ACC Flashcards
1
Q
Anesthetics:
how are drugs checked before administering them? (5)
what do you do before giving it IV? (1)
A
- Check the drug
- Check the ampoule
- Check the dilution
- Check the syringe
- Check the route of administration
It is good practice to always flush each intravenous drug with 0.9 % NaCI; this is to prevent incompatible drugs precipitating.
2
Q
Controlled drugs:
where to store controlled drugs? (1)
where to put excess drug in ampoule? (1)
name the 3 controlled drugs commonly used in surgery? (3)
A
- locked container
- squirt into sharps bin
- benzo
- cocaine
- opioids e.g. fentanyl, morphine, afentanil etc
- ket actually isn’t one! but treated like one in most places
- anesthetist and ODP/anesthetic nurse
- twice daily checks of # of ampoules made by 2 trained members of staff a day!!
3
Q
What are the three main blood bourne viruses?
A
- Hep B
- Hep C
- HIV
4
Q
ICU:
What is critical care?
A
Critical care is an umbrella term which encompasses both level 3 (ICU) and level 2 (HDU) care
Level 2= Patients requiring more detailed observation or intervention, including support for a single failing organ system or postoperative care and those ‘stepping down’ from higher levels of care. (HDU). Nurse ratio 2:1
Level 3=requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure and is provided on critical care units commonly known as intensive care units (ICUs) or intensive treatment/therapy units (ITUs)1:1 nursing care
5
Q
Conditions which may require critical care unit admission
A
- AKI
- brain injury (type 1, type 2, and due to systemic disease)
- post cardiopulmonary arrest
- post trauma (send to majr trauma centre)
- respiratory failure: ARDS, pneumonia, pulmonar oedema
- shock
- postoperative (planned or unplanned!)
6
Q
ICU:
Purpose of central venous catheters? (5)
A
- Infusion of drugs (esp irritants e.g. noradrenaline, amiodarone and total parenteral nutrition)
- rapid volume infusions
- invasive haemodynamic monitoring
- central venous access for regular blood sampling, pacing wire insertions and emergency access when peripheral cannulation is not achieved
- to facilitate renal support therapy, plasmapheresis and exchange transfusions
7
Q
ICU:
types of neurological monitoring? (2)
examples of each?
A
1- non-invasive
GCS, clinical observations, neurological examinations, electroencephalography (measures electrical activity in brain using electrodes on the scalp)
2- invasive intracranial pressure (ICP) monitor and intraventricular drain (EVD) for drainage of CSF for either diagnostic or therapeutic reasons
8
Q
ICU:
Scoring system to predict mortality in ICU? (1)
what does it encompass? (3)
A
APACHE II
- acute physiology score
- age
- chronic health problems
9
Q
A&E:
complications of MI? (9)
A
- cardiac arrest: often as MI–> VF–> arrest
- cardiogenic shock
- chronic heart failure: give loop diuretics, ACEi and BBs
- tachyarrythmias: VF (most common form of death post-MI), VT
- bradyarrhythmias: AV block more common in inferior MIs
- pericarditis: 48 hrs post transmural MI (pericardial rub, pericardial effusion and pain worse lying flat)
- Dressler’s syndrome: 2-6 weeks post-MI, autoimmune against new myocardium; fever, pleuritic pain, pericardial effusion and raised ER
- L ventricular aneurysm: persistent ST elevation and L ventricular failure –> stroke
- L ventriular free wall rupture (!!)
- ventricular septal defect: acute heart failure and pan-systolic murmur–> surgery ASAP!
- acute mitral regurgitation; ischaemia or rupture of papillary muscle, early-to-mid systolic murmo
10
Q
A&E:
acute MI ECG changes with timings?
A
1- hyperacute T waves
2- ST elevatation
3- T waves inverted in first 24 hours
4- pathological Q waves hours-days then persist forever
remember: posterior MI causes ST depression NOT elevation
11
Q
Pre-operative assessments:
what changes what investigations you get? (2)
what investigations are considered? (6)
what should you also consider? (1)
A
- ASA level of patinet
- Grade of the surgery (minor (level 1)/ intermediate (level 2)/ severe (level 3/4))
- Consider pre admission clinic to address medical issues.
