ACC Flashcards
1
Q
What is the trimodal distribution of trauma death?
A
FIRST: at time of injury (secs to mins)
SECOND: mins to hrs post injury
THIRD: days to weeks post injury
2
Q
How is major trauma defined?
A
Patients with injury severity score (ISS) >15
3
Q
What is the ABCDE approach when there is life threatening injury?
A
A: Airway management with cervical spine protection
B: Breathing and ventilation
C: Circulation with hemorrhage control (stop bleeding)
D: Disability and neurological status (GCS)
E: Exposure and environment (don’t let people become cold)
4
Q
What are the main features of an airway assessment?
A
1) ADEQUACY: assess for signs of obstruction
2) INJURIES: compromising airways?
3) MANAGE INADEQUATE AIRWAY IMMEDIATELY
4) DEFINITIVE AIRWAY
5
Q
What are the signs of obstructed airway?
A
- absent breath sounds
- snoring/ stridor/ gurgling
- hoarse voice
- obtundation (reduced conscious level)
- cyanosis
- paradoxical movements/intercostal recession/ accessory muscles
- tracheal deviation
- laryngeal crepitus
6
Q
What are examples of injuries that could compromise the airway?
A
- facial fractures
- facial burns
- neck wounds
- epistaxis/vomiting
- head injury with low GCS
7
Q
What is the immediate management for an airway?
A
- head tilt/chin lift
- jaw thrust
- oropharyngeal airway (Guedel airway)
- nasopharyngeal airway
- laryngeal mask airway
8
Q
What are examples of definitive airways?
A
ET intubation
SURGICAL AIRWAYS
- emergency cricothyroidotomy
- tracheostomy
9
Q
What can be done to protect the cervical spine in acute injury?
A
- hard collar, tape and blocks applied
- manual in-line stabilization
10
Q
What are the signs of ventilatory compromise?
A
- inadequate or asymmetrical chest rise and fall
- labored breathing
- decreased or absent air entry
- low oxygen sats
11
Q
What are the injuries that could compromise ventilation (ATOM FC)?
A
ATOM FC
A- airway obstruction
T- tension pneumothorax
O- open chest wound
M- massive haemothorax (>1500ml blood)
F- flail chest
C- cardiac tamponade
OTHERS INCLUDE
- simple pneumothorax
- blunt cardiac injury
- traumatic aortic disruption
- trachaeobronchial tree injury
- pulmonary contusion
- esophageal rupture
- diaphragmatic injury
- haemothorax
12
Q
What are the signs suggestive of thoracic injury?
A
- Abnormal oxygen sats or respiratory rate
- Abnormal chest movement
- Chest wall bruising, wounds, surgical emphysema
- Rib, clavicular, scapular or sternal fractures
- Tracheal deviation
- Abnormal air entry
13
Q
How is inadequate ventilation managed?
A
- Optimise oxygenation (15L NRBM)
- Needle/tube thoracocentesis
- Pericardiocentesis (for cardiac tamponade)
- Consider need for intubation
14
Q
How is shock defined?
A
A clinical syndrome caused by INADEQUATE TISSUE PERFUSION and OXYGENATION LEADING TO ABNORMAL METABOLIC FUNCTION
15
Q
What are the causes of shock in trauma?
A
- haemorrhagic (hypovolemic)
- obstructive
- cardiogenic
- neurogenic
16
Q
What is involved in the assessment for shock (HEP B)?
A
H- hands: temp, sweating, cap refill
E- End organ perfusion: conscious levels, UO
P- Pulse: rate, regularity, quality
B- Blood pressure: hypotension (late sign- stage 3 haemorrhagic shock)
Check for blood loss
- external wounds
- chest cavity
- abdo cavity (+ retroperitoneal)
- pelvic cavity
- long bone fractures
17
Q
What is done in a circulation assessment?
A
Assess for signs of shock
Any injuries which could or WILL cause shock?
18
Q
How is inadequate circulation managed immediately?
A
- Optimise oxygenation (15L NRBM)
- Splints/tourniquet/ direct pressure for active haemorrhage
- 2x large bore IV access in anterior cubital fossa
- fluid resuscitation: warm crystalloid, blood
- IV tranexamic acid if haemorrhaging
- Consider activation of massive transfusion protocol
- Definitive haemostasis
19
Q
What is the TRAUMA TRIAD OF DEATH?
A
1) HYPOTHERMIA
2) COAGULOPATHY
3) ACIDOSIS
20
Q
How does acidosis occur in trauma?
A
Haemorrhage leads to REDUCED OXYGEN DELIVERY which leads to ACIDOSIS due to INCREASED LACTATE
21
Q
What causes hypothermia in trauma?
A
HYPOPERFUSION and DECREASED HEAT GENERATION-
can induce coagulopathy, arrhythmias, increases SVR, reduces CO and left shift to Hb curve
22
Q
What causes coagulopathy in trauma?
A
induced by activation of fibrinolytic system and haemodilution from fluids
23
Q
What is reviewed in the disability portion of ABCDE approach?
A
- Review ABC, check not hypoxic or hypotenisve
- Check drug chat
- Examine pupils
- GCS and AVPU
- Check lateralising signs
- Capillary glucose
- Airway protection
24
Q
What is reviewed in the examination portion of ABCDE approach?
A
- Examine the patient
- eFAST: beside US to look for pneumothorax, haemothorax, pericardial effusion + intraperitoneal haemorrhage. Fluid is black on the scan. Peri-hepatic, splenic, pelvic, pericardial and anterior thoracic views.
- Check temperature
- Take a history and reassess
25
What is the main goal in management for head trauma in hospital?
To prevent secondary brain injury caused by:
- inadequate oxygenation
- hypoperfusion
- hyperglycemia
26
What are the severity scores for GCS assessment?
MINOR: GCS 13-15
MODERATE: GCS 9-12
SEVERE: GCS 3-8
GCS <8 = coma
27
What are the eye opening scores for GCS?
4 spontaneous
3 to voice
2 pain
1 none
28
What are the verbal response scores for GCS?
```
5 orientated
4 confused
3 inappropriate words
2 sounds
1 none
```
29
What are the best motor response scores for GCS?
```
6 obeys commands
5 localises to pain
4 normal flexion
3 abnormal flexion
2 extension
1 none
```
30
What is involved in a disability assessment following head trauma?
check for signs of head injury:
- facial/scalp bruising or hematoma
- scalp or facial lacerations
- pupil size and reaction
- capillary glucose
- GCS (if <8 early involvement of anaesthetist)
- Manage neurodisability
31
What are the steps for managing neurodisability?
- Optimise oxygenation
- Maintain cerebral perfusion (BP>90/>65)
- Avoid hyperglycemia
- Avoid pyrexia
- manage pain effectively- can lead to rise in ICP
- Definitive imaging and treatment
32
What is the NICE criteria for performing a CT head within 1 hour?
1) GCS <13 on initial assessment in ED
2) GCS <15 at 2hrs after injury on assessment in ED
3) Suspected open or depressed skull fracture
4) post traumatic seizure
5) Sign of basal skull fracture
6) Focal neurological deficit
7) >1 episode of vomiting
33
What is the NICE criteria for CT head within 8 hours of injury?
1) >65 years old
2) >30mins retrograde amnesia of events immediately before head injury
3) any history of bleeding/clotting disorders/ on warfarin
4) dangerous mechanism of injury
34
What are the signs of basal skull fracture?
- haemotympanum
- 'panda eyes'
- CSF leakage from ear or nose
- Battle's sign (bruising over mastoid process)
35
What is cerebral perfusion pressure defined as?
CPP = MAP - ICP
| mean arterial pressure- intracranial pressure
36
What is the Monro-Kellie hypothesis?
The cranial compartment is incompressible and the volume inside the cranium is fixed
Cranium and its constituents (blood, CSF, brain) are therefore in a state of equilibrium.
An increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another
37
What is the pathophysiology of traumatic brain injury?
- As ICP increases, CPP decreases
- The response to this is to RAISE systemic blood pressure and DILATE CEREBRAL BLOOD VESSELS
- But, this ACCELERATES INTRACRANIAL HAEMORRHAGE and INCREASES ICP due to increased cerebral blood volume, lowering CPP further
- Cushing response is a pre-terminal sign
38
What is Cushing response?
- hypertension
- bradycardia
- irregular respiration
39
What are the lateralising signs associated with raised ICP?
- dilated pupil, sluggish then fixed
| - aphasia
40
What is the most common injured spinal area?
CERVICAL (55%)
41
How are spinal injuries classified?
Split into COMPLETE and INCOMPLETE injury, 1 week post injury.
42
What is the sign on incomplete spinal injury?
SACRAL SPARING- perianal sensation
43
How is spinal injury clinically diagnosed?
- Presence of neurological deficit
- Presence of pain or tenderness along the spine
- No distracting injury should be present
- Patient should not be intoxicated
44
What is the log roll?
Manoeuvre used to move trauma patient and allows posterior to be examined without active movement.
45
How many people are required to perform log roll manoeuvre?
FIVE
1- to stabilise neck
3- to roll
1- to examine back/spine and perform DRE
46
What are the various spinal cord syndromes?
1) central cord syndrome
2) anterior cord syndrome
3) brown-sequard syndrome
4) complete spinal cord syndrome
47
What is central cord syndrome?
- incomplete injury to cervical cord leads to more extensive motor weakness in upper limbs than lower.
- the mechanism of injury for central cord syndrome is a hyperextension injury with pre-existent cervical spondylosis- without damage to the vertebral column.
There is a variable degree of sensory loss below level of injury in combination with bladder dysfunction and urinary retention.
48
What is anterior cord syndrome?
- interrupted blood supply to the anterior portion of spinal cord.
- characterized by loss of motor function below level of injury
- loss of sensations carried by spinothalamic tracts (pain and temp.)
- preservation of sensation carried by posterior columns (fine touch and proprioception)
- may have: areflexia, flaccid anal sphincter, urinary retention, intestinal obstruction
49
What is brown-sequard syndrome?
- lateral hemisection of spinal cord
- ipsilateral loss of motor function
- ipsilateral loss of vibration sense
- ipsilateral loss of fine touch and proprioception
- contralateral loss of pain and temperature
50
What is complete spinal cord syndrome?
- complete loss of sensory and motor function usually only clear 6-8 weeks after injury
51
What are the signs of spinal injury?
- diaphragmatic breathing
- evidence of neurogenic shock (low BP+ bradycardia)
- responds to pain only above clavicles
- priapism (prolonged erection)
- flexed posture of upper limbs or flaccid areflexia
- patient complains of loss of sensation or function
- spinal tenderness, bruising or swelling on log roll
52
How is spinal injury managed immediately?
- optimise oxygenation
- ensure adequate ventilation
- maintain spinal cord perfusion- avoid hypotension
- maintain immobilisation
- document thorough spinal cord examination
- urinary catheterization and NG tube
- definitive imaging
- early specialist advice
53
What constitutes most MSK trauma?
- pelvic fractures
| - limb injuries
54
What are the signs of MSK trauma?
- limb deformity or amputation
- patient localising pain to limb/body part
- soft tissue injury or wounds
- splinting applied pre-hospitally
- pelvic instability- do not spring pelvis
- neuromuscular compromise
55
How is MSK injury managed immediately?
- optimise oxygenation
- maintain tissue perfusion (avoid hypotension)
- apply splints (reduce blood loss, pain and improve alignment)
- analgesia
- IV antibiotics
- Monitor complications: compartment syndrome, skin necrosis, nerve compression
56
What are commonly used trauma scores?
- AIS (abbreviated injury scale)
- ISS (injury severity scale)
- RTS (revised trauma score)
- TRISS (trauma score- injury severity score)
57
What are the general principles of the RRAPID
Initial assessment:
- If patient not breathing and has no pulse- COMMENCE CPR and CALL FOR HELP
- Airway
- Breathing
- Circulation
- Disability
- Exposure
INFORM SENIORS (med reg, critical care outreach)
58
What are the principles of airway management in RRAPID?
- talking = patent airway
- look, listen and feel for breathing
- signs of partial airway obstruction: paradoxical chest and abdominal movements, grunting/gurgling, foreign bodies
- full obstructed airway = silent
- cyanosis/ hypoxia is a late sign
- if airway obstructed- CALL FOR HELP
- head tilt chin lift- jaw help
- oropharyngeal or nasopharyngeal airway
- suction of secretions (yankauer)
- oxygen
- call anesthetist
59
What are the principles of breathing in RRAPID?
- respiratory rate
- oxygen saturation
- ABG (include lactate if risk of sepsis)
60
What are the principles of circulation in RRAPID?
- hands-temp
- cap refill (<2 secs)
- pulse- character and HP obs
- BP
- JVP
- cannulate- bloods (blood culture, FBC, U+Es, CRP), cross match, group and save, fluid challenge
- urine output
61
What are principles of disability in RRAPID?
- AVPU faster than GCS
- Pupillary light reflex- equal and reactive
- blood glucose
62
What are principles of exposure in RRAPID?
- expose patient for examination and source of illness
- abdo exam (flatten patient)
- check legs (oedema and rashes)
- check back with assistants
- temperature
63
What are the 12 steps of management for the unconscious patient?
1) ABCDE assessment
2) Consider intubation if GCS <8
3) 15L O2 non-rebreathe
4) IV access- fluids if clinically indicated
5) Blood glucose and glucose for hypoglycemia
6) Control any seizures
7) IV thiamine (Pabrinex) if diagnosis unclear and wernicke's encephalopathy possible
8) Trial of naloxone/ flumazenil- easy and rapid response
9) Antibiotics (IV cefotaxime) if any signs of infection
10) Head CT if any suspicion of stroke
11) Routine biochemistry, hematology, thick films, blood cultures. blood ethanol. drug screen
12) Raised ICP- may require mannitol infusion
64
What are the causes of an unconscious patient?
COMA
- Cerebral
- Overdose
- Metabolic
- Any other
65
What are the cerebral causes of an unconscious patient?
Cerebral
- haemorrhage
- infarction
- tumour
- infection
- trauma
66
What are the overdose causes of an unconscious patient?
Overdose
- alcohol
- alcohol withdrawal
- drugs (sedative, narcotics, psychotropics)
- poisons (CN, CO)
- venom
67
What are the metabolic causes of an unconscious patient?
Metabolic
- endocrine
- hypoglycaemia
- hyperglycaemia
- environmental- hypo/hyperthermia
- organ failure
- electrolytes
- acid-base disorders
- vitamin deficiencies
- sepsis
68
What are the A- causes of an unconscious patient?
- arrhythmias
- asphyxia
- Anaemia
- AMI/PE
- Any cause of shock
69
What are the different types of shock?
- Septic shock
- Hypovolemic shock
- Anaphylactic shock
- Neurogenic shock
- Cardiogenic shock
70
What is the general assessment for shock?
- ECG: check the rate, rhythm, ischemia
- cold, clammy suggests cardiogenic shock or fluid loss, check for signs of anaemia or dehydration
- warm and well perfused with bounding pulse indicates septic shock
- features of anaphylaxis: history, urticaria, angiooedema, wheeze
- if JVP is raised, cardiogenic shock is likely
71
How is septic shock defined?
Severe sepsis with hypotension (systolic BP<90 or decrease of >40 from baseline)
OR
The requirement for vasoactive drugs- despite adequate fluid resuscitation
72
What is the response for septic shock?
A. Complete BUFALO within 1 hr
B. 15L/min O2 via reservoir bag
C. Fluid challenge of 500ml-1000ml Hartmann's bolus
D. Blood cultures- before antibiotics
E. Lactate and Hb via ABG or VBG
F. Administer start broad spectrum antibiotics
G. Insert urinary catheter and monitor hourly UO
73
How is hypovolemic shock defined?
Usual symptoms of shock will be present but also faintness on standing, cyanosis, dyspnoea, LoC and symptoms relating to bleeding site.
74
What are the causes of hypovolemic shock?
- Blood loss
- Burns
- Dehydration
75
What is the classification of hypovolemic shock?
