"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
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…
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
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
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
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
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
8
Q
The causes of iron def anaemia can be summarised into 4 catagories…
A
- BLOOD LOSS - menorrhagia, GI bleed, malignancy
- POOR INTAKE - kids/elderly/alcoholics/special diets
- MALABSOPTION - IBD, coeliac, drug interactions, hookworm*
- INCREASED DEMAND - preg, children, exfoliative skin D
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
10
Q
> 65 y/o + unexplained microcytic anaemia +/- ALARM symptoms —> ______________
A
OGD
Colonoscopy
Think CRC
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
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.
13
Q
At what point would you give a blood tranfusion?
A
Hb < 70
Hb < 80 + symptomatic
KNOW WHEN TO ACTIVATE MAJOR HAEMORRHAGE PROTCOL
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)
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
16
Q
A nurse calls you to an unresponsive patient.
How would you manage this?
A
- Confirm if alive or cardiac arrest. DR ABC
- Call help + crash team
- Start continuous CPR - whilst inserting IGel
- Place AED pads on chest - assess rythmn
- Insert cannula!!
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
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
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
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
21
Q
In ACS which catagories of pt may have no chest pain?
A
Elderly
Diabetics
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
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
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
25
How would you approach a pt who you suspect is having an MI?
Invstigations?
ABCDE
Troponin, ECG
26
State the ECG changes for each ACS
1. Unable angina
2. NSTEMI
3. STEMI
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
27
List other causes of raised troponin other than ACS.
When do you repeat it?
```
Heart strain or damage
Pericarditis, Myocarditis
PE
Heart failure, elderly
Renal failure
Sepsis
AAA
SAH
Rhabdomyalysis
```
Raises 3-12hrs of onset of CP
28
The true definition of MI is...?
Rise/Fall in troponin + 1 off following:
- symptoms of ischaemia
- New ECG changes
- Imaging showing loss of mycocardium function/ thrombus on angiography
29
What is the management of ACS?
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)
30
After giving the medical mx for ACS - what investigation/ intervention goes the pt need next?
what is the time-frame?
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)
31
The mneumonic for complications of MI is ________
Secondary prevention mneumonic is ____
DA*RTH* VADER
CAARBS
Clopidogrel, Atorvastatin, Aspirin, Ramipril, B-Blocker +/- Spironolactone
32
You cannot drive for 1 month after an MI unless you have definitive rx i.e stent.
True or False?
True
33
Occlusion of RCA can lead to...?
Complete heart block - RCA supplies SAN, AVN
34
Acute LVHF is a medical emergency.
List the causes.
Dysfunction: MI
Pressure: HTN (malignant), Aortic stenosis
Valvular HD, Arrythmias, Fluid overload - renal failure, ARDs, Head injury (neurogenic)
35
You should treat Acute LVHF before investigations.
True or False?
How will they present?
True
ACUTE PULMONARY OEDEMA - SOB, orthopnoea, PND, pink frothy sputum
```
Signs:
Resp distress
Peripheral oedema
Bilateral fine crackles
+/- Cardiac wheeze
```
36
The mneumonic for pulmonary oedema mx is PODAN.
What does it stand for?
After mx - manage underlying cause!
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
37
Whilst managing a pt with pulmonary oedema, which investigations do you want to order?
BEDSIDE - treat before investigations
BLOODS - U&Es, ABG, Troponin
IMAGING - CXR, ECG, ECHO
38
If pulmonary oedema is not-resolving/worsening. What do you do?
Give more Furosemide
| Call senior --> Consider CPAP, nitrate infusion
39
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
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)
40
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?
CAW HEAD
```
Constipation
Anorexia
Weight loss
Hepatosplenomegaly
Oedema
Ascites
Distended neck vein
```
Urinary frequency
41
Congestive heart failure is.............
It is managed with LAD:
- lifestyle modifications - cardiac-rehab, stop smoking / alcohol, vaccines
- ACE-In
- Diruetics
RVHF + LVHF
SCREEN FOR DEPRESSION
42
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?
ECHO + Cardiology assessment within 2 weeks
BNP - if > 400 then urgent assessment within 2 weeks, otherwise 6 weeks
43
Which medications are contra-indicated with B-Blockers?
Verapimil
Diltiazem
Risk of life-threatening arrythmias..?
44
If a patient presents with any bradycardia or tachycardia.
What is the first thing to consider?
ADVERSE FEATURES:
- shock
- syncope
- heart failure
- myocardial ischaemia - chest pain
45
Complete heart block = dissociation between P waves & QRS complexes leading to:
- Bradycardia
- Palpitations
- Syncope
- Dizzyness
- SOB
State the causes & mx
```
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
46
Bradyarrythmias & Tachyarythmias = peri-arrest.
True or False
True
47
List the types of heart block
| = delayed electrical impulses
AV heart block*
Bundle branch heart block
Tachybrady syndrome (aka Sick sinus)
48
Which heart blocks require pacemakers?
