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ACUTE Flashcards

1
Q

In broad terms, how should respiratory failure be managed?

A
  1. A –> E assessment
  2. O2
  3. Determine the cause: investigate
    Treat according to cause
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2
Q

How should oxygen therapy be escalated in a hypoxic patient?

A
  1. High-flow O2 (15L) via non-rebreathing mask (70% FiO2)
  2. NIV (CPAP or BiPAP)
  3. Intubation & mechanical ventilation
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3
Q

What investigations should be done to determine the cause of respiratory failure?

A

• Bloods: FBC, U&E, blood cultures, coagulation screen, CRP
• ABG
• CXR
ECG

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4
Q

What type of NIV should be used in type I respiratory failure? Why?

A

CPAP.

There is inadequate oxygenation. Alveoli need to be kept open/fluid pushed out of the lung.

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5
Q

What type of NIV should be used in type II respiratory failure? Why?

A

BiPAP.

There is inadequate ventilation. Alveoli need to be stretched open during inspiration and kept open during expiration.

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6
Q

What is the definition of respiratory failure?

A

PaO2 < 8

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7
Q

What is V/Q mismatch?

A

Ventilation perfusion mismatch or V/Q defects are defects in the total lung ventilation/perfusion ratio.
One or more areas of the lung receive oxygen but no blood flow, or they receive blood flow but no oxygen.

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8
Q

Name three causes of V/Q mismatch.

A

• Alveolar collapse
• Fluid build-up
- Bronchoconstriction

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9
Q

What are the two types of respiratory failure?

A

Type I - low O2, normal or low CO2

Type II - low O2, high CO2

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10
Q

Describe the pathophysiology of type I RF.

A

Inadequate oxygenation (hypoperfusion) due to:

1. Alveolar collapse e.g. pneumonia
2. Fluid in the alveoli e.g. heart failure

Ventilation is preserved - CO2 is normal or low –> V/Q mismatch.

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11
Q

Describe the pathophysiology of type II RF.

A

Inadequate ventilation (hypoperfusion AND hypoventilation) due to:

1. Obstruction: COPD, asthma, muscular dystrophy

CO2 is high. No V/Q mismatch.

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12
Q

When might pulse oximetry be misleading?

A 
CO poisoning
Poor peripheral perfusion/shock
Hypothermia
Nail varnish
Excessive movement
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13
Q

Name some causes of acute dyspnoea.

A 
Respiratory:
	• Asthma/COPD
	• Pneumonia
	• Pleural effusion
	• Pneumothorax
Cardiac:
	• Pulmonary oedema
	• MI
	• PE (see PE/DVT)
	• Arrhythmias 
Trauma:
	• Aspiration/FB
	• Flail chest
	• Haemothorax
	• Drowning
Other:
	• Hypovolaemia or fever
	• Hyperventilation syndrome
Respiratory compensation for metabolic acidosis e.g. DKA
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14
Q

How might a patient present with pulmonary oedema?

A 
• Tachypnoea
• Tachycardia
• Frothy pink sputum
• ^JVP
• Basal crackles or wheeze
Signs of reduced CO: sweaty, cool and pale
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15
Q

Name some features of pulmonary oedema on a CXR.

A 
• Cardiomegaly
• Kerley A, B or C lines
• Fluid in interlobar fissures
• Pleural effusions
Bat wing hilar shadows
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16
Q

What can cause non-cardiogenic pulmonary oedema?

A

ARDS (sepsis, trauma, pancreatitis), IV fluid overload, drowning, altitude, smoke inhalation

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17
Q

What is the treatment for pulmonary oedema?

A

PODMAN

  1. Position
  2. Oxygen
  3. Diuretics
  4. Morphine
  5. Anti-emetic
  6. Nitrates
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18
Q

What is primary and secondary hyperventilation? How should they be managed?

A

Primary = psychogenic:

  • Patient may be agitated or distress
  • Exclude serious secondary causes and reassure

Secondary = due to compensation:

  • Identify cause: metabolic acidosis, poisoning, pain, hypovolaemia
  • Treat the cause
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19
Q

What will the ABG show in a patient who is hyperventilating?

A

^O2.
CO2 is low as it’s ‘blown off’.
pH >7.45

Respiratory alkalosis.

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20
Q

How does hyperventilation lead to perioral and peripheral paraesthesia?

A

Hypocalcaemia.

H+ and Ca+ bind to albumin. In alkalosis, H+ dissociate from albumin and Ca+ are taken up.

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21
Q

What is the definition of shock?

A

Acute circulatory failure with inadequate tissue perfusion and cellular hypoxia.

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22
Q

What are the first signs of shock (compensated)?

A

^HR

Pallor
Anxiety
Sweating
Tachypnoea
>CRT
Narrow pulse pressure
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23
Q

What are the late signs of shock?

A

Hypotension
Bradycardia
Arrest

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24
Q

What are the four types of shock?

A
  1. Hypovolaemic
  2. Cardiogenic
  3. Distributive
  4. Obstructive
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25
Q

How can you classify the pathological processes of shock? (think like a plumber)

A

There is a problem with:

  1. Fluid - hypovolaemia
  2. Pump - obstructive, cardiogenic
  3. Pipes - distributive
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26
Q

What is the general approach to treating shock?

A
  1. A–>E (+call for help)
  2. O2
  3. Treat underlying cause
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27
Q

Generally, what are the three treatment options in shock?