- Blood tests including FBC, U+E, LFTs, Clotting, Group and Save
- Urine analysis
- Pregnancy test
- Sickle cell test
- ECG/ Chest x-ray
-VTE risk and plan
12
Q
Pre-operative assessments: what investigations do you get for: minor surgery? intermediate? major?
what to do extra if: female? (1) diabetic? (1) when to do: urine test? (1) CXR? (1) what to check in FHx? (1)
A
- pregnancy test (if relevant and consent obtained)
- HbA1c if not tested within last 3 months, if they have look at referral letter
- if the presence of UTI would influence the decision to operate
- CXR never routine
- if heart murmor AND any cardiac symptom (SOB, syncope, pre-syncope, chest pain) OR signs/Sx heart failure
- test for sickle cell if FHx
13
Q
Which routine tests do you do for minor, intermediate and major surgery for:
ASA1?
ASA2?
ASA3/4?
A
MINOR ASA 1 : none ASA 2: - U&E if risk of AKI - ECG if CVD, renal or diabetes ASA 3/4: - FBC if CVS/renal disease and not recently investigated - hemostasis if chronic live disease - U&E - ECG - possibly ABG
INTERMEDIATE: ASA 1: none ASA 2: - U&E if risk of AKI - ECG if CVD/ diabetes/ renal disease ASA 3/4: - basically all again
MAJOR: - FBC for all ASA 1: - U&E if risk of AKI - ECG >65 ASA 2: - FBC - U&E - ECG ASA 3/4: everything (FBC, U&Es, ECG, haemostasis if liver disease, consider lung function/ABG) https://www.nice.org.uk/guidance/ng45/chapter/recommendations
14
Q
What is periorbital ecchymosis? (1)
what is it a sign of? (1)
A
raccoon/ panda eyes
often accompanied by CSF rhinorrhoea
= basal skull fracture
15
Q
Trauma:
signs of basal skull fracture? (4)
what airway adjunct should be avoided? (1)
A
- periorbital ecchymosis
- CSF rhinorrhoea
- haemotympanum
- mastoid process bruising (battle’s sign)
nasopharyngeal airway is (relatively) contraindicated as risk of inserting it into the cranial cavity
(also avoid in coagulopathy)
16
Q
Anaesthetics:
which patients shouldn’t get LMA? (2)
A
- unfasted - it has poor control against reflux
- morbid obesity
patients don’t have to be completely asleep for LMAs
17
Q
Post-operative: How to assess who needs VTE prophylaxis? (2) mechanical prophylaxis? (2) pharmacological prophylaxis? (3) drugs to stop? (1) other? (2)
A
- assess risks
- compare risk of VTE to risk of bleeding
- anti-embolism (compression) stockings
- intermittent pneumatic compression device
one of:
- fondaparinux sodium (SC) or rivaroxaban (DOAC)
- LMWH e.g. eoxaparin
- Unfractionated heparin if CKD
- stop OCP 4 weeks pre surgery
- mobilise ASAP
- ensure hydration
18
Q
VTE prophylaxis:
which surgeries automatically require anticoagulation? (3)
when is surgery not a risk factor for VTE? (1)
when is BMI a risk factor? (1)
A
- elective hip
- elective knee
- fragility fractures of pelvis, hip or proximal femour
- if <90 mins or <60 mins if surgery of lower limb
- > 35
19
Q
Anesthetics:
in a hemodynamically unstable patient e.g. post motorbike crash, what induction agent is best? (1)
how does this drug work? (1)
A
Look at BP and HR!
Ketamine is best if hypotension
also an analgesic
remember that kid screaming post-accident on his bike on the Ambulance show, also causes antreograde amnesia so they won’t remember it!
