Act Conditions - Management COPY COPY Flashcards
Cardiac Arrest
- When to start CPR?
Patient unresponsive
No resp effort, no central pulse
Get Crash Trolley!
CALL CRASH TEAM!
Cardiac arrest algorithm?
CPR 30:2
- Attach Defib
- Assess Rhythm
Shockable rhythm?
VF or Pulseless VT
1 shock
Resume CPR for 2 mins
Assess Rhythm
Non- Shockable Rhythm
PEA or Aystole
Resume CPR for 2 mins
What to do if ROSC?
A-E approach
Normalise O2, CO2,
12 Lead ECG
Treat cause
Reversible causes (4H 4Ts)
Hypoxia
Hypothermia
Hyper/hypokalaemia
Hypovolaemia
Thrombosis
Tamponade
Toxins
Tension Pneumothorax
Doses in Cardiac Arrest
Adrenaline 1mg IV (10ml of 1:10000)
- repeat in alternate cycles
Amiodarone 300mg IV
- after 3rd shock
ACS Ix
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
ACS Initial Mx
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
ACS Definitive Mx - STEMI
STEMI
- PCI within 12 hours onset
- Consider thrombolysis if cannot get to PCI centre in 120 mins or would not cope with PCI procedure
ACS Definitive Mx - NSTEMI
NSTEMI
- Fondaparinux 2.5mg SC (discuss cardiology)
- TIMI/GRACE score: do they need cardiac catheter?
ACS - Go home on?
ACEi + beta blocker to reduce cardiac remodelling
Aspirin 75mg for life
Ticagrelor 90mg BD for 12 months
Secondary prevention statin e.g. Atorvastatin 80mg
Acute LVF: Ix
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
Acute LVF: A-E?
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
Acute LVF: Mx
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
Acute LVF: Subsequent mx
Rationalise meds Regular blood (UEs as on diuretics) Strict fluid balance +/- catheter Falls bundle DNACPR conversation
HTN Stages and Rx
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
HTN Ix
Cardiovascular Exam
Fundoscopy
Urine dip - proteinuria/haematuria
12 lead ECG
Bloods: UEs, LFTs, FBC, eGR, glucose/HbA1c, lipids
HTN Conservative Mx
Lifestyle
- Stop smoking
- Drink <14 U per week, 2 alcohol free days
- 30 mins exercise 5x week
- Low salt, high veg diet
HTN Medical Mx
<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
CCF Ix
Urine Dip
12 Lead ECG
Bloods
- FBC, UEs, eGFR, TFs, LFts, lipids, HbA1c
- BNP
CXR
ECHO
- transthoracic doppler = diagnostic
CCF Conservative Mx
Lifestyle
- Stop smoking/diet/alcohol
- Graded exercise programme for SOB
CCF Medical Mx
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
DVT Ix
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
DVT Mx
Treatment dose LMWH
- Enoxaparin 1.5mg/kg OD SC
When DVT confirmed, start warfarin
Acute Limb Ischaemia Ix
Doppler - reduced or absent pulse
ABPI <0.5 = critical (<0.9 = arterial disease)
Angiography will show obstruction
Acute Limb Ischaemia Mx
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
Superficial Thrombophlebitis General Mx
- Elastic support of limb
- Elevate leg
- Gentle exercise
Superficial Thrombophlebitis Medical Mx
- Topical analgesia cream
- DVT prophylaxis (LMWH for 1month)
Superficial Thrombophlebitis Surgical Mx
Treat varicose veins if contributing cause
Complete Heart Block Ix
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
Complete Heart Block Initial Mx
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
Complete Heart Block Definitive Mx
Refer cardiology:
Pacemaker!
Postural Hypotension Ix
Urine dip (protein)
Lying and Standing BP (>20/>10 = diagnostic)
ECG to rule out arrhythmia
Blood glucose
Bloods: UEs, FBC, LFTs, TFTs, HbA1c
Postural Hypotension Mx
Review Drugs
Treat cause
Angina Mx
- Sx
- Secondary Prevention
Symptomatic Relief:
- Beta-blocker
- GTN
- Isosorbide/nicorandil if cannot tolerate the above
Secondary Prevention
- Aspirin 75mg
- Atorvastatin 80mg
- ACEi if diabetic/hypertensive
Otitis Media Mx
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
Otitis Media: Who needs abx?