CLASS 1: 10-15% blood loss, physiological compensation, and no clinical changes appear
CLASS 2: 15-30% blood loss, postural hypotension, generalized vasoconstriction and reduction in urine output to 20-20ml/hr
CLASS 3: 30-40% blood loss, hypotension, tachycardia over 120, tachypnoea, urine output under 20ml/hour and the patient is confused
CLASS 4: 40% blood loss, marked hypotension, tachycardia and tachypnoea. No urine output and the patient is comatose
76
What are the investigations for hypovolemic shock?
- Check Hb, U+Es, LFTs and do group+ save and cross match
- Coagulation screen
- ABGs: metabolic acidosis with raised lactate
- Urine output
- US and imaging to assess site of bleeding
- CVP if evidence of shock
77
What is the management for hypovolemic shock?
- 15L O2 via NRBM and get IV access
- Fluid resuscitation and bloods
- SURGERY is the definitive treatment if actively bleeding
- Prevent multi organ failure
- Inotropes and vasopressors can be given in critical care setting
78
What is the pathophysiology of anaphylactic shock?
- Immediate type hypersensitivity reactions due to interaction of antigens with specific IgE antibodies bound to mast cells and basophils.
- Mast cells and basophils respond by releasing vasoactive and bronchoconstructive substances including histamine, leukotrienes and ECF-A.
79
How do we recognize anaphylactic shock?
- rash
- urticaria
- laryngeal oedema (choking, coughing, stridor)
- angio-oedema
- severe bronchospasm
- hypotension
- shock
- nausea
- vomiting or diarrhea
- rhinitis
- tachycardia
80
What is the response for anaphylactic shock?
1) ABCDE assessment
2) Secure airway and call an anaesthetist (imminent intubate + ventilate, in an emergency, cricothyoidectomy)
3) O2 15L/min NRBM
4) Call an anaesthetist
5) IV access and bloods: FBC, U+Es, LFTs, calcium and glucose
6) Raise legs to restore circulation (lie flat and head down tilt)
7) Adrenaline 0.5ml of 1:1000 IM (0.5mg)
8) Repeat adrenaline as necessary every 5 mins (by monitoring BP and pulse)
9) May use small IV boluses of adrenaline if have access and experience
10) Chlorphenamine 10mg slow IV (or IM)
11) Hydrocortisone 200mg slow IV (or IM)
12) Fluid bolus- 500ml 1L of warmed Hartmann's solution over 10mins
13) if audible wheeze, treat for asthma
14) ICU for inotropes
81
What is the triad of symptoms for acute severe symptoms?
- WHEEZE
- SoB
- COUGH
82
What are the signs and symptoms of moderate acute asthma?
- Increasing symptoms
- PEF >50-75% best or predicted
- No features of acute severe asthma
83
What are the signs and symptoms of acute severe asthma?
- PEF 33-50% best or predicted
- RR >25/min
- HR >110/min
- Inability to complete sentences in one breath
84
What are the signs and symptoms of life-threatening asthma?
- PEF <33% best or predicted
- SpO2 <92%
- PaO2 <8kPa
- Normal PaCO2 (4.6-6kPa)
- Silent chest
- Cyanosis
- Poor respiratory effort
- Arrhythmia
- Exhaustion
- Altered conscious level
- Hypotension
85
What are the signs and symptoms of near-fatal asthma?
- Raised PaCO2
| - Requiring mechanical ventilation with raised inflation pressures
86
What is the response for acute severe asthma?
- ABCDE assessment
- Sit patient up
- Give O2 15L via reservoir mask
- ABG
- IV access and bloods: FBC, U+Es, glucose
- Consider CRP, blood and sputum cultures if sepsis suspected
- Salbutamol 5mg nebulised with O2
- Ipratropium bromide 0.5mg nebulised with O2 (4-6hrly)
- Hydrocortisone 200mg stat + 100mg IV or prednisolone 40mg orally QDS for at least 5 days post attack
- Magnesium sulphate 1.2-2g IV over 20mins if life threatening
- CXR to exclude infection and pneumothorax
- ECG- assess right heart strain
- Monitor PEFR, ABG, K+
87
What is the action of salbutamol?
Smooth muscle relaxation leads to dilation of bronchial passages
88
What is the action of ipratropium bromide?
- Antimuscarinic leads to dilation of bronchi
| - Inhibits mucus secretion
89
What is the action of hydrocortisone?
- Glucocorticoid
- Activates anti-stress and anti-inflammatory pathways
- 40-50mg prednisolone daily for at least 5 days after admission
90
What is the action of magnesium sulphate?
- Inhibits smooth muscle contraction
- Decreases histamine release from mast cells
- Inhibits acetylcholine release
91
What are the causes of community acquired pneumonia?
- Strep pneumoniae = 40%
- H. influenzae
- Influenza A+B
- Staph. aureus
- Moraxella catarrhalis
92
What are the causes of atypical pneumonia?
- Mycoplasma
- Legionella pneumoniphilia
Chlamydia pneumonia
93
What is the presentation for pneumonia?
- Cough (productive or non-productive)
- SoB
- fever
- pleuritic chest pain
- prodromal coryzal symptoms
- Respiratory distress
94
What are the investigations for pneumonia?
- CXR
- FBC
- U+E
- LFT
- CRP
- ABG
- blood and sputum cultures
- urine for legionella antigen
95
What is CURB-65?
C- CONFUSION?
U- UREA>7mmol/L
R- RR> 30
B- BP <90 systolic or <60 diastolic
65- >65years old
96
What is the management for pneumonia?
- ABCDE
- Venous access- assess fluid status and manage accordingly
- O2 at least 35% if hypoxic on ABG
- Ventilation if hypercapnia or hypoxia not corrected with max inspired O2
- Analgesia
- Start empirical antibiotics after cultures have been taken usually 5-7 days, 10 days in high risk patients
- Salbutamol neb if asthma/COPD for bronchospasm + mucocilliary action
- Fluids
97
What is the medical management for pneumonia?
MILD TO MODERATE- Amoxicillin or doxycycline
SEVERE CAP- Co-amoxiclav TDS 1.2g + clarithromycin 500mg BD or. cefotaxime/cefuroxime + clarithromycin
HAP- cefotaxime and metronidazole
ASPIRATION PNEUMONIA- Cefuroxime + metronidazole or benzylpenicillin + gentamicin + metronidazole
98
What are the signs/symptoms of acute exacerbation of COPD?
- Increasing dyspnoea +cough
- reduced exercise tolerance
- use of accessory muscles
- tachypnoea
- cyanosis
- wheeze
- increased sputum purulence
- UR symptoms
99
What are the causes of acute exacerbation of COPD?
- Strep pneumonia
- Haemophilus influenza
- Moraxella catarrhalis
100
What is the response for acute exacerbation of COPD?
- ABCDE approach
- Sit patient up
- controlled O2 therapy with venturi mask- but always treat hypoxia with increasing O2
- ABG- decreased PaO2 and raised bicarb in chronic disease
- IV access and bloods: blood cultures, FBC, U+Es, glucose
- SALBUTAMOL 5mg neubliser 4hrly
- IPRATROPIUM BROMIDE 500mg nebuliser 6hrly
- HYDROCORTISONE 100mcg nebulizer 6hrly
- ECG evidence of for pulmonate
- Antibiotics if evidence of infection
- CXR to exclude infection and pneumothorax
- Sputum sample and chest physio
101
When should non invasive ventilation be considered?
- COPD with a respiratory acidosis
- Hypercapnic respiratory failure secondary to chest wall deformity or neuromuscular diseases
- cardiogenic pulmonary oedema unresponsive to CPAP
- weaning from tracheal intubation
102
When is NIV not indicated in?
- impaired consciousness
- severe hypoxaemia
- patients with copious respiratory secretions
- consider intubation and ventilation if appropriate
103
What is cardiogenic acute pulmonary oedema?
- Due to elevated capillary pressure from left sided heart failure.
- Valve disease
- Ischaemia
- Arrythmia
104
What is non-cardiogenic acute pulmonary oedema?
- Minimal elevation of pulmonary capillary pressure
- Caused by altered alveolar-capillary membrane permeability- ARDS or lymphatic insufficiency
- Neurogenic e.g. status epilepticus, head injury
- Hypoalbuminaemia- liver failure, sepsis, dilution
105
What are the causes of acute pulmonary oedema?
- High-output heart failure
- Heart disease
- acute PE
- cardiac tamponade
- cardiomyopathy
- fluid overload
- liver failure
- acute/chronic airway obstruction
106
What are the features of acute pulmonary oedema?
- dyspnoea
- orthopnoea
- cough pin frothy sputum
- inspiratory crackles
- wheeze
- collapse
- cardiac arrest
- shock
107
What are the findings of acute pulmonary oedema?
CXR: cardiomegaly, fluffy bilateral shadowing with peripheral sparing, kersey B lines, pleural effusions. Exclude pneumothorax and consolidation
ECG: IHD, arrhythmias
ABG: O2 down, CO2 up/normal/down
108
What is the response to acute pulmonary oedema?
- ABCDE assessment
- Sit patient up
- O2 15L/min NRBM
- IV access and bloods: FBC, U+Es, LFTs, glucose
- Monitor BP and O2 sats
- Treat any arrhythmias
- DIAMORPHINE 2.5mg-5mg IV
- FUROSEMIDE 40-120mg IV slowly
- METOCLOPRAMIDE 10mg IV
- GTN 2 sprays of 500mcg sublingual if BP>90
- GTN infusion 50mg in 50ml
109
What is the action of diamorphine?
- Opiate
| - To relieve anxiety and distress associated with dyspnoea
110
What is the action of furosemide?
- Loop diuretic
| - Improves breathlessness and relieves congestion
111
What are the features of pneumothorax?
- sudden onset dyspnoea
- pleuritic chest pain/dull central chest pain
- unilateral reduced chest expansion
- unilateral decreased breath sounds
- unilateral hyper resonance to percussion
- CXR confirmation
112
Who is likely to suffer from pneumothorax?
- Ventilation patients
- Trauma patients
- Patients who've had CPR (tension)
- Lung disease especially acute exacerbations of asthma or COPD
- Infection
- Blocked, clamped or displaced chest drains
- Patients receiving NIV
- Patients undergoing hyperbaric O2 treatment
- post-thoracic procedures e.g. subclavian vein cannulation
- primary- tall, young, male smoker
113
What are the margins of large pneumothorax?
- 50% of lung volume lost- lung margin is >2cm from chest margin on CXR
114
What are the margins of small pneumothorax?
lung margin <2cm from chest wall on CXR
115
What is the response for normal pneumothorax?
- ABCDE
- O2 increases rate of resorption and reduces hypoxia >35%
- CXR
- Small primary pneumothorax- discharge and safeguarding and follow up
- Chest aspiration in primary and small secondary if <50yrs and asymptomatic- 2nd intercostal space mid clavicular line
- intercostal chest tube drainage in all others- 5th intercostal space mid-axillary line
116
What is the response for tension pneumothorax?
- ABCDE approach
- O2 15L/min via reservoir mask
- do not delay in management by waiting for CXR
- needle decompression- large bore needle (14-16G) 2nd intercostal space mid clavicular line with syringe filled with 0.9% saline
- insertion of chest drain (5th intercostal space mid-axillary line)
117
What is the surgical response for pneumothorax?
- pleuredesis
| - pneumothorax if large defect in chest wall
118
What are the risk factors for pulmonary embolism?
- malignancy
- post surgery
- immobility
- OCP
- pregnancy
- previous DVT/PE
- increasing age
- obesity
- smoking
- infection
- dehydration
- inherited thrombophilias
- right heart failure/ pulmonary hypertension
119
What are the features of pulmonary embolism?
- sudden onset dyspnoea
- pleuritic chest pain
- haemoptysis
- syncope
- CVS collapse
- raised JVP
- hypoxia
- postural hypotension
- Massive PE
- cyanosis
120
What investigations are done in pulmonary embolism?
CXR is often normal
CT angiogram confirms
ECG: S1Q3T3, right axis deviation and RBBB
WELLS SCORE
121
What is the criteria for ruling out PE?
HAD CLOTS
H- hormone use
A- age >50yrs
D- DVT/PE history
```
C- Coughing up blood
L- unilateral Leg swelling
O- Oxygen sats
T- tachycardia>100
S- surgery or trauma
```
can rule out id NONE of the above criteria are satisfied AND the Wells score is <3 and there is no clinical suspicion
122
What is the response for PE?
1) ABCDE assessment
2) sit patient up
3) O2 15L/min reservoir mask
4) Consider if respiratory support required
5) ABG
6) IV access and bloods: FBC, U+Es, glucose
7) Attach cardiac monitor
8) Treat hypotension with fluid bolus
9) Give NSAIDs and if no repose then 10mg IV morphine and antiemetic
10) if high risk anticoagulant with LMWH
11) Once diagnosis is confirmed start warfarin for up to 6 months- INR 2-3
12) Can use IVC filter if confirmed DVT
123
What is the definition of AKI?
RISE IN SERUM CREATININE
- >26umol/L within 48hrs
- 1.5x baseline value within 1 week
OR
URINE OUTPUT <0.5ml/kg/hr for 6hrs
124
What is Stage 1 of AKIN staging?
- rise in serum creatinine >26umol/L within 48 hrs
- rise in serum creatinine 1.5-1.9x baseline value within 1 week
- urine output >0.5ml/kg/hr for 6 hrs
125
What is Stage 2 of AKIN staging?
- rise in serum creatinine 2-2.9x baseline value within 1 week
- urine output >0.5ml/kg/hr for 12 hrs
126
What is Stage 3 of AKIN staging?
- rise of serum creatinine >354umol/L
- rise in serum creatinine >3x baseline value within 1 week
- commenced renal replacement therapy
- urine output <0.3ml/kg/hr for 24 hrs
- anuric of 12hrs
127
What are the risk factors for AKI?
- age >65
- CKD
- cardiac failure
- liver disease
- PVD
- DM
- nephrotoxins
- hypovolaemia
- sepsis
- ethnicity (black)
- surgery
128
What are the pre-renal causes of AKI?
- dehydration
- hypotension
- shock
- sepsis
- cardiac failure
- renal artery stenosis
129
What are the intrinsic renal causes of AKI?
- prolonged hypo-perfusion
- nephrotoxins
- glomerulonephritis
- vasculitis
- interstitial nephritis
- hemolytic uraemic syndrome
- acute tubular necrosis
- eclampsia
- rhabdomyalsis
130
What are the post-renal causes of AKI?
OBSTRUCTION
- renal stones
- retro-peritoneal fibrosis
- thrombosis
- bladder cancer
- pelvic mass
- enlarged prostate
131
What are the clinical features of AKI?
- hypovolaemia
- palpable bladder
- signs of vasculitis
- bruits (renal artery stenosis)
- malaise, confusion, coma
- nausea/vomiting
- backache
- haematuria
- fluid overload
- pericardial rub
132
What investigations should be done in AKI?
- volume assessment
- septic screen
- USS
- urinalysis and microscopy
- FBCs, U+Es, bicarb, LFTs, calcium, phosphate, glucose, ANAs
- ECG (K+, arrhythmias)
- ABG
- CXR- HF with pulmonary oedema
- Nephrotoxic drugs
133
What is the response for AKI?
- ABCDE assessment
- IV access and bloods
- treat underlying cause
- optimise fluid balance
- treat overload with nitrates, furosemide and O2
- treat complications- hyperkalaemia, acidosis, pulmonary oedema, bleeding
- review drug chart (STOP nephrotoxic drugs)
- renal replacement therapy
134
What are the two types of urinary tract infection?
- LOWER: cystitis
| - UPPER: pyelonephritis
135
What are the causes of urinary tract infections?
- E.coli
- proteus
- klebsiella
- s. faecalis
- pseudomonas (mostly inpatients/catheterised)
136
What is the presentation for cystitis?
- dysuria
- frequency
- haematuria
- suprapubic discomfort
- urgency
137
What is the presentation for pyelonephritis?
- systemic features
- loin/back pain
- vomiting
- rigors
- preceding cystitis
- shock/sepsis
138
What are the investigations for UTI?
URINALYSIS
- haematuria
- proteinuria
- leucocytes
- nitrites
MCS
- leucocytes
- WBCs
- U+E
- FBC
- cultures and USS for upper UTI
139
What is the management for cystitis?
