ACC Flashcards
1
Q
what is GCS
A
glasgow coma scale
2
Q
what is the max and min GCS score
A
15-3
3
Q
what are the 3 sections of GCS
A
Movement (6), O, Voice (5), Eyes (4)
4
Q
Move (6)
A
Obeys command 6 points Localises to pain 5 points Withdraws to pain 4 points Flexion decorticate posture 3 points Abnormal extension decerebrate posture 2 points No response 1 point
5
Q
Voice (5)
A
Orientated 5 points Confused conversation 4 points Inappropriate words 3 points Incomprehensible sounds 2 points No response 1 point
6
Q
Eyes (4)
A
Eye-opening spontaneously 4 points
Eye-opening to sound 3 points
Eye-opening to pain 2 points
No response 1 point
7
Q
what does AVPU stand for
A
alert
voice
pain
unresponsive
8
Q
at what GCS score is intubation typically required
A
8 - as the airway may potentially become compromised
9
Q
how should you initially approach a pt
A
A-E assessment
10
Q
what is done in A in the A-E assessment
A
Airway
- can the pt talk?
- Look for signs of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
- Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object.
11
Q
what is done in B in the A-E assessment
A
Breathing
- general inspection
- RR
- SpO2
- auscultate, percuss, chest expansion, tracheal deviation
12
Q
what is a normal RR
A
12-20 breaths/min
13
Q
what are some of the causes of bradypnoea
A
- sedation
- opioid toxicity
- raised intracranial pressure (ICP)
- exhaustion in airway obstruction (e.g. COPD)
14
Q
what are some of the causes of tachypnoea
A
- airway obstruction
- asthma
- pneumonia
- pulmonary embolism (PE)
- pneumothorax
- pulmonary oedema
- heart failure
- anxiety
15
Q
what are some of the causes of hypoxemia
A
- PE
- aspiration
- COPD
- asthma
- pulmonary oedema.
16
Q
what is done in C in the A-E assessment
A
Circulation
- HR (pulse - regular/irregular, thready, bounding, slow-rising)
- BP
- cap refill (peripherally & centrally)
- general inspection of pallor/oedema
- auscultate
- look for signs of raised JVP
17
Q
what is tachycardia
A
HR>99bmp
18
Q
what is bradycardia
A
HR<60
19
Q
what are some of the causes of tachycardia
A
- hypovolaemia
- arrhythmia
- infection
- hypoglycaemia
- thyrotoxicosis
- anxiety
- pain
- drugs (e.g. salbutamol
20
Q
what are some of the causes of bradycardia
A
- acute coronary syndrome (ACS)
- ischaemic heart disease
- electrolyte abnormalities (e.g. hypokalaemia)
- drugs (e.g. beta-blockers)
21
Q
what is the range for a normal BP
A
90/60 - 140/90
22
Q
what are some of the causes of hypertension
A
- hypervolaemia
- stroke
- Conn’s syndrome
- Cushing’s syndrome
- pre-eclampsia (in pregnant females)
23
Q
what signs may be seen in a pt with severe hypertension
A
- confusion
- drowsiness
- breathlessness
- chest pain
- visual disturbances
24
Q
what is defined as severe hypertension
A
systolic BP > 180 mmHg or diastolic BP > 100 mmHg
25
what are some of the causes of hypotension
- hypovolaemia
- sepsis
- adrenal crisis
- drugs (e.g. opioids, antihypertensives, diuretics)
26
what is a third heart sound is typically associated with
congestive heart failure
27
what is an ejection systolic murmur is associated with
aortic stenosis
28
what is an early diastolic murmur is associated with aortic
aortic regurgitation
29
what is a mid-diastolic murmur is associated with
mitral stenosis.
30
what is a pan-systolic murmur is associated with
mitral regurgitation
31
what is a murmur of recent onset suggestive of
recent myocardial infarction (e.g. papillary muscle rupture) or endocarditis.
