ACC general Flashcards
Definition of AAA?
dilatation of greater than 50% diameter (>3cm)
Surgery performed electively for which aneurysms?
> 5.5cm or expanding more than 1cm per year, can do EVAR
Signs of ruptured AAA?
Shock, expansile mass, collapse abdo pain often radiates to the back and groins
When to consider AAA diagnosis clinically?
> 50 with abdo pain/back pain/hypotensive
Known AAA and collapse/pain
AAA must be excluded where another diagnosis is more likely.
Emergency management of AAA?
Vascular surgeon, ECG, blood Xmatch (10) consider FFP and haemhorrage protocol, catheter and wide bore cannulae. Shock treated with 0 neg.
Try keep systolic <100 to avoid rupturing leak.
Cef n Met
Appendicitis msot common what ages and sex?
10-20 rare under 2 males slightly more.
Risk factors appendicitis?
Frequent ABX smoking
Complications from appendicitis, perforation likely after how long?
Mass abscess, peritonitis and rupture more likely >12hrs
Suspect appendicitis?
Abdo pain, epigastric and umbilical worsens and migrates to RIF. Movement worsens pain.
Anorexia, nausea constipation vomiting. Low grade fever
Maximal tenderness in appendicitis where?
Mcburneys point
What is rosvigs sign?
palpate left quadrant gives pain in right
Psoas sign in appendicitis ?
right thigh extended when in left lat causes right quadrant pain
Initial investigations in appendicitis?
Pregnancy test (exclude ectopic) Urine dip but may be abnormal due to inflammation. FBC and CRP 80-90% neutrophillia and leukocytosis
Main cause of cholecystitis?
Stones, 90-95% only 0.5% no stones
Risk factors for cholecystitis?
Age, female, obesity, ^cholesterol, smoking, crohns, diabetes
Complications of cholecystitis?
necrosis, perforation, peritonitis, jaundice
Cholecystitis symptoms?
Severe sudden RUQ pain, anorexia, nausea vomiting.
Fever, tenderness RUQ +- murphys. Referred pain scapular.
Management of cholecystitis?
Abdo USS, FBC, CRP amylase, ABX, analgesia and fluids
What is charcots triad?
Fever, jaundice and RUQ pain (cholangitis)
Most common cause of cholecystitis?
Obstruction
Key features of cholangitis?
Age >50 with risks, jaundice, pruritis, clay stools, fever and chills, dark urine, mental state changes, hypotension
Diagnosis of cholangitis?
FBC, urea, creatinine, ABG, MRCP, CT USS
Bowel obstruction features?
N&V, anorexia, colicky pain, constipation and distention. tinkling bowel sounds.
Causes of small bowel obstruction?
Hernias and adhesion(75%) malignancy rare
Causes of large bowel obstruction?
Usually malignancy and aged over 70, can be sigmoid volvulus
Bowel sounds and symptoms in ileus?
Painless no bowel sounds
Strangulated obstruction symptoms?
Pt more ill than expected, sharp constant pain. Peritonism is cardinal. fever WCC and signs of mesenteric ischaemia
Xray findings SBO?
Small bowel obstruction- valvulae commintantes completely cross lumen, lack of gas in large bowel.
Xray findings LBO?
peripheral gas shadow proximal to the blockage but not in the rectum. Large bowel haustra do not cross the lumens width
Immediate action bowel obstructions?
NG tube free drainage, iv fluids for electrolyte abnormalities, analgesia. FBC AXR and erect chest plus catheter
AXR sign with sigmoid volvulus?
Coffee bean sign
Sigmoid volvulus treatments?
Flatus tube, sigmoidoscopy
Diverticulitis symptoms?
Altered bowel habit, left sided colic relieved by defecation, nausea and flatulence, pyrexia, possible tender colon?
Diverticulitis investigations?
Erect CXR for perf, USS bloods wcc, crp.
Diverticulitis management?
Mild treated at home with fluids and abx, admit if bad for nbm and iv fluids. Surgery for peritonitis and purulence. Elective resection if severe or stenosed or fistulae
Causes of pancreatitis?