- NMDA receptor antagonist
20
Q
Anesthetics:
side effects of non-depolarising neuromuscular blockers? (1)
depolarising? (3)
treatment for hyperthermia? (1)
A
Non-depolarising:
- hypotension
Depolarising: (succinylcholine/ suxamethonium)
- malignant HYPERthermia
- hyperkalaemia
- increases introcular pressure –> contraindicated in acute/ narrow eye injuries
IV dantrolene
(an autosomal dominant disorder that leads to a susceptibility of patients to malignant hyperthermia with depolarising)
21
Q
A&E:
Treatment of benzodiazepine overdose? (1)
A
Flumazenil
22
Q
A&E:
Treatment for paracetamol overdose? (1)
A
N-acetylcystine
23
Q
What do haematinic blood tests check? (1)
A
nutrients required for the formation of blood cells: iron, vit B12, folate
24
Q
What special preparation is required for: thyroid surgery? (1) parathyroid surgery? (1) sentinel node biopsy? (1) involving thoracic duct? (1) pheochromocytoma? (1) carcinoid tumours? (1) colorectal? (1) thyrotoxicosis? (1)
A
- vocal cord check
- methylene blue to indentify gland
- radioactive marker/ patent blue dye
- cream
- alpha and beta blockade
- cover with octreotide
- bowel preparation
- medial therapy
25
What properties do benzodiazepines have? (5)
anxiolytic, hypnotic, anticonvulsant, muscle relaxant, and amnesic
NOT analgesic
26
Anesthetics:
| In what ways are complications averted in surgery?
- WHO checklist
- prophylactic antibiotics
- VTE risk and prophylaxis
- MARK site of surgery
- tourniquets used with caution
- handle tissues with care
- be aware of coupling injuries using diathermy
- Remember the danger of end arteries and in situations where they occur avoid using adrenaline containing solutions and monopolar diatherm
27
Anaesthetics:
Patients with myasthenia gravis and Lambert-Eaton syndrome are particularly vulnerable to which part of general anaesthetics? (1)
how do you differentiate the symptoms of each? (2)
- MG patients are susceptible to non-depolarising and resistant to depolarising agents
- LEMS patients are susceptible to both depolarising and non-depolarising
- MG gets worse with use, i.e. later on in the day
- LEMS gets better with use
28
Anasthetics:
why is adrenaline added to local anaesthetics? (2)
who is it contraindicated in? (1)
constricts vessels so:
- prolongs duration
- permits usage of higher doses (apart from in bupivacaine)
lignocaine = 3mg/kg - 7mg/kg (with adrenaline
bupiva = 2mg/kg
prilocaine = 6 -> 9mg/kg
( These are a guide only as actual doses depend on site of administration, tissue vascularity and co-morbidities.)
- patients taking MAOIs or TCAs
29
Long-term ventilation:
a patient on long-term intubation gets abdominal distension and right sided consolidation, with raised WCC - what complication has happened? (1)
tracheo-oesophageal fistula formation (air into esophageal and gastric contents back)
- once endotracheal tubes are inserted they rarely aspirate, it normally occurs in the early stage
30
Surgery:
when can paralytic ileus occur other than surgery? (4)
what type of obstruction is it? (1)
PSEUDO-OBSTRUCTION
- chest infections
- MI
- stroke
- AKI
Deranged electrolytes can contribute to the development of paralytic ileus, so it is important to check potassium, magnesium and phosphate.
31
```
Post-operative pyrexia:
early causes (days 0-5)? (5)
late causes (>5 days)? (4)
```
- cellulitis
- blood transfusion
- UTI
- pulmonary atelectasis
- physiological systemic inflammation reaction (usually within a day following the operation)
INFECTION OR THROMBUS:
- VTE
- penumonia
- wound infection
- anastomotic leak
32
Anesthetics:
| if you cant get IV access in a cardiac arrest, what should you do? (1)
go for intraosseous (IO) access
33
Surgery:
| which drugs impair wound healing? (4)
- NSAIDS
- steroids
- immunosuppressants
- anti neoplastic drugs
34
```
ICU:
most common nosocomial infection? (1)
define it? (1)
what increases it's likelihood? (1)
what scoring systems aid diagnosis? (2)
```
ventilator-associated pneumonia (VAP) - occurs 48 hours or more after tracheal intubation
cause by microaspirations around the cuff of the tracheal tube
- longer intubation = higher risk
- clinical pulmonary infection score
- HELICS: Hospital In Europe Link for Infection Control though Surveillance
35
ICU:
definition of late and early onset VAP? (2)
what is late-onset associated with? (1)
- early-onset: within first 4 days
- late-onset- 5 days+ after admission
- late-onset usually assocaited with drug resistant microorganisms
Common causative pathogens of VAP include Gram negative bacteria such as Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Acinetobacter species, and Gram-positive bacteria such as Staphylococcus aureus.