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
Otitis Media: What abx?
Amoxicillin or Erythromycin
Tonsillitis: Centor Score
Exudate
Absence of cough
Cervical lymphadenopathy
Temperature
3+/4 = likely strep throat
0 of 4 = 80% not strep
Tonsillitis Conservative Mx
Regular Paracetamol and Ibuprofen
Mouthwash // numbing throat spray
Tonsillitis Medical Mx
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
Tonsillitis Surgical Mx
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
Anaphylaxis - Initial Mx
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
Anaphylaxis - Subsequent Mx
Hydrocortisone 200mg IV
Chlorphenamine 10mg IV
Salbutamol 5mg Neb (with O2)
- If wheeze
Sepsis - BUFALO
Within 1st hour
Blood cultures (pre-abx) Urine output Fluids Abx (broad spec) Lactate Oxygen 15L NRBM
Sepsis Ix
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
Sepsis Initial Mx
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)
Cardiogenic Shock Ix
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
Cardiogenic Mx
Work out if
Pump failure:
- LV dysfunction (post MI), aortic dissection, arrhythmia
Inadequate filling:
- PE/pneumothorax
- Cardiac tamponade
Treat cause
Hypovolaemic Shock
- Haemorrhagic Causes
Trauma
- Internal or external bleeding
Ruptured AAA
GI Bleed
Hypovolaemic Shock
- Non-Haemorrhagic Causes
Salt and water loss
- D&V, burns, polyuria, DKA
3rd Space loss
- CCF, acute pancreatitis, ascites
Hypovolaemic Shock
- Haemorrhagic Mx
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
Hypovolaemic Shock
- Non-Haemorrhagic Mx
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
Acute Resp Failure Ix
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
T1 RF Mx
Unrestricted O2 therapy to maintain sats > 94%
Check ABG after 20 mins to insure PaO2 improving and no rise in PaCO2
T2 RF Mx
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
PCM Overdose Ix
ABG: if pH <7.3 post fluid resus = bad sign
Bloods:
- FBCs, LFTs, UEs, BM, Clotting (PT)
- Paracetamol levels after 4 hours
PCM Overdose Mx
<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
PCM Overdose Doses
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.
Hypoglycaemia Ix
BM <4
UEs, C-peptide
Hypoglycaemia Initial Mx
- Conscious?
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
Hypoglycaemia Initial Mx
- Unconsicous?
ABCDE assessment
1mg Glucagon IM
OR
75ml of 20% glucose IV
Rpt BM after 10 mins
Hypoglycaemia: Subsequent Mx
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
DKA Ix
BM >11.1
Ketones >0.3 (blood) or ++ (urine)
pH <7.3 or bicarb <15
VBG
- low pH, low CO2 (comp), low Bicarb
DKA Mx
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
DKA Fluids
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
DKA: Insulin and monitoring
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
DKA: Monitoring
- Glucose and ketones 1 hourly
- venous pH/bicarb, K+ @ 60 mins, then 2 hourly
Hyperkalaemia: When to treat?
TREAT IF K+ >7 OR ECG CHANGES
Hyperkalaemia: Ix?
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)
Hyperkalaemia Initial Mx
ABCDE, 15L O2 NRBM,
ECG monitoring on defib
- If sine wave/VF = crash call
IV access, bloods, VBG
Treat
Hyperkalaemia Medica Mx
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+
Acute Angle Closure Glaucoma Mx
URGENT referral to opthalmology
Acute Angle Closure Glaucoma
Medical Mx
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
Acute Angle Closure Glaucoma
Definitive Mx
Peripheral Iridectomy
GI Bleed Ix
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
Upper GI Bleed: Score
Glasgow Blatchford
- Do they need endoscopy?
- Used in A+E to discharge patients
- Score 0-1 = OGD endoscopy
Rockall
- Post endoscopy w/ diagnosis
Upper GI Bleed Mx
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
Upper GI Bleed Medical Mx
- Ulcer v Varices
Ulcer:
- IV PPI post endoscopy
- 8mg/hr Omeprazole
Variceal bleed
- Terlipressin, can be given in A+E
Upper GI Bleed Mx
- Post endoscopy
NBM for 24 hours
Repeat FBC after 6 hours, transfuse if required.