3-6 DAYS
- trimethoprim/nitrofurantoin
men require a 2 week course
for catheterized patients: ciprofloxacin/ co amoxiclav for 7 days
140
What is the management for pyelonephritis?
- ABCDE
- IV antibiotics- gentamicin bolus
- Cefuroxime 750mg TDS 7-14 days
- await cultures
- monitor UO- high fluid balance
- opioids
141
What are the causes of male urinary retention?
- BPH/ cancer
- phimosis
- meatal stenosis
- UTI
142
What are the causes of female urinary retention?
- prolapse
- pelvic mass
- retroverted gravid uterus
- vaginitis
- lichen planus
- UTI
- post partum
143
What are the causes of urinary retention in males and females?
- drugs
- calculi
- cancer
- faecal impaction
- strictures
- neurological
- post surgery
- trauma
144
What are the presentations of urinary retention?
- inability to pass urine and bladder discomfort
- O/E: tender enlarged bladder, dull to percussion.
- Check for prolapsed disc/cord compression
145
What are the investigations for urinary retention?
- routine bloods
- urine MC+S
- US
- CT
- cystoscopy
- lower limb PNS and PR for anal tone
146
What is the management for urinary retention?
- Urethral catherization
- suprapubic catheterization if urethral is contraindicated
- Alpha blocker in men
- treat underlying cause
147
What are renal calculi?
They occur when urine is saturated with minerals such as calcium oxalate, struvite, uric acid or cysteine
Vary in size from gavel to large staghorn calculi
148
What is the most common type of renal calculi?
calcium oxalate (75%)
149
What are the risk factors for renal calculi?
- hyperparathyroidism
- prolonged immobility
- primary renal disease
- dehydration
- diuretics/steroids
- recurrent UTIs
- renal abnormalities
- FHx
150
What is the presentation for renal colic/stones?
PAIN
- dull loin ache= stone in renal pelvis
- severe colicky loin-groin pain, sudden onset= ureteric stone
- suprapubic/perineal/ testicular ache= bladder stone
HAEMATURIA
FEVER/RIGORS
SWEATY, NAUSEA, DISTRESS, PALE
ABDO TENDERNESS
151
What are the investigations for renal colic/stones?
- CT imaging of choice
- U+E
- glucose
- FBC
- HB and WCC
- calcium
- urine dipstick and MCS
- USS, AXR
152
What is the management for renal colic/stones?
- Diclofenac (IM/PR)
- antiemetics
- high fluid intake
- treat associated infection
- small stones will pass spontaneously
- large stones may need extracorporeal shock
- when discharged, encourage high fluid intake, reduced salt, oxalate and urate levels
153
What is testicular torsion?
twisting of spermatic cord causing compromised blood supply. Peak age range 7-14 years old bit also occurs commonly in the first 10 days of life.
154
What is the presentation of testicular torsion?
- acute swelling of scrotum with severe pain
- vomiting
- O/E red, tender, swollen testes, Angell's sign
- reducing pain may indicate necrosis?
155
What is Angell's sign?
- opposite testes horizontal position
156
What are the differentials for testicular torsion?
- epididymitis
- orchitis
- hydrocele
- hernia
- tumour
157
What is the management for testicular torsion?
- US integrated with color Doppler gold standard
- possible to reduce manually by specialist
- refer for: exploration, detorsion, orchidoplexy
158
How is hyperkalaemia recognized?
- serum K+ >5mmol
159
What are the ECG changes for hyperkalaemia?
- tall tented T waves
- small P waves
- wide QRS complexes
- VF
160
What are the signs and symptoms of hyperkalaemia?
- fast, irregular pulse
- chest pain
- weakness
- palpitations
- light-headedness
161
What are the causes of hyperkalaemia?
- oliguric AKI
- potassium sparing diuretics
- drugs (ACEi)
- rhabdomyolysis
- metabolic acidosis
- iatrogenic
- addisons disease
- massive blood transfusion
- artefact
162
What are the complications of hyperkalaemia?
- cardiac arrhythmia
| - sudden death
163
What is the response for hyperkalaemia?
- ABCD assessment
- IV access and bloods (FBC, U+Es, LFTs, glucose)
- attach to cardiac monitor
- monitor BP and O2 sats
- IMMEDIATE TREATMENT IF K>6mmol/L with ECG changes or potassium>6.5mmol/L regardless of ECG changes
164
What are the medical management options for hyperkalaemia?
- CALCIUM GLUCONATE
- INSULIN AND GLUCOSE
- SALBUTAMOL NEBULISER
- CALCIUM RESONIUM and LACTULOSE
165
What are the doses for administering calcium gluconate for hyperkalaemia management?
- 10% calcium gluconate 10mls IV over 2 mins
OR
- 10% calcium chloride 10mls over 10 mins
- Repeat dose after 5-10mins if ECG improvement
- Provides cardio-protection- no change in serum potassium level
166
What are the doses of insulin and glucose for hyperkalaemia management?
- short acting insulin 10U in 50mls of 50% glucose IV over 5-10mins
- insulin shifts potassium into cells temporarily
- monitor blood sugar levels regularly
167
What are the doses of salbutamol nebulizer for hyperkalaemia management?
- salbutamol 5mg nebuliser
| - shifts potassium into cells temporarily
168
What are the doses of calcium resonium and lactulose for hyperkalaemia management?
- 15mg orally every 6-8hrs
| - removes potassium from GI tract
169
What are the life threatening causes of chest pain?
- Acute MI
- Angina/ACS
- Aortic dissection
- Tension pneumothorax
- PE
- Oesophageal rupture
170
What are the non-life threatening causes of chest pain?
- pneumonia
- chest wall pain: muscular, rib, bony mets, chostochondritis
- GOR
- Pleurisy
- Empyema
- Pericarditis
- Oesophageal spasm
- Herpes zoster
- Cervical spondylitis
- Intra-abdo: cholecystitis, peptic ulcer, pancreatitis
- sickle cell crisis
171
What are types of ACS chest pain?
- dull retrosternal
- left sided pain
- tight/crushing heavy
- radiate to left arm, shoulder and jaw
172
What are the signs of cardiac ischemia?
- exacerbated by exercise/stress
| - relieved by rest/nitrates/O2
173
What are the autonomic symptoms associated with chest pain?
- nausea
- anxiety
- sweating
174
What are the symptoms associated with pleuritic irritation?
- sharp
- well localized pain
- exacerbated by breathing/coughing
175
What is the management for patients with acute chest pain?
- ABCDE assessment
- O2 if indicated- keep sats > 96%
- Analgesia
- Aspirin and GTN if cardiac is suspected
- ECG
- IV access and bloods- FBC, U+Es, troponin, D-dimer
- CXR (erect PA)
- further management dependent on most likely cause
176
What is aortic dissection?
- disruption of the medial layer of the wall of the aorta caused by intramural bleeding.
- leads to formation of a true and a false lumen
177
What are the risk factors of aortic dissection?
- genetic (Marfan's, Turner's, Ehler's Danlos)
- HTN
- previous cardiac surgery
- aortic coarctation
- pregnancy
178
What are the presentations of aortic dissection?
Presents in two phases:
- after first event with severe pain and pulse loss
- second event starts when pressure exceeds limit and rupture occurs into pericardium or pleural space leading to cardiac tamponade
O/E: aortic regurgitation
- different BP>20mmHg
- pleural rub
- haemothorax
- altered consciousness
- oliguria
179
What are the complications of aortic dissection?
- angina
- paraplegia
- limb ischaemia
180
What are the investigations for aortic dissection?
- ECG: signs of acute MI with ST changes
- CXR: widened mediastinum, abnormal aortic contour, tracheal shift, pleural effusion
- ECHOCARDIOGRAM- transoesophageal
- CT
181
What is the management for aortic dissection?
- ABCDE ICU
- Manage HTN with beta blockers
- Ascending type A- control of BP
- Descending type B- control of BP
182
What are acute coronary syndromes?
- Medical emergency classified on ECG and troponin levels.
- Classified into ST-ACS or NST-ACS
- Most ST-ACS will develop into STEMI
183
What are the features of NST-ACS?
- T wave inversion or ST depression
- NST-ACS further divided into
- - unstable angina
- - NSTEMI (which will show a rise in troponin level)
184
What are the risk factors for acute coronary syndrome?
- increasing age
- male
- family history of IHD
- smoking
- hypertension
- DM
- hyperlipidaemia
- obesity
- sedentary lifestyle
185
What is the general presentation of acute coronary syndrome?
- chest pain at rest>20mins
- tight, heavy, crushing, radiating to jaw and L arm
- history of angina
- shortness of breath
- sweating
- nausea
- palpitations
- signs of heart failure
- ECG changes
- troponin rise (12 hrs)
- CXR may show pulmonary oedema/cardiomegaly
186
What investigations are done in acute coronary syndrome?
- essential to exclude STEMI for which immediate thrombolysis is indicated
- routine bloods
- ECG
- troponin: peak at 12hrs
- echocardiography
- CXR
- angiography
187
What is the immediate management for general ACS?
- ABCDE assessment
- 15L O2 NRBM to maintain 94-98% oxygen saturations
- IV access and bloods: FBC, U+Es, calcium, magnesium, glucose and troponin
- serial ECGs
- Analgesia: morphine 2.5mg-10mg slow IV bolus
- antiemetic: 50mg cyclizing OR 10mg metoclopramide
- GTN spray x2 puffs
- aspirin 300mg oral loading dose
- clopidogrel 300mg for 12 months
188
What is the additional management for NSTEMI?
- refer to cardiology
- fondaparinux 2/5mg subcutaneously after discussion with cardiology
- assess need for revascularisation
189
What is the additional management for STEMI?
- refer to cardiology
- Primary PCI if within 12hrs of onset
- Thrombolysis if PCI not available
190
What are the long term medical management options in ACS?
- ACE inhibitors
| - Statins
191
What is myocardial infarction?
A condition which is included in the spectrum of acute coronary syndromes. Caused by necrosis of myocardium due to ischemia.
Most are anterior or inferior
CHD is the most common cause of death
192
What is the criteria or diagnosis in myocardial infarction?
RISE IN TROPONIN together with:
1) SYMPTOMS
2) ECG CHANGES
3) PATHOLOGICAL Q WAVES
4) IMAGING SHOWING DEATH OF MYOCARDIUM
193
What are the risk factors for MI?
- age
- male
- family history
- smoking
- DM
- HTN
- obesity
- south asian ethnicity
194
What is the presentation for MI?
CHEST PAIN
- central.epigastric crushing pain radiating to the arms, shoulders, neck or jaw
- radiation to the left arm or neck is common
- Associated with sweating, nausea, vomiting, dyspnoea, fatigue and/or palpitations
SHORTNESS OF BREATH
ABDOMINAL DISCOMFORT/JAW PAIN
195
What can be seen on examination in an MI?
- low grade fever, pale and cool and clammy skin
- hypotension or hypertension
- dyskinetic cardiac impulse (in anterior wall MI)
- 3rd and 4th heart sound, systolic murmur if mitral regurgitation or VSD develops, pericardial rub
- signs of congestive heart failure
196
What are the investigations for MI?
- routine bloods
- repeated troponin levels
- ECGs
- CXR, echocardiogram, SPECT scan
- monitor vital signs
- myocardial perfusion imaging and exercise ECG to assess risk before discharge
197
What is the management for MI?
- ABCDE assessment
- 15L O2 NRBM
- GTN spray
- morphine IV 5mg
- aspirin 300mg and clopidogrel 75mg
- beta blocker
- PCI within 90 mins
- if no PCI then fibrinolysis with alteplase IC
- CABG if failed PCI, cardiogenic shock or multi vessel disease
- ACE inhibitor
- Statin
198
What is stable angina?
- chest pain or discomfort caused by ischemia. Usually occurs because there is narrowing of the coronary arteries.
- Can also because by valvular disease
- occurs when the pain is precipitated by predictable factors (usually exercise)
199
What is the presentation for angina?
- Chest pain (if unresolved by GTN- treat as ACS)
Anginal pain is:
- constricting discomfort in chest, neck, shoulders, jaw, arm
- precipitated by exertion
- relieved by rest or GTN in 5 mins
200
What is a differential of anginal pain?
PRINZMETALS- which occurs at rest with circadian pattern
201
What are the investigations for angina?
- ECG: pathological Q waves, LBBB, ST depression, T wave inversion
- routine bloods
- baseline LFTs before beginning statins
- TFTs
- troponin
- echocardiography
- refer to secondary pain if pain at rest or rapidly progression
- refer to rapid access chest pain clinic if suspected angina
202
What is the management for angina?
- modify CV risk factors
advise that when an angina attack occurs:
- stop and rest
- use GTN
- take a second dose after 5 mins if not eased
- take a third dose after another 5 mins if still not eased
- call 999 if another 5 mins pass without ease
203
What additional medical management should be considered for angina?
```
BETA BLOCKER/CCB AS FIRST LINE TREATMENT
If ineffective, consider adding:
1. a long acting nitrate
2. Ivabradine
3. Ranolazine
```
ASPIRIN (75-300mg) or CLOPIDOGREL
ACE INHIBITOR
STATIN
204
How is cardiac arrest recognized?
The patient will be unresponsive and not breathing
| - perform airway manouevers and use adjuncts as appropriate
205
What is the management of cardiac arrest?
- establish IV access when possible
- call 222
- begin CPR at rate 30:2
- rate 100-120/min
- rescue breaths to last 1 sec with ventilation bag
- attach defibrillates and other monitoring equipment
- assess rhythm
206
What is the management of cardiac arrest in VF/pulseless VT?
- SHOCK
- return to chest compressions for 2 mins
- then assess pulse and rhythm
- Give 1mg IV adrenaline every 3-5 mins
- After 3rd shock give: 300mg IV amiodarone
207
What is the management of cardiac arrest in pulseless electrical activity (PEA)/asystole?
- NOT SHOCKABLE
- 1 mg IV adrenaline as soon as venous access
- Give 1mg IV adrenaline every 3-5mins
- After 3rd shock give: 300mg IV amiodarone
- Continue CPR
208
What are the reversible causes of cardiac arrest?
- hypoxia
- hypovolaemia
- hypothermia
- hyperkalaemia
- tension pneumothorax
- tamponade
- toxins
- thromboembolism
209
What is the action of adrenaline?
- vasoconstriction to increase myocardial and cerebral perfusion pressure.
- higher coronary blood flow increases frequency and amplitude of VF waveform.
- Improves short term survival
- can cause post cardiac arrest myocardial dysfunction and impairs microcirculation
210
What is the action of amiodarone?
- membrane stabilizing anti-arrythmic
- increases duration of action potential
- increases refractory period in atrial and ventricular myocardium. Slows atrioventricular conduction
- give IV bolus 300mg flushed with 20ml 0.9% NaCl or 5% dextrose
- further dose of 150mg may be given for recurrent/refractory VF/VT
211
What is pericarditis?
Acute inflammation of outer fibrous and inner serous membranes of the heart
212
What are the causes of pericarditis?
- MI
- viral (coxsackie, mumps, EBV, CMV, HIV)
- bacterial
- TB
- locally invasive carcinoma
- rheumatic fever
- uraemia
- post cardiac surgery
- collagen vascular disease (SLE)
213
What is the presentation of pericarditis?
CHEST PAIN
- central
- sharp
- retrosternal
- relieved by sitting forward
- SOB
- worse on exercise
- radiating to neck
PERICARDIAL FRICTION RUB
- intermittent
- positional
- louder during inspiration
- scratchy sound heard in midline
fever, cough, SOB, arthralgia, rash
pericardial effusion may develop- rise in venous pressure
214
What is Becks triad in cardiac tamponade?
1) hypotension
2) increased venous pressure
3) muffled HS
215
What are the investigations for pericarditis?
- ECG- 10% normal, sinus tachycardia, AF/flutter/atrial ectotropics, concave/saddle-shaped ST elevation in limb leads or all chest leads, prominent peaked T-waves
- pericardial effusion
- no pathological Q waves- unlike MI
- CXR heart size, pulmonary oedema, infection
- Bloods: FBC, ESR, CRP, U+E, troponin, cultures.