32
what is a pericardial rub or muffled heart sounds indicate
underlying pericarditis
33
what are the possible causes of a raised JVP
- Right-sided heart failure
- Tricuspid regurgitation
- Constrictive pericarditis
34
what are the possible causes of R-sided HF
- L-sided HF (eg. secondary to fluid overload)
| - Pulmonary Hypertension (often caused by COPD or interstitial lung disease)
35
what are the causes of tricuspid regurgitation
- infective endocarditis
| - rheumatic heart disease
36
what are the causes of constrictive pericarditis
- idiopathic
- rheumatoid arthritis
- TB
37
what is done in D in the A-E assessment
Disability
- consciousness level (AVPU)
- pupils
- BM
- temperature
38
what are the causes of a acute decreases in consciousness
Hypovolaemia
Hypoxia
Hypercapnia
Metabolic disturbance (e.g. hypoglycaemia)
Seizure
Raised intracranial pressure or other neurological insults (e.g. stroke)
Drug overdose
Iatrogenic causes (e.g. administration of opiates)
39
what is done in E in the A-E assessment
Exposure
- ask if the pt has pain anywhere
- ?rash
- ?bleeding
40
what is the normal range for temp
36-37.9
41
what can a rise in ICP cause
- decreased cerebral perfusion
- herniation
- death
42
what are the clinical features of raised ICP
Headache
Nausea and vomiting
Restlessness, agitation or drowsiness
Slow slurred speech
Papilloedema
Ipsilateral sluggish dilated pupil which then becomes fixed (“blown pupil”)
Cranial nerve palsy (e.g. CN III palsy with ‘down and out’ pupil)
Seizures
Reduced GCS
Abnormal respiratory pattern
Abnormal posturing, initially decorticate and then decerebrate
43
what is Cushing's reflex
a physiological response to raised ICP which attempts to improve perfusion.
It leads to a triad of hypertension, bradycardia, and an irregular breathing pattern
44
what is cerebral perfusion pressure (CPP)
the pressure driving blood through the brain tissue
45
how is CPP calculated
CPP = Mean Arterial Pressure (MAP) – ICP
46
what is herniation
the movement of brain structures from one cranial compartment to the other
47
what are the two main types of herniation
- 'conning' - Herniation of the cerebellar tonsils through the foramen magnum leads to compression of the brainstem and respiratory arrest
- "blown pupil" - Herniation of the uncus of the temporal lobe through the tentorial notch often leads to compression of cranial nerve three (oculomotor nerve)
48
what is a primary brain injury
injury caused by the forces of the traumatic event
49
what is a secondary brain injury
indirect damage to brain tissue that that occurs after the primary insult, worsening the original injury
50
what are some of the common causes of a secondary brain injury
- cerebral hypoxia
- acidosis
- hypoglycaemia
- cerebral oedema
51
what are the important aspects to cover in a traumatic head injury hx
- detailed account of event
- neurological symptoms
- raised ICP symptoms
- LoC
- anticoagulants/bleeding disorders
- baseline functioning
- any other injuries
52
what Ix could be considered in B
- ABG
| - CXR
53
what Ix could be considered in C
- cannulation
- bloods
- ECG
- bladder scan
- pregnancy test
- cultures/swabs
- fluid output monitoring/catheter
54
what bloods should be done in ?sepsis
- CRP
- lactate
- blood cultures
55
what bloods should be done in ?haemorrhage/emergency surgery
- coagulation
| - cross-match
56
what bloods should be done in ?ACS
troponin (repeated)
57
what bloods should be done in ?arrhythmia
- Ca
- Mg
- phosphate
- TFTs
- coagulation
58
what bloods should be done in ?PE
d-dimer
59
what bloods should be done in ?OD
- toxicology screen
