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FINALS > "Act" Core Conditions > Flashcards

"Act" Core Conditions Flashcards

Be able to recognise & initiate management in all these conditions as F1. (then call for senior input)

1
Q

The “Act” conditions for haematology are….

A

Iron deficiency anaemia

Acute non-haemolytic reactions during transfusion

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2
Q

State the 4 main haematological investigations.

A

FBC
Blood films
Coagulation screen: PT, APTT, TT, Fibrinogen
Bone marrow aspirate - under LA - Trephine

Also: ferritin, iron studies…

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3
Q

Microcytic hypochromic RBC on blood film has what features on FBC…..?

List the causes of this type of anaemia?

A

Low Hb
Low MCV
Low MCH - pale

Iron def, Thallassaemia, Anaemia of chroninc D, Lead poisoning

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4
Q

Low Hb
Normal MCV
Normal MCH

State the diagnosis and common causes.

A

Normocytic normochromic anaemia

Haemolytic anaemias
Acute blood loss
Renal D
Bone marrow failure
Mixed def
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5
Q

Macrocytic anaemia has a low Hb + high MCV on FBC.

List the common causes.

A 
ALCOHOL*
Chronic liver disease
Folate / B12 def
Myelodysplasia - bone marrow struggling so releasing immature big RBC quickly
Hypothyroid
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6
Q

Which chronic conditions can cause anaemia of chronic disease?

Why might the ferritin be normal or unhelpful and therefore do iron studies?

A

Inflammatory eg IBD, RA..
CKD

Ferritin is acute phase reaction proein in inflam which is often high in these pt

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7
Q

Iron def anaemia is the most common anaemia worldwide.

Which group has the highest incidence?

A

Pre-menopausal women - preg esp if multiple. Mennorhagia

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8
Q

The causes of iron def anaemia can be summarised into 4 catagories…

A
  1. BLOOD LOSS - menorrhagia, GI bleed, malignancy
  2. POOR INTAKE - kids/elderly/alcoholics/special diets
  3. MALABSOPTION - IBD, coeliac, drug interactions, hookworm*
  4. INCREASED DEMAND - preg, children, exfoliative skin D
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9
Q

A 25 y/o F with 3 children complains of tiredness & lethargy. You have exclude other causes and suspect iron deficiency.

What investigations would you do to confirm this diagnosis?

A

FBC - low Hb, low MCV, low MCH

Ferritin - low

Blood film - microcytic hypochromic

+/- Iron studies: serum iron, total iron-beinding capacity (high if def), ferritin

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10
Q

> 65 y/o + unexplained microcytic anaemia +/- ALARM symptoms —> ______________

A

OGD
Colonoscopy

Think CRC

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11
Q

Ferrous suplhate treats iron def anaemia.

What are the SE? When should FBC be repeated?

(Feri-inject if in-patient in GI)

A

SE: constipation, dark stools

Re-test FBC & ferritin after 3 months

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12
Q

What acute non-haemolytic transfusion reactions should I counsel patients about?

A 
Fever
TRALI
TRACO
Anaphylaxis
Transfusion-related infection

Severe reaction: unexplained pain around cannula site, loin pain, sense of impending doom, bone pain, temp >2 degrees higher than baseline, rapid deterioration, shock, collapse.

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13
Q

At what point would you give a blood tranfusion?

A

Hb < 70
Hb < 80 + symptomatic

KNOW WHEN TO ACTIVATE MAJOR HAEMORRHAGE PROTCOL

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14
Q

If pt has B12 & folate def, why do you give B12 1st then folate later?

A

To prevent Subacute combined degeneration of the spinal cord (SACD)

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15
Q

List the “Act” conditions for Cardiology

A 
Cardiac arrest
ACS
Acute LV failure
Chronic heart failure
Postural hypotension
HTN
Complete heart block
Acute limb ischaemia
DVT
Superficial thrombophlebitis
Cannula-related phlebitis
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16
Q

A nurse calls you to an unresponsive patient.

How would you manage this?

A
  1. Confirm if alive or cardiac arrest. DR ABC
  2. Call help + crash team
  3. Start continuous CPR - whilst inserting IGel
  4. Place AED pads on chest - assess rythmn
  5. Insert cannula!!
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17
Q

The shockable rythmns are….?

What treatment do you administer and when?

A

Pulseless VT
VF

After 3rd shock:

  • 1mg IV Adrenaline 1:10,000
  • 300mg IV Amiodarone

Continue CPR/shocks –> Repeat adrenaline every 3-5 mins

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18
Q

If pt has asytole or PEA then it is classified as a _______?

How do you manage this?