Gallstones, ethanol. trauma, steroids, mumps, autoimmune, ERCP, drugs hyperlipid.
Signs and symptoms of pancreatitis?
Gradual or sudden severe epigastric pain, radiates to back. Vomiting, tachy, fever jaundice, rigid abdomen,
Cullen’s sign?
periumbilical brusing
Grey-turners sign?
Flank bruising retroperitoneal haemorrhage
Investigations for pancreatitis?
> 1000 amylase, lipase(more specific) ABG, AXR, erect CXR USS, ERCP
Management of pancreatitis?
NBM likely NG tube needed. IV fluids ensure urine 30ml/hr
How do you assess pancreatitis severity?
Glasgow modified criteria >3 prompts ITU/HDU
Symptoms of peptic ulcer disease?
Epigastric pain, often hunger related or food or time of day. Fullness, heartburn, tender epigastrium,
Peptic ulcer red flags? ALARMS
anaemia, loss of weight, anorexia, recent onset, melena, swallowing difficulty
Which is more common gastric or duodenal ulcer?
Duodenal 4X more
Risk factors for duodenal ulcers?
H.pylori, nsaids, ssris, steroids. Pain before meals relieved by drinking milk/meals
Gastric ulcers most common in who? where?
Elderly, lesser curvature.
Gastric ulcer risks?
H pylori, NSAIDS,smoking, burns. relieved by antacid related to food.
Gastric ulcer complications?
Bleeding, perf, malignancy, reduced gastric outflow
What happens in AKI?
Rapid reduction (hours to days) in the eGFR due to renal hypoperfusion, damage to the glomeruli, tubules, interstitial or the obstruction to urine outflow.
When is it diagnosed (AKI)?
is an ^ serum creatinine concentration with or without a decrease in urine production. (inverse proportion to eGFR)
Causes of AKI broadly?
Pre-renal, Renal, Post-renal
Pre-renal causes AKI?
- Hypovolaemia
- Reduced cardiac output- liver failure, cardiac failure
- Sepsis
- Renal artery stenosis
- ACE inhibitors
Renal causes of AKI?
Ischaemic, cytotoxic or inflammatory processes in urinary tract.
Post renal causes of AKi?
- Luminal- stones, clots and sloughed papillae
- Mural- malignancy (ureteric, bladder and prostate), BPH and strictures
- Extrinsic compression- malignancy (pelvic) and retroperitoneal fibrosis
Stages of AKI?
1= 1.5 X creat 0.5ml/kg urine 6hr
2= 2-2.9 times base 0.5ml/kg >12hrs
3 = 3x creat0.3ml/kg >24 hr or anuria for 12hr
Risk factors for AKI?
> 75 years, CKD, cardiac failure. liver and vascular disease DIABETES! drugs, sepsis, poor fluid
AKI assessment?
A-E assess volume status, check K urgently. Dip urine (infection or blood)
Bence jones proteins assoc with?
Multiple myeloma
Drugh overdoese treated with dialysis? (BLAST)
barbiturates, lithium, alcohol, salicylates and theophylline)
Indications for renal replacement therapy?
Uraemic complications, acidosis, pulmonary oedema, hyperkalaemia >7
Management of post renal aki?
: catheterise and consider CT of the renal tract and urology referral if obstruction is most likely
Why is ketamine good in asthma?
Smooth muscle relaxation
How does ketamine work?
Non competitive NMDA antagonist brain and spine.
Ventricular rate in AF?
160-180bpm
Define paroxysmal AF?
> 30s less than 7days
Persistent AF?
> 7days
Permanent AF?
Not terminated by cardioversion, or relapses <24hrs
Causes of AF?
Most have a cause-
IHD, HTN, Hyperthy, rhematic, WPW, heart failure, caffeine, drugs, infection
AF complications?
Stroke and emboli, HF, Tachy induced myopathy and ischaemia
ECG AF?
Absent P chaotic baseline
AF treatment?
