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- FINALS: Presentations > Act Conditions - Management > Flashcards

Act Conditions - Management Flashcards

1
Q

Cardiac Arrest

- When to start CPR?

A

Patient unresponsive

No resp effort, no central pulse

Get Crash Trolley!
CALL CRASH TEAM!

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2
Q

Cardiac arrest algorithm?

A

CPR 30:2

  • Attach Defib
  • Assess Rhythm
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3
Q

Shockable rhythm?

A

VF or Pulseless VT

1 shock

Resume CPR for 2 mins

Assess Rhythm

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4
Q

Non- Shockable Rhythm

A

PEA or Aystole

Resume CPR for 2 mins

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5
Q

What to do if ROSC?

A

A-E approach

Normalise O2, CO2,
12 Lead ECG

Treat cause

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6
Q

Reversible causes (4H 4Ts)

A

Hypoxia
Hypothermia
Hyper/hypokalaemia
Hypovolaemia

Thrombosis
Tamponade
Toxins
Tension Pneumothorax

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7
Q

Doses in Cardiac Arrest

A

Adrenaline 1mg IV (10ml of 1:10000)
- repeat in alternate cycles

Amiodarone 300mg IV
- after 3rd shock

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8
Q

ACS Ix

A

ECG

  • ST or New LBBB (STEMI)
  • ST depression, inverted t waves (NSTEMI)

Cardiac Markers
- Troponin T&I 3-12 hour post event

CXR
- check for signs of cardiomegaly, LVF

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9
Q

ACS Initial Mx

A

A to E approach

MONAT

Morphine 2.5mg IV
Oxygen (if O2 sats <94%)
Nitrities (2 puffs GTN)
Aspirin 300mg 
Ticagrelor 180mg

May need antiemetic e.g. cyclazine 50mg IV

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10
Q

ACS Definitive Mx - STEMI

A

STEMI

  • PCI within 12 hours onset
  • Consider thrombolysis if cannot get to PCI centre in 120 mins or would not cope with PCI procedure
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11
Q

ACS Definitive Mx - NSTEMI

A

NSTEMI

  • Fondaparinux 2.5mg SC (discuss cardiology)
  • TIMI/GRACE score: do they need cardiac catheter?
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12
Q

ACS - Go home on?

A

ACEi + beta blocker to reduce cardiac remodelling
Aspirin 75mg for life
Ticagrelor 90mg BD for 12 months
Secondary prevention statin e.g. Atorvastatin 80mg

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13
Q

Acute LVF: Ix

A

Initial:

ECG: arrhythmias, acute STEMI, old infarct, LVH

Bloods: FBC, UEs, LFTs, glucose, troponin, BNP
ABG: hypoxia?

CXR: cardiomegaly, upper lobe diversion, pleural effusion and patchy opacification showing alveolar oedema

Then:
- ECHO: check LV function/ejection fraction

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14
Q

Acute LVF: A-E?

A

A to E

  • A: Sit up and give 15 L
  • B: crackles bibasal, high RR, low O2 (get CXR, do ABG)
  • C: IV access, bloods, check BP + HR (ECG)
  • D: check GCS, BM, pupils
  • E: peripheral oedema, rule out dvt?

Initiate mx
Call Senior
Reassess

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15
Q

Acute LVF: Mx

A

Oxygen
Morphine 2.5mg IV
Furosomide 40-80mg slow IV (watch renal failure)
GTN (check BP)

If BP >90 = GTN 2 puffs
If BP <90 = inotropes required as cardiogenic shock
—- CALL SENIOR!

Salbutamol nebs if wheezing

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16
Q

Acute LVF: Subsequent mx

A 
Rationalise meds
Regular blood (UEs as on diuretics)
Strict fluid balance +/- catheter
Falls bundle
DNACPR conversation
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17
Q

HTN Stages and Rx

A

Stage 1 >135/85
- Treat based on total CV risk

Stage 2 >150/95 or systolic >160
- Treat with antihypertensive

Severe >180 systolic or >110 diastolic
- Start antihypertensive

If w/ papilloedema/retinal haemorrhage
- Same day admission

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18
Q

HTN Ix

A

Cardiovascular Exam
Fundoscopy

Urine dip - proteinuria/haematuria
12 lead ECG

Bloods: UEs, LFTs, FBC, eGR, glucose/HbA1c, lipids

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19
Q

HTN Conservative Mx

A

Lifestyle

  • Stop smoking
  • Drink <14 U per week, 2 alcohol free days
  • 30 mins exercise 5x week
  • Low salt, high veg diet
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20
Q

HTN Medical Mx

A

<55 years A+C+D
ACEi
+ Amlodipine,
+Indapamide

> 55 years/black C+A+D
Amlodipine
+ ACEi/ARB(if black)
+ indapamide

Resistant hypertension
 = A+C+D and 
          alpha/beta blocker OR
          spiranolactone (check K+)
Refer to specialist
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21
Q

CCF Ix

A

Urine Dip
12 Lead ECG

Bloods

  • FBC, UEs, eGFR, TFs, LFts, lipids, HbA1c
  • BNP

CXR

ECHO
- transthoracic doppler = diagnostic

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22
Q

CCF Conservative Mx

A

Lifestyle

  • Stop smoking/diet/alcohol
  • Graded exercise programme for SOB
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23
Q