Check obs hourly
Follow up OGD after 8 eeks
Constipation Ix
Elderly
- Flexi sig/barium enema post treatment
Cancer or diverticular disease
- Bloods: FBC, UEs, LFTs, Ca2+, glucose
Review Meds
Constipation Conservative Mx
Drink more fluids Reassure Increase fruit and veg in diet Gentle exercise Behavioural e.g. gastrocolic reflex, stool
Laxatives
- Bulk forming
- Fybogel
Take with loads of fluids to increase peristalsis
Laxatives
- Softeners
Liquid paraffin, docusate
Good for painful anal conditions
Laxatives
- Osmotic
Lactulose
Retain fluid in bowel
Laxatives
- Combination
Movicol
- Osmotic and stimulant
Docusate/co-danthromer (terminally ill only)
- Softening and stimulant
Laxatives
- Stimulant
Senna
- Increase intestinal motiliyu
- Avoid in obstruction
Constipation: Late Mx
Phosphate enema
MDT approach
Diarrhoea Bloods Ix
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
Diarrhoea Ix
Bloods
Stool - if infective cause MC&S
Colonoscopy (with biopsy)
- Cancer
- IBD
Diarrhoea General Mx
Treat cause
WORK:
- with food: avoid until stool sample negative - hospital: 48 hours clear of sx
- ISOLATE PATIENTS
Diarrhoea Rehydration Mx
Oral better than IV
- Fruit juice and salty soup, ORS in children
- NaCl with 20 mmol K+
Diarrhoea Antimotility Drugs
Codeine 30mg or Loperamide 2mg
Avoid in colitis or children
C Diff Mx
SIGHT
- suspect, isolate, gloves and apron, hand hygiene, test
Stop causative abx
Test stool sample
Rx Metronidazole 14 days if sx severe
Post Op Infection - Wound
Ix and Mx
Ix
- Wound swab + culture
- FBC, UEs, CRP
- Cultures if septic
Rx
- Release pus if collection
- Flucloxacillin for SA, rx from culture
Post Op Infection - Chest
Ix and Mx
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
Post Op Infection - UTI
Ix and Mx
Ix
- Urine dip + MSU/Catheter sample
- FBC, UEs, LFTs, CRP
- Cultures if septic
Mx
- Remove catheter if possible
- Abx e.g. trimethoprim (get sensitivites)
Post Op Infection - Prosthesis
Ix and Mx
Ix
- Joint aspiration (if will not increase infection)
- FBC, UEs, LFTs, CRP
- Cultures if septic
Mx
- Refer ortho for washout
- Prolonged Abx course
Post Op Infection - Peritonitis
Ix and Mx
Ix
- FBC, UEs, LFTs, CRP (serial)
- Cultures if septic
Mx
- A to E
- BUFALO if septic
- NBM, work up for surgery
EBV Ix
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
EBV Mx
SUPPORTIVE
- Avoid Amoxicillin - rash
Advice
- avoid alcohol
- no contact sports for 3 weeks
HAP Ix
> 48 hours
Bloods
- FBC, UEs, LFTs, CRP, glucose
- Cultures if septic
- ABG if resp failure
Sputum/urine
- Culture
- Legionella antigen
CXR
HAP Mx
Gentamicin IV + antipseudamonal penicillin
OR
3rd gen cephalosporin
Pyrexia of Unknown Origin Mx
ONLY IF
- criteria for culture -ve IE
- Temporal arteritis with vision loss
- Disseminated TB or granulomatous infection
Iron Deficiency Anaemia Ix
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
Iron Deficiency Anaemia Mx
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
Acute Transfusion Rxn
- Common
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)
Acute Transfusion Rxn
- Serious
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
Septic Arthritis Ix
Bloods
- FBC (high WCC)
- CRP
- cultures
Joint aspirate
- yellow/purulent,
- high WCC, organisms and +ve culture
Xray
- As baseline
Septic Arthritis Mx
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
Giant Cell Arteritis Ix
Bloods
- ESR++++, CRP
FBC (high platelets, low Hb)
Temporal Artery Biopsy
- within 7 days of starting steroids
Giant Cell Arteritis Mx
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
MSCC Ix and Mx
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
Cauda Equina
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
TACS Classification
All of:
1. Motor/sensory deficit in 2 or more of face, arm or leg
- Homonymous hemianopia
- Higher cortical function
- Left lesion – language functions affected
- Right lesion – neglect, apraxia, agnosia
PACS Classification
Either
2 out of 3 of TACS criteria met
Or
Higher cortical dysfunction alone
Or
Isolated motor deficit not meeting LACS criteria
Lacunar Classification (LACS)
Motor and/or sensory deficit affecting 2 or more of face, arm, leg
No higher cortical dysfunction or hemianopia (pure sensory/motor)
POCS Classification
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
Stroke Ix
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.
