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Phase 3b Revision > ACC > Flashcards

ACC Flashcards

1
Q

what is GCS

A

glasgow coma scale

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2
Q

what is the max and min GCS score

A

15-3

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3
Q

what are the 3 sections of GCS

A

Movement (6), O, Voice (5), Eyes (4)

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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
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5
Q

Voice (5)

A 
Orientated	5 points
Confused conversation	4 points
Inappropriate words	3 points
Incomprehensible sounds	2 points
No response	1 point
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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

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7
Q

what does AVPU stand for

A

alert
voice
pain
unresponsive

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8
Q

at what GCS score is intubation typically required

A

8 - as the airway may potentially become compromised

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9
Q

how should you initially approach a pt

A

A-E assessment

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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.
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11
Q

what is done in B in the A-E assessment

A

Breathing

  • general inspection
  • RR
  • SpO2
  • auscultate, percuss, chest expansion, tracheal deviation
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12
Q

what is a normal RR

A

12-20 breaths/min

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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)
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14
Q

what are some of the causes of tachypnoea

A
  • airway obstruction
  • asthma
  • pneumonia
  • pulmonary embolism (PE)
  • pneumothorax
  • pulmonary oedema
  • heart failure
  • anxiety
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15
Q

what are some of the causes of hypoxemia

A
  • PE
  • aspiration
  • COPD
  • asthma
  • pulmonary oedema.
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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
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17
Q

what is tachycardia

A

HR>99bmp

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18
Q

what is bradycardia

A

HR<60

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19
Q

what are some of the causes of tachycardia

A
  • hypovolaemia
  • arrhythmia
  • infection
  • hypoglycaemia
  • thyrotoxicosis
  • anxiety
  • pain
  • drugs (e.g. salbutamol
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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)
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21
Q

what is the range for a normal BP

A

90/60 - 140/90

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22
Q

what are some of the causes of hypertension

A
  • hypervolaemia
  • stroke
  • Conn’s syndrome
  • Cushing’s syndrome
  • pre-eclampsia (in pregnant females)
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23
Q

what signs may be seen in a pt with severe hypertension

A
  • confusion
  • drowsiness
  • breathlessness
  • chest pain
  • visual disturbances
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24
Q

what is defined as severe hypertension

A

systolic BP > 180 mmHg or diastolic BP > 100 mmHg

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25
Q

what are some of the causes of hypotension

A
  • hypovolaemia
  • sepsis
  • adrenal crisis
  • drugs (e.g. opioids, antihypertensives, diuretics)
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26
Q

what is a third heart sound is typically associated with

A

congestive heart failure

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27
Q

what is an ejection systolic murmur is associated with

A

aortic stenosis

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28
Q

what is an early diastolic murmur is associated with aortic

A

aortic regurgitation

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29
Q

what is a mid-diastolic murmur is associated with

A

mitral stenosis.

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30
Q

what is a pan-systolic murmur is associated with

A

mitral regurgitation

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31
Q

what is a murmur of recent onset suggestive of

A

recent myocardial infarction (e.g. papillary muscle rupture) or endocarditis.

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32
Q

what is a pericardial rub or muffled heart sounds indicate

A

underlying pericarditis

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33
Q

what are the possible causes of a raised JVP

A
  • Right-sided heart failure
  • Tricuspid regurgitation
  • Constrictive pericarditis
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34
Q

what are the possible causes of R-sided HF

A
  • L-sided HF (eg. secondary to fluid overload)

- Pulmonary Hypertension (often caused by COPD or interstitial lung disease)

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35
Q

what are the causes of tricuspid regurgitation

A
  • infective endocarditis

- rheumatic heart disease

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36
Q

what are the causes of constrictive pericarditis

A
  • idiopathic
  • rheumatoid arthritis
  • TB
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37
Q

what is done in D in the A-E assessment

A

Disability

  • consciousness level (AVPU)
  • pupils
  • BM
  • temperature
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38
Q

what are the causes of a acute decreases in consciousness

A

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)

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39
Q

what is done in E in the A-E assessment

A

Exposure

  • ask if the pt has pain anywhere
  • ?rash
  • ?bleeding
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40
Q

what is the normal range for temp

A

36-37.9

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41
Q

what can a rise in ICP cause

A
  • decreased cerebral perfusion
  • herniation
  • death
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42
Q

what are the clinical features of raised ICP

A

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

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43
Q

what is Cushing’s reflex

A

a physiological response to raised ICP which attempts to improve perfusion.