36
ICU:
| how do they avoid VAP?
- avoid uncesarry intubation (NIV if possible)
- airway tube: try use one with subglottic
- hand washing
- isolation of infectious patients suction ports
- minimize duration of VAP (assess frequently if they can be extubated)
- true to reduce bacterial load in secretions: (1) decontamination of respiratory tract with chlorhexidine gel, (2) minimizing acid reflux drugs e.g. H2-receptor antagonists and PPIs
- reduce micro aspiration: avoid supine positioning, maintain endotracheal tube cuff seal, use suction to remove subglottic secretion pooled above endotracheal cuff
37
ICU:
what are the gastrointestinal complications of invasive ventilation? (2)
why do these occur? (1)
- stress-related mucosal damage: stress ulcers --> most common cause of GI bleeding in ICU, use PPIs
- GI hypomotility : ICUs have protocols to follow which may involve prokinetics (metolopromide), sometimes neostigmine
- splanchnic hypoperfusion
38
```
Anaesthetics:
doses of local anaesthetics:
Bupivacaine? (1)
Lignocane? (1)
Prilocaine? (1)
```
Bupivacaine / levobupivacaine ( with or without adrenaline): 2 mg/kg
Prilocaine: 6mg/kg
Lignocaine without adrenaline: 3 mg/kg
Lignocaine with adrenaline: 7 mg /kg
39
Anaesthetics:
how are local anaesthetics defined? (3)
what affects pattern of toxicity?
- REVERSIBLY prevents transmission of the nerve impulse
- in the REGION to which it is applied
- WITHOUT affecting consciousness
Joined by either an ester link or an amide link.
- route of administration
- speed at which toxic plasma level occurs
(if rises slowly the CNS is affected first)
40
Anaesthetics:
symptoms of local anaesthetic toxicity?
management: two things to do? (2)
A-E approach? (4)
Symptoms are generally excitatory, possibly due to inhibition of inhibitory neurons via GABA receptors. Patients may report perioral and tongue paraesthesia, a metallic taste, and dizziness, then develop slurred speech, diplopia, tinnitus, confusion, restlessness, muscle twitching and convulsions. At higher plasma levels there is widespread sodium channel blockade with more generalised neuronal depression leading to coma followed by respiratory arrest and then cardiac arrest
- STOP INJECTING IT
- call for help
- A: maintain and if necessary, tracheal tube
- B: give 100% O2 and ensure adequate lung ventilation
- C: IV access
- D: control seizures: benzodiazepines, thiopental or propofol, consider drawing blood for analysis,
If circulatory arrest: start CRP, use standard protocols
- give IV lipid emulsion
41
```
Postoperative pain:
what affect does it have on
cardiovascular system? (3)
respiratory? (4)
GI? (2)
other? (2)
```
- tachycardia
- hypertension
- increased myocardial O2 demand
- decreased vital capacity
- decreased FCR
- basal atelectasis
- resp infection
- ileus
- N&V
- urinary retention
- DVT+PE
42
Anaesthetics:
Who helps control chronic pain? (1)
is it curable? (1)
Multidisciplinary: anesthetist coordinates pain nurses, psychologist, physiotherapist, pharmacist
chronic pain is often neuropathic and incurable
though can be managed effectively
43
Post op complications:
immediate? (3)
early? (6)
late? (2)
- bleeding/ haemorrhage
- basal atelectasis
- renal impairment
- MI
- VTE
- pneumonia
- other infections
- confusion
- renal failure
- wound dehiscence
- incisional hernia
44
How to assess JVP? (3)
- impalpable
- complex pulsation
- hepatic reflex
45
```
Anaesthetics:
what are the risk factors for PONV?
patient factors (5)
anaesthetic factors? (4)
surgical factors? (5)
```
- young
- female
- hisotry motion sickness
- anxious
- non smoker
- opioids
- etomidate
- N2O
- volatile
- gynae
- abdo
- middle ear
- neuro
- opthalamic
46
Critical care:
| how are the long-term complications of critical care managed?