A

Unshockable rythmn

Continuous CPR & re-asessing of rythmn

Give Adrenaline IMMEDIATELY

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19
Q

Whilst CPR & medications are being given during a cardiac arrest.

What other measures should be done?

A

Cannula
Think & investigate reversible causes:

4 H’s - fluids, VBG, warm

4 T’s - thrombolysis? decompression. +.- imaging cannulation

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20
Q

A 60 y/o has had a cardiact arrest for 6 mins and is now breathing for himself and has a pulse.

What is the next step?

A

Post-resus ABCDE

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21
Q

In ACS which catagories of pt may have no chest pain?

A

Elderly

Diabetics

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22
Q

ACS = group of symptoms caused by partial or complete occlusion of coronary arteries.

List the typical symptoms

A 
Typical: PULSE
Persistent chest pain +/- radiation to L
Upset stomach - N/V
Light-headed
SOB
Excessive sweating
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23
Q

Is it more likely to have an atypical presentation of a common condition than a common presentation of a rare condition.

What are atypical presentations of ACS?

A 
Epigastric pain
Vommiting
Unresponsive - cardiac arrest
Syncope
Post-op hypotension
Hyperglycaemia
Pulmonary oedema
Stroke
Delirium
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24
Q

What is a type 2 MI?

What is a cardiac wheeze which can be present in ACS?

A

Anaemia

Pulmonary oedema causing a wheeze on auscultation

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25
Q

How would you approach a pt who you suspect is having an MI?

Invstigations?

A

ABCDE

Troponin, ECG

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26
Q

State the ECG changes for each ACS

  1. Unable angina
  2. NSTEMI
  3. STEMI
A
  1. Unstable - ST depression, T wave inversion, normal
  2. NSTEMI - ST depression, T wave inversion
  3. STEMMI - ST elevation (> 1mm in 2+ limb leads OR > 2mm in “+ chest leads). New LBBB
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27
Q

List other causes of raised troponin other than ACS.

When do you repeat it?

A 
Heart strain or damage
Pericarditis, Myocarditis
PE
Heart failure, elderly
Renal failure
Sepsis
AAA
SAH
Rhabdomyalysis

Raises 3-12hrs of onset of CP

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28
Q

The true definition of MI is…?

A

Rise/Fall in troponin + 1 off following:

  • symptoms of ischaemia
  • New ECG changes
  • Imaging showing loss of mycocardium function/ thrombus on angiography
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29
Q

What is the management of ACS?

A

ROMANCE

  • Reassure + OBS
  • +/- Oxygen
  • Morphine IV 2-10mg (titrate to pain) + anti-emetic
  • Aspirin 300mg (crushed)
  • Nitrates (if CP)
  • Clopidogrel 300mg OR Ticagrelor 180mg
  • Fonduparinex - (if NSTEMI give for up to 1w. if STEMMI call to see if give before angio)
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30
Q

After giving the medical mx for ACS - what investigation/ intervention goes the pt need next?

what is the time-frame?

A

Coronary angiography +/- PCI

If STEMMI - do PCI within 2hrs (must have presented within 12hrs onset of CP).
If unable to do PCI within 2hrs then give thrombolysis.
- If successful: PCI within 24hrs
- If unsuccessful: Rescue PCI (or CABG)

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31
Q

The mneumonic for complications of MI is ________

Secondary prevention mneumonic is ____

A

DARTH VADER

CAARBS
Clopidogrel, Atorvastatin, Aspirin, Ramipril, B-Blocker +/- Spironolactone

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32
Q

You cannot drive for 1 month after an MI unless you have definitive rx i.e stent.

True or False?

A

True

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33
Q

Occlusion of RCA can lead to…?

A

Complete heart block - RCA supplies SAN, AVN

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34
Q

Acute LVHF is a medical emergency.

List the causes.

A

Dysfunction: MI
Pressure: HTN (malignant), Aortic stenosis

Valvular HD, Arrythmias, Fluid overload - renal failure, ARDs, Head injury (neurogenic)

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35
Q

You should treat Acute LVHF before investigations.

True or False?

How will they present?

A

True

ACUTE PULMONARY OEDEMA - SOB, orthopnoea, PND, pink frothy sputum

Signs:
Resp distress
Peripheral oedema
Bilateral fine crackles
\+/- Cardiac wheeze
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36
Q

The mneumonic for pulmonary oedema mx is PODAN.

What does it stand for?

After mx - manage underlying cause!