Rate control - atenolol or diltiazem/verapamil)
cardioversion new onset or reversible cause/HF
CHADVASc score for anticoag ?
1= antiplatelet or anticoag, 2 = anticoag
Atrial flutter?
Atrial tachy usually 250-300bpm
Causes of atrial flutter?
CHD, Open heart, HTN, obesity, WPW, etoh, thyrotox, copd
ECG atrial flutter
Saw tooth, no p waves but regular
Treatment of atrial flutter?
reversible causes, if unstable cardiovert, anticoag, able, amiodarone, flecainide, also rate control!
What typically required to initiate svt?
Extrasystole makes re entrant circuit.
ECG SVT?
narrow complex, QRS<120ms rate greater than 100 p absent or inverted
SVT management?
Vagal manouvres first if stable, then adenosine 6mg with flush. Then verapamil, then cardiovert DC (if unstable)
Ventricular tachycardia?
Vent rhythm >100bpm wide QRS or needing termination due to instability
Deviation in VT?
Left axis
Management of VT?
Give 02, IV, ECG, ABG, Amiodarone, if torsades give MGSO4 - may need defib inplant
Why does torsades come about?
Prolonged QT
Triad of DKA?
Ketonaemia, Hyperglycaemia, Acidaemia (metabolic)
Features of DKA?
Malaise, polyuria, dipsia, abdo pain, laboured breathing, dehydration, pear drops, N&V
Diagnostic criteria DKA?
pH<7.3 or bicarb <15 kotnes >3 or marked on urine, glucose >11mmol
Investigations in DKA?
Bloods, leucocytosis common not usually infection, ECG to check for hyper or hypo kal. Can be silent MI
Rate of fixed insulin per hour in DKA?
0.1units per kg/hr
DKA, pH <7.1 Ketones >6 GCS <12 02 <92 consider what?
ITU admission
DKA management?
Large bore cannulae, fluid challenge, to restore bp >90
If bp >90 in DKA how to replace fluids?
NaCl over 1 hour or to replace deficit
What to include in fluids for DKA?
KCL if anuria not suspected
How much should values fall per hour in dka treatment?
Ketone 0.5, and glucose 3mmol per hour
What glucose level do you start to give glucose in dka?
14mmol
How long to continue insulin infusion in DKA?
until pH >7.3 ketones <0.3 and pt can then eat
DKA complications?
Cerebral oedema, hypokal, pneumonia, hypomag, VTE
Define hypoglycaemia?
<4plasma glucose
Symptoms of hypoglycaemia?
Sweating, hunger, anxiety, tremor, confusion drowsiness, eventually coma
Causes of Hypo? (ExPLAIN)
Exogenous drugs- oral antidiabetics, aspirin, betablockers acei, alcohol.
Pituatary insufficiency liver failure addisons islet cell non pancreatic neoplasm
Treating hypo?
initial 10-20g glucose in drink or solid then give carbs If cannot swallow IV glucose 200ml 10% 100ml 20%
Hypo unconscious?
Glucagon 0.5-2mg IM
Hyperglycaemic hyperosmolar state?
Symptoms present over days not hours and it is mostly a complication of type 2 diabetes. Typically older pts higher mortality than DKA
Diagnosis of HHS?
hypovolaemia, severe, glucose up to and over 30, no significant acidosis or ketones, osmalality raised >320
Treatment of HHS?
ketones <1 use fluids, ketones >1 start fixed rate insulin look for infection,
What do inotropes do?
Increase cardiac contractility and thus output.
Main receptor to affect rate and force of contraction in heart?
B1
How and on what does dobutamine work?
Predominant B1 increase contractility, and HR also B2 increases afterload
Isoprenaline can cause what?
Tachy
Noradrenaline is primarily what?
Vasopressor- maintains BP often used with others
What does witholding treatment entail?
Not starting or increasing interventions
Withdrawing treatment means?
actively stopping a life sustaining intervention (passive euthanasia)
**Both withholding and withdrawing treatment are accepted to be equally morally and ethically the same
Define death?
irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe
Confirming death?