| - paracetamol levels
60
what bloods should be done in ?anaphylaxis
serial mast cell trytpase levels
61
what Ix are done in D
- blood glucose and ketones
| - imaging (eg. CThead)
62
what Ix are done in E
cultures/swabs of any infective site
63
what are the 4 reversible H's for a cardiac arrest
- hypothermia
- hyper/hypokalaemia
- hypoxia
- hypovolaemia
64
what are the 4 reversible T's for cardiac arrest
- toxins
- thromus (PE)
- tamponade
- tension pneumothorax
65
what are the risk factors for PE
- recent surgery
- recent fractures
- recent immobility
- personal/FHx
- obesity
- malignancy
- infection
- pregnancy
- OCP/HRT
66
what are the clinical features of a PE
- SOB
- pleuritic chest pain
- cough
- haemoptysis
- syncope
67
what is pleuritic chest pain
'sharp' chest pain when the pt breathes in
68
what are the clinical signs of PE
- tachypnoea
- tachycardia
- hypotension
- evidence of DVT
- pleural rub
- cyanosis
69
what is pretest probability
the chance that the pt has the disease, estimated before the test result in known
70
what is a D-dimer
test used to look for blood clots - measures the amount of D-dimer, a type of protein the body produces to break down a blood clot, in the blood
71
what is sensitivity of a test
the ability of a test to correctly identify pts with the disease
72
what is specificity of a test
the ability of a test to correctly identify people without the disease
73
after a positive d-dimer what Ix is done for ?PE
CTPA
74
what is a pneumothorax
a collection of air between the parietal and visceral pleura
75
what are the different ways to describe a pneumothorax
- primary
- secondary
- spontaneous
- traumatic
- tension
76
what is a tension pneumothorax
when a sudden rise in intrathoracic pressure reduces venous return to the heart and ultimately causes cardiac arrest
77
what is a primary pneumothorax
when it develops in the abscence of underlying disease
78
what is secondary pneumothorax
when it develops as a result of underlying disease (eg. asthma/COPD)
79
what are the clinical symptoms of a pneumothroax
- sudden onset chest pain
- acute SOB
- feeling of not being able to take a full breath
80
what are the clinical signs of a pneumothorax
- tachypnoea
- tachycardia
- hypoxia
- reduced breath sounds
- hyper-resonance
- tracheal deviation (TENSION)
81
is tension pneumothorax a clinical diagnosis
yes
82
what is the Mx of a small simple pneumothorax
discharge and review within 2-4wks as long as pt is not breathless!
83
what is the Mx of a simple pneumothorax in pts who are SOB
- aspirate with a 16-18G cannula
- admit and administer high flow oxygen
- chest drain
84
what is the Mx of a tension pneumothorax
immediate needle decompression
85
where do you insert the needle with a pneumothorax
2nd intercostal space, mid-clavicular line
86
What are the three characteristic signs of DKA
- hyperglycaemia
- acidosis
- ketonaemia
87
what is ketonaemia
- ketones > 3.0mmol/L
| - Ketonuria > 2+
88
what is acidosis
- HCO3<15.0mmol/L
| - venous pH < 7.3
89
what is hyperglycaemia
blood glucose > 11.0mmol/L
90
what causes DKA
- absolute insulin deficiency (T1DM)
| - complete insulin insensitivity (T2DM
91
what are the clinical symptoms of DKA
- palpitations
- nausea/vomiting
- sweating
- thirst
- weight loss
- leg cramps
92
what are the clinical signs of DKA
- tachycardia
- hypotension
- reduced skin turgor
- dry mucous membranes
- reduced urine output
- altered consciousness
- kussmaul breathing
93
what is kussmaul breathing
deep, rapid, laboured breathing
94
what is the initial Mx of DKA
- fluid resuscitation (if pt conscious encourage oral rehydration!)