CCF Medical Mx

A

1st

  • ACEi
  • Beta blockers

2nd

  • ARB
  • Spiranolactone
  • Hydralazine + nitriate

3rd

  • Digoxin (if sedentary)
  • Ivibradine

WITH: Furusomide to control Sx

AND:

  • Anticoagulation if AF
  • Antiplatelets if HF and IHD
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24
Q

DVT Ix

A

Well’s score

Low risk <2
- D Dimer:
Normal - discharge with safetynetting
High - USS doppler

High risk >2

  • LMWH
  • USS doppler

Gold standard: Contrast venography

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25
Q

DVT Mx

A

Treatment dose LMWH
- Enoxaparin 1.5mg/kg OD SC

When DVT confirmed, start warfarin

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26
Q

Acute Limb Ischaemia Ix

A

Doppler - reduced or absent pulse

ABPI <0.5 = critical (<0.9 = arterial disease)

Angiography will show obstruction

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27
Q

Acute Limb Ischaemia Mx

A

A to E

  • Pain relief, NBM, consider ABx
  • IV access, bloods and fluids
  • ECG and CXR if needed for surgery

REFER VASCULAR SURGEONS
- embolectomy, thrombolysis, stent, bypass, amputation

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28
Q

Superficial Thrombophlebitis General Mx

A
  • Elastic support of limb
  • Elevate leg
  • Gentle exercise
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29
Q

Superficial Thrombophlebitis Medical Mx

A
  • Topical analgesia cream

- DVT prophylaxis (LMWH for 1month)

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30
Q

Superficial Thrombophlebitis Surgical Mx

A

Treat varicose veins if contributing cause

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31
Q

Complete Heart Block Ix

A

ECG

  • P and QRS complete disociation
  • Bradycardia
  • Broad QRS
  • Look for evidence of prior MI (q waves)

Bloods

  • FBC, UEs, LFTs, Ca2+, Mg2+, glucose
  • TFTs, cardiac markers, clotting
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32
Q

Complete Heart Block Initial Mx

A

A to E (IV access, bloods, ECG)
Continuous Cardiac Monitoring

Same rx if stable/unstable (as high risk of asystole)

  • Atropine 500mcg (repeat up to 3mg)
  • Pacing if unsuccessful
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33
Q

Complete Heart Block Definitive Mx

A

Refer cardiology:

Pacemaker!

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34
Q

Postural Hypotension Ix

A

Urine dip (protein)

Lying and Standing BP (>20/>10 = diagnostic)

ECG to rule out arrhythmia

Blood glucose

Bloods: UEs, FBC, LFTs, TFTs, HbA1c

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35
Q

Postural Hypotension Mx

A

Review Drugs

Treat cause

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36
Q

Angina Mx

  • Sx
  • Secondary Prevention
A

Symptomatic Relief:

  • Beta-blocker
  • GTN
  • Isosorbide/nicorandil if cannot tolerate the above

Secondary Prevention

  • Aspirin 75mg
  • Atorvastatin 80mg
  • ACEi if diabetic/hypertensive
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37
Q

Otitis Media Mx

A

Reassurrance
- Most recover in 3 days without abx

Analgesia
- Paracetamol/ibuprofen as required

Antibiotics

  • No prescribing
  • Delayed rx if >4 days lentgth
  • Immediate rx if fits criteria
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38
Q

Otitis Media: Who needs abx?

A

Systemically unwell patient

Signs/sx of complications:
- pneumonia, mastioditis, Quinsy

High risk pt due to comorbidities
- CF, prem baby, Heart, liver, renal lung disease

Older than 65 years w/ cough and 2 of

  • hospital admission in previous year
  • T1/T2 DM
  • CCF
  • Current steroid use
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39
Q

Otitis Media: What abx?

A

Amoxicillin or Erythromycin

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40
Q

Tonsillitis: Centor Score

A

Exudate
Absence of cough
Cervical lymphadenopathy
Temperature

3+/4 = likely strep throat
0 of 4 = 80% not strep

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41
Q

Tonsillitis Conservative Mx

A

Regular Paracetamol and Ibuprofen

Mouthwash // numbing throat spray

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42
Q

Tonsillitis Medical Mx

A

Do not routinely rx abx, only if Centor +ve

  • Penicillin V 10 days
  • Clarithromycin/erythromycin if pen. allergic

EXTRA

  • Seek specialist review if immunosuppressed
  • If on DMARD or Carbimazole check FBC: risk agranulocytosis
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43
Q

Tonsillitis Surgical Mx

A

Recurrent sore throat due to tonsillitis
Disabling and prevent normal functioning

  • 7 eps in 1 year
  • 5 in each of last 2 years
  • 3 in each of last 3 years
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44
Q

Anaphylaxis - Initial Mx

A

ABCDE

  • Call for SENIOR help: anaesthetist
  • STOP allergen

Oxygen 15L through NRB mask

ADRENALINE 0.5ml 1:1000 IM

  • Lie down and elevate legs
  • IV access and bloods
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45
Q

Anaphylaxis - Subsequent Mx

A

Hydrocortisone 200mg IV

Chlorphenamine 10mg IV

Salbutamol 5mg Neb (with O2)
- If wheeze

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46
Q

Sepsis - BUFALO

A

Within 1st hour

Blood cultures (pre-abx)
Urine output
Fluids
Abx (broad spec)
Lactate
Oxygen 15L NRBM
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47
Q