- follow-up clinics
problems include:
- neurological
- psychological
- airway
47
Indications for renal replacement? (4)
RENAL:
- symptomatic uremia
- fluid overload unresponsive to medical management
- electrolytes (high K+ or N+ abnormlaities)
- acid base disturbance - metabolic acidosis especially
Post-renal:
- intoxication if drug is removed by renal replacement
48
How is renal replacement classified?
- The predominant method used to remove waste products (urea) - filtration or dialysis
- The length of treatment - intermittent or continuous
- The vessel used to obtain blood - arterial or venous
49
Why is codeine a rubbish painkiller (says the ICU consultant)
a lot of people have no effect as it's a pro-drug!
Codeine is metabolised by the liver enzyme CYP2D6 into morphine, its active metabolite. If a patient has a deficiency or is completely lacking this enzyme an adequate analgesic effect will not be obtained. Estimates indicate that up to 7% of the Caucasian population may have this deficiency
50
Tramadol vs morphine bioavailability - why care about this?
tramadol has 100% bioavailability --> IV dose the same as oral
morphine has ~50% so does for IV and oral differs
51
Renal replacement therapy:
which is used in ICU (1) and why? (1)
how is RRT classified (3)
what would you try first before RRT? (1)
- continuous haemofiltration
slow but easiest on the heart and doesn't cause massive fluid shifts
RRT depends on:
1- the predominant method used to remove waste products (urea)
(filtration or dialysis)
2- the length of time (intermittent vs continuous)
3- the vessel used to obtain blood (arterial or venous)
- can be arterio-venous or veno-venous
need to anticoagulate the blood with citrate or heparin
try giving furosemide and get them to pee it out!
52
Anaesthetics:
| what are the post-postoperative complications and when do they occur? (5)
5W's of Post-op Pyrexia:
- Wind (1day): atelectasis
- Water(3days): UTI
- Wound(5days): surgical site infection/abscess
- Walking(7days): DVT/PE
- Wonder-drugs(Anytime): adverse drug reaction
53
Total parenteral nutrition:
| how is it administered? (1)
Total parenteral nutrition should be administered via a central vein as it is strongly phlebitic
54
A&E:
what would blood tests show for an acute GI bleed? (2)
what risk assessments to use and when? (2)
normocytic anaemia with raised urea
Urea is a breakdown product of red blood cells and is raised here due to digestion of the blood in the stomach. The blood acts as a protein 'meal'.
- use the Blatchford score at first assessment, and
- the full Rockall score after endoscopy
55
A&E:
| why don't you give Hartmaans in resuciation?
- have to be careful with rapid infusion of K+
| - max 10mmol/hour !!!!!!!
56
How much weight loss is significant?
~5% of total body weight in 1 month
57
Stridor: inspiratory or expiratory?
INSPIRATORY
58
contraindications of nasopharnygeal tube?
- basal skull fracture
- epistaxis
note may need to use NP if in seizure and mouth is seized shut.. try oropharyngeal first but may have to use naso if cant fit it
59
When do you use BPAP vs CPAP?
BPAP= VENTILATION PROBLEM
| Type 2 respiratory failure.. CO2 high so you need to get the CO2 out
60
Menigitis:
descirbe the rash? (1)
the rash is caused by what? (1)
what is it similar to?
purpuric rash, non-blaching = DIC
= septicaemia, v concerning sign
- similar to vasculitis and idiopathic thrombocytic rash
61
UTI:
| when to not do dip? (1)
if >65
| do MSU!
62
ECG:
| if completely flat, what does it show? (1)
LEADS NOT CONNECTED PROPERLY!
| If approx flat = asystole
63
MI:
| If a person collapsed after MI and you want to go to PCI, who should you give the antiplatelets?
through an NG tube
64
```
A-E GI bleed:
concerning sign? (1)
what else to check for in GI bleed? (1)
what scoring system to use? (1)
what to do? (1)
```
dizzy - especially if lying down
check for melena
always do a PR!