What is the difference between Mobitz type 1 and type 2?
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
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?
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
How do you manage postural hypotension?
Conservative: stand up slowly, salt & fluid intake.
Medical: treat underlying cause. Optimise diabetes control. Fludrocortisone (converts to aldosterone)
51
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?
6Ps
- Pain
- Pallor
- Paraesthesia
- Pulseless
- Paralysis
- Perishingly cold
OR Sudden deterioration of PVD
URGENT CALL VASCULAR SURGEON - surgery OR IV heparin infusion
6hrs
52
What injury can occur after revascularisation of a limb?
Reperfusion injury --> compartment syndrome
53
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?
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
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?
Associations: DVT (or mimic), GI Cancers, Clotting disorder, infections
Tender firm hardened/ swollen vein +/- erythema
55
How is superficial thrombophlebitis managed?
Investigations:
- FBC (infection)
- Colour doppler USS (DVT)
Mx: warm compress + NSAIDs
Resolves in 1-2 weeks
56
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?
- 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
Triggers for an acute asthma attack include infection, cold.
List the different catagories of severity of asthma & their parameters
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
Exacerbations of asthma are managed through ABCDE.
What is the medical mx?
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
Sudden deterioration in asthmatic, think ___________
Pneumothorax
60
A COPD exacerbation is described as: _____________________
You must decide if pt needs admission: severe SOB, cyanosis, delirium, CXR changes - pneumonia, lives alone)
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
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?
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
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?
Call senior - NIV
Indication for NIV (BIPAP) = RESPIRATORY ACIDOSIS (not hypercapnoea)
63
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?
Cor pulmonale
64
Lobar pneumonia = acute LRTI = infection of the distal airways & alveoli forming inflam exudate --> consolidation
List the typical vs atypical organisms
Typical: *Strep. pneumoniae, Moraxella Catarralis, H. Influenzae. S. Aureas
Atypical: Mycoplasma, Klebsiella, Legionella (abroad), Influenza, Fungal, pneumocystis
65
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?
CURB-65 + CLINICAL JUDGEMENT!
Score 2 = moderate severity. Hospital admission. IV Abx
66
How can an atypical pneumonia present?
What additional investigations would you if you suspect this or someone has a high CURB-65?
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
When should a CXR be repeated after an episode of pneumonia?
6 weeks
68
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
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
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?
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
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?
TENSION PNEUMOTHORAX
Presentation: Acute SOB + haemodynamically unstable, Pleuritic chest plain, Collapse, cardiac arrest
Mx: Needle decompression 2ICS-MCL + chest drain
71
Does the trachea deviate towards or away from affected side in a tension pneumothorax?
AWAY
| air pushing it away
72
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
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
If you suspect PE: TREAT BEFORE YOU INVESTIGATE.
How would you treat it and for how long?
If haemodynamically unstable or cardiac arrest - Thrombolysis
If stable: NOAC
(LMWH if known cancer)
- 3m if provoked
- 6m if unprovoked (investigate cause)
74
How long do you have to continue CPR if you give thrombolysis to a pt with PE in cardiac arrest?
90 mins
75
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?
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
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?
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
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
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
Any shocked pt should have a fluid status assessment.
What would be the signs?
```
Cold peripheries
Cap refil > 3 secs
Tachycardia
Low BP
Dry mucous membranes
Reduced GCS*
Reduced urine output*
```
79
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?
```
Life-threatening:
A - Stridor, Tongue swelling, Hoarse voice
B - Tachypnoeic, Low SATs, wheeze
C - Shock, pale/ clammy/ drowsy
E - urticarial itchy rash,
```
80
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?
- 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
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?
3
82
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?
When persistent shock despite adequate fluid resuscitation
2L
83
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.
1": ACS, Arrhythmias, Aortic dissection, Heart failure, Acute valvular failure, Myocarditis
2": Cardiac tamponade, Tension pneumothorax, PE
84
Which vasoactive medication:
1. Increases the HR?
2. Causes vasoconstriction?
3. Increases contractility of the heart so increases HR & BP?
1. Chronotropes - Adrenaline
2. Vasopressors - Noradrenaline
3. Inotropes
85
List the complications of shock
AKI
Brain hypoxia
MODS
Cardiac arrest
86
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.
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
# Define type 1 respiratory failure.
It uses the HYPOXIC DRIVE
What are common causes?
It is managed through oxygen therapy +/- CPAP
Type 1 RF = P02 < 8 + PC02 < 6 (normal)
Causes: (hypoxia)
- PE
- Acute severe asthma exacerbation
- Infective
- Pulmonary oedema
- Upper airway obstruction
88
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
Hypoventilation
- Opiates
- Muscle weakness - MG
- Low GCS
Poor lung mechanics:
- COPD ex
- Near-fatal asthma
- Chest wall deformity
P02 < 8 + PC02 > 6
89
The next step when NIV fails is ___________
Invasive ventilation
Resp failure not responding to other rx or with low GCS. Tiring eg asthma, airway compromise, post-arrest etc.