Sepsis Ix

A

ABG, ECG, Urine Dip

Bloods
- FBC, UEs, LFTs, CRP, Glucose, clotting, procalcitonin

Cultures

  • Bloods: 2 seperate sites, from line
  • Wound, skin, urine, stool

Erect CXR
- Peforation, consolitation

ECHO
- if suspect IE

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48
Q

Sepsis Initial Mx

A

ABCDE - Call senior

Lie flat and elevate legs

  • O2, IV access, bloods and cultures
  • Catheter to monitor urine output
Broad spectrum abx (dictated by source)
Fluid challenge (500ml NaCl 20 mins)
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49
Q

Cardiogenic Shock Ix

A

ECG: MI, arrhythmia, small voltage QRS (tamponade)

ABG: low O2

Bloods
- FBC, UEs, Glucose, Clotting, X-match

CXR
- pneumothorax, cardiomagaly, fluid overload

ECHO
- dissection, tamponade, LVF

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50
Q

Cardiogenic Mx

A

Work out if

Pump failure:
- LV dysfunction (post MI), aortic dissection, arrhythmia

Inadequate filling:

  • PE/pneumothorax
  • Cardiac tamponade

Treat cause

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51
Q

Hypovolaemic Shock

  • Haemorrhagic Causes
A

Trauma
- Internal or external bleeding
Ruptured AAA
GI Bleed

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52
Q

Hypovolaemic Shock

  • Non-Haemorrhagic Causes
A

Salt and water loss
- D&V, burns, polyuria, DKA

3rd Space loss
- CCF, acute pancreatitis, ascites

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53
Q

Hypovolaemic Shock

  • Haemorrhagic Mx
A

Senior help and ABCDE

Lay flat, elevate legs, O2 15L,
IV Access (2 large bore) + Bloods
- FBC, UEs, LFTs, clotting, crossmatch 4U, VBG (quick hB)

1L saline stat, give another 1L if no response in BP
Attempt to stop bleeding with compression
Keep Systolic BP <100 (prevent bleeding out)

Give up to 4U of blood (Xmatch or O-ve)

Involve ICU, reassess

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54
Q

Hypovolaemic Shock

  • Non-Haemorrhagic Mx
A

SENIOR help and ABCDE

Lay flat, elevate legs, O2 15L,
IV Access (2 large bore) + Bloods
- FBC, UEs, LFTs, glucose, ketones , CRP, amylase,
- VBG for electolytes (K+ and Na2+)

1L saline stat, give another 1L if no response in BP/HR

Identify cause and treat

Reassess

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55
Q

Acute Resp Failure Ix

A

ABG

  • T1: O2 <8.0, Co2 <6.5 (V/Q mismatch)
  • T2: O2 <8.0, Co2 >6.5 (hypoventilation)

ECG/PEFR

Bloods
- FBC, UEs, LFTs, CRP, glucose
Cultures
- Bloods, sputum, urine

CXR

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56
Q

T1 RF Mx

A

Unrestricted O2 therapy to maintain sats > 94%

Check ABG after 20 mins to insure PaO2 improving and no rise in PaCO2

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57
Q

T2 RF Mx

A

Titrated oxygen: 24% O2 and go up

ABG after 20 mins to check no rise in CO2, or for resolution of resp acidosis.

If no resolution: NIV

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58
Q

PCM Overdose Ix

A

ABG: if pH <7.3 post fluid resus = bad sign

Bloods:

  • FBCs, LFTs, UEs, BM, Clotting (PT)
  • Paracetamol levels after 4 hours
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59
Q

PCM Overdose Mx

A

<4 hrs
- Wait until 4 hours to take levels

4-8 Hours

  • Take levels
  • Treat if over line of graph
  • Pysch assessment

8-15 hour

  • Treat before level comes back
  • Stop rx if levels below line

> 15 hours/Staggered
- Treat

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60
Q

PCM Overdose Doses

A

150mg/kg IV infusion in 200ml/1 hour
50mg/kg infusion in 500ml/4 hours
100mg/kg infusion in 1L/16 hours

CHECK PT, stop bag when this comes back normal.

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61
Q

Hypoglycaemia Ix

A

BM <4

UEs, C-peptide

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62
Q

Hypoglycaemia Initial Mx

  • Conscious?
A

4-5 glucotabs or glucogel

Repeat BM after 10 mins

If no improvement, rpt up to 3 times

Still no improvement: IM glucagon/IV glucose

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63
Q

Hypoglycaemia Initial Mx

  • Unconsicous?
A

ABCDE assessment

1mg Glucagon IM

OR

75ml of 20% glucose IV

Rpt BM after 10 mins

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64
Q

Hypoglycaemia: Subsequent Mx

A

If caused by long acting insulin

  • Glucose 10% IV infusion for 8 hours
  • Do no omit long acting doses
Regular BM monitoring
Treat cause (give thiamine if due to alcohol)

Once BM >4 = long acting carbohydrate

No driving for 45 mins

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65
Q

DKA Ix

A

BM >11.1
Ketones >0.3 (blood) or ++ (urine)
pH <7.3 or bicarb <15

VBG
- low pH, low CO2 (comp), low Bicarb

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66
Q

DKA Mx

A

ABCDE - Senior!