- Echo: if cardiac tamponade/ pericardial effusion suspected
216
What is the management for pericarditis?
- ABCDE
- Analgesia- NSAIDs- naproxen 250mg TDS increases coronary flow + PPI
- opioids may be needed
- steroids (prednisolone 60mg PO OD for 2 weeks)
- Colchicine analgesia 1mg/day
- pericardiocentesis for pericardial effusion
- stop anticoagulants in case of haemopericardium
217
What causes supraventricular tachycardia (Narrow QRS complexes)?
1. Abnormalities of impulse conduction
| 2. Disorders of impulse initiation causing narrow complex tachycardias
218
What are the risk factors of SVT?
- MI
- mitral valve prolapse
- pericarditis
- pneumonia
- chronic alcohol
- digoxin toxicity
219
What is the presentation of SVT?
- palpitations
- dizziness
- fatigue
- chest pain
- dyspnoea
- syncope
220
What can be seen on examination for SVT?
- tachycardia (140-250bpm)
- resulting HF may lead to tachypnoea
- hypotension
- fluid overload
221
What are the investigations for SVT?
- routine bloods
- ECG: acute, 24hr ambulatory, exercise
- cardiac enzymes
- electrolytes
- CXR
- echocardiogram
222
What is the management for SVT?
- Address precipitating factors: caffeine, alcohol, digoxin, drugs, hyperthyroidism
- DC cardio version is most effective means or terminating unstable tachycardia
- If stable then vagal manoeuvres (Valsalva, carotid massage)
223
What is the management for sinus tachycardia?
BETA BLOCKER
| NO DIHYDROPYRIDINE CCB e.g. diltiazem, verapamil
224
What is the management for sinus node re-entry tachycardia?
BETA BLOCKER
| DILTIAZEM, VERAPAMIL
225
What is the management of focal atrial tachycardia?
- CCBs
- BETA BLOCKER
- Flecainide
- Sotalol
- Amiodarone
226
When is radio frequency catheter ablation indicated for supra ventricular tachycardia?
1. First line therapy as a curative option
2. If the SVT is refractory to antiarrythmic drug therapy
3. If the person is intolerant of anti arrhythmic drug therapy
4. If antiarrhythmic drug therapy is contraindicated
227
When should urgent referral be made in conjunction with SVT?
- syncope with palpitations on exertion
- broad complex tachycardia
- pre-excitation (delta wave) on a 12 lead ECG
- structural heart disease
- severe symptoms
228
What are the complications associated with SVT?
- haemodynamic collapse
- HF
- DVT
- tamponade
- MI
- cardiomyopathy
229
What is ventricular tachycardia?
- Broad complex tachycardia defined as >3 ventricular extrasystoles in succession at rate of >120bpm
- Can be monomorphic VT is regular rhythm from a single focus
- Can be polymorphic VT which is irregular with beat to beat variations in QRS
230
What are the different types of VT?
FASICULAR TACHYCARDIA
- originates from the LBB
- produces QRS complexes of relatively short duration
RIGHT VENTRICULAR OUTFLOW TRACT TACHYCARDIA
- originates from right ventricular outflow tract
- ECG typically shows right axis deviation with LBBB pattern
- usually responds to drugs such as alpha-blocker or calcium antagonists
TORSADES DE POINTES TACHYCARDIA
POLYMORPHIC VENTRICULAR TACHYCARDIA
231
What is the presentation of ventricular tachycardia?
- Symptoms of IHD or hemodynamic compromise
| - Chest pain, palpitations, dyspnoea, dizziness, syncope, fluid overload
232
What are the clinical signs of ventricular tachycardia?
- degree of haemodynamic instability
- respiratory distress
- basal fine lung
- crepitations
- raised JVP
- hypotension
- anxiety
- agitation
- lethargy
- coma
233
What are the investigations for VT?
ECG
- rate greater than 100bpm
- wide QRS complexes
- presence of AV dissociation
- fusion beats
ELECTROLYTES: hypokalaemia, hypomagnesaemia, hypocalcaemia
LEVELS OF DRUGS
TROPONIN
CXR: CHF signs
234
What is the management for pulseless VT?
- ABCDE
- VF or pulseless VT is treated by unsynchronized defibrillation
- Defibrilation is followed by airway management if required
- supplemental oxygen
- vascular access
- amiodarone
235
What is the management for stable VT?
- lidocaine
| - cardioversion
236
What is ventricular fibrillation?
When the ventricle contracts randomly causing complete failure of cardiac function. Most commonly identified arrhythmia in cardiac arrest.
237
What are the risk factors for ventricular fibrillation?
- coronary artery disease
| - acute MI
238
In which conditions or situations would VF occur?
- Antiarrhythmic drug administration
- Hypoxia
- Ischaemia
- Atrial fibrillation
- Pre-excitation syndrome
- Electrical shock
239
What is the presentation of VF?
- History of chest pain
- fatigue
- palpitations
- known diagnosis of pre-existing heart disease
240
What are the investigations associated with VF?
- routine bloods
- cardiac enzymes (e.g. creatinine kinase, myoglobin, troponin)
- drug levels (e.g. tricyclic antidepressants, digoxin)
- toxicology screen
- TSH
- ECG: evidence of MI, prolonged QT interval, short PR, WPW
- CXR: signs of left heart failure, pulmonary hypertension
- ECHOCARDIOGRAPHY: underlying abnormalities and cardiac dysfunction
- coronary angiography
- - cardiac catheterization in patients who survive VF
- - identify patients for angioplasty or CABG
241
How is first degree heart block defined?
PR interval >0.2 seconds. Each atrial activation leads to a ventricular activation
242
How is second degree heart block defined?
Prolongation of the PR interval with intermittent failure of conduction of atrial impulses to the ventricles, causing 'dropped' beats. It is usually associated with cardiac pathology.
243
What are the two types of second degree heart block?
- Mobitz Type 1
| - Mobitz Type 2
244
What are the features of Mobitz type 1?
Progressive prolongation following each atrial impulse, until an atrial impulse fails to be conducted to the ventricles.
The condition is usually die to impaired AV nodal conduction, so the QRS complexes tend to be of normal width.
245
What are the features of Mobitz type 2?
Intermittent failure of conduction of atrial impulses to the ventricles without progressive lengthening of the PR interval, thus the PR interval of conducted beats is constant.
Regular pattern to the number of atrial impulses that lead to ventricular activation.
246
What are the possible causes of mobitz type 2?
- MEDICATION
- STRUCTURAL ABNORMALITIES OF THE HEART
- ISCHAEMIC HEART DISEASE
- MI
- INFLAMMATORY CARDIAC DISEASE
- CARDIAC INFILTRATION CAUSED BY CANCER
- HYPERKALAEMIA, HYPERMAGNESAEMIA AND ADDISON'S DISEASE
247
What is third degree heart block?
Complete failure of transmission of atrial impulses to the ventricles. P waves will occur regularly, usually at a rate of around 75bpm. They are completely unconnected to the rhythm of the QRS complexes. Third degree AV block can occur at the AV node or infra-nodally in his the Purkinje system.
248
What are the features of left bundle branch block (LBBB)?
The intraventricular septum is normally activated by the left bundle branch. LBBB shows:
- a prolonged QRS complex
- Replacement of the usual small Q wave win the left ventricular leads by a LARGE PROLONGED POSITIVE R WAVE.
- Secondary R waves in the left ventricular leads causing an M shaped pattern in leads 1, V4, V5 or V6.
- Left axis deviation may be seen.
249
What are the features of right bundle branch block (RBBB)?
The activation of the right ventricle is delayed and slowed conduction from the left to right ventricles:
- A prolonged QRS complex
- A secondary R wave in leads orientated to the right ventricle (V1 and V2) giving an M shaped ventricular complex in these leads
- T wave inversion may be seen in leads V1 and V2.
- A deep slurred S wave is seen in leads 1 and V6
250
How is hypokalemia recognized?
Serum K+ <3.5mmol/L
| if <2.5- seek urgent treatment
251
What ECG changes are associated with hypokalemia?
- small or inverted T waves
- prominent U waves
- long PR interval
- depressed ST segments
252
What are the signs and symptoms associated with hypokalemia?
- muscle weakness
- hypotonia
- hyporeflexia
- cramps
- tetany
- palpitations
- light-headedness (arrhythmias)
253
What are the causes of hypokalemia?
- diuretics
- D&V
- pyloric stenosis
- rectal villous adenoma
- intestinal fistula
- Cushing's syndrome/ steroids/ ACTH
- Conn's syndrome
- alkalosis
- purgative and liquorice abuse
- renal tubular failure
254
What is the response for hypokalemia?
MILD (>2.5mmol/L): oral K+ supplement and review after 3 days
SEVERE (<2.5mmol/L): IV potassium cautiously, no more than 20mmol/hr and not more concentrated than 40mmol/L
255
When is potassium contraindicated in hypokalaemic response?
- if the patient is OLIGURIC
| - NEVER AS STAT BOLUS
256
What is hypernatraemia?
- Plasma Na >145mmol/L
257
What are the signs and symptoms of hypernatraemia?
- lethargy
- thirst
- weakness
- irritability
- confusion
- coma
- fits
- signs of dehydration
258
What are the lab features of hypernatraemia?
- high sodium
- high PCV
- raised albumin
- raised urea
259
What are the causes of hypernatraemia?
- excess water loss:
- diarrhoea
- burns
- vomiting
- incorrect IV fluid replacement
- diabetes insipidus
- osmotic diuresis
- primary aldosteronism
260
What is the response for hypernatraemia?
- encourage oral fluids
- if not, dextrose 5% IV slowly (1L/6hr) guided by urine output and plasma sodium
- Use 0.9% saline IV if hypovolemic (less marked fluid shifts)
- Avoid hypertonic fluids
261
What is hyponatraemia?
- plasma Na <135mmol/L
262
What are the signs and symptoms of hyponatraemia?
- anorexia
- nausea
- malaise initially
- headache
- irritability
- confusion
- weakness
- reduced GCS
- seizures
- increased risk of falls in elderly
263
What are the possible causes of hyponatraemia if the patient is dehydrated?
- Addison's disease
- renal failure
- diuretic excess
- osmolar diuresis
- D&V
- fistulae
- burns
- rectal villous adenoma
- small bowel obstruction
- trauma
- cystic fibrosis
- heat exposure
264
What are the possible causes of hyponatraemia if the patient is not dehydrated?
- nephrotic syndrome
- cardiac failure
- liver cirrhosis
- renal failure
- SIADH
- water overload
- severe hypothyroidism
- glucocorticoid insufficiency
265
What is the response for hyponatraemia?
- correct underlying cause
- replace sodium and water in same way they were lost
- slowly rehydrate with -.9% saline- do NOT correct quickly as central potion myelinolysis. (Max rise 15mmol/L per day)
- vasopressor receptor antagonists promote water excretion without loss of electrolytes and appear effective at treating hypervolaemic and euvolaemic hyponatraemia
266
What is hypercalcaemia?
- Normal calcium= 2.25-2.60 mmol/L
267
What are the general signs and symptoms for hypercalcaemia?
- lethargy, malaise
- dehydration
- depression
- renal colic from stones
- polyuria/nocturia
- hematuria
- hypertension
- bone pain
- abdo pain
268
What are the acute signs and symptoms associated with hypercalcaemia?
- dehydration
- nausea and vomiting
- nocturia
- polyuria
- drowsiness/ altered consciousness
- serum Ca >3mmol/L
269
What are the ECG changes associated with hypercalcaemia?
- shortened QT
- heart block
- VF
270
What are the lab features and imaging features of hypercalcaemia?
- U+Es
- serum PTH
Abdo X-ray: renal calculi
271
What are the causes of hypercalcaemia?
- EXCESSIVE PARATHYROID HORMONE SECRETION: PRIMARY HYPERPARATHYROIDISM, adenoma, hyperplasia, carcinoma
- MALIGNANCY: myeloma, bone secondaries, osteoclastic factors produced by tumours
- EXCESS SECRETION OF VITAMIN D: Iatrogenic, self administered excess, granulomatous disease
- EXCESSIVE CALCIUM INTAKE
- OTHER ENDOCRINE DISEASE: thyrotoxicosis, Addison's
- DRUGS: thiazide diuretics, vit D analogues, lithium, vit A
- long term immobility, familial hypocalciuric hypercalcaemia
>90% DUE TO PRIMARY HYPERPARATHYROIDISM AND MALIGNANCY
272
What is the response for acute hypercalcaemia?
- ABC
- Stop: blood transfusion, calcium supplements, thiazide diuretics
- Rehydrate: >4-6L of 0.9% saline on D1, 3-4L for several days
- IV bisphosphonates
- Reduce calcium resorption from bone
- Prednisolone effective in some
- Calcitonin IV if no significant reduction in 3 days
273
What is collapse?
Syncope or transient LoC is caused by transient global cerebral hypoperfusion. Characterised by rapid onset, duration and spontaneous recovery. Affects 40% in their lifetime. Neurally mediated syncope is most common.
274
What are the risk factors for falls in the elderly?
- Age >80
- female gender
- low weight
- previous falls
- dependency in ADLs
- orthostatic hypotension
- medication (benzodiazepines, antidepressants, antipsychotic, anticnvulsants, anti-HTN)
- Polypharmacy
- Alcohol abuse
- Diabetes mellitus
- Confusion
- Disturbed vision
- Disturbed balance or co-ordination
- Gait disorders
- Urinary incontinence
- Inapporpriate footwear
- Environmental factors
- Muscle weakness
- Depression
275
What are the causes for collapse?
NMS or REFLEX SYNCOPE
- Vasovagal: emotional or orthostatic stress. Precipitated by stress or lack of food/drink/prolonged standing
- Usually preceded by: pallor, sweating, nausea and dizziness
- Situational: cough/micurition/heat/pain
- Carotid sinus hyper sensitivity- head turning, tight fitting collar
POSTURAL HYPOTENSION
- consider if on vasodilators or has autonomic dysfunction e.g. diabetes
HYPOVOLAEMIA
CARDIAC
- Arrhythmia- bradycardia, tachycardia, heart block
- Outflow obstruction- PE, aortic stenosis, HOCM
- Reduced CO- MI/ aortic dissection
```
NEUROLOGICAL
- epilepsy
- stroke/TIA
HYPOGLYCAEMIA
SUBSTANCE ABUSE
PSYCHOGENIC
DROP ATTACKS
```
276
What should have been in the history for collapse?
- Sequence of events before, during, after
- LoC complete? How long did it last and what do they remember?
- Any pre warning? (Nausea, sweating, weakness, visual)
- What were they doing when it happened? Previous falls?
- Associated symptoms such as chest pain?
- Recovery spontaneous? Post ictal?
- Any residual neurological deficit?
- Any recent changes in health or medication?
277
What is the management of collapse?
1) ABCDE assessment if applicable- full cardiovascular and neurological exam
2) Remember blood glucose
3) ECG (24hr ambulatory), exercise testing, tilt test, carotid sinus massage and BP
4) Urinalysis- rule out UTI or pregnancy
5) USS if considering ruptured AAA
6) IV access and bloods: FBC, U+Es
7) Identify cause so managed appropriately
8) No restriction on driving if simple fait, but take care
9) In elderly- increase exercise, review meds, environmental factors
278
What is delirium?
Clinical syndrome characterized by disturbed consciousness, cognitive function or perception, which has acute onset and fluctuating course. Usually develops over 1-2 days
279
How is delirium classified?
- HYPOACTIVE: withdrawn, quiet, sleepy
- HYPERACTIVE: agitated, restless, aggressive
- MIXED
280
What are the risk factors for delirium?
- Age >65
- Infection
- Previous mental health disorder
- Prior cognitive impairment
- Male sex
- Severe comorbidity
- Operative factors
- Certain conditions- burns, AIDS fractures
- current hip fracture/ severe illness
- Drug and substance abuse
- poor mobility
- social isolation
- terminally ill
- movement to a new environment
- urea/creatinine abnormalities
281
What is the cognitive presentation of delirium?