- Observed for a minimum of 5 mins
- Absence of a central pulse and absence of heart sounds on auscultation
- Asystole on continuous ECG
- After 5 minutes of CPR confirm absence of pupillary light reflexes, corneal reflexes and motor response to supra-orbital pressure
Diagnosisng brain death what should be considered?
Potential reversible causes-
depressant drugs
- hypothermia- core temp should be >34 at testing
- metabolic/endocrine disturbance
- neuromuscular blocking agents and high cervical cord injury can cause apnoea
Criteria for brain death?
¬ The pupils are fixed and do not repond to light
¬ There is no corneal reflex
¬ The oculo-vestibular reflexes are absent
¬ No motor response within the cranial nerve distribution (supra-orbital pressure)
No cough reflex to bronchial stimulation or gag reflex to pharyngeal stimulation
Over what age can adult brainstem testing be used?
> 2months
How many years registered to certify brain death?
At least 5 and 1 doctor must be consultant
What should happen if you suspect a pt may be eligible for donating?
Contact SNOD in first instance
Trauma triangle of death?
Coagulopathy, acidosis, hypothermia
Clinically relevant hypothermia?
<36 for >4hrs
What is cerebral perfusion pressure?
MAP-ICP
How is CPP usually controlled in practice?
Raising MAP ICP should be <20
What is the cushings response?
HTN, Bradycardia and irregular respiration - pre terminal sign
Managing ICP?
Head elevated, Mannitol boluses 0.5-1g/kg (no good if renal problems) hypervent (controversial) RSI
Head injury history?
Mechanism, LOC, amnesia, vom and headache any alcohol or drugs and anticoag, pre-injury functioning
Examination head injury?
GCS, cranial nerves, focal neurology, neck tender
Ct scan within 1 hour of head injury if …
GCS <13 at time, <15 2 hrs post, suspected fractures, battles sign or panda eyes, seizure, >1 vomit
How many hours for ct if head injury on warfarin?
Within 8 hrs and report within 1 of doing scan
Psych disorder linked to head injury?
PTSD
Where is fast scan looking?
Liver, spleen, pelvic, pericardiac and anterior chest
Brief canadian c spine rules?
IF suspect need radiology immobilise! or if high risk mechanism of injury. If no pain and was ambulatory and can move neck is fine,
Broadly speaking what is resp failure (Pa02)
<8 divided in to 2
What is type 1 resp failure?
Pa02< 8 with normal or low CO2
Causes of type 1 resp failure?
Asthma, PE, oedema, Pneumonia, ARDS, Fibrosis
What is type 2 resp failure?
pa02 <8 and co2 >6
Causes of type 2 resp failure?
COPD, asthma, pneomonia fibrosis, reduced resp drive, neuromuscular disease and lesion, myasthenia gravis and guillan barre thoracic wall defects
Management of type 1 resp failure?
Treat underlying give oxygen 35-60% face mask assited vent if pa02 low despite 60% oxygen
Which NIV used for type 1 failure?
CPAP
Which NIV used for type 2 failure?
Bipap
Type 2 resp failure treatment?
Underlying causes, then start 24% oxygen and titrate up, check abg 20mins if paco2 continues to rise and hypoxic consider support
ARDS?
May be caused by direct lung injury or occur secondary to severe systemic illness. Lung damage and release of inflammatory mediators
Causes of ARDS?
Aspiration, vaculitis, shock, sepsis, DIC, pancreatitis, liver failure, fat embolism, burns, drugs
Management of ARDS?
resp support with cpap, if cant keep pa02 >8.3 with 60% oxygen
may need circulatory support and organ support
When should u give nasal cannulae as well as nebuliser?
If copd to maintain sats as neb through air (1-6l)
What does CPAP increase in the lungs?
Functional residual capacity reduces atelectasis
Anterior or anteroseptal Mi casued by which vessel occlusion?
LAD
Lateral infarction caused by occlusion of?
Circumflex
Chest pain investigations?
ECG, ST elevation, or new BBB
Changes after MI?