A
  1. Position upright
  2. Oxygen
  3. Diuretic - IV Furosemide 40-80mg slowly
  4. IV Diamorphine - 2.5mg slowly
  5. Anti-emetic
  6. Nitrates - GTN 2 sprays
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37
Q

Whilst managing a pt with pulmonary oedema, which investigations do you want to order?

A

BEDSIDE - treat before investigations
BLOODS - U&Es, ABG, Troponin
IMAGING - CXR, ECG, ECHO

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38
Q

If pulmonary oedema is not-resolving/worsening. What do you do?

A

Give more Furosemide

Call senior –> Consider CPAP, nitrate infusion

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39
Q

LVHF is causes by

  • dysfunction (MI)*
  • pressure: HTN, aortic stenosis.

It presents with Fatigue, SOB, pulmonary oedema symptoms with dullness, bi-basal creps & peripheral oedema

What 4 investigations are needed?

State the mx

A
  1. ECG (if normal then 7% chance of HF - look for signs of IHD/LVH)
  2. BNP (if no previous MI)
  3. ECHO (EF <40%)
  4. CXR

Mx: BAD
B-blockers (deactivate sympathetic response to low CO), ACE-In (deactivate RAS), Diuretics (symptomatic relief)

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40
Q

RVHF can be caused by:

  • dysfunction: MI
  • pressure: pulmonary stenosis, PE
  • others: LVHF, Cor pulmonale etc

The investigations and mx is the same as LVHF.

How does it present?

A

CAW HEAD

Constipation
Anorexia
Weight loss
Hepatosplenomegaly
Oedema
Ascites
Distended neck vein

Urinary frequency

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41
Q

Congestive heart failure is………….

It is managed with LAD:

  • lifestyle modifications - cardiac-rehab, stop smoking / alcohol, vaccines
  • ACE-In
  • Diruetics
A

RVHF + LVHF

SCREEN FOR DEPRESSION

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42
Q

If you suspect HF + previous MI - Do urgent referral to HF team. What will be done and within what time frame?

If no previous MI, what test do you order?

A

ECHO + Cardiology assessment within 2 weeks

BNP - if > 400 then urgent assessment within 2 weeks, otherwise 6 weeks

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43
Q

Which medications are contra-indicated with B-Blockers?

A

Verapimil
Diltiazem

Risk of life-threatening arrythmias..?

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44
Q

If a patient presents with any bradycardia or tachycardia.

What is the first thing to consider?

A

ADVERSE FEATURES:

  • shock
  • syncope
  • heart failure
  • myocardial ischaemia - chest pain
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45
Q

Complete heart block = dissociation between P waves & QRS complexes leading to:

  • Bradycardia
  • Palpitations
  • Syncope
  • Dizzyness
  • SOB

State the causes & mx

A 
Causes:
V- Inferior MI* (RCA occlusion)
M - Aortic stenosis
T - Cardiac trauma (post-op)
I - Idiopathic fibrosis, Digoxin toxicity

Mx: BRADYCARDIA ALGORITHM

  • +/- IV 500mcg Atrophine
  • Definitive: Pace-maker
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46
Q

Bradyarrythmias & Tachyarythmias = peri-arrest.

True or False

A

True

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47
Q

List the types of heart block

= delayed electrical impulses

A

AV heart block*
Bundle branch heart block
Tachybrady syndrome (aka Sick sinus)

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48
Q

Which heart blocks require pacemakers?

What is the difference between Mobitz type 1 and type 2?

A

Mobitz type 2
Complete heart block

Mobitz type 1 = PR interval gets longer and longer then drops QRS.

Mobitz type 2 = PR interval usually normal but some P waves not followed by QRS

49
Q

Postural or orthostatic hypotension is an important differential in someone who collapses.

What investigation is diagnostic for this?

Give the risk factors, what investigations should be done?

A

Lying and standing BP (>20 drop systolic or >10 diastolic)

VOLUME DEPLETION:
Aortic stenosis - ECG
CHF
Dehydration: U&Es

AUTONOMIC NEUROPATHY:
Diabetes - glucose
Elderly, Parkinsons

IATROGENIC:
Diuretics & anti-HTN meds

Preg - preg test

50
Q

How do you manage postural hypotension?

A

Conservative: stand up slowly, salt & fluid intake.

Medical: treat underlying cause. Optimise diabetes control. Fludrocortisone (converts to aldosterone)

51
Q

Acute limb ischaemia = SURGICAL EMERGENCY

Causes:

  • Thrombus (40%)
  • Emboli (38%) - AF, mural, aneurysm
  • Angioplasty occlusion (15%)
  • Trauma

How does it present classically?

What is the mx and how long is there to save the limb?