- Glasgow Blatchford Score
will let you know if you need urgent endoscopy
they will do band ligation, sclerotherapy OR adrenaline OR go to surgery if they can't sort it there and then
- CALL FOR HELP ASAP
- A-E, crossmatch 4 units, start giving blood
- upper GI = medical team
- lower GI = surgical team
*Hb won't drop immediately*
giving fluids neither good nor bad... you're just diluting out the Hb. If Hb has dropped in an acute setting then it shows they have lost a LOT of blood.
-- MASSIVE HAEMORAHGE PROTOCOL --- prepares blood ready
65
A-E:
how to request observations? (1)
what is closed-loop communication? (1)
- please can you get a full set of observations, and I'll ask for them as I go through them.
"can you do X and let me know when its done, thank you"
66
```
A-E seizures:
what to do at start? (1)
what to look for? (1)
who to call? (1)
position to put the patient in?
```
ASK HOW LONG and start TIMING IT
reversible causes
call anesthetists at 15 mins - they wont be bothered before this!
tiopenitone is epileptic protective so they may use this
RECOVERY POSITION
67
RSI:
| why is cricoid pressure done? (1)
remember that pregnant lady after GA for her birth of baby said she remembers them pressing on her throat
- stops aspiration, they press quite hard!
68
A-E anphylaxis:
how much adrenaline and which route? (2)
how does this compare to in cardiac arrest? (1)
IM and 0.5mg 1:1000
LESS VOLUME and HIGHER CONCENTRATION as given IM not IV.. you dont want to give large volume IM!!
mast cell tryptase - measure at 1hrs, 4hr, 12hrs, lets you know progression of the anapyhlaxis
69
Penicillin allergy:
| which other Abx don't you give and why? (2)
Ceftrioixone = cross-reaction 10% to penecillin
70
A-E asthma:
why use nebulizer and not inhaled? (1)
what NOT to do in A-E asthma? (1)
nebs at a much HIGHER dose as lots of it is lost as they aren't effective at breathing it in as with inhalers where it goes directly to their throat
DON'T DO AN ABG - IF YOU KNOW ITS ASTHMA DO A VBG AS IT WILL PUT THEM OFF COMING AGAIN.
hold off and see how they go..
"magnesium treats everything"
71
PE:
| ECG changes?
R axis deviation
S1 Q3 T3
(T wave inversion, pathological Q and deep S wave)
72
how many mls to put in each blood culture pot?
8-10mls
73
Anaesthetics:
LA toxicity.. what to give? (2)
how never to give LA? (1)
why don't thy use Sux for everyone? (1)
intraipid
+supportive care
IV
suxamethasone apnoea - lack the enzyme to break it down so they end up asleap for hours, remember that aneasthetist who said patient was asleep for 4 hours overnight post surgery and he had to wait
74
Before giving drug, what to do?
```
YOU MUST CHECK
name
dose
route
packaging
expiry date REMEMBER TO BE SURE
```
75
Anaesthetics:
| when to use ET tube rather than LMA (igel)?
- laproscopic surgery (high pressure in intraabdominal space as they blow it up makes it an aspiration risk!)
- ENT surgery (sharing the airway)
- RSI (aspiration risk)
with igel you cant give that much pressure but recovery after is quicker as they can go straight through to recovery, so they keep oxygen high and ratio 1.5:1 so inspiratory time is longer and more O2 in at lower pressure
76
Why is bleeding risk so high in thryoid?
very large blood supply as needs to concentrate iodine there to make thyroxine --> bleeds easily after surgery
check PTH before and after to check they hadn't messed with the parathyroid glands
PTH ranges are narrower than normal ... they are quite individual as our bodies regulate to our own normals
77
```
ABx:
which to give in surgery? (1)
what to give for skin infections? (1)
what does tacozin do? (1)
what does mtronidazole do? (1)
what to always ask before giving? (1)
```
JUST LOOK AT GUIDELINES
always changes, some surgeries need them prophylactically like C-sections others not
- flucloxacillin
- tazocin covered everything, usually for sepsis
- metronidazole for anaerobie, mouth sores/gi stuff
ASK ALLERGIES
think about route- what is safe
10% cross over between vancomycin and penicillin
78
ABG:
| when to do one? (1)
RESPIRATORY PROBLEM
not asthma
defo not something like DKA
79
Lactate:
| what level is concerning? (1)
>4
| can be high in those taking metformin
80
What to always give with potassium?
magnesium
moves with potassium so will be low too
81
Paracetamol overdose:
| what rises first if liver failure?
