ACC Flashcards
What equipment may be required when preparing for the arrival of a seizing patient?
Airway adjuncts (nasopharyngeal and oropharyngeal airways) ET tubes Suction Oxygen Cannula bloods and fluid
What is the initial medical treatment of the seizing patient?
Buccal midazolam at home
PR 10mg diazepam
IV lorazepam
Maximum of two doses, including pre-hospital treatment
What is the second line treatment of status epilepticus if benzodiazepines fail to control cease seizures?
IV phenytoin bolus
Could also use Keppra (levotiracetam)
What should be checked before administering phenytoin?
Check the patient is not in respiratory depression
If phenytoin does not work, what is the next step in management?
Call anaesthetist for rapid sequence induction with sodium thiopentol
Give five causes of status epilepticus.
Hypoglycaemia Meningitis SAH and brain injury Eclampsia Alcohol/drug withdrawal/overdose
What are some complications of status epilepticus?
Aspiration Hypoxia and brain damage Death from airway occlusion Rhabdomyolysis Metabolic lactic acidosis
What are features of early alcohol withdrawal?
Shakiness
Insomnia
Nausea
Tachycardia
What is delirium tremens and how is it treated?
Acute confusional state, tremor, and vivid/disturbing abnormal perceptions secondary to alcohol withdrawal
Chlordiazepoxide
How can you assess alcohol dependence?
AUDIT
CAGE
What are five non-ACS causes of chest pain?
Pericarditis Aortic dissection Oesophageal spasm Pulmonary embolism Costochondritis
Which troponin is more specific?
Troponin I > C
When do troponins peak after myocardial infarction?
12-24 hours
Therefore tested 6-12 hours after pain
What is the diagnostic criteria for MI?
2/3 of:
Consistent history
Raised enzymes
Abnormal ECG
What other investigations are required in MI?
CXR and/or echo
Angiogram
Myoview
How can you tell the difference between anterior ischaemia and posterior infarction (ST depression in anterior leads)?
Do posterior leads
What is the subsequent management of an ACS patient?
PCI within 90 minutes of diagnosis, if unavailable IV alteplase with heparin
Glycoprotein IIb/IIIa inhibitor (abciximab, tirofiban, eptifibatide)
What is the most important test to do for the unconscious patient?
Blood glucose
Which methods can be used for applying painful stimuli?
Sternal rub
Supraorbital pressure
Trapezius squeeze
What are 6 causes of decreased consciousness?
Hypoglycaemia Sepsis Addisonian crisis Meningitis Cardiovascular syncope (tamponade, arrhythmias) PE
What is the treatment of an opiate overdose?
IV naloxone 0.4-2mg adult
What is found on examination in opiate overdose?
Pinpoint pupils
Decreased respiratory rate
Hypotension
Tachycardia
What does blood in the external auditory canal suggest and what measures should be taken?
Fracture of base of the skull
Stabilise C-spine and CT scan
What is the ATMIST mnemonic for trauma?
Age Timing (incident and arrival) Mechanism Injuries Signs Treatment
Which team members are in the trauma team?
Anaesthetist
Radiologist
General surgery
Trauma and orthopaedics
What additional equipment is required in a trauma call?
Pelvic binder, collar and block, trauma mattress
What is a good indicator of blood volume and whether the pelvic fractures are stable or not?
Blood pressure
What causes tachycardia in traumas?
Shock Collapsed lung Bleeding from fractures Pain Anxiety
What is a FAST scan?
Looks for free fluid around abdominal organs and cardiac tamponade
What is the pathophysiology of a tension pneumothorax?
Injury to lung, inhalation causes indrawing to lungs. On exhalation, the injury (valve) closes so air cannot escape.
How does a tension pneumothorax cause cardiac arrest?
Pressure on the mediastinum and vena cava reduces cardiac output and preload resulting in hypotension and tachycardia
What are signs of tension pneumothorax?
Reduced breath sounds, tracheal deviation, apex beat deviation, resp distress, cyanosis
What is the treatment of tension pneumothorax?
Needle decompression large bore cannula 2nd IC space, mid clavicular line, above the rib to avoid neurovascular bundle
Followed by chest drain in 5th IC space mid clavicular line
What is ARDS?
Non-cardiogenic pulmonary oedema leads to respiratory failure
What are the signs of ARDS?
Cyanosis
Bilateral fine inspiratory crackles
Peripheral vasodilation
What is the treatment of ARDS?
CPAP, unless mechanical ventilation is required
What is permissive hypotensive resuscitation?
Intentional lowering of blood pressure during fluid resuscitation until definitive surgical control of bleeding occurs
What is contained in a massive transfusion pack?
Platelets, FFP, clotting factors
What type of hypersensitivity reaction is anaphylaxis?
Type 1
Rapid release of stored histamine
Give five symptoms of anaphylaxis from different body systems.
Hypotension Bronchospasm (wheeze) Laryngeal oedema (stridor) Vomiting Urticarial rash
What is the treatment of an acute allergic reaction?
PO/IV chlorphenamine
Fluids
Oxygen
What is the treatment of anaphylaxis?
IM adrenaline 500mcg
Hydrocortisone IV or PO
Prednisolone
Can be repeated after 5 minutes
IV adrenaline after two attempts
How long does it take for paracetamol to reach plasma concentration after ingestion?
One hour
When does hepatic toxicity of paracetamol overdose occur?
24-72h
What is the pathophysiology of paracetamol overdose?
Metabolism of paracetamol results in toxic metabolite NAPQI.
NAPQI is inactivated by glutathione.
When glutathione stores are depleted to <30%, NAPQI leads to necrosis of the liver and kidney tubules
When is blood taken in paracetamol overdose?
4 hours post overdose - indicates whether liver damage will occur
Which patients are at higher risk of liver damage?
Malnutrition
HIV positive
Alcohol or other liver disease
Which patients should receive N-acetyl cysteine?
Timed plasma paracetamol level plotted above the graph
Any doubt about timing of ingestion or a staggered overdose
What is NAC?
Glutathione analogue
Name three side effects of a spinal anaesthetic.
Hypotension
Low pressure headache (better when lay down)
High spinal block (limb/respiratory weakness)
Which airway adjunct reduces the risk of aspiration of stomach contents into the lungs?
Tracheal tube
For a short operation in a diabetic patient, what should be done about their medications?
Omit sulfonylureas
Continue metformin
Usually depends on their blood glucose whether they will need a sliding scale
What are the indications for a sliding scale in surgery for diabetics?
What are the fluids of choice for the insulin infusion?
On insulin
BM>12mmol/L
<14 run in 10% dextrose; BM>14 run in saline
What is a risk of emergency surgery from an anaesthetic point of view?
Increased aspiration risk
In DKA, what rate of insulin is required after fluid resuscitation?
Fixed rate, as background level of insulin is required to suppress ketosis
0.1IU/kg/hr
Which coagulation pathways are represented by PT and APTT?
PT: extrinsic –> warfarin
APTT: intrinsic –> heparins and NOACs
What are five differentials for hypoglycaemia?
Addison's disease Undiagnosed T1DM Paracetamol overdose Alcohol consumption Pituitary failure Insulinoma
What are the normal agents for rapid sequence induction (non fitting patient)?
Suxamethonium/rocuronium
With propofol
What is the treatment of DIC?
Cryoprecipitate
What are the indications for dialysis?
Acidosis Electrolytes e.g. hyperkalaemia Intoxication Overload Uraemia