- worsened concentration
- slow responses
- confusion
- impaired recent and immediate memory
- physical function
- reduced mobility/movement
- restlessness/ agitation
- changes in appetite
- sleep disturbance
282
What perceptual changes occur in delirium?
- auditory/visual hallucinations
283
What are the social behavior changes associated with delirium?
- lack of cooperation with reasonable requests
- withdrawal
- altered communications
- mood/attitude
284
What are the causes of delirium?
- Pain- urinary retention or constipation
- Hypoxia
- Metabolic- hypercalcaemia, renal failure, liver failure, hypoglycemia
- Endocrine- Addison's disease, DM, thyrotoxicosis
- Infection
- Cardiac- MI, CCF, endocarditis
- Neuro- HI, subdural, post-ictal
- Drugs and alcohol
- Malignancy
285
What are the methods of diagnosis for delirium?
- Diagnostic and statistical manual of mental disorders (DSM-V)
- Short Confusion Assessment Method (short CAM)
- AMTS
- MMSE
286
What is the management for delirium?
- ABCDE
- Identify underlying cause/causes: septic screen, bloods, ECG, imaging, meds
- Effective communication- involve family
- If distressed or at risk to self/others consider haloperidol 2.5mg-10mg
- Avoid atypical antipsychotics e.g. olanzinpine and risperidone in the elderly
- may add lorazepam but try to avoid benzo's as tolerance and dependence may occur
- reduce stimulus environment- quiet side room. Familiar people/staff
287
What is diabetic ketoacidosis?
HYPERGLYCAEMIA (>11 or known DM)
ACIDOSIS (bicarb <15 or pH<7.3)
KETONAEMIA (>3 or ketonuria ++)
288
What are risk factors for DKA?
- infection
- poor med compliance or interactions
- physiological stress
- alcohol
289
What is the presentation for DKA?
- Polyuria and polydipsia
- weight loss
- weakness
- blurred vision
- vomiting
- abdo pain
- infective symptoms
290
What can be seen on examination in a patent with DKA?
- tachycardia
- weak pulse
- hypotensive
- increased RR
- ketones smell on breath
- signs of dehydration
- tender abdo
- reduced conscious level/ confusion
291
What is the pathophysiology of DKA?
- insulin deficiency
- hormone imbalance enhances hepatic gluconeogenesis and glycogenolysis which leads to SEVERE HYPERGLYCAEMIA
- Enhanced lipolysis increases serum free fatty acids which are METABOLISED
- there is therefore an accumulation of ketone bodies and therefore METABOLIC ACIDOSIS
292
What are the typical deficits in DKA?
- Water (ml/kg) 100
- Sodium (mmol/kg) 7-10
- Chloride (mmol/kg) 3-5
- Potassium (mmol/kg) 3-5
293
What is the management for DKA?
- ABCDE assessment
- O2 15L NRBM
- Capillary blood glucose
- 2 x IV access- VBG/ABG, U+Es, bicarb, FBC, ketones, amylase
- Urinalysis (ketones) and send for MCS
- Septic screen and pregnancy test
- NBM (as gastroparesis is common)
- catheter if oliguric
- critical care review
- fluid 0.9% NaCl 500ml over 15mins
- potassium supplementation
294
What is the action of insulin in the management of DKA?
- SUPPRESSES KETONE PRODUCTION
- REDUCES BLOOD GLUCOSE
- CORRECTS ELECTROLYTE IMBALANCE
295
What are the complications associated with the management of DKA?
- CEREBRAL OEDEMA
| - PULMONARY OEDEMA
296
What is Hyperosmolar Non Ketotic state?
HONK
Affects T2DM and is a complication whereby hyperglycemia causes severe dehydration. Has a 50% mortality with the main causes of death being aspiration due to gastroparesis, cerebral oedema, VTE.
297
How is HONK diagnosed?
- hyperglycaemia
- usually no ketones in urine unless vomiting
- no severe acidosis
- hyperosmolality
- 50% hypernatraemic
- +/- decreased conscious level and confusion
298
What is the management for HONK?
- Look for precipitating factor
- ABCDE
- blood glucose
- ABG
- IV access: blood cultures, U+Es, amylase, serum osmolality
- Urinalysis
- ECG + CXR
299
What are the other components of management for HONK?
- NG tube
- insulin
- 1. 10 units Human Actrapid state IV or IM
- 2. IV insulin infusion (50 units in 50mls of saline)
FLUIDS
- initially replace with 0.9% NaCl
- Change to 5% dextrose once blood sugar 15mmol/L
- regularly check potassium
- stop metformin
300
What is Whipple's triad in the diagnosis of hypoglycaemia?
1) GLUCOSE <3mmol/L
2) SYMPTOMS OF HYPO
3) RESOLUTION AFTER CORRECTION
301
What is the presentation of hypoglycaemia?
- autonomic: sweating, palpitations, shaking, hunger, anxiety, tachycardia
- neuroglycopenic: confusion, drowsiness, odd behaviours, speech difficulty, incoordination, FND
- general: malaise, headache, nausea. COMA/ unconscious (CBG <1.5mmol/L)
302
What are the causes of hypoglycaemia?
- too much insulin, too much, exercise, too little carbohydrates or combination
- alcohol
- sulphonylureas
- adrenal failure
- liver failure
- hypopituitarism
- infection
- patients with DM secondary to total
- pancreatectomy more susceptible
- insulinomas
303
What are the investigations for hypoglycaemia?
- CBG
- HbA1c
- U+Es
- LFTs
- TFTs
- C-peptide- low C peptide= exogenous insulin, high C peptide= endogenous insulin
304
What is the management for hypoglycaemia in those that are able to swallow?
- 15-20g quick acting carbs e.g. glucogel, fruit juices
- repeat blood glucose after 10-15 mins
- if glucose < 4mmol/L repeat glucotabs up to x3
- if no improvement after 3 times, consider IM glucagon or IV 10% glucose
305
What is the management of hypoglycaemia in unconscious patients?
- ABCDE assessment
- 75-100ml 20% glucose or 150-200ml 10% glucose over 15 mins
- 1mg IM glucagon repeat blood glucose after 10-15mins
306
How factors are important in recognizing stroke?
- time of onset (sudden onset focal neurology or confusion due to neurology)
- type and duration of symptoms (<24h= TIA)
- Risk factors for atherosclerosis
- Risk factors for embolism
307
What are the risk factors for atherosclerosis?
- diabetes
- smoking
- HTN
- high cholesterol
- FH
308
What are the risk factors for embolism?
- AF
- valvular disease
- coagulopathy
309
What are the conditions that mimic stroke?
- Hypoglycaemia (exclude on arrival)
- Seizures- Todd's paresis
- Trauma suggests subdural haematoma
- Infection- fever: sepsis, encephalitis, meningitis, brain abscess
- Exclude malignancy
- Migraine
- GCA
310
What are the different parts of the brain affected by stroke?
1) ANTERIOR CIRCULATION (40%)
2) LACUNAR INFARCTION (30%)
3) POSTERIOR CIRCULATION INFARCTION (15%)
4) HAEMORRHAGE: Intracerebral (10%), Subarachnoid (5%)
311
What are the features of anterior circulation infarction?
- limb weakness with visual field loss and cortical dysfunction
- aphasia and apraxia, if more dominant hemisphere
312
What are the features of lacunar infarction?
```
- infarct of internal capsule
motor/sensory loss affecting >2 of the following:
- face
- arm
- leg
- without visual or speech disturbance
```
313
What are the features of posterior circulation infarction?
- visual problems
- cerebellar symptoms (ataxia, nausea and vomiting)
- cranial nerve defects
314
What are the features in presentation of haemorrhage in stroke?
- warfarin therapy
- early vomiting
- severe headache
- drowsiness
- hypertension
315
What are the contraindications of thrombolysis in stroke management?
- BP > 185/110, bleeding
- Recent MI/ stroke/ head injury
- Recent LP
- Pregnancy
- Seizures at onset
- INR <1.7
316
What is the general management for stroke?
- ABCDE assessment- intubate if unconscious
- Blood glucose
- ECG and BP
- IV access and bloods (FBC, U+E, clotting, glucose, ESR, CRP)
- CXR
- Immediate CT/MRI to exclude hemorrhage inside thrombolysis window.
- Screen swallowing to prevent aspiration
317
What is the management for ischemic stroke in less than 4.5 hours?
if there is no bleeding on CT and clinical symptoms present:
| - thrombolyse with tissue plasminogen activator- IV ALTEPLASE
318
What is the management for ischemic stroke in one 4.5 hours?
- start ASPIRIN immediately
| - carotid doppler
319
What is the management for hemorrhagic stroke?
- fresh frozen plasma or prothrombin complex
- vitamin K
- surgical review
320
How do generalized/ tonic-clonic seizures present?
- loss of consciousness
- body tenses
- rhythmic contraction affecting all muscles
321
How do partial seizures present?
- wide spectrum of patterns
| - motor activity and sensory disturbance to area affected
322
What is the general management of seizure?
- ABCDE assessment- do not force mouth open
- Ensure patient will not hurt themselves during fit
- 100% O2 via 15L NRBM
- Blood sugar- if <4mmol/L give 50ml of 50% dextrose IV or 1mg IM glucagon
IF NO IV ACCESS
- buccal midazolam 10mg
- rectal diazepam 10mg
IV ACCESS/ FAILED BUCCAL OR RECTAL
- IV lorazepam 4mg
- IV diazepam 10mg
323
What is the third line management for seizures?
- PHENYTOIN loading dose over 30mins
324
What investigations should be done as part of the management process for a seizure?
- BLOODS: FBC, U+E, calcium, anticoagulant levels, prolactin levels
- CT if 1st seizure or abnormal neuro
- Screen for cause
325
What is status epilepticus?
Seizures lasting >5mins or repeated seizures without regaining consciousness
326
What are the features of status epilepticus?
- tonic-clonic seizure
| - non-convulsive status more difficult
327
What is the response for status epilepticus?
- ABCDE assessment
- maintain airway- recovery position
- O2 15L/min via reservoir mask
- IV access and bloods: FBC, UEs, LFTs, Ca, Mg, glu, ABG, tox screen
- Consider blood cultures if sepsis suspected
- If hypoglycaemia -> 50ml dextrose
- if alcohol induced give 250mg of IV thiamine over 10mins
- LORAZEPAM (1-4mg), DIAZEPAM (10mg) slow IV bolus
- buccal midazolam/rectal diazepam if no IV access
- Attempt to give anti-epileptic meds if already on treatment
- If seizures continue, load with IV PHENYTOIN 20mg/kg max of 2g, at max rate of 50mg/min
- Give PHENOBARBITONE if known heart block or already on phenytoin
- If continued seizures (30-60mins after onset) consider anaesthetic sedation with propofol, midazolam or thiopentone
328
What are the actions of lorazepam?
BENZODIAZEPINE
- attach to region on GABA receptor complex to facilitate opening of chloride channel by GABA making cell hyperpolarized, therefore less excitable
329
What are the actions of phenytoin?
Binds to Na channel responsible for depolarization keeping it open
330
What is the general management for self-injury?
- Assess mental state- suicide risk assessment
- Explain treatment options and discuss preferences
- Analgesia for treatment
- Superficial uncomplicated injury
331
What are the different types of self-poisoning?
30% involve multiple drugs
50% involve alcohol
ingestion of harmful substances
332
What is the general treatment for ingestion?
- ABCDE
- Seizures/convulsions use diazepam
- Monitor pH, BP, HR, RR, GCS, temp
- Bloods: FBC, UE, LFT, INR, clotting, paracetamol levels, salicylate levels, creatinine, glucose
- ABG
- ECG
- GI decontamination
- gastric lavage
- offer activated charcoal* as early as possible within 1h (50g)
- dialysis may be needed in severe cases
- CONSULT TOXBASE
333
When is charcoal ineffective?
- iron
- lithium
- ethanol
- methanol
- organic solvents
334
When is activated charcoal contraindicated?
- bowel obstruction
- perforation
- ileum
- haemodynamic instability
335
What is the antidote to ASPIRIN?
ALKALINE DIURESIS
336
What is the antidote to BENZODIAZEPINES?
FLUMAZENIL
337
What is the antidote to CARBON MONOXIDE?
HYPEBARIC O2
338
What is the antidote to IRON TABLETS?
DESFERRIOXAMINE
339
What is the antidote to METHANOL?
ETHANOL
340
What is the antidote to OPIATES?
NALOXONE
341
What is the antidote to PARACETAMOL?
N-acetylcysteine (PARVOLEX)
342
What is the antidote to TCA?
SODIUM BICARBONATE
343
What is the risk of severe liver damage compared to amount of paracetamol ingested?
- <150mg/kg UNLIKELY DAMAGE
- >250mg/kg LIKELY DAMAGE
- >12g total POTENTIALLY FATAL
344
Who are the high risk patients in paracetamol overdose?
- those on drugs that induce p450
- chronic alcoholics
- low glutathione stores e.g. HIV, anorexia, CF
345
What is the pathophysiology of paracetamol overdose?
- Paracetamol inactivated in liver by conjugation, producing metabolites glucuronide/sulphate which are excreted renally.
- In OD- the liver is overwhelmed so paracetamol is metabolized by an alternate pathway
- In this pathway, a toxic metabolite N-acety-p-benzoquinone imine (NAPQI) is produced by cytochrome p450.
- glutathione inactivates NAPQI, therefore preventing harm HOWEVER when the glutathione stores are depleted, NAPQI reacts with the nucleus of cells
- this leads to necrosis of the liver and kidney tubules
- Hepatic necrosis beings to develop 24h after ingestion
346
What is the presentation for paracetamol overdose?
- none initially or vomiting with RUQ pain
- after 24hrs: jaundice, encephalopathy from liver failure +/- renal failure, oliguria
- late: lactic acidosis
347
What are the complications associated with paracetamol overdose?
- acute liver failure
- cerebral oedema
- hypoglycaemia
- GI bleeding
- severe metabolic acidosis
- pancreatitis
- renal failure
348
What should be elicited in the history of a patient with paracetamol overdose?
- Number of tablets, formulation, dose
- Concomitant medication/tablets including herbal (enzyme inducers)
- TIME of OD
- SUICIDE RISK ASSESSMENT
- ALCOHOL ingestion
- other poisons taken?
- weight (calculate toxic doses)
349
What is the management for paracetamol overdose?
- ABCDE assessment
- maintain and clear airway
- ABG
- ECG
- IV access- bloods: glucose, UEs, FBC, INR, LFTs, PT
- paracetamol levels
- activated charcoal if <1hr after ingestion
- IV N-acetylcysteine in 5% dextrose (3 doses)
- Vitamin K IV
- if liver failure develops may require a liver transplant
350
When and how should paracetamol levels be measured?
- 4hr post ingestion
- IMMEDIATE if time of OD >4h ago or staggered, or unknown
- DO NOT TAKE >15h after ingestion
351
Who should receive N-acetylcysteine (PARVOLEX)?
- ALL PATIENTS with plasma paracetamol on or above normal treatment line (200mg at 4hrs), (30mg at 15hrs)
- HIGH RISK PATENTS i.e. if takes enzyme inducing drugs, reduced glutathione stores, or chronic alcohol use
- STAGGERED OD/ DOUBT TIMING
If patients have a rash, bronchospasm or hypotension, STOP INFUSION and give chlorphenamine.
If truly allergic use METHIONINE instead.
352
What is the action of N-acetylcysteine (PARVOLEX)?
- Acts as precursor for glutathione
- therefore replenishing stores
- promotes normal conjugation and supplies thiols to act as antioxidants
- 100% EFFECTIVE at preventing liver damage when given <8hr after ingestion
353
What is the dose of PARVOLEX?
- Give initial dose as 150mg/kg infusion over 15mins in 5% glucose
- Give as 3 infusions
354
What is the presentation for benzodiazepine overdose?
```
- rapidly develop in 4 hours
MILD:
- intoxication
- somnolence
- diplopia
- impaired balance
- impaired motor function
- anterograde amnesia
- ataxia
- slurred speech
```
SEVERE:
- coma
- apnoea
- respiratory depression
- hypoxaemia
- hypothermia
- hypotension
- bradycardia
- cardiac arrest
- pulmonary aspiration
355
What is the management for benzodiazepine overdose?