New LBBB, Hyper acute t waves
Days after Mi ecg changes?
pathological Q waves or t wave inversion
Normal ecg and normal troponin more than 6 hrs after pain?
Unlikely to be MI
How quickly for primary PCi?
2hrs
NSTEMI management?
Morphine plus antiemetic aspirin followed by 75mg daily or clopi GTN B Blocker (metoprolol/bisop) Fondaparinux
STEMI management?
Morphine plus antiemetic, , aspirin clopidogrel 300mg (ticagrelor) GTN oxygen if needed
What is unstable angina?
pain on minimal exertion and angina that seems to be progressing rapidly despite increasing medical treatment. Is an acute coronary syndrome that is defined by the absence of biochemical evidence of myocardial damage
What is nicorandil?
Long acting nitrate for angina
Wells score >what do CTPA?
4
Wells score <4 do what?
Arrange d dimer, if neg consider alternative if pos do ctpa
When is a v/q scan used?
Pregnancy, renal impairment and dye allergies
CXR finding in PE?
Normal in context of hypoxaemia suggests PE
Ecg changes in PE?
RBBB Right axis deviation t wave inversion (right sided strain)
IS d-dimer sensitive or specific?
Sensitive, negative almost excludes PE
PE treatment?
LMWH for stable pts, continued for at least 5 days or until inr >2 offer rivaroaxaban or warfarin for 3 months then assess (depends if provoked)
Renal impairment or haemodynamic instability in PE use what?
Unfractionated heparin
Symptoms of aortic dissection?
Sudden tearing pain radiating to the back. leading to hemiplegia and unequal arm pressures and pulses limb ischaemia
Two types of aortic dissection?
Type A (70%) ascending aorta consider all for surgery
Type B Ascending not involved surgery if leaking or ruptured
Management of aortic dissection?
Xmatch 10 units major haemorrhage! ECG possible chest xray (widening of mediastinum) CT/MRi needs ITU keep BP 100-110 (labetolol or esmolol)
8 signs of delirium?
DELIRIUM
Disordered, Euphoric, Language impaired, Illusions, Reversal(sleep), Inattention, Unaware, Memory
Hyponatraemia definition?
< 135mmol/l Na
What may plasma Na not show?
True depletion of Na as depends on water in plasma too so volume status important.
Causes of hyponatraemia?
Decreased volume, (third space infections) SIAD, Hypothyroid, anorexia, Heart failure, Drugs (diuretics thiazide nsaids)
Features of hyponatraemia?
Usually incidental, non specific and onset is unsure. Vomiting, drowsiness, headache, seizures, cerebral oedema and raised ICP. Chronic can lead to brain problems.
Hyperkalaemia serum ?
> 5.5
How is K balance achieved?
Through renal and gut excretion
Causes of Hyperkalaemia?
massive blood transfuse, burns rhabdomyolsis, tumour lysis, drugs (spiron and digox), renal addisons, conpartment shift
^K symptoms/signs
Muscle weakness ECG changes, paralysis, renal impairment, parasthaesia
Immediate management of ^K?
Anatagonise cardiac toxicity with calcoium gluconate (10% 15-30ml)
After immediate management of K^ what should you do?
Drive K in to cells, nebulised salbutamol(10-20mg) or insulin dextrose infusion.
What serum K do you expect ecg changes?
> 6 usually, once >9 Vfib and death!
Most common cause of SAH?
- Rupture of saccular aneurysms- berry aneurysms (80%)
- Arteriovenous malformations (15%)
- No causes are identified in <15%
Risks for SAH?
- Smoking
- Alcohol misuse
- Hypertension
- Bleeding disorders
- Mycotic aneurysm
What is a sentinel haemorrhage?
- 50% of patients experience a warning leak (sentinel haemorrhage) in the hours to weeks before the major bleed. This headache may be mild, generalised or resolve within minutes
- Upper neck pain or stiffness is common
Imaging for SAH?
non contrast CT in first 24hrs >95% demonstrates blood after days MRI is better
When to do LP in SAH?
suspicion but CT negative and no ICP^ 6-12hrs after symptoms meaning degradation of blood in csf
Lentiform on head CT ?