- fixed-rate IV insulin infusion
- normal saline and 5% dextrose IV infusion
- normal saline with additional K
95
what is the normal K level
4-5.5mmol/L
96
what two things do you need to be careful about when tx DKA
- hypoglycaemia
| - hypokalaemia
97
what are the most common causes of DKA
- infection
- dehydration
- fasting
- first presentation of T1DM
98
what Ix would you do for ?DKA
- blood glucose
- blood ketones
- U&E
- ABG
- urinary glucose and ketones
- blood cultures
- ECG
99
what is the main complication of DKA
cerebral oedema
100
how to you avoid cerebral oedema in DKA pts
rehydrate them slowly over 48hrs
101
What is measured in an FBC
- Hb
- WBC
- RBC
- MCV
- Platelets
- neutrophils
- lymphocytes
- basophils
- monocytes
- eosinophils
102
What is measured in an LFT
- ALT
- AST
- alkaline phosphate
- GGT
- total protein
- albumin
- globulin
- bilirubin (total/direct/indirect)
103
What is measured in a TFT
- TSH
- thyroxine T4
- triiodothyronine T3
104
What is measured in an U&E
- Na
- K
- Chloride
- Bicarbonate
- Urea
- Creatinine
- Ca
- Mg
- Phosphate
105
What are the autonomic features of hypoglycaemia
Sweating
Palpitations
Tremor
Hunger
106
what are the neurological features of hypoglycaemia
```
Confusion
Drowsiness
Behavioural changes
Speech abnormalities
Incoordination
```
107
what are the general symptoms of hypoglycaemia
Nausea
| Headache
108
what are the risk factors for hypoglycaemia
```
Insulin-dependent diabetes
Previous history of hypoglycaemic episodes or reduced hypoglycaemia awareness
Impaired renal function
Cognitive dysfunction/dementia
Alcohol misuse
Profound starvation
Increased exercise
Food malabsorption issues (e.g. coeliac disease, bariatric surgery, gastroenteritis)
```
109
what is the normal range for fasting plasma glucose
4.0-5.8 mmol/L
110
What should you think about if hypoglycaemia persists
Insulin overdose
| Oral hypoglycaemic overdose (e.g. sulphonylureas)
111
What are the symptoms of Sepsis
```
Localising symptoms of infection (e.g. productive cough, vomiting, diarrhoea, dysuria)
Drowsiness
Confusion
Dizziness
Malaise
```
112
What are the signs of Sepsis
```
Tachycardia
Hypotension
Tachypnoea
Cyanosis
Fever/hypothermia
Oliguria
Non-blanching rash
Mottled/ashen appearance
```
113
what are the red flags for sepsis
- B (RR>24 or O2 required to keep stats above 92%)
- C (HR>130, BP<90, Lactate>1)
- D (responds only to VPU, acute confusional state)
- E (non-blanching rash, mottled/ashen/cyanotic, UO<0.5ml/kg/hr)
114
What is the initial Ix of sepsis
Sepsis 6
115
What is the Sepsis 6
```
Administer high flow oxygen and maintain SpO2 >94%
Take blood cultures
Measure serial lactate levels
Administer intravenous antibiotics
Administer intravenous fluids
Monitor urine output
```
116
What is a good way to remember the sepsis 6 - 3 give and 3 take
Take blood cultures, give IV antibiotics
Take lactate, give oxygen
Take urine output, give IV fluids
117
what is the immediate Mx of Sepsis
broad spec abx
118
how soon should abx be given for ?sepsis
within 1 hr of presentation
119
acute Mx of STEMI
- ABC & O2 by non-rebreather if hypoxic
- Hx, o/e, inv., diagnose STEMI
- aspirin 300mg oral
- Morphine 5-10mg IV, Cyclizine 50mg IV
- GTN spray/tablet
- Primary PCI or thrombolysis
- Bb (Bisoprolol 2.5mg oral)
- Transfer CCU
120
acute Mx of NSTEMI
- ABC & O2 by non-rebreather if hypoxic
- Hx, o/e, inv., diagnose NSTEMI
- aspirin 300mg oral
- Morphine 5-10mg IV, Cyclizine 50mg IV
- GTN spray/tablet