90
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
ARDS = Adult respiratory distress syndrome
Many causes:
- pneumonia 85%
- severe chest trauma 14%
Mx: ABCDE --> ICU
91
In order to deliver oxygen adequately you need good cardiac output + good SATs
True or False?
True
92
Falls are a common reason for admission of the elderly.
What structure should be used in a falls hx?
BEFORE - set scene + adverse symptoms
DURING - LOC, how long
AFTER - recovery, pain, injuries, head, bleeding, stroke, epilepsy symptoms
93
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.
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
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?
```
Acute
Reversible
Fluctuating
Inattention
Change in consciousness
Change in mobility / E/D
```
PINCH ME
95
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?
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
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?
1. Talk to pt calmly. Find connecting point
2. Talk to team
3. Psych liaison
4. Security (restrain)
5. Anti-psychotic
97
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?
Glutathione
8-24hrs
98
In paracetamol overdose - no symptoms are often seen in < 24hrs.
What symptoms may you see between: 24-72hrs and 72hrs-1 week?
24-72hrs
- RUQ pain
- N/V
72hrs - 1 weeks
- jaundice
- coagulopathy
- encephalopathy
- seizures
- hypoglycaemia
- death
99
In any overdose hx there needs medical + psych assessments.
The medical assessment should include ____________
```
What was taken
How much
What time
How obtained
Other substances
PMH - esp liver
DH
```
100
List the blood tests need for paracetamol overdose
Paracetamol level (at 4hrs+)
LFTs, INR
U&Es, Bicarbonate
101
Parvolex = N-Acetylcysteine = Glutathione is given over how many hours?
You can get a pseudo-allergic reaction
21hrs
- 1 bag in 1hr
- 1 bag in 4hrs
- 1 bag in 16hrs
102
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
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
An IVDU presents with drowsiness - GCS 9 and pinpoint pupils.
What would you give them?
A-E assessment
IV Naloxone 400 mcg
104
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?
TCA
| ```
Sodium bicarbonate
activated charcoal if within 1hr
```
105
With many substances - tests can be done to detect if they are present in the body using __________
Urine dip
106
List the antidotes for the following overdoses:
- Warfarin
- Aspirin
- Benzodiazepines
- Methanol
- B-blockers
- Iron
- Digoxin
- Prothrombin Complex Concentrate (PCC)
- Bicarbonate
- Flumezenil
- Ethanol
- Glucagon
- Desferroxamine
- Digibinib
107
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?
1. Cocaine
2. Heroin
3. Cannabis
4. Ketamine
108
Smoking is a major risk factor for cancers & other long term illnesses.
List 4 cessation techniques in place.
- NRT - patch/ tablet/ gum/ inhaler/ spray
- Champix - daily tab for 12w, reduce cravings
- Bupropion - daily tab
- E-cigs
109
The recommended limits of alcohol units/wk = 14
When doing an alcohol hx - what screening tools should be used?
```
4P's - predisposing, precipitating, perpetuating, protective
CAGE - 2+
6 signs of dependancy - £+ >12m
Psych risk assessment
AUDIT
```
110
Alcohol dependence can have bio-psycho-social implications.
List biological complications.
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
Which emergency neurological disorder causes by thiamine def has 3 cardinal features?
Mx: Pabrinex
If untreated 20% die & 80 progress to ________
Wernicke's
- Delirium
- Cerebellar dysfunction - DANISH
- Ocular dysfunction - nystagmus, lateral gaze, ptosis, blurry
Korsakoff's psychosis: memory loss +confabulations
112
Which emergency can present 1-3 days after the last drink in an alcohol dependant person causing rapid-onset delirium?
How is it managed?
Delirium tremens
Symptoms: delirium, disorientation, amnseia, , withdrawal symptoms, lilliput hallucinations
Mx: Chlodiazepoxide + Pabrinex
113
In anyone who is alcohol dependant or malnourished - which bloods are important to do before referring to dietician?
Refeeding bloods - K+, Mg, Pi
114
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?
```
Fracture*
Crush injury*
Cast to limb before swelling stopped
Burns
Angioplasty revascularisation
```
115
Acute compartment syndrome is a clinical diagnosis.
How does it present?
What is the management?
What would an AKI indicate?
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
Define hypoglycaemia
Glucose < 3
Glucose < 4 + symptoms: nausea, sweaty, weakness, visual changes, dizziness, hunger, headache, tremor, drowsy, agitation, collapse, coma
117
If you are called to see a pt with hypoglycaemia, what 5 important questions should you always ask?
1. Are they conscious?
2. Do they have a safe swallow?
3. Do they have diabetes?
4. Are they on insulin?
5. NEWS
118
How would you manage a pt with hypoglycaemia:
1. Conscious, safe swallow?
2. Unconscious, unsafe swallow, reduced GCS?
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!
