A&E, ANAETHETICS + PALLIATIVE Flashcards
END OF LIFE CARE
In terms of managing end of life care, what should be given for nausea and vomiting?
Haloperidol 0.5-1.5mg SC
do not repeat within 4 hrs, max dose 3mg in 24hrs
END OF LIFE CARE
In terms of managing end of life care, what should be given for agitation, anxiety, or dyspnoea?
Midazolam 2.5-5mg SC
do not repeat within 1hr, max 4 doses in 24hrs
if not in terminal phase of illness
1st line = haloperidol
other options = chlorpromazine + levomepromazine
END OF LIFE CARE
In terms of managing end of life care, what should be given for constipation?
Start with stimulant laxative (senna) as opiates decrease peristalsis or stool softener if not on opiates, if not suppositories, enemas, PR evacuation
END OF LIFE CARE
In terms of managing end of life care, what should be given for hiccups?
- chlorpromazine
- haloperidol + gabapentin also used
- dexamethasone if hepatic lesions
ANAPHYLAXIS
when would discharge after a minimum of 12 hours be considered?
- severe reaction requiring > 2 doses of IM adrenaline
- patient has severe asthma
- possibility of an ongoing reaction (e.g. slow-release medication)
- patient presents late at night
- patient in areas where access to emergency access care may be difficult
- observation for at 12 hours following symptom resolution
ANIMAL BITES
what is the most common isolated organism in animal bites?
Pasteurella multocida
HUMAN BITES
what are the most common organisms?
Streptococci spp.
Staphylococcus aureus
Eikenella
Fusobacterium
Prevotella
HIV and hep C should also be considered
BED BUGS
what is the causative organism?
Cimex hemipteru
BURNS
how do you assess the extent of burns?
Wallace’s Rule of Nines:
- head + neck = 9%,
- each arm = 9%,
- each anterior part of leg = 9%,
- each posterior part of leg = 9%,
- anterior chest = 9%,
- posterior chest = 9%,
- anterior abdomen = 9%,
- posterior abdomen = 9%
Lund and Browder chart: the most accurate method
- the palmar surface is roughly equivalent to 1% of total body surface area (TBSA).
- Not accurate for burns > 15% TBSA
BURNS
what is a superficial epidermal (1st degree burn)?
- red and painful
- dry
- no blisters
BURNS
what is a Partial thickness (superficial dermal) (2nd degree burn)?
- pale pink
- painful
- blistered
- slow CRT
BURNS
what is a Partial thickness (deep dermal) (2nd degree burn)?
- white
- may have patched of non-blanching erythema
- reduced sensation
- painful to deep pressure
BURNS
what is a full thickness (3rd degree burn)?
- white (waxy) / brown (leathery) / black in colour
- no blisters
- no pain
BURNS
how do you calculate the fluids required for burns?
parkland formula
volume = %SA burnt x weight (kg) x 4
half of fluid should be administered within first 8 hours
BURNS
how much fluid should be administered within the first 8 hours according to the parkland formula?
50% of all fluid calculated from parkland formula should be given within the first 8hrs
BURNS
what features would be suspicious for smoke inhalation?
- burning sensation in nose + throat
- productive cough
- stridor
- dyspnoea
- SOB
- wheeze
- hoarse voice
- accessory muscle usage
- headache
- cyanosis
- decreasing consciousness
ADVANCED LIFE SUPPORT
what are the reversible causes of cardiac arrest?
Hs + Ts
- hypoxia
- Hypovolaemia
- Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
- Hypothermia
- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Tamponade - cardiac
- Toxins
ACID-BASE ABNORMALITY
what are the different causes of metabolic acidosis?
NORMAL ANION GAP
- GI bicarbonate loss (diarrhoea, ureterosigmoidstomy, fistula
- renal tubular acidosis
- drugs (acetazolamide)
- ammonium chloride injection
- addisons disease
RAISED ANION GAP
- lactate (shock, hypoxia)
- ketones (DKA, alcohol)
- urate (renal failure)
- acid poisoning (salicylates, methanol)
ACID-BASE ABNORMALITY
what are the causes of metabolic alkalosis?
usually GI/renal
- vomiting/aspiration
- diuretics
- liquorice, carbenoxolone
- hypokalaemia
- primary hyperaldosteronism
- cushings syndrome
- Bartter’s syndrome
- congenital adrenal hyperplasia
ACID-BASE ABNORMALITY
what are the causes of respiratory acidosis?
Caused by inadequate alveolar ventilation, leading to CO2 retention
- COPD
- decompensation in other respiratory conditions (life-threatening asthma/pulmonary oedema)
- sedative drugs (benzodiazepines, opiate overdose)
- GBS
ACID-BASE ABNORMALITY
what are the causes of respiratory alkalosis?
caused by excessive alveolar ventilation, resulting in more CO2 than normal being exhaled.
- anxiety leading to hyperventilation
- PE
- salicylate poisoning
- CNS disorders (stroke, SAH, encephalitis)
- altitude
- pregnancy
ACID-BASE ABNORMALITY
what are the causes of mixed respiratory and metabolic acidosis?
cardiac arrest
multi-organ failure
ACID-BASE ABNORMALITY
what are the causes of mixed respiratory and metabolic alkalosis?
- liver cirrhosis in addition to diuretic use
- hyperemesis gravidarum
- excessive ventilation in COPD
CARBON MONOXIDE POISONING
what are the clinical features?
- headache
- nausea + vomiting
- vertigo
- confusion
- subjective weakness
severe toxicity = ‘pink’ skin + mucosa, hyperpyrexia, arrhythmias, extrapyramidal features, coma + death
CARBON MONOXIDE POISONING
what is the effect of carbon monoxide on the oxyhaemoglobin dissociation curve?