- ABCDE assessment
- Maintain and clear airway
- ABG
- ECG
- IV access- bloods: glucose. UEs, FBC
- Flumazenil
356
What is the action for flumazenil?
- benzodiazepine antagonist
| - can cause acute withdrawal and intractable seizures
357
What is the action for naloxone?
- give slowly
- 0.4-2mg
- If long acting e.g. methadone give IV infusion
358
What is the presentation of opioid overdose?
- drowsiness
- nausea and vomiting
- hypoventilation
- miosis
- coma
- cyanosis
- alcohol exacerbates depressant effects
359
What is the management of opioid overdose?
- ABCDE assessment
- O2
- close monitoring of respiratory system- pulse oximetry RR, depth
- maintain and clear airway
- ABG
- ECG continuous for arrhythmias
- IV access: bloods, glucose, UEs, FBC, CK
- Activated charcoal if airway protected and substantial amount in last 2 hours
- Naloxone
360
What is the presentation for amphetamine overdose?
- mydriasis (pupillary dilation)
- hypertension
- tachycardia
- pallor
- hyperexcitability
- agitation
- talkativeness
- paranoia
361
What are the complications associated with amphetamine overdose?
- SAH
| - vasospasm
362
What is the management for amphetamine overdose?
- ABCDE
- IV access: UEs, LFT, FBC, VBG
- ECG
- Monitor urine output
363
What is the medical management for amphetamine overdose?
There is no drug that directly counteracts amphetamines so manage symptoms
- BENZODIAZEPINES for seizures and agitation
- HALOPERIDOL for psychosis
- IV DIAZEPAM or NITRATES for controlling hypertension
- Monitor core temperature and neurology hourly
- Hyperpyrexia treated by cooling (cool fluids, sponging, exposure), chlorpromazine, dantrolene
- Treat dysrhythmias
364
What is the presentation for tricyclic antidepressant overdose?
- dry mouth
- dilated pupils
- blurred vision
- tachycardia
- urinary retention
- agitation
- hallucination
- myoclonic jerking
- arrhythmias, hypotension, convulsions, coma
- loss of oculocephalic and oculovestibular reflexes
- prolonged QRS
365
What are the complications associated with tricyclic antidepressant overdose?
- respiratory depression
- coma
- metabolic acidosis
- hypoxia
366
What is the management for tricyclic antidepressant overdose?
- ABCDE
- CNS depression-> ICU
- gastric lavage and activated charcoal if <1hr
- 48hr ECG monitoring
- sodium bicarbonate 50mmol IV 8.4% boluses
- benzodiazepines for agitation and seizures
- aim for pH 7.45-7.55
- glucagon/vasodepressors for hypotension
- only correct arrhythmias that compromise CO
- sedation during recovery
367
How is alcohol misuse detected?
- By ascertaining the quantity drunk and whether others/self have concerns
- dependency
- social problems e.g. missing work
- physical problems e.g. head injury, seizures
- CAGE
368
What are the features of uncomplicated alcohol withdrawal?
- Symptoms are seen 6-8 hours of last drink
- commonly peaks at 10-30 hours
- tremor
- agitation
- anorexia
- nausea
- fever
- insomnia
- sweating
- irritability
- increase HR and BP
- anxiety
- ataxia
369
What are the features of severe alcohol withdrawal (DELIRIUM TREMENS)?
- Hyperadrenergic state
- Is seen 2-5 days after cessation
- MEDICAL EMERGENCY
- hallucinations
- delusions
- severe tremor
- agitation
- clouding of consciousness
- confusion/disorientated
- HR >100/min
- fever
- labile mood
370
What assessments are done in those with alcohol withdrawal?
- Routine bloods
- ABG
- alcohol
- coagulation
- amylase
- creatinine kinase
- CXR
- CT
- ECG
371
What is the screening tool used to assess alcohol withdrawal?
Clinical Institute Withdrawal Assessment for Alcohol
(CIWA-Ar)
Scores from 1-7 for each category
372
What are the categories assessed in CIWA-Ar?
- nausea and vomiting
- tactile disturbance
- tremor
- auditory disturbance
- paroxysmal sweats
- visual disturbance
- anxiety
- headache
- agitation and orientation
373
What is the scoring system for the CIWA-Ar?
CIWA-Ar score <10: mild alcohol withdrawal
CIWA- Ar score 10-20: moderate alcohol withdrawal
CIWA- Ar score >20: severe withdrawal
374
What is wernicke's encephalopathy?
- Reversible biochemical lesion of CNS caused by, thiamine deficiency with chronic alcohol use.
- May develop over days
- If inappropriately managed can cause death or Korsakoff's psychosis (permanent brain damage and memory problems).
375
What is the presentation of Wernicke's encephalopathy?
- acute confusion
- amnesia
- ataxia
- opthalmoplegia
- nystagmus
- bilateral lateral rectus and conjugate palsy
376
What is the management of Wernicke's encephalopathy?
PABRINEX IV (500mg thiamine)
377
What is the management of alcohol withdrawal with a CIWA-Ar score of <10?
- ABCDE
- small doses of oral chordiazepoxide
OR
- no direct treatment just symptom relief e.g. paracetamol
378
What is the management of alcohol withdrawal with a CIWA-Ar score of 10-20?
- ABCDE
| - Chlordiazepoxide 10-20mg PO QDS, reduced over 5 days
379
What is the management of alcohol withdrawal with a CIWA-Ar score of >20?
- ABCDE
| - Chlordiazepoxide 20-40mg PO, reduced over 5 days
380
What is the management of alcohol withdrawal for those who cannot tolerate oral treatment?
- 10mg slow IV diazepam
| - 500mg/kg rectal diazepam solution
381
When can management of alcohol withdrawal be done as an outpatient?
- Current or HX of delirium tremens
- Wernicke's
- seizures
- mental/physical illness
- suicide risk
- unstable home environment
382
What are the classifications of lower back pain?
- ACUTE
- SUBACUTE
- CHRONIC
383
What are the causes of sinister back pain?
- Leaking aortic aneurysm: pulsatile mass, peritonism, radial-femoral delay, shock
- Cauda equina syndrome: lower limb weakness, altered perianal sensation, sphincter disturbance
- Malignancy: weight loss, high lesion
- Infection: discitis, epidural abscess
- Osteoporotic crush fracture
384
What are the red flags associated with back pain?
- recent trauma
- young or old
- cancer
- drug abuse
- immunosuppression
- fever
- weight loss
- pain that is worse when supine
- pain that is worse at night, or constant, thoracic, non-mechanical impacts ADL
- Saddle anaesthesia, bowel or bladder problems
385
What should be elicited in the history of someone with back pain?
Decide if it is MECHANICAL, INFLAMMATORY OR SINISTER
MECHANICAL: improved on movement, exacerbate by long sitting or standing
INFLAMMATORY: early morning stiffness
SINISTER: see red flag symptoms
386
What is done on examination in back pain?
- Combined back and PNS exam
- flexion, extension, rotation in all directions
- straight leg raise- note the angle which reproduces pain, lumbar root irritation
- crossed straight leg raise: symptoms on raising contralateral leg- lumbar disc prolapse
- neurological exam
- rectal exam- tone, masses, blood
387
What are the investigations done in back pain?
- X-ray (malignancy, infection, HIV, age >55)
- CRP
- FBC
- ESR
- UE
- MRI
- calcium
- alk phosp
- phosphate
- immunoglobulins
- PSA
388
What is the management for back pain?
- ABCDE
- Recognise red flags
- Refer if: <20 or >55, unremitting or increasing symptoms, neurological signs, weight loss, systemically unwell, chronic steroid use, HIV
- Mechanical back pain- NSAIDs, avoid bed rest, turn to normal activity, recovery in 4-6 weeks
- Safety net- return if weakness, loss of sphincter control, numbness
389
What is are the boundaries of hip fracture?
- A fracture that affects the proximal femur and is common in the elderly
- They are divided into intracapsular and extracapsular.
- Most are intrascapular affecting the femoral neck which may lead to avascular necrosis of femoral head
390
What are the various presentations of hip fracture?
- ELDERLY= simple fall
- YOUNG= high impact trauma- RTA
- ATHLETES= stress fractures
- Pain in upper outer thigh or groin
- Affected leg may be shortened, adducted and externally rotated
- immobility
391
What are the risks of obtaining a hip fracture?
- previous fractures e.g. Colles
- Osteoporosis
- Maternal hx
- neuro impairment
- corticosteroid use
- smoking
- institutions
- low body weight
392
What is done on examination of hip fracture?
LOOK, FEEL, MOVE
LOOK
- inspection
- deformity
- haematoma
- laceration
- asymmetry
FEEL
- tenderness over trochanters/neck depending on fracture
MOVE
- range of movement- may be painful
- neuromuscular exam
- assess for shock/blood loss- can loose up to 1500ml of blood into femur
393
What are the investigations associated with hip fracture?
- BLOODS: FBC, UEs, G+S
- X-RAY
- Classified by Gardens classification
394
What is the management of hip fracture?
- ABCDE
- Orthopaedic consult, surgery within 1 day to repair to hip replacement
- Large IV access- in case of need for transfusion
- Analgesia- possible femoral nerve block if needed
- VTE prophylaxis
- splint to reduce blood loss
395
What are the different types of distal radius fracture?
1) COLLES'
2) SMITH'S
3) BARTON'S
4) SCAPHOID
5) CHAUFFEUR'S: radial styloid
6) GREENSTICK: children, bone bends and breaks
396
What are the features of Colles' fracture?
- distal fracture of radius with or without ulnar involvement.
- particularly common in older people with osteoporosis
- dorsal displacement
397
What are the features of Smith's fracture?
- distal fracture of radius with or without ulnar involvement.
- anterior displacement
398
What are the features of Barton's fracture?
- distal radial fracture with dislocation of radiocarpal joint
399
What should be done in examination of distal radius fracture?
- XR is gold standard
- check radial head and ulnar styloid for tenderness
- check median, radial and ulnar nerve- sensation and movement
- Colles' fracture= dinner fork deformity
400
What is the management for distal radial fracture?
1) Reduction of fracture (Entonox)
2) May need surgery
3) Apply back slab, then a few days later, a full cast is applied. Repeat XR.
4) Analgesia: paracetamol, codeine
401
What are the complications associated with distal radial fractures?
- median/ulnar nerve damage
- avascular necrosis
- compartment syndrome
- deformity
- arthritis
402
What are the features of shoulder dislocation?
- most common type is anterior shoulder dislocation
- where the humeral head lies anterior and inferior to glenoid
- almost always due to trauma
- commonly falling onto outstretched arm
FORCED EXTERNAL ROTATION/ABDUCTION OF THE SHOULDER
403
What is the presentation of shoulder dislocation?
- Patient holds arm at side of body in external rotation
- Humeral head is palpable anteriorly
- Abduction and internal rotation are resisted
404
What should be done on examination of shoulder dislocation?
- check radial pulses
- check sensation in regimental badge area (deltoid) for axillary nerve damage
- check radial nerve function (thumb wrist and elbow weakness on extension and dorsal sensation)
- examine rotator cuff muscles especially after reduction
405
What are the complications associated with shoulder dislocation?
- bankart lesions
- hill-sachs lesions
- recurrent dislocations
406
What is the management of shoulder dislocation?
- analgesia
- temporary sling
- X-ray prior to reduction to exclude associated fractures
- reduction with sedation and analgesia
407
What are the features of posterior shoulder dislocation?
- blow to or fall onto internally rotated arm or post seizure
- uncommon
- internally rotated shoulder
- may require modified axial X-ra to diagnose
- much less obvious and may mimic frozen shoulder
408
What is ankle sprain?
- injury to ligament but it is important to rule out fracture
- ABCDE assessment if following trauma
- mechanism commonly inversion
- damage to anterior-talofibular ligament and lateral malleolus
- Other type is syndesmotic (high ankle) sprain caused by dorsiflexion.
- Sprains are classified from grade 1-3
409
What is the presentation of ankle sprain?
- weight bearing impossible immediately after injury- fracture
- 'crack'- not necessarily fracture
410
What should be done in examination for ankle sprain?
LOOK, FEEL, MOVE
- Special ankle tests: Thompson's test, anterior draw, talar tilt tests
- Examine tenderness at: proximal fibula, lateral malleolus and ligaments, medial malleolus and ligaments, navicular, calcaneum, Achilles tendon, base of 5gh metatarsal
411
What are the Ottawa ankle rules?
- Unable to walk 4 steps in ED or immediately after injury
- Bony tenderness over points described
- Pain in either mid foot (foot x-ray) or malleolar zone (ankle x-ray)
412
What is the management for ankle sprain?
1) RICE: Rest (48hrs), Ice, Compression, Elevation
2) simple analgesia
3) if the ligament is fully ruptured it will require surgery
413
What main aspects should be elicited on history of headache (S)?
SITE
- unilateral
414
What main aspects should be elicited on history of headache (O)?
ONSET
- Sudden, occipital, 'thunderclap'- SAH
- History of recent trauma
415
What main aspects should be elicited on history of headache (C)?
CHARACTER
- pain and tenderness on side of the head (GCA)
- dull ache +gradual onset (SOL)
- eye pain, blurred vision, malaise, N+V- acute angle closure glaucoma
416
What main aspects should be elicited on history of headache (A)?
ASSOCIATED SYMPTOMS
1) FOCAL NEURO SYMPTOMS? (migraine, SOL, SAH)
2) NAUSEA + VOMITING (migraine, infections, raised ICP, SAH, SOL)
3) FEVER, PHOTOPHOBIA, NECK STIFFNESS (meningitis)
4) PAPILLOEDEMA (raised ICP)
5) VISUAL DISTURBANCE (migraine, glaucoma, GCA)
6) REDUCED CONSCIOUSNESS, CONFUSION, SEIZURES OR FOCAL NEURO
7) PERSONALITY CHANGE - SOL
417
What main aspects should be elicited on history of headache (T+E)?
TIMING + EXACERBATING FACTORS
- Worse on waking (raised ICP, SOL)
- straining/bending over/cough
- Alcoholism, anticoagulation, (subdural haematoma)
418
What are some of the differentials for headache with no signs on examination?
- tension headache
- migraine
- cluster headache
- post traumatic
- drugs
- carbon monoxide poisoning
- SAH
419
What are some of the differentials for headache with signs of meningism?
- meningitis
- SAH
- carotid/ vertebral artery
- dissection
420
What are some of the differentials for headache with decreased level of consciousness or localizing signs?
- stroke
- encephalitis/ Meningitis
- cerebral abscess
- SAH
- venous sinus occlusion
- tumour
- subdural haematoma
- TB meningitis
- carotid/vertebral artery
- dissection
421
What are some of the differentials for headache with papilloedema?
- tumour
- venous sinus occlusion
- malignant hypertension
- idiopathic intracranial
- hypertension
- SAH
- any CNS infection if >2wks
422
What are some of the other differentials for headache?
- GCA
- acute glaucoma
- vertebral artery dissection
- cervical spondylosis
- sinusitis
- Paget's disease
- Altitude sickness
423
What is the management for most presentations of headache in AE?
- ABCDE assessment
- Blood glucose
- IV access: FBC, CRP, blood cultures if suspect infection.
- INR clotting if warfarinised
- ESR if suspecting GCA
- IV fluids: 2L IV 0.9% NaCl
- Analgesia: paracetamol, codeine
- Anti-emetic: metochlopramide, prochlorperazine, chlorpromazine
- CT head- to detect SAH within 12 hours of onset
- Lumbar puncture
424
When should LP not be done?
- In drowsy/unconscious patients due to risk of coning
| - CI if clotting is abnormal
425
When should LP be done in possible SAH?
- perform at >12hours after onset of headache to to allow XANTHOCHROMIA to develop (yellow CSF due to bilirubin leaking from RBCs)
- only if CT is not diagnostic
426
What would some of the features of meningitis on LP?
- opening pressure of >14cm CSF
- high WCC and neutrophils
- plasma glucose <0.31
- protein elevated
427
What is subarachnoid hemorrhage?