15L O2 NRBM
IV Access (2 cannulas, one for fluids, one for insulin)
Capillary: BM and Ketones

  • Bloods: FBC, UEs, LFTs, Glucose, Bicarb, ketones, amylase, septic screen
  • VBG: pH <7.1 = ICU, check K+

Catheter (if low urine output/high creat)
NBM until ketone free

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67
Q

DKA Fluids

A

Systolic >90

  • 1L normal saline over 1 hour
  • 2L normal saline over 4 hours (w 20mmol K+/bag)
  • 2L normal saline over 8 hours (w 20mmol K+/bag)

If systolic <90

  • Fluid challenge with 500ml normal saline over 15 mins
  • Keep giving until BP responds
  • ICU referral

Withhold K+ only if >5.5

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68
Q

DKA: Insulin and monitoring

A

Fixed rate 0.1U/kg/hr
- 50U actrapid in 50ml normal saline

Stop IV insulin when ketones <0.3 and pH >7.3

Convert to regular IV insulin when E+D
- stop IV 30 mins post SC dose

DO NOT STOP basal insulin

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69
Q

DKA: Monitoring

A
  • Glucose and ketones 1 hourly

- venous pH/bicarb, K+ @ 60 mins, then 2 hourly

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70
Q

Hyperkalaemia: When to treat?

A

TREAT IF K+ >7 OR ECG CHANGES

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71
Q

Hyperkalaemia: Ix?

A

ECG

  • Broad QRS, absent P waves, tall tented T waves
  • Sine wave, VF

Bloods

  • VBG for K+, must have repeat lab U+E sample
  • Check pH (metabolic acidosis in renal failure)
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72
Q

Hyperkalaemia Initial Mx

A

ABCDE, 15L O2 NRBM,
ECG monitoring on defib
- If sine wave/VF = crash call

IV access, bloods, VBG

Treat

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73
Q

Hyperkalaemia Medica Mx

A

Calcium Gluconate
- 30ml 10% IV over 5 mins

Insulin

  • 10 U of actrapid in 100ml of 20% glucose
  • Check BM before and after

Salbutamol
- 5mg Nebuliser

Haemodialysis if refactory high K+

74
Q

Acute Angle Closure Glaucoma Mx

A

URGENT referral to opthalmology

75
Q

Acute Angle Closure Glaucoma

Medical Mx

A

Timolol (beta blocker drops)
— decrease aqueous fluid production

Pilocarpine (ach drops)
— constrict pupil and relieve pressure

Acetazolamide IV (Carbonic anhydrase inhimbitor)
--- decrease aqueous production in hosp

Give analgesia, anti emetics as required

76
Q

Acute Angle Closure Glaucoma

Definitive Mx

A

Peripheral Iridectomy

77
Q

GI Bleed Ix

A

Bloods

  • FBC, UEs, LFTs, Amylase, Glucose, Clotting
  • VBG for Hb level (lag in acute bleed)

High Risk
- Crossmatch

Low Risk
- Group and Save

CXR + ECG
- Free air under diaphragm

78
Q

Upper GI Bleed: Score

A

Glasgow Blatchford

  • Do they need endoscopy?
  • Used in A+E to discharge patients
  • Score 0-1 = OGD endoscopy

Rockall
- Post endoscopy w/ diagnosis

79
Q

Upper GI Bleed Mx

A

ABCDE, call senior

O2 15L NRBM

2 Large bore cannulas

  • Bloods,
  • Fluid resus
  • Xmatch for blood, group O if life threatening

Transfuse if Hb <70 - aim for 70-90 (higher if anginal sx)

NEED URGENT ENDOSCOPY

80
Q

Upper GI Bleed Medical Mx

- Ulcer v Varices

A

Ulcer:

  • IV PPI post endoscopy
  • 8mg/hr Omeprazole

Variceal bleed
- Terlipressin, can be given in A+E

81
Q

Upper GI Bleed Mx

  • Post endoscopy
A

NBM for 24 hours
Repeat FBC after 6 hours, transfuse if required.
Check obs hourly

Follow up OGD after 8 eeks

82
Q

Constipation Ix

A

Elderly
- Flexi sig/barium enema post treatment
Cancer or diverticular disease
- Bloods: FBC, UEs, LFTs, Ca2+, glucose

Review Meds

83
Q

Constipation Conservative Mx

A 
Drink more fluids
Reassure
Increase fruit and veg in diet
Gentle exercise
Behavioural e.g. gastrocolic reflex, stool
84
Q

Laxatives

- Bulk forming

A
  • Fybogel

Take with loads of fluids to increase peristalsis

85
Q

Laxatives

- Softeners

A

Liquid paraffin, docusate

Good for painful anal conditions

86
Q

Laxatives

- Osmotic

A

Lactulose

Retain fluid in bowel

87
Q

Laxatives

- Combination

A

Movicol
- Osmotic and stimulant

Docusate/co-danthromer (terminally ill only)
- Softening and stimulant

88
Q

Laxatives

- Stimulant

A

Senna

  • Increase intestinal motiliyu
  • Avoid in obstruction
89
Q

Constipation: Late Mx

A

Phosphate enema

MDT approach

90
Q

Diarrhoea Bloods Ix

A

FBC

  • Low MCV: blood loss, coeliac
  • High MCV: alcohol or low B12
  • Eosinophilia if parasitic

ESR/CRP
- infection, IBD, cancer

UEs
- Na + K+ abnormalities

TFTs: hyperthyroid
TTG: coeliac

91
Q

Diarrhoea Ix

A

Bloods

Stool - if infective cause MC&S

Colonoscopy (with biopsy)

  • Cancer
  • IBD
92
Q

Diarrhoea General Mx

A

Treat cause

WORK:

  • with food: avoid until stool sample negative - hospital: 48 hours clear of sx
  • ISOLATE PATIENTS
93
Q