Stroke Mx
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
Post Stroke Mx
Aspirin 300mg 14 days
Then clopidogrel 75mg for life
ABCD2 Score in TIA and Mx
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
TIA Ix
ECG
Bloods
- FBC, U+E, LFT, lipids, glucose, cardiac markers, clotting
Carotid doppler
Echo
Meningitis LP
Viral
- Clear, lymphoctyes, normal glucose, high protein
Bacterial
- Cloudy, neutrophils, low glucose, low protein
TB
- Cloudy, lymphocytes, very low glucose, very high protein
Meningitis Bloods
FBC, CRP, UEs, glucose, clotting
Cultures
Meningococcal/pneumococcal PCR
LP Contraindications
Focal neuro signs
Rasied ICP (low HR, High BP, papilloedema)
Shock/instability
Bleeding risk
Meningitis Mx
ABCDE
Viral
- Supportive e.g. analgesia, fluids, antipyretics,
Bacterial
- Supportive
- Ceftriaxone IV (with amox if old/young)
- Culture for sensitiity
Acute Confusional State Causes
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
Delerium Ix
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
Delerium General Mx
Calming environment Rationalise medication Hydrate (oral better than IV) Monitor bowels/treat constipation Frequently re-orientate and reassure Do not confront
Delerium Medical Mx
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
SAH Ix
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
SAH Initial Mx
ABCDE, call senior
Neuro observations
IV Access, bloods
Analgesia
SAH Medical Mx
Nimodipine
Do not try and lower BP acutely as is a compensatory response to improve brain perfusion
SAH Surgical Mx
Refer neurosurgeons for endovascular clipping
Coronary Artery supplys
Right = Inferior (and AV node) LAD = Anterior/septal Circum = Lateral
Status Mx
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
Dementia Ix
Memory Bloods
- FBC, UEs, Ca, Lipids, LFTs, TFs, B12, folate, glucose
CT/MRI head
Other:
- Syphylis, toxic, HIV screen
- autoimmune (vasculitis)
- Copper studies
Dementia Social Mx
Assess
- Functional ability
- Risk to self, others, neglect
Advise
- Regular routine
- Carer education and support
- Social, finacial, care support
Alzheimer’s Medical Mx
Cholinesterase inhibitors
- Donepizil, rivastigmine
NMDA receptor antiagonist
- Memantine
ALSO:
- Benzos if agitated
- SSRIs if depressive
- Antipsychotic ONLY if psychotic
Vascular Dementia Mx
Same as AD
Avoid anti-psychotics
Manage CVD risk factors
Lewy Body Mx
AChE inhibitors
Carer and social support
Fronto-temporal Mx
No real treatment
UMN Lesion
Normal bulk except if disuse atrophy Increased tone +/- clonus No fasiculations Reduced power Brisk reflexes Upgoing babinski
LMN
Muscle wasting Decreased tone Fasiculations present Reduced Power Absent reflexes Normal Babinski
Testicular Torsion Mx
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
Ectopic Pregnancy Ix
Urine PT
Bloods
- FBC, UEs, LFTs, CRP, Clotting, Glucose, G+S, bHCG
USS
- Free fluid, foetal sac in adnexa
Ectopic Pregnancy Mx
ABCDE, Call Senior
NBM, IV Access, Bloods
Fluid resus if ruptured
Analgesia, antiemetic
REFER URGENTLY TO GYNAE
Acute Asthma Ix
O2 Sats, PEFR
CXR/ ABG only if life-threatening or deterioration (as repeat attenders)
Severe Asthma
Unable to complete sentences
RR >25
HR >110
Peak flow 33-50%
Life Threatening Asthma
33 92 CHEST
PEFR <33%
O2 sats <92%
Cyanosis Hypotension Exhaustion Silent Chect Tachycardia
CAN DO ABG to look at CO2
Near-Fatal Asthma
33 92 CHEST
with high CO2 (exhaustion)
Acute Asthma Mx
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
Acute Exacerbation of COPD Ix
ECG
- RVH, arrythmia, ischamia
Bloods
- FBC, UEs, CRP, glucose
- ABG if worried re. ventilation (T1/T2RF?)