A
  1. Fluid
  2. Vasopressor
  3. Inotrope
28
Q

What is a passive leg raise (PLR)? Why is it used?

A

Lie the patient flat, raise legs to 45 degrees.
Mimics fluid bolus by increasing venous return.
Used to predict whether a patient will respond to a fluid bolus.

29
Q

How can you classify the types of hypovolaemic shock?

A
  1. Blood loss e.g. trauma, GI bleed, AAA, ectopic pregnancy.

2. Fluid loss e.g. burns, vomiting, pancreatitis and sepsis.

30
Q

What is the management of hypovolaemic shock?

A

Fluids or blood

31
Q

How is blood loss classified in haemorrhagic shock?

A

Class I = <15%
Class II = 15-30%
Class III = 31-40%
Class IV = >40%

32
Q

What 5 parameters are used in the classification of haemorrhagic shock?

A 
Blood loss %
Heart rate
Blood pressure
Mental status
Fluid requirements
33
Q

How is heart rate classified in haemorrhagic shock?

A

Class I = 60-100
Class II = 100-120
Class III = 120-140
Class IV = >140

34
Q

How is mental state classified in haemorrhagic shock?

A

Class I = slight anxious
Class II = Mildly anxious
Class III = anxious, confused
Class IV = Confused, lethargic

35
Q

What is the most likely cause of shock in trauma? Which other causes should be considered?

A

Haemorrhagic

Also consider: neurogenic (spinal cord injury), obstructive (tension PTX, cardiac tamponade)

36
Q

What is the definition of cardiogenic shock?

A

Relative or absolute reduction in cardiac output due to a primary cardiac disorder
Circulatory collapse occurs as a result of pump failure

37
Q

What signs might be seen in a patient with cardiogenic shock?

A

Raised JVP

Cardiac arrythmia

38
Q

Name some causes of cardiogenic shock.

A

Ischaemia - ACS
Heart failure
Arrythmias
cardiomyopathy

39
Q

What are the aims of treatment in cardiogenic shock?

A

Increase cardiac output
Improve myocardial perfusion
Decrease cardiac workload

40
Q

What is the management of cardiogenic shock?

A

Inotrope = dobutamine (5-20mcg/kg/min)

+ fluids (slowly)
+ norepinephrine (vasoconstriction)

41
Q

Give some examples of distributive shock.

A 
Sepsis
Anaphylaxis
Neurogenic shock
Drug/toxin
Addisonian crisis
42
Q

What is the pathophysiology of distributive shock?

A

Problem with peripheral vascular vasodilation

43
Q

What is the management of distributive shock?

A

Vasopressors

44
Q

What is the definition of septic shock?

A

an infection that triggers a particular Systemic Inflammatory Response Syndrome (SIRS).

45
Q

How does a patient present with septic shock?

A

^temp
^HR
^RR

Low BP

46
Q

Describe the pathophysiology of distributive shock due to spinal cord injury.

A

Interruption of the autonomic nervous system.
Decreased sympathetic tone/increased parasympathetic tone = decrease in peripheral vascular resistance.
Decreased cardiac output, bradycardia.

47
Q

How might a patient present with neurogenic shock secondary to spinal cord injury?

A

Sinus bradycardia
Low BP
Flushed peripheries

48
Q

What is obstructive shock?

A

Extracardiac obstruction to blood flow.

49
Q

Give three causes of obstructive shock.

A

Massive PE
Cardiac tamponade
Tension pneumothorax

50
Q

What is the management of obstructive shock?

A

Remove the obstruction e.g. pericardiocentesis/anticoagulation

51
Q

What is the management of a small PTX? <1cm

A

Admit
O2
Reassess in 24 hours

52
Q

What is the management of PTX 1-2cm?

A

Aspiration should be attempted (needle thoracocentesis)

53
Q

What is the management of a PTX >2cm?

A

Chest drain insertion

54
Q

What is the management of a PTX >2cm?

A

Chest drain insertion

55
Q

How do you assess for a c-spine injury?

A

Canadian C-spine rules

needs to be GCS 15 to give a good history

56
Q

When do you need imaging in a suspected C-spine injury?

A

Can’t move neck 45 degrees to the left or right

Neck pain

57
Q

When should you order a CT head following head injury?

A 
GCS 13 or less
Fall in GCS
Basal skull fracture signs
Suspected open/depressed skull fracture
Seizures
Focal neurological deficit
>1 episode of vomiting
58
Q

How should you manage a seizure?

A

A –> E
O2
Remove dangerous objects
IV access/bloods –> 4mg IV lorazepam (can use rectal diazepam if no IV access)

59
Q

What can cause seizures in known epileptics?

A

Infection
Electrolyte disturbance
Non-compliance
Alcohol withdrawal

60
Q

What are the sepsis red flags?

61
Q

What is the definition of sepsis? And septic shock?

62
Q

Which score can be used to rule out a PE?

A

PERC (if >50 then automatically scores 1)

> 0 = investigate for PE

63
Q

How should the Well’s score be interpreted?

A 
<4 = d-dimer
>4 = CTPA + treat
64
Q

What is a massive PE? How is it managed?

A

Systolic <90

Thrombolyse

65
Q

How do you quantify asthma exacerbations?

A

Moderate
Severe
Life-threatening

66
Q

What are the causes of SAH?

A

70% berry aneurysm
20% AVM
10% no lesion

FINALS (26 decks)

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