Diarrhoea Rehydration Mx

A

Oral better than IV

  • Fruit juice and salty soup, ORS in children
  • NaCl with 20 mmol K+
94
Q

Diarrhoea Antimotility Drugs

A

Codeine 30mg or Loperamide 2mg

Avoid in colitis or children

95
Q

C Diff Mx

A

SIGHT
- suspect, isolate, gloves and apron, hand hygiene, test

Stop causative abx
Test stool sample
Rx Metronidazole 14 days if sx severe

96
Q

Post Op Infection - Wound

Ix and Mx

A

Ix

  • Wound swab + culture
  • FBC, UEs, CRP
  • Cultures if septic

Rx

  • Release pus if collection
  • Flucloxacillin for SA, rx from culture
97
Q

Post Op Infection - Chest

Ix and Mx

A

Ix

  • Sputum sample
  • FBC, UEs, LFTs, CRP, VBG
  • Cultures if septic
  • CXR

Mx

  • Abx (local guidelines, HAP if >48 hours)
  • Chest physio/mobilisation
  • Good analgesia for deep breathing
98
Q

Post Op Infection - UTI

Ix and Mx

A

Ix

  • Urine dip + MSU/Catheter sample
  • FBC, UEs, LFTs, CRP
  • Cultures if septic

Mx

  • Remove catheter if possible
  • Abx e.g. trimethoprim (get sensitivites)
99
Q

Post Op Infection - Prosthesis

Ix and Mx

A

Ix

  • Joint aspiration (if will not increase infection)
  • FBC, UEs, LFTs, CRP
  • Cultures if septic

Mx

  • Refer ortho for washout
  • Prolonged Abx course
100
Q

Post Op Infection - Peritonitis

Ix and Mx

A

Ix

  • FBC, UEs, LFTs, CRP (serial)
  • Cultures if septic

Mx

  • A to E
  • BUFALO if septic
  • NBM, work up for surgery
101
Q

EBV Ix

A

Blood film
- Lymphocytosis

Bloods

  • FBC: high lymphocytes, >20% atypical
  • LFTs: raised ALT

Monospot antibody test
- False positive in pregnancy, AI disease, Ca

Serology

  • IgM acute infection
  • IgG past infection
102
Q

EBV Mx

A

SUPPORTIVE
- Avoid Amoxicillin - rash

Advice

  • avoid alcohol
  • no contact sports for 3 weeks
103
Q

HAP Ix

A

> 48 hours

Bloods

  • FBC, UEs, LFTs, CRP, glucose
  • Cultures if septic
  • ABG if resp failure

Sputum/urine

  • Culture
  • Legionella antigen

CXR

104
Q

HAP Mx

A

Gentamicin IV + antipseudamonal penicillin

OR

3rd gen cephalosporin

105
Q

Pyrexia of Unknown Origin Mx

A

ONLY IF

  • criteria for culture -ve IE
  • Temporal arteritis with vision loss
  • Disseminated TB or granulomatous infection
106
Q

Iron Deficiency Anaemia Ix

A

FBC

  • Low hb, low MCV
  • low ferritin, low serum iron

High TIBC

If significantly low Hb and no obvious source of bleeding - may need referral to GI

107
Q

Iron Deficiency Anaemia Mx

A

Ferrous Sulphate TDS

  • should increase Hb by 20 in 1 month
  • continue for 3 months to replenish iron stores

SE: abdo pain, black stools, constipation, nausea

108
Q

Acute Transfusion Rxn

  • Common
A

SLOW transfusion, monitor

Febrile

  • Up to 2 Hours After
  • Slow or temp. stop transfusion (if severe)
  • Paracetamol

TACO

  • Within 6 hours, elderly/small pts
  • Stop/slow transfusion
  • Fluid assessment
  • Diuretics/O2 if required

Allergic

  • Immediate
  • Rash, itch, no change in obs
  • Slow tranfusion
  • Anti-histamine (chloramphenamine 10mg IV)
109
Q

Acute Transfusion Rxn

  • Serious
A

MUST STOP THE TRANSFUSION

TRALI

  • Within 2 hours
  • Severe SOB, cough + low BP
  • ICU and O2 Therapy

Bacterial Contamination

  • Immediate
  • More common in platelets
  • High temp, rigors, low BP, low GCS
  • ICU and IV abx

Anaphylaxis

  • Immediate
  • Urticaria, wheeze, stridor
  • Adrenaline 0.5ml 1:1000
110
Q

Septic Arthritis Ix

A

Bloods

  • FBC (high WCC)
  • CRP
  • cultures

Joint aspirate

  • yellow/purulent,
  • high WCC, organisms and +ve culture

Xray
- As baseline

111
Q

Septic Arthritis Mx

A

ABCDE, call senior

REFER ORTHOPAEDICS
- BUFALO if septic 
- High dose abx (post aspirate)
      Flucloxacillin IV (clindamycin if pen. allergy)
      Gram -ve = Cefotaxime IV 
- May need surgical wash out
112
Q

Giant Cell Arteritis Ix

A

Bloods
- ESR++++, CRP
FBC (high platelets, low Hb)

Temporal Artery Biopsy
- within 7 days of starting steroids

113
Q

Giant Cell Arteritis Mx

A 
Prednisolone 60mg/day 
PPI 
Bone protection
- Bisphosphonates is >65 or hx fragility #
- DEXA if <65

