

A

white - waxy
brown -leathery
black
no blisters
no pain

374
Q

who with burns should be referred to secondary care?

A

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

375
Q

what is the initial management of superficial dermal burns?

A

cleanse wounds
leave blisters intact
non-adherent dressing
avoid creams
review in 24 hours

376
Q

what is the management of suspected airway burns or smoke inhalation airway oedema?

A

Intubation

377
Q

at what total body SA burns do children require IV fluids?

A

10%

378
Q

at what total body SA burns do adults require IV fluids?

A

15%

379
Q

what calculation is used to calculate how much fluid to give in burns?

A

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

380
Q

what are 8 complications of extensive burns?

A

Haemolysis due to erythrocyte damage by heat
Plasma leakage
Hypovolaemic shock
Protein loss
Secondary infection
ARDS
Curlings ulcer - acute peptic stress ulcer
Compartment syndrome

381
Q

what are 6 manifestations of dehydration?

A

Thirst
Dry mucous membranes
Hypotension
tachycardia
decreased skin turgor
altered mental status

382
Q

what is sepsis?

A

life threatening organ dysfunction due to dysregulated host response to an infection

383
Q

what is the pathophysiology of sepsis?

A

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

384
Q

what criteria can be used to assess severity of organ dysfunction in sepsis?

A

sepsis-related organ failure assessment SOFA

385
Q

what parameters does the SOFA assessment look at?

A

Hypoxia
Increased O2 requirements
requiring mechanical ventilation
low platelets
reduced GCS
Raised bilirubin
Reduced BP
Raised creatinine

386
Q

what does the quick SOFA assessment take into consideration?

A

qSOFA
RR >22
Altered mentation
Systolic <100 mmHg

heightened risk >2

387
Q

what are 10 red flags for sepsis?

A

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

388
Q

what are 10 amber flags for sepsis?

A

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

389
Q

what are the sepsis 6?

A

Give 3
- O2
- IV fluids
- Abx

Take 3
- Lactate
- Blood cultures
- Urine output (catheterise)

390
Q

what are 6 risk factors for sepsis?

A

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

391
Q

what are 9 medications that can cause neutropenic sepsis?

A

chemotherapy
clozapine
hydroxychloroquine
methotrexate
sulfasalazine
carbimazole
quinine
infliximab
rituximab

Phase 4 (22 decks)

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