- 85% bleed from intracranial arterial aneurysms
- 15% from other arteriovenous malformations
- can occur due to trauma
428
What is the presentation for subarachnoid haemorrhage?
- THUNDERCLAP HEADACHE
- typically pulsates towards occiput, lasting a week or two
- vomiting, confusion, seizures and coma
- neck stiffness, meningism
- warning headaches and other neuro symptoms can occur in the weeks before SAH
429
What may be seen on examination in SAH?
- depressed conscious level
- neck stiffness
- intraocular haemorrhages
- loss of light reflex
- focal neurological signs
- papilloedema
430
What is the investigation for SAH?
- CT SCAN 1ST LINE
- CT angiography if SAH confirmed
- LP if CT is negative, but history suggestive
- ECG check for QT prolongation, ST elevation
431
How is SAH classified?
Hunt and Hess scale for severity:
- from minimal headache + neck stiffness
- to comatose and severe rigidity
432
What is the management for SAH?
- ABCDE - intubation and ventilator support
- Initial management is to prevent further bleeding and reduce secondary complication
- Endovascular obliteration via femoral artery and platinum coils or clipping
- Nimodipine 60mg four hourly- reduce vasospasm
- Address modifiable risk factors
433
What are space occupying lesions?
- Most commonly due to malignancy e.g. gliomas, meningiomas, pituitary adenomas, acoustic neuromas and metastases.
- Abscesses and haematomas
434
What are the generalized symptoms associated with space occupying lesion?
- HEADACHE: wise in the morning and on bending. Change in pattern
- VOMITING AND NAUSEA
- CAHNGE IN BEHAVIOUR
- WEAKNESS
- CEREBELLAR SIGNS: ataxia, tremor, dysdiadochokinesis, nystagmus, staccato
- SPEECH and visio disturbance
- CONVULSIONS
435
What are the localizing signs associated with temporal space occupying lesions?
- depersonalisation, emotional changes and disturbances of behaviour
- temporal lobe epilepsy
- hallucinations of smell, taste, sound and sight
- dysphasia
- visual field defects involve the contralateral upper quadrant
- other psychological problems include forgetfulness, psychosis and fear
436
What are the localizing signs associated with frontal space occupying lesions?
- ansomnia
- change in personality (indecent, indiscreet or dishonest)
- dysphasia can occur if Broca's rea is involved
- Hemiparesis or fits may affect the contralateral side
437
What are the localizing signs associated with parietal space occupying lesions?
- hemisensory loss
- astereogenesis
- extinction
- sensory inattention
- dysphasia
438
What are the localizing signs associated with occipital space occupying lesions?
- visual field defects
439
What are the localizing signs associated with cerebellopontine angle space occupying lesions?
- ipsilateral deafness
- tinnitus
- nystagmus
- reduced corneal reflex
- facial and trigeminal nerve palsies
- ipsilateral cerebellar signs
440
What are the localizing signs associated with midbrain space occupying lesions?
- unequal pupils
- inability to move eyes up or down
- amnesia
- somnolence
441
What are the investigations associated with space occupying lesions?
- routine blood tests
- hyponatraemia due to inappropriate ADH
- CT and MRI scans
- biopsy of lesions
442
What is the management for space occupying lesions
- Treat cause
- Treat raised ICO
- Treat seizures
- Treat N+V
443
What is temporal/ giant cell arteritis (GCA)?
- systemic immune mediated vasculitis affecting medium and large arteries particular the aorta and its extra cranial branches
- More common in women
- Linked to polymyalgia rheumatic
444
What is the presentation of GCA?
- >50years
- recent onset of temporal headache
- weight loss
- night sweats
- fever
- scalp tenderness
- jaw claudication
- diplopia
- abnormality on palpation of the temporal artery
445
What is seen on examination of TCA?
- fundoscopy showing ischemic changes
- Prominent, tender, beaded pulseless temporal arteries
- carotid bruits
- fever
- myalgia
- arthralgia
446
What are the investigations associated with TCA?
- FBC
- ESR
- UE
- LFT
- CRP
- CXR
- urinalysis
- US
- temporal artery biopsy to confirm diagnosis within 48hrs
447
How is diagnosis of TCA made?
DIAGNOSIS (3 out of 5)
- >50 years old
- new headache
- temporal artery abnormality
- elevated ESR (>50)
- abnormal artery
- biopsy showing vasculitis
448
What is the management of TCA?
- urgent referral but begin high dose steroid treatment alongside:
- IV HYDROCORTISONE 200mg
- PO PREDNISOLONE 40mg
- Reduce dose in 10mg every 2 weeks
- Remain on gradually decreasing steroid dose for 9-12 months
- Aspirin (75mg) long term + PPI
449
What are the complications of TCA?
- loss of vision
- aneurysms
- CNS disease and steroid related complications
450
What is cerebral/venous sinus thrombosis?
```
- Thrombosis of cerebral veins or sinuses leading to cerebral infarction
Common in:
- prothrombin states (pregnancy)
- infection (sinusitis with S. aureus)
- malignancy
- dehydration
- trauma
```
451
What is the presentation of cerebral/ venous sinus thrombosis?
- Headache (sudden onset and severe like SAH)
- seizures
- stroke syndrome (weakness)
- SAH
- isolated raised ICP
- nausea and vomiting
- confusion
- papilloedema
452
What are the investigations associated with cerebral/venous sinus thrombosis?
- FBC (elevated Hb)
- ANAs
- clotting
- thrombophilia screen
- D-dimer
- Diagnosis with CT angiography
- MRI
453
What are the management for cerebral/venous thrombosis?
- ABCDE
- Reduce ICP- elevate head, avoid pyrexia
- Anticonvulsants
- Anticoagulation with heparin and then warfarin
- May require surgery to remove thrombus
454
How is severe traumatic brain injury defined?
GCS <9
455
What are the main causes for brain injury?
- falls and assaults
- RTAs
- alcohol is a major risk factor
456
What is done for examination in brain injury?
- ABCDE assessment
- cervical spine immobilization if GCS
- neck pain
- focal neuro deficit
- paraesthesia
457
When should patients with brain injury be referred to hospital?
- A high-energy head injury
- GCS <15 at any time since injury
- Any loss of consciousness as a result of the injury
- Any focal neurological deficit since the injury
- Amnesia for events before or after the injury
- Persistent headache since the injury
- Any vomiting episodes or seizures
- Irritability or altered behavior
- Any suspicion of a skull fracture or penetrating head injury since the injury
458
When should CT scans be done in adults within 1 hr of head injury?
1) GCS <13 when first assessed or GCS <15 2hrs after injury
2) Suspected skull fracture
3) Post-traumatic seizure
4) Focal neurological deficit
5) >1 episode of vomiting
459
When should CT scans be done in children within 1 hr of head injury?
1) Suspicion of NAI
2) post-traumatic seizure
3) GCS<14 or if <1yr GCS <15
4) GCS <15 two hours after injury
5) suspected skull fracture or tense fontanelle
6) focal neurological deficit
7) aged <1- bruise, swelling/laceration >5cm on the head
8) Witnessed loss of consciousness >5 mins
9) Amnesia >5mins
10) >3 discrete episodes of vomiting
11) dangerous mechanism of injury
460
What is the management of head injury?
- High dose MANNITOL in pre-operative management of patients with haematomas
- Anticonvulsants if seizures
- ICU admission if necessary
- neurosurgery
461
What are the complications associated with head injury?
- amnesia
- cerebral herniation
- CSF leak
- meningitis
- intracranial haemorrhage
- cerebral contusions
- seizures
- concussion
462
What is DVT?
Venous thrombosis that occurs in the deep vein of the leg or pelvis
Clot can dislodge and travel to lungs causing a PE
463
What are the risk factors associated with DVT?
- age >60
- immobility
venous damage
- thrombophilia
- previous DVT/PE
- family history
- oral contraceptive pill
- pregnancy
- obesity
- malignancy
- nephrotic syndrome
464
What is the presentation of DVT?
- pain and tenderness in calf
- pitting oedema
- warm and red
- cellulitis adds to the problem and can often be disguised by DVT symptoms
465
What can be seen in examination of DVT?
- dissension of superficial veins
- low grade fever
- pain in calf on dorsiflexion
- pitting oedema
466
What are the investigations associated with DVT?
- US and D-Dimer
- Calculate Well's score
- routine bloods
- CXR
- contrast venography
- identify cause- coagulation screen, malignancy
467
What should occur if a low risk score occurs on Well's score?
Is the D-dimer:
- Normal? discharge
- Abnormal? US scan
468
What should occur if a high risk score occurs on Well's score?
- Low molecular weight heparin
| - US scan
469
What is the management for DVT?
- commence treatment LMWH (tinzaparin) or fonapurinux- 175 units/kg OD
- when confirmed start warfarin for at least 3 months
- take off LMWH when INR normal
- TED stockings for future prevention
- IVC filter if recurrent despite anticoagulation
- Prevent PE
470
What are the causes of acute limb ischemia?
- Can be due to thrombus (40%)
- emboli (38%)
- graft occlusion (15%)
- trauma
471
What are the 6P's of acute limb ischaemia?
- pallor
- pulseless
- paraesthesia
- paralysis
- pain
- perishingly cold
472
What are the investigations associated with acute limb ischemia?
- Doppler US
- FBC
- ESR
- glucose
- UE
- urinalysis
- CXR
- ECH, echo
473
What is the management for acute limb ischemia?
1) ABCDE, fluids and analgesia
2) Systemic anticoagulation with unfractionated heparin
3) Urgent open surgery or angioplasty
4) Amputation if irreversible damage
5) Modifiable CV risk factors at follow up
474
What are the complications associated with acute limb ischemia?
- compartment syndrome: when perfusion pressure falls below tissue pressure in closed space.
- treat with fasciotomy
- re-perfusion injury: neutrophils leak in due to tissue causing injury
- rhabdomyolysis
475
What are the four types of gout?
1) ASYMPTOMATIC
2) HYPERURICAEMIA
3) ACUTE
4) INTERCRITICAL AND CHRONIC TOPHACEOUS
476
What are the main causes of gout?
Monosodium urate crystal deposition
- precipitated by trauma
- diet
- diuretics
- renal failure
- myeloproliferative disease
- infection
- excess alcohol
- dietary purines
- starvation
477
What is the presentation of gout?
- Acute gout most often 1st MTP of big toe but also knee
- Sudden onset of inflamed, red, painful joint
- pain lasting 6-12 hours
- May be polyarticular
- shiny skin
478
What can be seen on examination of gout?
- florid synovitis
| - swelling and erythema
479
What are the investigations associated with gout?
- clinical diagnosis mainly
- raised serum urate
- joint aspiration (NEGATIVELY BIREFRINGENT CRYSTAL)
- joint cultures to exclude septic arthritis
- X-rays- soft tissue swelling and later punched out lesions
- exclude IHD, HTN, metabolic syndrome
480
What is the management for gout?
- Rest
- NSAIDs - diclofenac/naproxen/ colchicine
- Prednisolone 15mg OD
- Allopurinol for prevention if recurrent attacks
481
What is the conservative management for gout?
- lose weight
- avoid starvation
- avoid fatty foods
- avoid excess alcohol
482
What are the causes of septic arthritis?
- Staph aureus (70%)
| - Neisseria gonorrhoea in sexually active young population
483
What are the risk factors associated with septic arthritis?
- Rheumatoid arthritis
- Steroid use
- immunosuppressed
- prosthetic joints
484
What is the presentation of septic arthritis?
- Only one joint affected in 85%
- red, hot, painful swollen
- movement not tolerated
- fever, rigors
- IVDU may have unusual joints affected e.g. sacroiliac
- differentiate from gout and pseudogout
485
What are the investigations associated with septic arthritis?
- FBC
- CRP
- ESR
- blood cultures
- joint aspiration (yellow, purulent, cell count >10,000 neutrophils, gram positive)
- XRAY will show bone destruction
- test for lyme disease
486
What is the management for septic arthritis?
- ABCDE
- Joint aspiration until dry and splint joint in position of function
- Analgesia- NSAIDs
- Rest joint
- Antibiotics: Flucloxacillin and benzylpenicillin (IV 2 weeks, oral 4 weeks)
487
What should be elicited in the history of acute abdomen?
- SOCRATES
- associated gastro + urinary symptoms
- PMH/PSH
- gynae and obstetric history
488
What is the general management for acute abdomen?
- nil by mouth
- O2 therapy as appropriate
- blood glucose
- ABG if v. unwell
- IV access and bloods
- blood cultures, FBC. UEs, LFTs, amylase, clotting, group and save
- IV fluids if indicated
- analgesia
- ABx- IV Cephalosporin if sepsis, peritonitis or severe UTI suspected
- urinalysis and pregnancy test
- ECG
- AXR/ abdo CT/ abdo USS
- arrange surgical/gynae
489
What are the conditions associated with right lower quadrant pain?
- appendicitis
- salpingitis
- tube-ovarian abscess
- ruptured ectopic pregnancy
- renal/ureteric stone
- incarcerated hernia
- mesenteric adenitis
- Meckel's diverticulitis
- Crohn's disease
- Perforated caecum
- Psoas abscess
490
What are the conditions associated with (medial) left lower quadrant pain?
- sigmoid diverticulitis
- salpingitis
- tube-ovarian abscess
- ruptured ectopic pregnancy
- renal/ureteric stone
- incarcerated hernia
- diverticulitis
- Crohn's disease
- Ulcerative colitis
- Perforated colon
491
What are the conditions associated with (lateral) left lower quadrant pain?
- intestinal obstruction
- acute pancreatitis
- early appendicitis
- mesenteric thrombosis
- aortic aneurysm
- diverticulitis
492
What are the conditions associated with left upper quadrant pain?
- ruptured spleen
- gastric ulcer
- aortic aneurysm
- perforated colon
- pyelonephritis
- left sided pneumonia
493
What are the conditions associated with epigastric pain?
- myocardial infarct
- peptic ulcer
- acute cholecystitis
- perforated oesophagus
494
What are the conditions associated with right upper quadrant pain?
- acute cholecystitis
- duodenal ulcer
- hepatitis
- congestive hepatomegaly
- pyelonephritis
- appendicitis
- right sided pneumonia
495
What is the presentation for abdominal aortic aneurysm?
CLASSIC TRIAD:
- pain in flank/ back
- hypotension
- pulsatile abdominal mass (at bifurcation just above umbilicus)
496
What can be seen on examination of AAA?
- pale
- sweaty
- thread weak pulse
- tachycardic
- hypotensive
- distressed
- mottled skin on lower body
- pulsatile abdominal mass
- absent femoral pulse
- bruits
497
What are the investigations associated with AAA?
- routine bloods
- ECG
- Portable US if no time for detailed examination and strong suspicion of rupture
- abdo XR and CT angiography will confirm in the stable patient
498
What is the management for AAA?
- ABCDE- major hemorrhage
- allow some degree of hypotension SBP>90mmHg
- Large bore IV access
- FBC, UE, glucose, coagulation, LFTs, emergency, cross match
- arterial line
- CXR
- IV morphine
- IV cyclizine 50mg
- aortic corse clamping
- surgery- endovascular stent grafts
499
What are the scores used for appendicitis?
Alvarado and RIPASA
However, diagnosis is made on clinical assessment
500
What is the presentation of appendicitis?
- Initially periumbilical colicky abdominal pain
- vomiting
- right iliac fossa pain (peritoneal involvement)
- altered bowel habit or urinary frequency
- nausea and vomiting
501
What can be seen on examination in appendicitis?
- signs of septic shock
- tachycardia
- fever
- distress
- guarding and rebound tenderness in RIF
- Rosving's sign
502
What are the investigations used in appendicitis?
- urinalysis and pregnancy test
- FBC, CRP
- US when diagnosis is doubtful but CT more sensitive
503
What is the management for appendicitis?
- ABCDE
- IV access: opioid and antiemetic (metochlopramide 10mg)
- fluids
- antibiotics
- NBM- refer to surgeons for appendectomy
504
What are the complications associated with appendicitis?
- perforation
- abscess
- wound infection
505
What is the pathophysiology of acute cholecystitis?