INR goes high
then LFTs
if they start getting confused that/s worrying signifies encephalopathy due to the high urea
82
Tingling in extremities:
| differentials? (2)
anxiety
| anaphylaxis
83
Pneumonia:
when to repeat X-rays? (1)
Why? (1)
at 6 weeks
| check no cancer behind the fog
84
Why might you shit loads if alcoholic?
increase ammonia
-> encepalopathy
85
Chlordiazepoxide in alcoohlics:
why not given out of hospital? (1)
what does it do? (1)
treats the withdrawal they will get whilst in hospital
sort of sedative
if given out of hospital they will just take it whilst they drink alcoohl --> v bad!
86
why do ABG in complete heart block?
may be hyperkalaemia
87
Metoclopramide:
| which group more likely to get acute dystonic reactions? (2)
young women and parkinsons
88
pathological Q waves
>2mm deep, 2 small deep, or 25% of QRS complex
= previous MI
remember normal in some leads?
89
MI management:
| when to give IV nitrates?
when senior review - can be risky so ask first
| give sublingual whilst wait
90
Cerebellar problems:
| acronym?
DANISH
dystidokinaesia, ataxia (walk like drunk), nystagmus, intention tremor, stacatto speech, Hypotonia/heel-shin test
could be a cerebellar STROKE
-->dizzy and vomiting!
91
DKA in kids:
| why give fluids slowly?
worried about low sodium
92
The patient is in pain and pale and clammy: what does this tell you about their pain?
it is severe
93
HINTS test?
central vs peripheral vertigo
```
central = BAD !! cerebellar problem/ stroke
peripheral = ENT problem e.g. labrynthitis, miniers etc
```
94
Fall:
| what to do in initial obs?
lying standing BP
and do it dizzy/ syncope
95
Seizure history:
what to ask? (1)
what might you look for in ECG? (1)
Lactate in the seizure?
REINACT IT
did it start of focal/ generalised?
get them to video next seizure
do ECG to look for prolonged QT as --> seizures
raised after ~1hr
96
CO poisoning:
how to treat? (1)
how to diagnose? (1)
give O2 and it replaces it (high flow)
it will show up on ABG as HbCO
HbCO can also be high in smokers!
97
Codeine in C-section:
| why not give?
can't have if breastfeeding
98
RSI:
| which give sodium citrate?
given for all GAs as better for them to aspirate less acidy contents, outcomes better
99
Spinals:
| layers they go through? (7)
- skin
- subcutanous tissue
- supraspinous ligament
- intraspinous ligament
- ligamentum flavum (THE POP) ->epidural
- dura
- arachnoid
- pia
100
Dermatomes on hand? (3)
| how to make spinal move across dermatomes? (1)
C6-C7-C8
C3,4,5 keeps the diaphragm alive
```
T10 = umbilicus
T4= nipples (used up to in C-sections)
```
tilt the patient
101
Breathing ratio:
normal ratio? (1)
what might you use in asthma? (1)
- 1:2 insp:exp
1:3 increase exp to increase CO2 coming off the lungs
in intensive care might increase insp to get in more O2 (1:1)
102
LA:
| when to never use adrenaline? (1)
extremities (toes/fingers) as will be necrotic!
103
Dobutamine:
| when used? (1)
very strong so bad sign if used!
104
In pregnancy: why worry about BP control more than other patients?
normally organs are all autoregulated in terms of BP
in pregnancy the PLACENTA is NOT autoregulated --> if mums BP drops then the baby could get less blood
MAP is a good indicator of actual organ perfusion