It leads to a triad of hypertension, bradycardia, and an irregular breathing pattern

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44
Q

what is cerebral perfusion pressure (CPP)

A

the pressure driving blood through the brain tissue

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45
Q

how is CPP calculated

A

CPP = Mean Arterial Pressure (MAP) – ICP

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46
Q

what is herniation

A

the movement of brain structures from one cranial compartment to the other

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47
Q

what are the two main types of herniation

A
  • ‘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)
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48
Q

what is a primary brain injury

A

injury caused by the forces of the traumatic event

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49
Q

what is a secondary brain injury

A

indirect damage to brain tissue that that occurs after the primary insult, worsening the original injury

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50
Q

what are some of the common causes of a secondary brain injury

A
  • cerebral hypoxia
  • acidosis
  • hypoglycaemia
  • cerebral oedema
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51
Q

what are the important aspects to cover in a traumatic head injury hx

A
  • detailed account of event
  • neurological symptoms
  • raised ICP symptoms
  • LoC
  • anticoagulants/bleeding disorders
  • baseline functioning
  • any other injuries
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52
Q

what Ix could be considered in B

A
  • ABG

- CXR

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53
Q

what Ix could be considered in C

A
  • cannulation
  • bloods
  • ECG
  • bladder scan
  • pregnancy test
  • cultures/swabs
  • fluid output monitoring/catheter
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54
Q

what bloods should be done in ?sepsis

A
  • CRP
  • lactate
  • blood cultures
55
Q

what bloods should be done in ?haemorrhage/emergency surgery

A
  • coagulation

- cross-match

56
Q

what bloods should be done in ?ACS

A

troponin (repeated)

57
Q

what bloods should be done in ?arrhythmia

A
  • Ca
  • Mg
  • phosphate
  • TFTs
  • coagulation
58
Q

what bloods should be done in ?PE

A

d-dimer

59
Q

what bloods should be done in ?OD

A
  • toxicology screen

- paracetamol levels

60
Q

what bloods should be done in ?anaphylaxis

A

serial mast cell trytpase levels

61
Q

what Ix are done in D

A
  • blood glucose and ketones

- imaging (eg. CThead)

62
Q

what Ix are done in E

A

cultures/swabs of any infective site

63
Q

what are the 4 reversible H’s for a cardiac arrest

A
  • hypothermia
  • hyper/hypokalaemia
  • hypoxia
  • hypovolaemia
64
Q

what are the 4 reversible T’s for cardiac arrest

A
  • toxins
  • thromus (PE)
  • tamponade
  • tension pneumothorax
65
Q

what are the risk factors for PE

A
  • recent surgery
  • recent fractures
  • recent immobility
  • personal/FHx
  • obesity
  • malignancy
  • infection
  • pregnancy
  • OCP/HRT
66
Q

what are the clinical features of a PE

A
  • SOB
  • pleuritic chest pain
  • cough
  • haemoptysis
  • syncope
67
Q

what is pleuritic chest pain

A

‘sharp’ chest pain when the pt breathes in

68
Q

what are the clinical signs of PE

A
  • tachypnoea
  • tachycardia
  • hypotension
  • evidence of DVT
  • pleural rub
  • cyanosis
69
Q

what is pretest probability

A

the chance that the pt has the disease, estimated before the test result in known

70
Q

what is a D-dimer

A

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
Q

what is sensitivity of a test

A

the ability of a test to correctly identify pts with the disease

72
Q

what is specificity of a test

A

the ability of a test to correctly identify people without the disease

73
Q

after a positive d-dimer what Ix is done for ?PE

A

CTPA

74
Q

what is a pneumothorax

A

a collection of air between the parietal and visceral pleura

75
Q

what are the different ways to describe a pneumothorax

A
  • primary
  • secondary
  • spontaneous
  • traumatic
  • tension
76
Q

what is a tension pneumothorax

A

when a sudden rise in intrathoracic pressure reduces venous return to the heart and ultimately causes cardiac arrest

77
Q

what is a primary pneumothorax

A

when it develops in the abscence of underlying disease

78
Q

what is secondary pneumothorax

A

when it develops as a result of underlying disease (eg. asthma/COPD)

79
Q

what are the clinical symptoms of a pneumothroax

A
  • sudden onset chest pain
  • acute SOB
  • feeling of not being able to take a full breath
80
Q

what are the clinical signs of a pneumothorax

A
  • tachypnoea
  • tachycardia
  • hypoxia
  • reduced breath sounds
  • hyper-resonance
  • tracheal deviation (TENSION)
81
Q

is tension pneumothorax a clinical diagnosis

A

yes

82
Q

what is the Mx of a small simple pneumothorax

A

discharge and review within 2-4wks as long as pt is not breathless!

83
Q

what is the Mx of a simple pneumothorax in pts who are SOB

A
  • aspirate with a 16-18G cannula
  • admit and administer high flow oxygen
  • chest drain
84
Q

what is the Mx of a tension pneumothorax

A

immediate needle decompression

85
Q

where do you insert the needle with a pneumothorax

A

2nd intercostal space, mid-clavicular line

86
Q

What are the three characteristic signs of DKA

A
  • hyperglycaemia
  • acidosis
  • ketonaemia
87
Q

what is ketonaemia

A
  • ketones > 3.0mmol/L

- Ketonuria > 2+

88
Q

what is acidosis

A
  • HCO3<15.0mmol/L

- venous pH < 7.3

89
Q

what is hyperglycaemia

A

blood glucose > 11.0mmol/L

90
Q

what causes DKA

A
  • absolute insulin deficiency (T1DM)