A

6Ps

  • Pain
  • Pallor
  • Paraesthesia
  • Pulseless
  • Paralysis
  • Perishingly cold

OR Sudden deterioration of PVD

URGENT CALL VASCULAR SURGEON - surgery OR IV heparin infusion

6hrs

52
Q

What injury can occur after revascularisation of a limb?

A

Reperfusion injury –> compartment syndrome

53
Q

When filling a VTE risk assessment, you must ask the patient of risk factors for VTE & for bleeding.

You should always squeeze the calves in the E aspect of ABCDE!

How do you manage a pt with suspected DVT?

A

Bedside - Wells score, measure leg circumference
Bloods - D-Dimer
Imaging - Colour Doppler USS (If 2+ Wells OR +ve D-Dimer)

NOAC for 3m (if provoked)

If unprovoked DVT –> INVESTIGATE MALIGNANCY

54
Q

Superficial thrombophlebitis = inflamm of superficial veins due to blood clot just below surface of skin

It commonly occurs in the legs (also arms, neck)

What is is associated with?
How does it present?

A

Associations: DVT (or mimic), GI Cancers, Clotting disorder, infections

Tender firm hardened/ swollen vein +/- erythema

55
Q

How is superficial thrombophlebitis managed?

A

Investigations:

  • FBC (infection)
  • Colour doppler USS (DVT)

Mx: warm compress + NSAIDs

Resolves in 1-2 weeks

56
Q

Cannula thrombophlebitis = inflam of tunica intima of vein where cannula inserted.

What is the aetiology of the inflam?

How does it present?

What is the mx?

A
  • Mechanical - size too big for vein
  • Chemical - meds
  • Infectious - poor aseptic technique

Warm painful area of skin, erythema +/- tracking, pain during drug administration, difficulty injecting, hardened vein, infusion occlusion
IF SEPTIC - pyrexia, haemodynamic instability

Re-site cannula +/- Septic mx

57
Q

Triggers for an acute asthma attack include infection, cold.

List the different catagories of severity of asthma & their parameters

A

Moderate: Peak flow: 50-75%

Acute severe: Incomplete sentences, accessory muscles, wheeze, HR >110, RR >25. Peak flow: 33-50%

Life-threatening:
SATs <92%
Cyanosis
Reduced GCS
Silent chest
Peak flow < 33%
Normal C02

NEAR-FATAL
Hypercapnoea or on NIV
Hypotension
Arrythmias

58
Q

Exacerbations of asthma are managed through ABCDE.

What is the medical mx?

A

0 SHIT ME

Oxygen
Salbutamol neb - 5mg/20 mins
IV Hyrdocortisone 100 mg OR Oral Prednisolone 40mg (5d)
Ipratropium bromide 500mcg/4-6hrs
Theophylline, MgS04
ESCULATE
59
Q

Sudden deterioration in asthmatic, think ___________

A

Pneumothorax

60
Q

A COPD exacerbation is described as: _____________________

You must decide if pt needs admission: severe SOB, cyanosis, delirium, CXR changes - pneumonia, lives alone)

A

INCREASED AMOUNT OF SPUTUM or
CHANGE TO PURULENT SPUTUM or
INCREASED SOB

(is infective exacerbation even if -ve CXR findings for pneumonia so still give abx)

61
Q

You perform an A-E assessment of 62 y/o man who came in with increased SOB with his COPD.

What investigations & treatment do you give?

A

Investigations: sputum culture +/- blood culture, ABG, CXR

Mx: 0 SHIT
Oxygen - Venturi 24% if C02 retainer
Salbutamol neb 5mg (in air)
Hydrocortisone or Oral Prednisolone 30mg (7d)
Ipratropium bromide 500mcg
Theophylline

Abx: Amoxicillin or Doxycline

62
Q

You repeat an ABG 20 mins then another 20 mins after starting oxygen therapy and treatment for COPD exacerbation.

The patient still has a pH of 7.24.

What is the next step in mx?

A

Call senior - NIV

Indication for NIV (BIPAP) = RESPIRATORY ACIDOSIS (not hypercapnoea)

63
Q

COPD is most commonly caused by smoking.

Diagnosis: > 35 yrs + Spirometry (irreversible obstructive picture)

What is a presentation that can also be a complication of COPD?

A

Cor pulmonale

64
Q

Lobar pneumonia = acute LRTI = infection of the distal airways & alveoli forming inflam exudate –> consolidation

List the typical vs atypical organisms

A

Typical: *Strep. pneumoniae, Moraxella Catarralis, H. Influenzae. S. Aureas

Atypical: Mycoplasma, Klebsiella, Legionella (abroad), Influenza, Fungal, pneumocystis

65
Q

Types of pneumonia include:

  • CAP - 3 usual suspects
  • HAP - MRSA, S.aurea, gram -ve
  • VAP
  • Aspiration
  • Immunocompromised

What scoring system is used for CAP?
How would you manage score 2?