Cultures
- Bloods
- Sputum
CXR
- Infection, pneumothorax?
Acute Exacerbation of COPD Mx
- Primary Care
Prednisolone 30mg Od for 7-14 days
Abx if purulent spurum or consolidation
- Amoxicillin 500mg TDS 7 days
Increase freq of inhalers
Safetynet
Acute Exacerbation of COPD Mx
- Secondary Care
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
Tension Pneumothorax Mx
ABCDE! Senior.
Needle decompression, large bore needle into 2nd intercostal space, mid-clavicular line
Then chest drain
Refer resp.
Hyperventilation Ix
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
Hyperventilation General Mx
Rebreathing into paper bag
Relaxation techniques
Propanolol if asthma excluded
Benzo’s last line, if acute/severe.
Acute Bronchitis Ix
Only if systemicall unwell // pneumonia
Acute Bronchitis Mx
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
PE Ix
O2 Sats
ECG
- sinus tachy, RBBB, S1Q3T3
Bloods
- FBC, UEs, LFTs, CRP, Clotting, Troponin
- D dimer if Wells <4
- ABG = T1RF
CXR
- Exclude pnuemothorax
Well’s in PE
<4 unlikely, do d dimer
if +ve = CTPA/anticoag
> 4
+ve = treatment dose LMWH, urgent CTPA
If CTPA -ve = proximal USS
CTPA contraindications
Allergy to contrast
Renal impairment
Pregnancy
Do V/Q scan instead
PE Mx
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
PE Follow Up Mx
Rivaroxaban 20mg
3m provoked, 6m unprovoked
CURB-65 Score
Confusion = 1 Urea >7 = 1 RR >30 = 1 BP <90/<60 = 1 Age >65 = 1
CURB-65 Mx
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
Pneumonia Ix
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
Compartment Syndrome Ix
Work up for surgery
- ECG
- Bloods: FBC, UEs, LFTs, clotting, G&S, CRP
Compartment Syndrome Mx
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
UTI Ix
Urine dip
+ve = treat and MSU
-ve = MSU if child, male, low immune, pregnant or unwell
UTI Mx Female
- Not pregnant
Trimethoprim 200mg BD 3 days
Nitrofurantoin 50mg QDS 3 days
Encourage fluids and voiding frequently
If itch/discharge ?STI ? thrush
UTI Mx Pregnant
Urine Dip and culture at every visit
Rx aysmptomatic +ve urine dip
1st trimester: nitro 7 days
2rd trimester: trimeth 7 days
UTI Male
Usually due to structural abnormality
Rx for 7 days
Refer urology if prostatitis
Acute Pylo Ix
Urine dip and MCS
Bloods
- FBC, UEs, LFTs, CRP, Clotting, Amylase
- cultures if Septic
USS KUB
Acute Pylo Mx
- Primary Care
MSU and Abx
Ciprofloxacin 500mg BD 7 days
Check sensitivity
Acute Pylo Mx
- Secondary Care needed?
Dehydration, not taking oral fluids Sepsis Pregnant Frail/eldery No response to Abx after 24hours
Acute Pylo Mx
BUFALO if septic
- IV Access, bloods, fluids
- Analgesia
- Co-amocivlave 1.2g 14 days
REFER urology
Acute Prostatic Obstruction Ix
Urine dip + MSU
Bladder scan
Pass a catheter
URGENT MRI If any focal neurology or diminished perianal sensation
Acute Prostatic Obstruction Mx
Catheter (400-500ml normal)
Fluid balance assessment
- Beware post obstruction diuresis
Treat cause