Extradural extra lentils
Crescent on CT head?
Subdural
What is cerebral vaso spasm?
occurs in 20% of patients. Major cause of death and morbidity. Tends to occur 3-15 days after SAH with peak incidence 6-8 days. Vasospasm causes ischaemia or infarction
SAH management?
Nimodipine prevent vasospasm
Coiling
Maintain 160BP for perfuson if clipped and 120-140 if unclipped
Presssure and appearance of csf in bacterial meningitis?
High turbid
Low glucose in csf sign of what meningitis?
Bacterial
Fibrin web csf?
Fungal/TB
CSF monocytes ?
Viral
Protein in CSF how does it change?
<1 in viral >1 in bacterial
Signs and symptoms of temporal arteritis?
- New onset localised headache that is usually unilateral
- Temporal artery abnormality such as tenderness, thickening or nodularity
- Fever, fatigue, anorexia and weight loss
pain on eating visual disturbance
Temporal arteritis diagnosis?
♣ Temporal artery biopsy. If there is visual impairment arrange an urgent (same day) assessment by an ophthalmologist
Treatment of temporal arteritis?
60mg/day prednisolone
How long is temporal arteritis treated for?
Can be years as reducing the steroids counsel pts about this
FBC of temporal arteritis?
Normocytic normochromic anaemia and elevated platelet count
Venous sinus thrombosis symptoms? saggital?
Headache, vomiting seizures, pappiloedema
Transverse sinus thrombosis symptoms?
Headache mastoid pain, focal cns papilloedema
Sigmoid sinus thrombosis symptoms?
cerebellar signs
5th and 6th cranial nerve palsies with which thrombosis?
Inferior petrosal
Cavernous sinus thrombosis spread from where?
facial pustules or folliculitis
Common causes of sinus thromboses?
Pregnancy, oral contraceptive, head injury, dehydration, abscess, meningitis, tb
Venous sinus thrombosis treatment?
Heparin, seek expert help
Signs and symptoms of DVT?
1/3 no signs, pitting oedema, tenderness politeal or femoral veins, dull ache
Management of DVT?
Acute (LMWH) warfarin or noac for 3months (lmwh in preg or cancer)
Wells score to do d dimer?
<2
Travel delayed by how long after dvt anticoag?
2 weeks
Management of DVT?
warfarin or noac for 3months (lmwh in preg or cancer)
Wells for pregnancy?
No not useful neither is D dimer
Risk factors for cellulitis?
Leg ulceration, Atopic eczema, funal infection, lymphoedema, obesity venous insufficiency
What classification is used for severity of cellulitis?
ERON - 4 classes
ABX for cellulitis? Penicillin allergy too? primary care
Fluclox 500mg qds 7/7
Clarithro 500mg BD 7/7
Secondary care abx for cellulitis?
Iv fluclox or if more severe, ben pen, cipro and cinda!
How long can an ischaemic limb wait for revascularisation?
4-6hrs
Causes of ischaemic limb?
Thrombosis, emboli, graft occlusion, trauma
6 P’s of ischaemia?
Pale Pulseless Painful Paralysis Paraesthesia Perishingly cold
Complications of ischaemic limb treatment?
Reperfusion injury, compartment syndrome
What is gout, where most common?
Typically presents with acute monoarthropathy with severe joint inflammation. More than 50% occurs at the metatarsophalangeal joint of the big toe.
NSAIDS contraindicated what used for gout?
Colchicine
Most common site for septic arthritis?
Knee >50%
Risks for septic arthritis?
- Pre existing joint disease
- Diabetes
- Immunosuppression
- Chronic renal failure
- Recent joint surgery
- Prosthetic joints
- IV drug abuse
Age > 80 years
Investigation suspected septic arthritis?
Urgent joint aspiration for synovial fluid microscopy and culture is the key investigation C~RP may be normal as may radiographs
ABX for septic arthritis?
Fluclox, vanc, clind
Common organisms septic arthritis?
Staph, strep, gonococcus,