A

CURB-65 + CLINICAL JUDGEMENT!

Score 2 = moderate severity. Hospital admission. IV Abx

66
Q

How can an atypical pneumonia present?

What additional investigations would you if you suspect this or someone has a high CURB-65?

A

Presentation: dry cough + abnormal LFTs, normal/low WCC, diffuse opacification on CXR

Additional:
FBC, U&Es, LFTs
Legionella urinary antigens, sputum culture, resp viral PCR. Serology for mycoplasma, chlamydia, HIV etc

67
Q

When should a CXR be repeated after an episode of pneumonia?

A

6 weeks

68
Q

Pneumothorax = collapse of the lung due to air in the pleural cavity

Presentation: Acute SOB, pleuritic chest pain, deterioration in lung D, asymptomatic!

List the common causes

A

1” = SPONTANEOUS - young/thin male, sub-pleural bullae, trauma, iatrogenic

2” = UNDERLYING PATHOLOGY

  • Lung D - smoker, asthma, COPD, bronchiectasis, malignancy, CF, pneumonia
  • Conn Tissue D - Marfan’s, Enlos-Danlos
69
Q

A 26 y/o male comes to A&E with acute SOB, reduced chest expansion of the left with hypersonance and reduced breath sounds.

How would you manage this pt?

A

Investigations

  • Bloods: ABG
  • Imaging: ECG, CXR

Use pneumothorax algorithm
1”
- < 2cm - discharge + r/v in 4 weeks
- > 2cm - aspirate - if successful then discharge + r/v, if unsuccessful then chest drain

2”

  • < 2cm - admit for OBS or aspirate if 1-2cm
  • > 2cm - chest drain
70
Q

If pneumothorax persists then more air becomes trapped with each inspiration –> pushes mediastinum to contralateral hemithorax –> compress great veins –> risk of arrest.

What is this called?
How may it present?
What is the management?

A

TENSION PNEUMOTHORAX

Presentation: Acute SOB + haemodynamically unstable, Pleuritic chest plain, Collapse, cardiac arrest

Mx: Needle decompression 2ICS-MCL + chest drain

71
Q

Does the trachea deviate towards or away from affected side in a tension pneumothorax?

A

AWAY

air pushing it away

72
Q

The risk factors for PE & DVT are the same.

PE: sudden SOB, hypoxia, pleuritic chest pain, collapse, haemoptysis, cardiac arrest

What score do you use?
What score numbers mean what?

List other +ve findings on investigations for PE

A

PE-Well’s score. PESI
= 4 = LOW RISK - D-Dimer
>4 = HIGH RISK - CTPA

ABG - type 1 RF
ECG - sinus tachycardia, S1Q3T3, new RBBB, new AF
Troponin - elevated (if severe)
CXR - wedge infarct (previous PE)

73
Q

If you suspect PE: TREAT BEFORE YOU INVESTIGATE.

How would you treat it and for how long?

A

If haemodynamically unstable or cardiac arrest - Thrombolysis

If stable: NOAC
(LMWH if known cancer)
- 3m if provoked
- 6m if unprovoked (investigate cause)

74
Q

How long do you have to continue CPR if you give thrombolysis to a pt with PE in cardiac arrest?

A

90 mins

75
Q

Hyperventilation or panic attacks can be distressing & present with:
chest pain, palpitations, SOB, choking sensation, paraesthesia, sweating, fear etc

How would you manage this pt?

A

Exclude sinister causes: ACS, PE, Tachyarrythmia, Anaphylaxis, hypoglycaemia etc

  1. Talking down - explain symptoms, count breaths
  2. Breathing techniques - breath through paperbag
  3. +/- Medication: Propanolol 10mg STAT
76
Q

Acute bronchitis = inflam of the main bronchi often post-URTI.

It is self-limiting. A potential complication is viral pneumonia.

How does it present?
How do you management this pt?

A

Presents: dry cough, SOB, fever, wheeze, flu-like hx

Conservative: paracetamol, fluids
Medical: +/- Salbutamol

Only give Abx if: immunocompromised, systemically unwell, signs or at risk of pneumonia

77
Q

Shock = a state of circulatory failure causing a syndrome of inadequate tissue perfusion leading to abnormal metabolic function

SBP <90. MAP <60. Drop of SBP >40.