STEROID WARNING

  • Do not suddenly stop taking them
  • Double dose if unwell

Usually 2 years of steroids

114
Q

MSCC Ix and Mx

A

Bilateral leg weakness + numbness
Back pain
Urinary/faecal incontinence
UMN signs

Ix

  • MRI whole spine
  • CXR for lung Ca
  • Bloods: FBc, UEs, ESR, B12, LFTs, PSA, serum electrophoresis (myeloma)

Mx

  • ABCDE (senior)
  • Dexamethasone 16mg IV (4mg/hr)
  • Analgesia
  • Refer oncology for radiotherapy
115
Q

Cauda Equina

A

Bilateral leg weakness +/-Back pain
Urinary/faecal incontinence/retention
Saddle anaesthesia, decreased anal tone
LMN signs

Ix

  • MRI whole spine
  • CXR for lung Ca
  • Bloods: FBc, UEs, ESR, B12, LFTs, PSA, serum electrophoresis (myeloma)

Mx

  • ABCDE (senior)
  • Analgesia
  • Refer neurosurgery
116
Q

TACS Classification

A

All of:
1. Motor/sensory deficit in 2 or more of face, arm or leg

  1. Homonymous hemianopia
  2. Higher cortical function
    - Left lesion – language functions affected
    - Right lesion – neglect, apraxia, agnosia
117
Q

PACS Classification

A

Either

2 out of 3 of TACS criteria met

Or

Higher cortical dysfunction alone

Or

Isolated motor deficit not meeting LACS criteria

118
Q

Lacunar Classification (LACS)

A

Motor and/or sensory deficit affecting 2 or more of face, arm, leg

No higher cortical dysfunction or hemianopia (pure sensory/motor)

119
Q

POCS Classification

A

Any of:

Ipsilateral cranial nerve palsy + contralateral motor/sensory deficit

Bilateral motor/sensory deficit

Disordered conjugate eye movement

Cerebellar dysfunction

Isolated hemianopia or cortical blindness

120
Q

Stroke Ix

A

Bloods
- Acute: FBC, U+E, LFT, lipids, glucose, cardiac markers, clotting, G+S

ECG + CXR

CT head – urgent if within thrombolysis window, low GCS, headache, raised ICP or on anticoagulants; otherwise within 24h.

Echo/carotid Doppler/24h ECG – if anterior circulation stroke.

121
Q

Stroke Mx

A

Call for senior help
ABCDE

15 L/min O2 via NRBM
Monitor O2 sats, RR, HR, cardiac trace, temp and BP

Venous access + take bloods

NBM + start IV fluids for hydration
- 0.9% saline at 100ml/h

Examine the patient
– document exact neurological deficits.

Request urgent CT scan ?haemorrhagic
Speak to STROKE CONSULTANT

Consider thrombolysis OR aspirin 300mg PO STAT after CT excludes haemorrhage

Reassess - ABCDE

122
Q

Post Stroke Mx

A

Aspirin 300mg 14 days

Then clopidogrel 75mg for life

123
Q

ABCD2 Score in TIA and Mx

A 
Age >60 =1
BP - HTN = 1
Character: weakness =2, speech =1 
Duration: >60 = 2, 10-59 = 1
Diabetes = 1

> , warfarin or crescendo = 24 hours
<3 = 1 week TIA Clinic

Give Aspirin 300mg

124
Q

TIA Ix

A

ECG

Bloods
- FBC, U+E, LFT, lipids, glucose, cardiac markers, clotting

Carotid doppler
Echo

125
Q

Meningitis LP

A

Viral
- Clear, lymphoctyes, normal glucose, high protein

Bacterial
- Cloudy, neutrophils, low glucose, low protein

TB
- Cloudy, lymphocytes, very low glucose, very high protein

126
Q

Meningitis Bloods

A

FBC, CRP, UEs, glucose, clotting
Cultures

Meningococcal/pneumococcal PCR

127
Q

LP Contraindications

A

Focal neuro signs
Rasied ICP (low HR, High BP, papilloedema)
Shock/instability
Bleeding risk

128
Q

Meningitis Mx

A

ABCDE

Viral
- Supportive e.g. analgesia, fluids, antipyretics,

Bacterial

  • Supportive
  • Ceftriaxone IV (with amox if old/young)
  • Culture for sensitiity
129
Q

Acute Confusional State Causes

A

DELIRIUM

Drugs (withdrawal/toxicity, anticholinergics)/Dehydration

Electrolyte imbalance/Environmental factors

Level of pain

Infection/Inflammation (post surgery)

Respiratory failure (hypoxia, hypercapnia)

Impaction of faeces

Urine retention

Metabolic disorder (liver/renal failure, hypoglycaemia)/Myocardial infarction

130
Q

Delerium Ix

A

Urine Dip/MC+S
Blood glucose
ECG

Bloods:

  • FBC, U&Es, glucose, calcium, Mg, LFTs,
  • TFTs, cardiac enzymes, vitamin B12 levels, - - - syphilis serology, autoantibody screen,
  • PSA,
  • eGFR

Blood cultures/serology

ABG

131
Q

Delerium General Mx

A 
Calming environment 
Rationalise medication 
Hydrate (oral better than IV) 
Monitor bowels/treat constipation 
Frequently re-orientate and reassure 
Do not confront
132
Q

Delerium Medical Mx

A

Haloperidol 0.5mg PO, 1-2 hourly PRN – daily max = 5mg

Caution in prolonged QRS, DLB, Parkinson’s disease or Parkinsonism.