- shifts curve to the LEFT
- CO has greater affinity for Hb than O2
- Left shift = increased affinity of Hb to O2 so Hb holds onto O2 more tightly
- this reduces release of O2 at tissues, causing hypoxia
LEAD POISONING
what are the clinical features?
- abdominal pain
- peripheral neuropathy (mainly motor)
- neuropsychiatric features
- fatigue
- constipation
- blue lines on gum margin
(consider in questions giving combination of abdominal pain + neurological signs along with acute porphyria)
LEAD POISONING
what are the investigations?
- blood lead level (>10 mcg/dL)
- FBC = microcytic anaemia
- blood film = basophilic stippling + clover leaf morphology
- raised serum + urine levels of delta aminoaevulinic acid
LEAD POISONING
what is the management?
- dimercaptosuccinic acid (DMSA)
- D-penicillamine
- EDTA
- dimercaprol
LEAD POISONING
what is the pathophysiology?
lead poisoning results in defective ferrochelatase + ALA dehydratase function
ORGANOPHOSPHATE INSECTICIDE POISONING
what are the clinical features?
SLUD
- salivation
- lacrimation
- urination
- defecation/diarrhoea
- hypotension
- bradycardia
- small pupils
- muscle fasciculation
ORGANOPHOSPHATE INSECTICIDE POISONING
what is the pathophysiology?
- inhibition of acetylcholinesterase leads to upregulation of nicotinic + muscarinic cholinergic neurotransmission
ORGANOPHOSPHATE INSECTICIDE POISONING
what is the management?
- atropine
OVERDOSE
what is the management for ethylene glycol overdose?
fomepizole
OVERDOSE
what is the management for methanol poisoning?
fomepizole or ethanol
haemodialysis
OVERDOSE
what is the management of cyanide poisoning?
hydroxocobalamin
SEPSIS
what is the immediate management for suspected sepsis?
SEPSIS 6 (BUFFALO)
IN
- oxygen (titrate to 94-98%)
- IV fluids (crystalloid bolus 500ml over 15 mins + reassess)
- broad-spectrum antibiotics (CO-AMOXICLAV with GENTAMICIN)
OUT
- measure lactate
- blood cultures
- urine output
OVERDOSE
what are the clinical features of lithium overdose?
SYMPTOMS
- acute confusion
- N+V
- polyuria secondary to nephrogenic DI
SIGNS
- coarse tremor
- hyperreflexia
- seizures
- reduced GCS
- ataxia
OVERDOSE
what is the criteria for liver transplant following paracetamol overdose?
KINGS COLLEGE HOSPITAL CRITERIA FOR LIVER TRANSPLANT
- pH < 7.3 24 hours after ingestion
or all of the following
- prothrombin time >100 seconds
- creatinine >300umol/L
- grade III or IV encephalopathy
OVERDOSE
what are the clinical features of salicylate (aspirin) overdose?
SYMPTOMS
- N+V
- abdominal pain
- SOB initially
- sweating later
- tinnitus
SIGNS
- epigastric tenderness
- hyperventilation
- kussmaul breathing
- pyrexia
- severe signs (confusion, seizures, reduced GCS)
OVERDOSE
what are the investigations for salicylate (aspirin) overdose?
- salicylate levels (taken at 2hrs post-ingestion if symptomatic or 4hrs if asymptomatic)
- ABG = respiratory alkalosis followed by metabolic acidosis
- U&Es = renal failure
- LFTs + clotting
- glucose levels
- ECG
OVERDOSE
what are the clinical features of benzodiazepine overdose?
SYMPTOMS
- drowsiness (reduced GCS)
- coma
SIGNS
- ataxia
- slurred speech
- respiratory depression
OVERDOSE
what are the clinical features of TCA overdose?
SYMPTOMS
- dizziness
- dry mouth + eyes
- blurred vision
- urinary retention
- altered mental status
- seizures
SIGNS
- tachycardia
- hypotension
- mydriasis (dilated pupils)
- ataxia
- decreased bowel sounds
OVERDOSE
what are the clinical features of beta-blocker overdose?
SYMPTOMS
- dizziness
- syncope
- fatigue
- SOB
SIGNS
- bradycardia
- hypotension
- reduced GCS
- features of hypoglycaemia
OVERDOSE
what are the clinical features of iron overdose?
SYMPTOMS
- abdominal pain
- N+V
- diarrhoea
- dizziness
SIGNS
- abdominal tenderness
- haematemesis
- haematochezia
- tachycardia
- hypotension
TOXIC SHOCK SYNDROME
what is the management?
- IV antibiotics (LINEZOLID or CLINDAMYCIN) with (PENICILLIN/CEPHALOSPORIN/VANCOMYCIN)
- remove focus of infection
- IV fluid boluses
- catheterise
- correct coagulopathy or deranged glucose or electrolytes
- steroids/IVIG occasionally required
- Intensive care usually required
ANAPHYLAXIS
what is the management for children?
IM adrenaline
- <6m = 100-150 micrograms
- 6m - 6yrs = 150 micrograms
- 6-12yrs = 300 micrograms
SURGICAL SITE INFECTIONS
what are the most common causative organisms?
- orthopaedic surgery = s.aureus
- abdominal surgery = e.coli
- other = pseudomonas aeruginosa
MALIGNANT HYPERTHERMIA
what is it associated with?
gene defect on chromosome 19
it is autosomal dominant inherited
HYPOTHERMIA
what are the risk factors?
- general anaesthetic
- substance misuse
- hypothyroidism
- impaired mental status
- homelessness
- extremes of age