List the different types of shock and common causes

A

HYPOVOLAEMIC** - N/V, Diarrhoea, burns, bleeding, pancreatitis

SEPTIC*

ANAPHYLACTIC* - GA, contrast dye, abx, food

OBSTRUCTIVE - Tension pneumothorax, cardiac tamponade

CARDIOGENIC - post-MI, valvular, arrhythmia

NEUROGENIC - stroke, MND, toxins

78
Q

Any shocked pt should have a fluid status assessment.

What would be the signs?

A 
Cold peripheries
Cap refil > 3 secs
Tachycardia
Low BP
Dry mucous membranes
Reduced GCS*
Reduced urine output*
79
Q

Anaphylaxis = sudden-onset generalised immune response to a substance in a sensitised person.

Symptoms usually occurs within 30 mins of exposure or 5 mins if IV

How may it present?

A 
Life-threatening:
A - Stridor, Tongue swelling, Hoarse voice
B - Tachypnoeic, Low SATs, wheeze
C - Shock, pale/ clammy/ drowsy
E - urticarial itchy rash,
80
Q

The intial mx of anaphylaxis in an adult once recognised is:

  1. Call for help
  2. Lie pt flat with legs up
  3. Stop precipitating medication
  4. What next?

How long should they stay in hospital and why?

What test can be done to confirm anaphylaxis?

A
  • IM Adrenaline 0.5mg 1:1000. START TIMER!!!
  • IV 0.9% saline 500ml bolus
  • IM/IV Chloramphenamine 10mg
  • IM/IV Hydrocortisone 200mg

24hrs - bi-phasic reaction common

Mast cell tryptase

81
Q

Once anaphylaxis is confirmed to a medication, it is important to update the drug chart of this new allergy.

How many IM Adrenaline doses can be given before an anaesthetist should be called to give IV Adrenaline?

A

3

82
Q

When does sepsis becomes septic shock?

What volume of fluid is the maximum until escalation to ICU for vasoactive meds should be considered to raised the BP?

A

When persistent shock despite adequate fluid resuscitation

2L

83
Q

Cardiogenic shock = inadequate perfusion due to pump failure from cardiac dysfunction.

The causes can be 1” or 2”.

List the causes.

This pt should be managed in CCU or ICU as theres a high mortality.

A

1”: ACS, Arrhythmias, Aortic dissection, Heart failure, Acute valvular failure, Myocarditis

2”: Cardiac tamponade, Tension pneumothorax, PE

84
Q

Which vasoactive medication:

  1. Increases the HR?
  2. Causes vasoconstriction?
  3. Increases contractility of the heart so increases HR & BP?
A
  1. Chronotropes - Adrenaline
  2. Vasopressors - Noradrenaline
  3. Inotropes
85
Q

List the complications of shock

A

AKI
Brain hypoxia
MODS
Cardiac arrest

86
Q

Signs of respiratory distress include: use of accessory muscles, tripod position, pale, cyanosis/confusion, high or LOW RR.

You should perform a thorough breathing assessment in A-E mx.

List the oxygen devices with their corresponding flow rates.

A

Nasal cannula - 1-4L
Hudson/simple face mask: 5-10L
Venturi - 24%-60% - any C02 retainer
BVM - 21% 02 - need breathing assistance
15L non-re-breath - 85%. Critically unwell
NIV - CPAP - hold alveoli open to reduce WOB, BIPAP - C02 retaining

87
Q

Define type 1 respiratory failure.

It uses the HYPOXIC DRIVE

What are common causes?

It is managed through oxygen therapy +/- CPAP

A

Type 1 RF = P02 < 8 + PC02 < 6 (normal)

Causes: (hypoxia)

  • PE
  • Acute severe asthma exacerbation
  • Infective
  • Pulmonary oedema
  • Upper airway obstruction
88
Q

Type 2 respiratory failure is caused by hypoventilation or poor lung mechanics from chronic lung D

It uses the HYPERCAPNIC DRIVE.

List common causes.

It is managed with oxygen therapy (venturi) +/- BIPAP

A

Hypoventilation

  • Opiates
  • Muscle weakness - MG
  • Low GCS

Poor lung mechanics:

  • COPD ex
  • Near-fatal asthma
  • Chest wall deformity

P02 < 8 + PC02 > 6

89
Q

The next step when NIV fails is ___________

A

Invasive ventilation

Resp failure not responding to other rx or with low GCS. Tiring eg asthma, airway compromise, post-arrest etc.

90
Q

What is the term given to a life-threatening condition developed of non-cardiogenic pulmonary oedema from severe inflamm of acutely damaged alveoli?