Give Lorazapam 2mg
- Patients with seizures, rec drug intoxication/withdrawal and alcohol withdrawal

133
Q

SAH Ix

A

ECG

  • QT prolongation, Q waves
  • ST elevation

CT head
- blood in basal cisterns

12 hour LP

  • If CT negative
  • look for xanthachromia

Angiography to determine vessel bleeding

134
Q

SAH Initial Mx

A

ABCDE, call senior
Neuro observations
IV Access, bloods
Analgesia

135
Q

SAH Medical Mx

A

Nimodipine

Do not try and lower BP acutely as is a compensatory response to improve brain perfusion

136
Q

SAH Surgical Mx

A

Refer neurosurgeons for endovascular clipping

137
Q

Coronary Artery supplys

A 
Right = Inferior (and AV node)
LAD = Anterior/septal 
Circum = Lateral
138
Q

Status Mx

A

ABCDE, start timer
- Airway: recovery postition, NP airway, O2 15L NRBM

0-10 mins

  • IV Access
  • Bloods (UEs, LFTs, AE levels, Glucose, Ca levels, FBC)

10-30mins

  • Lorazapam 2-4mg IV slowly
  • Fluids
  • CALL SENIOR (bleep anaesthetist)

30-60mins

  • Phenytoin + cardiac monitoring
  • ICU

60-90 mins
- need RSI

139
Q

Dementia Ix

A

Memory Bloods
- FBC, UEs, Ca, Lipids, LFTs, TFs, B12, folate, glucose

CT/MRI head

Other:

  • Syphylis, toxic, HIV screen
  • autoimmune (vasculitis)
  • Copper studies
140
Q

Dementia Social Mx

A

Assess

  • Functional ability
  • Risk to self, others, neglect

Advise

  • Regular routine
  • Carer education and support
  • Social, finacial, care support
141
Q

Alzheimer’s Medical Mx

A

Cholinesterase inhibitors
- Donepizil, rivastigmine

NMDA receptor antiagonist
- Memantine

ALSO:

  • Benzos if agitated
  • SSRIs if depressive
  • Antipsychotic ONLY if psychotic
142
Q

Vascular Dementia Mx

A

Same as AD
Avoid anti-psychotics

Manage CVD risk factors

143
Q

Lewy Body Mx

A

AChE inhibitors

Carer and social support

144
Q

Fronto-temporal Mx

A

No real treatment

145
Q

UMN Lesion

A 
Normal bulk except if disuse atrophy
Increased tone +/- clonus
No fasiculations
Reduced power
Brisk reflexes
Upgoing babinski
146
Q

LMN

A 
Muscle wasting
Decreased tone
Fasiculations present
Reduced Power
Absent reflexes
Normal Babinski
147
Q

Testicular Torsion Mx

A

EMERGENCY - call a senior
Refer urology urgently!

NBM, 
IV Access + Bloods (FBC, UEs, LFTs, CRP, Clotting, Glucose, G+S)
Fluids
Morphine IV 4mg
Cyclazine 50mg IV

Book emergency theatre

148
Q

Ectopic Pregnancy Ix

A

Urine PT

Bloods
- FBC, UEs, LFTs, CRP, Clotting, Glucose, G+S, bHCG

USS
- Free fluid, foetal sac in adnexa

149
Q

Ectopic Pregnancy Mx

A

ABCDE, Call Senior

NBM, IV Access, Bloods
Fluid resus if ruptured
Analgesia, antiemetic

REFER URGENTLY TO GYNAE

150
Q

Acute Asthma Ix

A

O2 Sats, PEFR

CXR/ ABG only if life-threatening or deterioration (as repeat attenders)

151
Q

Severe Asthma

A

Unable to complete sentences
RR >25
HR >110
Peak flow 33-50%

152
Q

Life Threatening Asthma

A

33 92 CHEST

PEFR <33%
O2 sats <92%

Cyanosis
Hypotension
Exhaustion
Silent Chect
Tachycardia

CAN DO ABG to look at CO2

153
Q

Near-Fatal Asthma

A

33 92 CHEST

with high CO2 (exhaustion)

154
Q

Acute Asthma Mx

A

ABCDE, call senior

Sit patient up, 15L O2 NRBM

Salbutamol 5mg Nebuliser
Ipratropium 500mcg Nebs

IV access
- Bloods: FBC, UEs, CRP, Glucose, cultures

Hydrocortisone 200mg IV
SENIOR!!!!
- Magnesium Sulphate 2mg IV

Refer ICU if Life-threatening or above

155
Q

Acute Exacerbation of COPD Ix

A

ECG
- RVH, arrythmia, ischamia

Bloods

  • FBC, UEs, CRP, glucose
  • ABG if worried re. ventilation (T1/T2RF?)

Cultures

  • Bloods
  • Sputum

CXR
- Infection, pneumothorax?

156
Q

Acute Exacerbation of COPD Mx

- Primary Care

A

Prednisolone 30mg Od for 7-14 days
Abx if purulent spurum or consolidation
- Amoxicillin 500mg TDS 7 days

Increase freq of inhalers
Safetynet

157
Q

Acute Exacerbation of COPD Mx

- Secondary Care

A

ABCDE, call senior

Sit pt up,
O2 (15L if moribund, controlled O2 if not)

Salbutamol 5mg Nebuliser
Ipratropium 500mcg Nebs

IV Access, bloods, cultures

  • Hydrocortisone 200mg IV
  • Broad spec abx

Consider NIV if resp. acidosis on controlled O2 therapy

158
Q

Tension Pneumothorax Mx

A

ABCDE! Senior.