- complete insulin insensitivity (T2DM

91
Q

what are the clinical symptoms of DKA

A
  • palpitations
  • nausea/vomiting
  • sweating
  • thirst
  • weight loss
  • leg cramps
92
Q

what are the clinical signs of DKA

A
  • tachycardia
  • hypotension
  • reduced skin turgor
  • dry mucous membranes
  • reduced urine output
  • altered consciousness
  • kussmaul breathing
93
Q

what is kussmaul breathing

A

deep, rapid, laboured breathing

94
Q

what is the initial Mx of DKA

A
  • 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
Q

what is the normal K level

A

4-5.5mmol/L

96
Q

what two things do you need to be careful about when tx DKA

A
  • hypoglycaemia

- hypokalaemia

97
Q

what are the most common causes of DKA

A
  • infection
  • dehydration
  • fasting
  • first presentation of T1DM
98
Q

what Ix would you do for ?DKA

A
  • blood glucose
  • blood ketones
  • U&E
  • ABG
  • urinary glucose and ketones
  • blood cultures
  • ECG
99
Q

what is the main complication of DKA

A

cerebral oedema

100
Q

how to you avoid cerebral oedema in DKA pts

A

rehydrate them slowly over 48hrs

101
Q

What is measured in an FBC

A
  • Hb
  • WBC
  • RBC
  • MCV
  • Platelets
  • neutrophils
  • lymphocytes
  • basophils
  • monocytes
  • eosinophils
102
Q

What is measured in an LFT

A
  • ALT
  • AST
  • alkaline phosphate
  • GGT
  • total protein
  • albumin
  • globulin
  • bilirubin (total/direct/indirect)
103
Q

What is measured in a TFT

A
  • TSH
  • thyroxine T4
  • triiodothyronine T3
104
Q

What is measured in an U&E

A
  • Na
  • K
  • Chloride
  • Bicarbonate
  • Urea
  • Creatinine
  • Ca
  • Mg
  • Phosphate
105
Q

What are the autonomic features of hypoglycaemia

A

Sweating
Palpitations
Tremor
Hunger

106
Q

what are the neurological features of hypoglycaemia

A 
Confusion
Drowsiness
Behavioural changes
Speech abnormalities
Incoordination
107
Q

what are the general symptoms of hypoglycaemia

A

Nausea

Headache

108
Q

what are the risk factors for hypoglycaemia

A 
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
Q

what is the normal range for fasting plasma glucose

A

4.0-5.8 mmol/L

110
Q

What should you think about if hypoglycaemia persists

A

Insulin overdose

Oral hypoglycaemic overdose (e.g. sulphonylureas)

111
Q

What are the symptoms of Sepsis

A 
Localising symptoms of infection (e.g. productive cough, vomiting, diarrhoea, dysuria)
Drowsiness
Confusion
Dizziness
Malaise
112
Q

What are the signs of Sepsis

A 
Tachycardia
Hypotension
Tachypnoea
Cyanosis
Fever/hypothermia
Oliguria
Non-blanching rash
Mottled/ashen appearance
113
Q

what are the red flags for sepsis

A
  • 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
Q

What is the initial Ix of sepsis

A

Sepsis 6

115
Q

What is the Sepsis 6

A 
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
Q

What is a good way to remember the sepsis 6 - 3 give and 3 take

A

Take blood cultures, give IV antibiotics
Take lactate, give oxygen
Take urine output, give IV fluids

117
Q

what is the immediate Mx of Sepsis

A

broad spec abx

118
Q

how soon should abx be given for ?sepsis

A

within 1 hr of presentation

119
Q

acute Mx of STEMI

A
  • 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
Q

acute Mx of NSTEMI

A
  • 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
Q

Mx of acute LVF

A
  • 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
Q

actue Mx of anaphylaxis

A
  • 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
Q

Mx of acute exacerbation of asthma (adult)

A
  • 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
Q

Mx of acute exacerbation of COPD

A
  • 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
Q

Acute Mx of pneumonia

A
  • 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
Q

acute Mx of PE

A
  • 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
Q

acute Mx of gastric bleeding

8 “C’s” of GI bleed

A
  • 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
Q

Acute Mx of bacterial meningitis

A
  • 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
Q

acute Mx seizures

A
  • 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
Q

acute Mx of stroke

A
  • ABC
  • Hx, o/e, inv., diagnose ischaemic stroke
  • if onset <4.5hrs = thrombolysis
  • aspirin 300mg oral/rectal
  • transfer to stroke unit
131
Q

acute Mx of DKA

A
  • 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
Q

acute Mx of AKI

A
  • 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
Q

Mx of acute poisening

A
  • ABC
  • Hx, o/e, inv.,
  • cannula and catheter, strict fluid balance
  • supportive measures
  • correct electrolyte disturbance
  • reduce absorption
  • increase elimination
  • psychiatric management

Phase 3b Revision (2 decks)

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