Mortality: 1 in 3

A

ARDS = Adult respiratory distress syndrome

Many causes:

  • pneumonia 85%
  • severe chest trauma 14%

Mx: ABCDE –> ICU

91
Q

In order to deliver oxygen adequately you need good cardiac output + good SATs

True or False?

A

True

92
Q

Falls are a common reason for admission of the elderly.

What structure should be used in a falls hx?

A

BEFORE - set scene + adverse symptoms

DURING - LOC, how long

AFTER - recovery, pain, injuries, head, bleeding, stroke, epilepsy symptoms

93
Q

Falls are often multifactorial.

When taking a hx you must ask questions from each of these risk factors.

List the intrinsic vs extrinsic risk factors/ causes of falls.

A

INTRINSIC
- Sinister: ACS, PE, Stroke, cardiac syncope, Arrhythmias, Seizures, AAA, Head injury, Heart block

  • Postural hypotension - DM, PD, Anti-HTN, AS
  • Peripheral neuropathy - DM, Alcohol, B12
  • Joint D - OA, RA, #NOF
  • Balance/gait - ENT, stroke
  • Visual
  • Drugs - opiates, anti-HTN
  • Other: incontinence, infections, cognitive impairment

EXTRINSIC (environment)
- unfamiliar, carpet, uneven, lighting, obstructions

94
Q

Delirium = an acute medical condition with psych symptoms of change in cognitive function / mental state.

List the features of delirium.

What mneumonic is used to think about common causes?

A 
Acute
Reversible
Fluctuating
Inattention
Change in consciousness
Change in mobility / E/D

PINCH ME

95
Q

Differentials of delirium include:

  • Affective D: depression, anxiety, mania
  • Pysch disorders: schizophrenia
  • Substance misuse
  • Organic brain pathology: Head injury, stroke, cancer, dementia
  • Electrolyte imbalance, hypo!

Therefore a top-to-toe examination is needed incl neuro, abdo.

What tests are encompassed in a delirium screen?

A

BEDSIDE: OBS, urinalysis, glucose**

LABS: FBC, U&Es, Mg, Ca, Pi, CRP, Folate/ B12, LFTs, TFTs

IMAGING: ECG, CXR, CT head

Mx: Treat underlying cause using PINCH ME

96
Q

If the pt has hyperactive delirium then do a risk assessment to determine best mx.

Are they at risk or others or staff?

What step-wise approach is there to manage such a pt?

A
  1. Talk to pt calmly. Find connecting point
  2. Talk to team
  3. Psych liaison
  4. Security (restrain)
  5. Anti-psychotic
97
Q

In paracetamol metabolism:
95% metabolised into harmless substance

5% NAPQI - toxic to liver

What substance in the liver mops up the NAPQI?
How long do these stores last?

A

Glutathione

8-24hrs

98
Q

In paracetamol overdose - no symptoms are often seen in < 24hrs.

What symptoms may you see between: 24-72hrs and 72hrs-1 week?

A

24-72hrs

  • RUQ pain
  • N/V

72hrs - 1 weeks

  • jaundice
  • coagulopathy
  • encephalopathy
  • seizures
  • hypoglycaemia
  • death
99
Q

In any overdose hx there needs medical + psych assessments.

The medical assessment should include ____________

A 
What was taken
How much
What time
How obtained
Other substances
PMH - esp liver 
DH
100
Q

List the blood tests need for paracetamol overdose

A

Paracetamol level (at 4hrs+)
LFTs, INR
U&Es, Bicarbonate

101
Q

Parvolex = N-Acetylcysteine = Glutathione is given over how many hours?

You can get a pseudo-allergic reaction

A

21hrs

  • 1 bag in 1hr
  • 1 bag in 4hrs
  • 1 bag in 16hrs
102
Q

What is the mx of each of the following pt with paracetamol overdoses:

  1. Taken overdose 10 hours ago
  2. Take overdose 2 hours ago
  3. Taken staggered overdose
  4. Taken overdose 6hrs ago
A
  1. Treat with Parvolex (8-15hrs). take PT level and continue to stop based on graph
  2. Wait until 4 hours post-overdose to do PT level
  3. Just treat (>15hrs or staggered)
  4. Take PT levels and treat or not according to graph
103
Q

An IVDU presents with drowsiness - GCS 9 and pinpoint pupils.

What would you give them?

A

A-E assessment

IV Naloxone 400 mcg

104
Q

A 56 y/o female presents to A&E with GCS 10 with ECG of sinus tachycardia + wide QRS, metabolic acidosis.

She recently ingested a series of tablets.

What did she take?
What is the treatment?