- Clopidogrel 300mg oral & LMWH/Fondaparinux 2.5mg od SC
- Bb (Bisoprolol 2.5mg oral)
- Transfer CCU
121
Mx of acute LVF
- ABC & O2 by non-rebreather if hypoxic
- Hx, o/e, inv., diagnose LVF
- sit pt up
- Morphine 5-10mg IV, Cyclizine 50mg IV
- GTN spray/tablet
- Furosemide 40-80mg IV
- if inadequate response, isosorbide dinitrate infusion
- Transfer CCU
122
actue Mx of anaphylaxis
- ABC & O2 by non-rebreather if hypoxic
- Hx, o/e, inv., diagnose anaphylaxis
- remove the cause ASAP
- Adrenaline 500micrograms of 1:1000IM
- Chlorphenamine 10mg IV
- Hydrocortisone 200mg IV
- Asthma tx if wheeze
- Amend drug chart allergies box
123
Mx of acute exacerbation of asthma (adult)
- ABC
- Hx, o/e, inv., diagnose asthma
- 100% O2 by non-rebreather mask
- Salbutamol 5mg neb
- Hydrocortisone 100mg IV (severe)/Prednisolone 40-50mg oral (moderate)
- Ipratropium 500micrograms Neb
- Aminophylline (only if life threatening)
124
Mx of acute exacerbation of COPD
- ABC
- Hx, o/e, inv., diagnose asthma
- 100% O2 by non-rebreather mask
- Salbutamol 5mg neb
- Hydrocortisone 100mg IV (severe)/Prednisolone 40-50mg oral (moderate)
- Ipratropium 500micrograms Neb
- Aminophylline (only if life threatening)
add abx if infective exacerbation
125
Acute Mx of pneumonia
- ABC
- Hx, o/e, inv., diagnose pneumonia
- high-flow O2
- abx (amoxicillin 500mg TDS, 5days/doxycycline)
- paracetamol
- if low BP or raised HR, IV fluids as normal
126
acute Mx of PE
- ABC
- Hx, o/e, inv., diagnose PE
- high-flow oxygen
- morphine 5-10mg IV, Cyclizine 50mg IV
- LMWH (tinzaparin 175 units/kg SC daily)
- if low BP; IV fluid bolus, contact ITU, consider thrombolysis
127
acute Mx of gastric bleeding
8 "C's" of GI bleed
- ABC & O2 15L via non-rebreather
- Hx, o/e, inv., diagnosis acute GI bleed
- Cannulae (2x large bore)
- Catheter (and strict fluid monitoring)
- Crystalloid bolus
- Cross-match 6 units blood
- Correct clotting abnormalities (fresh frozen plasma/platelet transfusion)
- Endoscopy
- stop culprit drugs (NSAIDs, aspirin, warfarin , heparin)
- call surgeons if severe
128
Acute Mx of bacterial meningitis
- ABC
- Hx, o/e, inv., diagnose meningitis
- high-flow O2
- IV fluid
- 4-10mg dexamethasone IV
- LP (+/- CT head)
- 2g cefotaxime iV (if immunocompromised or >55yrs add 2g ampicillin IV)
- consider ITU
129
acute Mx seizures
- ABC
- hx, o/e, inv., diagnose seizure
- put pt in recovery position
>5mins
- Lorazepam 2-4mg IV or 10mg diazepam IV or 10mg midazolam buccal
- after 5mins repeat BZs
- inform anaesthetist
- after 5mins phenytoin 15-20mg/kg IV
- after 5mins intubate & ventilate
130
acute Mx of stroke
- ABC
- Hx, o/e, inv., diagnose ischaemic stroke
- if onset <4.5hrs = thrombolysis
- aspirin 300mg oral/rectal
- transfer to stroke unit
131
acute Mx of DKA
- ABC
- Hx, o/e, inv., diagnose DKA
- IV fluid
- fixed rate insulin (eg. 50units Actrapid in 50ml 0.9% saline at 0.1 units/kg/hr)
- monitor capillary glucose and ketones hrly
- repeat VBG 2-hlry
- hunt for trigger ?infection, ?MI, ?missed insulin
132
acute Mx of AKI
- ABC
- Hx, o/e, inv.
- cannula and catheter, strict fluid monitoring
- IV fluid: 500ml stat. then 1L 4hrly
- Hunt for cause and complications (eg. fluid overload, hyperkalaemia, acidosis
- moniter U&Es and fluid balance
133
Mx of acute poisening
- ABC
- Hx, o/e, inv.,
- cannula and catheter, strict fluid balance
- supportive measures
- correct electrolyte disturbance
- reduce absorption
- increase elimination
- psychiatric management