- Gallstones containing cholesterol, bile pigments and phospholipids impact in gallbladder causing inflammation
506
What are the five F's of cholecystitis?
- FAT
- FAIR
- FERTILE
- FORTY
- FEMALE
507
What occurs if the gall bladder is obstructed?
Could fill with pus leading to septic shock
508
What occurs if there are stones in the common bile duct?
- Pancreatitis
- Obstructive jaundice
- Ascending infection
509
What is the presentation of chronic cholecystitis?
- vague abdominal discomfort
- nausea
- flatulence
- fat intolerance
- distension
510
What is the presentation of biliary colic?
- RUQ pain
- radiates to back
- (+/-) jaundice
- analgesia
- cholecystectomy
511
What are the investigations associated with cholecystitis?
- routine bloods especially LFTs: ALT raised
- urinalysis, CXR and ECG for other causes
- US
512
What is the management for cholecystitis?
- IV access: fluids, opioid or diclofenac (rectal) and antiemetic
- IV cefotaxime 1g
- NBM
- Refer to surgeons for laparoscopic cholecystectomy
- Ursodeoxycholic acid useful in preventing in high risk patients
513
What is cholangitis?
- infection of the biliary tract which can be caused by stones, ERCP, malignancy cysts or parasites
514
What is the presentation of cholangitis?
CHARCOT'S TRIAD
1) Jaundice
2) Fever
3) RUQ pain
- achoic stools
- pruritis
- peritonism
515
What are the investigations associated with cholangitis?
- routine bloods
- LFTs: jaundice and raised liver enzymes, raised amylase
- Abdo XR and US
- CT/MRI
516
What is the management for cholangitis?
- ABCDE with emphasis on fluids, correction of coagulopathy and abx
- endoscopic biliary drainage to treat underlying obstruction
517
What are the complications associated with cholangitis?
- liver abscesses
- sepsis
- perforation
518
What are the causes of paralytic ileus?
- post operative ileus
- electrolyte disturbance
- pseudo-obstruction
- occurs with many medical conditions
519
What are the causes of mechanical obstruction?
- adhesions
- obstructed hernia
- tumour
- volvulus
- crohn's/ diverticular disease
- gallstone ileus
- intussusception
- malignancy
520
What is the presentation of bowel obstruction?
- diffuse
- central colicky abdominal pain
- distension
- vomiting
- constipation
- faeculant vomiting (sigmoid obstruction)
- history of severe pain (strangulation and ischemia)
521
What is seen on examination of bowel obstruction?
- fever
- dehydration
- shock
- hernias
- tinkling or absent bowel sounds
522
What are the investigations for bowel obstruction?
- bloods: UE, glucose, amylase, FBC, LFT, clotting, G+S
- erect CXR to rule out perforation
- supine AXR
- CT
- ECG in older adults
- ABG if suspect shock
523
What is the management for bowel obstruction?
- ABCDE
- drip and suck- NG tube and IV fluids
- consider urinary catheter or central line for increased monitoring
- involve ICU
- IV opioid
- Cyclizine 50mg
- Refer to surgeons
- oncology if malignancy
524
What are the complications of bowel obstruction?
- perforation
- ischaemia
- septic shock
525
What is diverticulitis?
- Diverticua consist of herniation of mucosa through thickened colonic muscle.
- Vary massively in numbers
526
What is the presentation of diverticulitis?
- left lower quadrant pain which can be associated with bowel habits
- fever
- tenderness
- rigidity
- mass in lower left quadrant
- tachycardia
- reduced bowel sounds
- PR can reveal a tender mass
527
What are the investigations associated with diverticulitis?
- Bloods: FBC, UE, G+S, CRP, cultures
- AXR- elude perforation or obstruction
- CXR- pneumoperitoneum
- CT with rectal contrast
- sigmoidoscopy at later date
528
What is the management for diverticulitis?
- ABCDE
- IV analgesia, abx, fluids
- Monitor bleeding
- NBM
- Refer to surgeons if complications develop
529
What are the complications associated with diverticulitis?
- perforation
- abscess
- colovesical fistula
- strictures
- obstruction
- bleeding
530
What is the presentation for ruptured/ perforated peptic ulcer?
- Sudden onset
- Severe epigastric pain
- worse on coughing and moving
- may radiate to shoulder and whole abdomen
- recent indigestion symptoms
- absent bowel sounds
- shock
- peritonitis and fever
- hematemesis
- coffee ground vomit and melaena
531
What can be seen on examination of ruptured/perforated peptic ulcer?
- ABCDE assessment
532
What are the investigations for ruptured/perforated peptic ulcer?
- routine bloods
- erect CXR
- Contrast CT may help if unclear
- endoscopy if active bleeding to elect source
- ECG- rule out MI
533
What are the scores used for the severity of ruptured/perforated peptic ulcer?
ROCKALL
| GLASGOW-BLATCHFORD
534
What is the management of ruptured/perforated peptic ulcer?
- ABCDE
- O2 15L NRB
- IV opioid and metoclopramide
- 0.9% saline if resuscitation needed
- activate major hemorrhage protocol if active bleeding with large loss: crossmatch
- IV antibiotics- cefotaxime 1g + metronidazole 500mg
- H. Pylori at follow up
- PPI
535
What is pancreatitis?
- Acute inflammation of the pancreas releasing exocrine enzymes causing auto-digestion of the organ,
536
What are the causes of pancreatitis?
I GET SMASHED
```
I- Idiopathic
G- gallstones
E- ethanol
T- trauma
S- steroids
M- mumps
A- autoimmune disorder
S- scorpion venom
H- hypercalcaemia, hyperlipidemia, hyperparathyroidism
E- ERCP
D- Drugs (isoniazid)
```
537
What is the presentation of pancreatitis?
- sudden onset severe
- constant
- left upper quadrant epigastric pain
- radiates to back
- nausea and vomiting
538
What can be seen on examination of pancreatitis?
- fever
- distress
- shock
- tachycardia
- abdominal tenderness
- guarding
- possible jaundice
- paralytic ileus
- CULLENS/ GREY-TURNERS
539
What are the investigations associated with pancreatitis?
- Amylase (severely raised)
- FBC (increased WCC)
- UE
- Ca
- LFTs (gallstones)
- glucose, coagulation
- CXR if unsure clinically of the diagnosis
- percutaneous aspiration of peritoneal fluid culture
540
What is the management for pancreatitis?
- ABCDE
- ITU if severe
- O2 15L NRBM
- IV analgesia
- IV antiemetic
- NG tube and catheter
- ERCP if biliary cause, TREAT CAUSE
- surgery if infection and necrosis
- prevention: alcohol and gallstones
541
What are the complications associated with pancreatitis?
- necrosis
- infection
- acute ascites
- abscess
- cholecystitis
- DIC
- pulmonary oedema
- effusions
542
What are the main outcomes of ectopic pregnancy?
- extrusion (tubal abortion)
- spontaneous involution
- rupture
543
What are the risk factors associated with ectopic pregnancy?
- PID
- pelvic surgery/adhesions
- previous ectopic
- endometriosis
- IVF
- uterine/ovarian cysts
- tubal ligation
544
What is the presentation of ectopic pregnancy?
- sudden
- severe
- lower abdominal pain
- collapse
- vaginal bleeding
- Hx of amenorrhoea
- shoulder tip and abdominal pain
- nausea and vomiting
545
What can be seen on examination for ectopic pregnancy?
- hypovolaemic shock
- abdominal, pelvic and adnexal tenderness mass
- speculum shows vaginal blood
546
What are the investigations for ectopic pregnancy?
- routine bloods
- pregnancy test (+ve but serum b-HCG lower than expected)
- transvaginal US: exclude intrauterine pregnancy and free fluid in such of douglas
547
What is the management for ectopic pregnancy?
- ABCDE
- Methotrexate alone if no rupture and no pain
- IV access: 2x large bore. Cross match, anti-D prophylaxis
- Referral to gynae
- Urgent surgery if pain or large adnexal mass
548
What is pelvic inflammatory disease?
Infection which has spread from the cervix to the uterus, fallopian tubes, ovaries or peritoneum. Acute infection with severe symptoms can cause an abscess formation
549
What are the causes of PID?
- Commonly sexually transmitted diseases
- terminations
- dilatation
- curettage
550
What are the organisms that are associated with PID?
- Chlamydia trachomatis
- Vaginal flora
- Neisseria gonorrhoea
- gardnerella vaginalis
551
What is the presentation for PID?
- lower abdominal tenderness
- vaginal discharge
- deep dyspareunia
- fever
- abnormal vaginal bleeding
552
What can be seen on examination in PID?
- Abdo tenderness
- mucopurulent cervical discharge
- cervical motion tenderness
- adnexal tenderness
553
What are the investigations for PID?
- pregnancy test
- urinalysis and mc+s
- cervical and high vaginal swabs
- endometrial biopsy and US
- laparoscopy is best diagnostic test but not routine
554
What is the management for PID?
- refer if severe
- ABCDE
- IV access: fluids and analgesia
- Ceftriaxone 500mg (IM) then doxycycline 100mg (PO BD) + metronidazole 400mg (BD) for 14 days
OR
Oral floxacin 400mg BD+ metronidazole 400mg BD for 14 days
- inform sexual partners
555
What are the complications associated with PID?
- infertility
- ectopics
- abscesses
- chronic pelvic pain
556
How is miscarriage defined?
Defined as foetal loss before 24 weeks gestation
557
What is threatened miscarriage?
Vaginal bleeding through closed cervical os
558
What is inevitable miscarriage?
Cervical os is open and products lost. Heavy bleeding or clots
559
What is complete miscarriage?
All products passed
560
What is incomplete miscarriage?
Some products retained
561
What is septic miscarriage?
retained products become infected
562
What is missed miscarriage?
- retained products weeks to months after foetal death risk of DIC
563
What are the causes of miscarriage?
- Chromosomal abnormalities
- maternal disease
- first pregnancy
- maternal age >30
- uterine abnormalities
- drugs (isotreatnoin)
- cervical incompetence
564
What is the presentation of miscarriage?
- vaginal bleeding (light->severe)
- abdominal pain (lower chance of foetal survival)
- light 'period-like' pain= threatened abortion'
- severe pain + hypotension + bradycardia = cervical shock
565
What are the investigations associated with miscarriage?
- Transvaginal US: if no heartbeat ten repeat at 7/14 days
- Serum hCG
- USS exclude ectopic, indicate foetal viability
566
What is the management for miscarriage?
- ABCDE
- Routine bloods
- vaginal misoprostol for missed or incomplete miscarriages
- IV access: rhesus, crossmatch, analgesia, antiemetics
- if cervical shock remove products with cervical sponge
- Continued bleeding -> ERGOMETRINE 500mcg IM
- Co-amoxiclav for septic abortion
- Surgery: vacuum aspiration
counselling
advise bed rest and avoid sexual intercourse for 2 days
gynae referral
567
What are the three main groups of ovarian cyst?
BENIGN- 70%
FUNCTIONAL- 24%
MALIGNANT- 6%
568
What are the different types of ovarian cyst?
BENIGN EPITHELIAL NEOPLASTIC (60%)
- serous cystadenoma
- mutinous cyst adenoma
BENIGN OF GERM CELL ORIGIN
BENIGN NEOPLASTIC SOLID
569
What are the risk factors for ovarian cysts?
- irregular menses
- obesity
- tamoxifen
- early menarche
- infertility
- family history
570
What is the presentation of ovarian cysts?
- Asymptomatic (chance finding)
- dull ache or pain in the lower abdomen
- dyspareunia
- swollen abdomen, with palpable mass arising out of the pelvis- dull to percussion and remains after bladder emptying
- pressure effects
- torsion, infarction or haemorrhage causing severe pain
- rupture- causing peritonitis and shock
- ascites- suggests malignancy or Meig's syndrome
571
What are the investigations associated with ovarian cysts?
- pregnancy test
- routine bloods + Ca 125 epithelial carcinoma raised
- urinalysis
- pelvic US
- Diagnostic laparoscopy with biopsy
- Calculate risk malignancy index: Ca 125 + menopausal status + US scan score
572
What is the management for ovarian cysts?
- If >50mm then require yearly follow up
- surgical intervention if large, torsion, haemorrhage or rupture
- ABCDE id complications occur
573
What is the cause of cellulitis?
- infection of dermis and SC tissue
| - commonly caused by Strep or Staph
574
How is cellulitis recognized?
- red
- warm
- poorly circumscribed
- may have systemic symptoms and lymphadenopathy
- crepitus with anaerobic organisms
575
What is the management for cellulitis?
- paracetamol and ibuprofen
- draw redness around to monitor change
- flucloxacillin 500mg QDS or erythromycin 500mg QDS for 7 days
- co-amoxiclav if facial involvement
- follow up after 7 days
576
What are the features of orbital cellulitis?
- fever
- eyelids swollen
- redness
- proptosis
manage with:
- ABCDE
- IV abx
- Cultures
- fluids
577
What are the causes of tonsillitis?
VIRAL
- EBV
- HSV
- adenovirus
BACTERIAL
- group A beta haemolytic strep
578
What is the presentation of tonsillitis?
- sore throat
- fever
- headache
- presence of pus on tonsils suggests infection
- generalized lymphadenopathy indicates glandular fever
579
What is the management of tonsillitis?
- throat swabs and anti-streptolysin titre
- FBC and Paul-Bunnell test for glandular fever
- Paracetamol 1g QDS
- Ibuprofen 400mg QDS
Oral antibiotics penicillin 500mg QDS 5 days if:
- valvular heart disease
- immunosuppression
- diabetes
- systemically unwell
- peritonsillar cellulitis
580
What are the causes of otitis media?
- STREP PNEUMONIA
| - H. INFLUENZA
581
What is the presentation of otitis media?
- follows URTI
- earache
- fever
- deafness
- irritability
- lethargy
582
What can be seen on examination of otitis media?
- inflamed tympanic membrane
- loss of light reflex
- bulging drum
Perforation
- purulent discharge
- relief of pain
- swelling or tenderness of mastoid
583
What is the management for otitis media?
- oral analgesia
- oral amoxicillin for 5 days (no improvement in 72 hrs, deterioration or perforation)
- if perforation, advise not to swimming
584
What are the causes of meningitis?
BACTERIAL
- meningococci
- pneumococci
- H. influenza
- listeria
- TB
VIRAL
- mumps
- coxsackie
FUNGAL
- usually in immunosuppressed (HIV/ lymphoma)
- Cryptococcus neoformans
- insidious onset
585
What is the presentation of meningitis?
- headache
- fever
- neck stiffness
- photophobia
- drowsiness
- rash (petechial/purpura in meningococcal)
- confusion
- focal neurological signs
- seizures
- flu-like symptoms
586
What is the management for meningitis?
- ABCDE
- Venous access: FBC, UE, clotting, glucose, CRP, cultures, ABG
- Commence Abx immediately- do not wait for CSF
- CEFTRIAXONE OR CEFOTAIME 2g IV
- >55yrs add ampicillin 2g QDS to cover listeria
- CT scan prior to LP if raised ICP or FND
- LP for definitive diagnosis- high WCC with neutrophil predominance, low glucose, high protein
- Prophylaxis for contacts: rifampicin, ciprofloxacin or ceftriaxone
- NOTIFY PUBLIC HEALTH
587
What is covered in SITUATION for SBARR?
- who you are
- where you are
- what has happened
- when
- why did it start
588
What is covered in BACKGROUND for SBARR?
Patient's:
- name
- gender
- PMH
- diagnosis
- progress
- interventions
- key recent investigation results
- DNAR status
589
What is covered in ASSESSMENT for SBARR?
- diagnosis
- underlying cause
- MEWS
- concerns
590
What is covered in RECOMMENDATION for SBARR?
- management plan
- further investigations
- whether senior review is required
- whether transfer to higher level of care is required
591
What is covered in RESPONSE for SBARR?
- document respondents name
- grade
- bleep
- advice
- when this should be done
592
What is the formula for sensitivity?
TRUE POSITIVE TEST/ TOTAL NUMBER WITH CONDITION
593
What is the formula for specificity?
TOTAL NUMBER WITH NEGATIVE TEST/ TOTAL NUMBER WITHOUT CONDITION