A

TCA

```
Sodium bicarbonate
activated charcoal if within 1hr
~~~

105
Q

With many substances - tests can be done to detect if they are present in the body using __________

A

Urine dip

106
Q

List the antidotes for the following overdoses:

  • Warfarin
  • Aspirin
  • Benzodiazepines
  • Methanol
  • B-blockers
  • Iron
  • Digoxin
A
  • Prothrombin Complex Concentrate (PCC)
  • Bicarbonate
  • Flumezenil
  • Ethanol
  • Glucagon
  • Desferroxamine
  • Digibinib
107
Q
  1. Which stimulant makes you alert, “on top of the world”, has sympathetic drive & can cause cardiac arrest?
  2. Which opiate makes you feel warm/ sleepy and can progress to resp failure + pin-point pupils?
  3. Which hallucinogen & sedative can give you munchies and makes you feel chilled that you can smoke?
  4. Which substance is used as a GA causing paraesthesia, analgesia, hallucinations and can cause bladder problems?
A
  1. Cocaine
  2. Heroin
  3. Cannabis
  4. Ketamine
108
Q

Smoking is a major risk factor for cancers & other long term illnesses.

List 4 cessation techniques in place.

A
  • NRT - patch/ tablet/ gum/ inhaler/ spray
  • Champix - daily tab for 12w, reduce cravings
  • Bupropion - daily tab
  • E-cigs
109
Q

The recommended limits of alcohol units/wk = 14

When doing an alcohol hx - what screening tools should be used?

A 
4P's - predisposing, precipitating, perpetuating, protective
CAGE - 2+ 
6 signs of dependancy - £+ >12m
Psych risk assessment
AUDIT
110
Q

Alcohol dependence can have bio-psycho-social implications.

List biological complications.

A

Neuro - Seizures, Sleep disturbance, peripheral neuropathies, Delirium tremens
CV - AF
Resp
GI - Malnutrition/ Wernicke’s, PUD, pancreatitis, chronic liver disease / cirrhosis / bleeds
Endocrine - hypo’s

111
Q

Which emergency neurological disorder causes by thiamine def has 3 cardinal features?

Mx: Pabrinex

If untreated 20% die & 80 progress to ________

A

Wernicke’s

  • Delirium
  • Cerebellar dysfunction - DANISH
  • Ocular dysfunction - nystagmus, lateral gaze, ptosis, blurry

Korsakoff’s psychosis: memory loss +confabulations

112
Q

Which emergency can present 1-3 days after the last drink in an alcohol dependant person causing rapid-onset delirium?

How is it managed?

A

Delirium tremens

Symptoms: delirium, disorientation, amnseia, , withdrawal symptoms, lilliput hallucinations

Mx: Chlodiazepoxide + Pabrinex

113
Q

In anyone who is alcohol dependant or malnourished - which bloods are important to do before referring to dietician?

A

Refeeding bloods - K+, Mg, Pi

114
Q

Acute compartment syndrome is life & limb threatening.

It is an acute swelling of tissues in an anatomical compartment after trauma

What are the common causes?

A 
Fracture*
Crush injury*
Cast to limb before swelling stopped
Burns
Angioplasty revascularisation
115
Q

Acute compartment syndrome is a clinical diagnosis.

How does it present?

What is the management?

What would an AKI indicate?

A

SEVERE PAIN - disproportionate to injury, worsening, UNRESPONSIVE TO OPIATES
Red swollen mottling limb
Numbness / Poor pulses
Reduced movement

Mx: Emergency fasciotomy

  • If AKI - tissue necrosis -> rhabdomyolysis
116
Q

Define hypoglycaemia

A

Glucose < 3
Glucose < 4 + symptoms: nausea, sweaty, weakness, visual changes, dizziness, hunger, headache, tremor, drowsy, agitation, collapse, coma

117
Q

If you are called to see a pt with hypoglycaemia, what 5 important questions should you always ask?

A
  1. Are they conscious?
  2. Do they have a safe swallow?
  3. Do they have diabetes?
  4. Are they on insulin?
  5. NEWS
118
Q

How would you manage a pt with hypoglycaemia:

  1. Conscious, safe swallow?
  2. Unconscious, unsafe swallow, reduced GCS?
A
  1. Oral glucose 20g - re-rest glucose in 15 mins X 3
    CALL SENIOR
    Then IV 10% glucose 150mls OR IM 1mg glucagon
  2. IV 10% glucose 150mls OR IM 1mg glucagon.
    CALL SENIOR
    Re-test in 10 mins

Once stabilised carb-rich meal!

FINALS (4 decks)

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