Needle decompression, large bore needle into 2nd intercostal space, mid-clavicular line

Then chest drain
Refer resp.

159
Q

Hyperventilation Ix

A

ABG
- May have resp alkalosis due CO2 blow off.

  • Be wary if low bicarb and acidosis, may be hyperventilating to blow CO2 off to compensate for renal failure and loss of HCO3

ECG
CXR: PE/pneumothorax
Toxicology screen

160
Q

Hyperventilation General Mx

A

Rebreathing into paper bag
Relaxation techniques

Propanolol if asthma excluded
Benzo’s last line, if acute/severe.

161
Q

Acute Bronchitis Ix

A

Only if systemicall unwell // pneumonia

162
Q

Acute Bronchitis Mx

A

NO routine abx

  • can have 7 day delayed rx
  • e.g. Amoxicillin 500mg TDS for 5 days

Abx if >80 (with 1 of) or >65 (with 2 of)

  • hospitalisation in past year
  • oral steroids
  • diabetic
  • CCF
163
Q

PE Ix

A

O2 Sats

ECG
- sinus tachy, RBBB, S1Q3T3

Bloods

  • FBC, UEs, LFTs, CRP, Clotting, Troponin
  • D dimer if Wells <4
  • ABG = T1RF

CXR
- Exclude pnuemothorax

164
Q

Well’s in PE

A

<4 unlikely, do d dimer
if +ve = CTPA/anticoag

> 4
+ve = treatment dose LMWH, urgent CTPA

If CTPA -ve = proximal USS

165
Q

CTPA contraindications

A

Allergy to contrast
Renal impairment
Pregnancy

Do V/Q scan instead

166
Q

PE Mx

A

ABCDE, senior

O2 + Iv Access, bloods
Fluid challenge if hypotensive

LMWH e.g. enoxaparin 1.5mg/kg SC
- Unfractionated if eGFR <30

Stabilise before CTPA

167
Q

PE Follow Up Mx

A

Rivaroxaban 20mg

3m provoked, 6m unprovoked

168
Q

CURB-65 Score

A 
Confusion = 1
Urea >7 = 1
RR >30 = 1
BP <90/<60 = 1
Age >65 = 1
169
Q

CURB-65 Mx

A

0-1
Home with oral abx, only admit if no care
Amoxicillin 500mg TDS 7 days

2
Hosp with oral abx 
Amoxicillin 500mg TDS 7 days 
\+ Clarithromycin 500mg 
Sputum culture
Urinary antigen for legionella
3+
Hosp with IV abx
Co-Amoxiclav 1.2g IV 
\+ clarithromycin 500mg IV
Sputum, blood and urine culture
170
Q

Pneumonia Ix

A

Bloods:

  • FBc, UEs, CRP, LFTs,
  • ABG if worried re. ventilation (T1RF)

Curb >2

  • Blood cultures
  • Sputum cultures
  • Urine antigens

CXR

  • Acute: consolidation, air bronchograms
  • 6 weeks post admission to check no underlying malignancy
171
Q

Compartment Syndrome Ix

A

Work up for surgery

  • ECG
  • Bloods: FBC, UEs, LFTs, clotting, G&S, CRP
172
Q

Compartment Syndrome Mx

A

Release/remove cast or dressings down to level of skin

CALL SENIOR, REFER ORTHO
- Need fasciotomy

  • Elevate limb to level of heart
  • Give analgesia
  • Fluids if low BP
173
Q

UTI Ix

A

Urine dip

+ve = treat and MSU

-ve = MSU if child, male, low immune, pregnant or unwell

174
Q

UTI Mx Female

  • Not pregnant
A

Trimethoprim 200mg BD 3 days

Nitrofurantoin 50mg QDS 3 days

Encourage fluids and voiding frequently

If itch/discharge ?STI ? thrush

175
Q

UTI Mx Pregnant

A

Urine Dip and culture at every visit

Rx aysmptomatic +ve urine dip
1st trimester: nitro 7 days
2rd trimester: trimeth 7 days

176
Q

UTI Male

A

Usually due to structural abnormality

Rx for 7 days
Refer urology if prostatitis

177
Q

Acute Pylo Ix

A

Urine dip and MCS

Bloods

  • FBC, UEs, LFTs, CRP, Clotting, Amylase
  • cultures if Septic

USS KUB

178
Q

Acute Pylo Mx

- Primary Care

A

MSU and Abx

Ciprofloxacin 500mg BD 7 days
Check sensitivity

179
Q

Acute Pylo Mx

- Secondary Care needed?

A 
Dehydration, not taking oral fluids
Sepsis
Pregnant
Frail/eldery
No response to Abx after 24hours
180
Q

Acute Pylo Mx

A

BUFALO if septic

  • IV Access, bloods, fluids
  • Analgesia
  • Co-amocivlave 1.2g 14 days

REFER urology

181
Q

Acute Prostatic Obstruction Ix

A

Urine dip + MSU
Bladder scan

Pass a catheter

URGENT MRI If any focal neurology or diminished perianal sensation

182
Q

Acute Prostatic Obstruction Mx

A

Catheter (400-500ml normal)

Fluid balance assessment
- Beware post obstruction diuresis

Treat cause

- FINALS: Presentations (30 decks)

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