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Acute > Acute > Flashcards

Acute Flashcards

1
Q

CT head guidelines - criteria for immediate CT?

A

Immediate: initial GCS <13
<15 2hrs post injury
Suspected open/ depressed skull #

signs of basal skull # - haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign

post traumatic seizure
>1 ep of vomiting.
Focal neurological deficit

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2
Q

Summary of brain herniation

A

Brain structures forcefully displaced. Compression.
Subfalcine: cingulate gyrus displaced under falx cerebri
Central: downward displacement.
Transtentorial: uncal, expanding IC haematoma may cause temporal lobe (uncus) to herniate through tentorial notch.
Foramen magnum/ tonsillar: BS compression, coning.
Transcalvarial: brain displaced through defect in skull

Transtentorial: compression of CN3, ipsilat pupil dilation, loss of eye movement, down + out gaze. Compression of ipsilat CS tracts in brainstem/ cerebral peduncle. Contralat hemiparesis.
Foramen magnum: ↓LOC, posturing, irregular resp, loss of BS reflexes. Bilat fixed + dilated pupils. Cushing’s response

Neurosurgical emergency
Osmotherapy: hypertonic saline or mannitol
Surgical decompression

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3
Q

Canadian C spine rule:

A

high RF (>65, dangerous MOI, numbness/ tingling in extremities).

Absence of low risk (simple rear-end MVC, ambulatory at any time at scene, no neck pain at scene, no pain during midline c-spine palpation).

Pt unable to voluntarily actively rotate neck 45° L+R.

Need immobilisation

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4
Q

1st degree burns (superficial)

A

Superficial epidermis only

Pain, erythema
Dry
No blisters

Heals within 1-2 wks no scarring

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5
Q

2nd degree, superficial dermal - partial thickness

A

Papillary layer of dermis
Epidermis + upper dermis

Extremely painful
Skin pale pink
Blistering
Blanches, rapidly returns
Brisk bleeding on pinprick
Slow CRT

Takes 2-8 wks

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6
Q

2nd degree, deep partial thickness

A

Deep reticular layer of dermis
Epidermis + upper + deeper layer of dermis

Varies colour, white, yellow, cherry red
Blisters
Wet or dry
Patches of non-blanching erythromycin
May only be pain due to pressure bc of nerve/ BV damage.
↓sensation
Blanches with sluggish return or doesn’t blanch

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7
Q

3rd degree, full thickness

A

Hypodermis
Extends through all layers of skin to SC tissues.

No pain, no blisters 
Dry, white leather, grey, black
Non blanching, no CR
Elastin damage, burn stiff/ inelastic 
No/delayed bleeding on pinprick

Surgical Tx
Skin grafting

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8
Q

Inhalation injury (burn)

A

Burn anywhere in rest tract
Laryngospasm > hypoxia + straining, hypoxic cord relaxation.
Explosion burns to head/ torso, confined space.

Singed nasal hairs 
Carbon particles in sputum 
Inflamed oropharynx 
Hoarseness/ voice change 
Harsh cough 
Stridor 
Burns to face 
Impaired LOC

↑CO in blood

ET tube
Swelling worsens 1st 24-48hrs after injury
100% O2

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9
Q

RFs for paracetamol poisoning

A

liver inducing drugs rifampicin, phenytoin, carbamazepine, chronic alcohol XS, st John’s Wort, malnourished

Acute alcohol XS protective

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10
Q

Tx of paracetamol poisoning

A

Staggered: all pts have acetylcysteine

> 10mg/L Tx: acetylcysteine, infused over 1hr

<1 hr: activated charcoal

SEs of acetylcysteine: anaphylaxis (non IgE mediated mast cell release, stop infusion, restart at lower rate, chorphenamine if rash.

Liver transplant criteria: arterial pH <7.3 24hrs after ingestion. Or ALL of: PT >100s, Cr >300, grade ¾ encephalopathy

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11
Q

Tx of ecstasy poisoning

A

Supportive

Dantrolene for hyperthermia

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12
Q

Tx of methanol poisoning

A

Fomepizole (competitive inhib of alcohol dehydrogenase) or ethanol

Haemodiaysis

Cofactors with folinic acid to reduce opthalmoplegic SE

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13
Q

Summary of organophosphate poisoning

A

Inhib ACh upreg of cholinergic neurotransmission
Insecticides, herbicides, nerve agents

Salivation/ sweating 
Lacrimation 
Urination, defecation/ diarrhoea
Bradycardia, hypotension
Abdo pain, vom 
Bronchorrhea, chest crackles, ronchi/wheezes >pul oedema bronchospasm 
Small pupils, visual disturbance 
Muscle fasciculation, weakness, spasms, paralysis

Plasma cholinesterae: decreased activity
ECG: QT prolongation
SLUD: salivation, lacrimation, urination, diarrhoea

Pt decontamination eg remove clothes, wash skin
Atropine
Pralidoxime: administered after atropine risk of transient worsening acetylcholinsterase inhibitors
BDZ for seizures

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14
Q

Summary of CO poisoning

A

Badly maintained house eg student house
CO high affinity for HB + myoglobin, left shift of O2 dissociation curve, tissue hypoxia + tissue hypoxia

Headache, confusion 
N+V
Vertigo 
Subjective weakness
Severe: ‘pink’ skin + mucosa, hyperpyrexia, arrhythmia, extrapyramidal, coma, death

Pulse Ox, may be falsely high due to similarities between oxyhemoglobin + carboxyhaemoglobin
ECG for cardiac ischaemia
ABG
Carboxyhaem: <3% non smokers, <10% smokers, 10-30% symptomatic, >30% severe toxicity

100% O2 via non rebreather mask min 6hrs, target sats 100%
Tx continued until no Sx
Hyperbaric O2

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15
Q

Summary of TCA poisoning

A

Early: dry mouth, dilated pupils, agitation, blurred vision, dry eyes
Ophthalmic signs: divergent squint, gaze, paralysis, inter nuclear ophthalmoplegic, nystagmus
Warm, dry, flushed skin
Decreased/ absent BS
Urinary retention
Dizziness, palpitations, pyrexia w/o sweating
Confusion, LOC, delirium, agitation, visual/aud hallucinations
Ataxia, myoclonic, choreathetoid movements

Metabolic acidosis
ECG: sinus tachy, widening of QRS, prolongation of QT
Increased tone, hypereflexia, extensor plantar responses
QRS >100ms seizures, >160 ventricular arrhythmia

IV bicarb
IV fluids
1a (quinidine) + 1c (flecainide) CI as prolong depolarisation 
Class 3 amiodarone avoided as prolong QT 
IV lipid emulsion to bind free drug
Dialysis removes TCA
O2 
Diazepam for convulsions
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16
Q

Summary of opioid poisoning

A 
Rhinorrhoea, watering eyes
Needle track marks 
Pinpoint pupils 
Apnoea, RR<12, shallow 
Unconscious, drowsy, coma
Confusion, yawning 
Pruritus,
N/V/C, abdo pain 
Bradycardia, hypotension, vasodilation 
Unresponsive

IV/IM naloxone: competitive opioid receptor antagonist, ½ life 60-90 mins. Initial 400mg, if no response 800mg for up to 2 doses
Ventilation

17
Q

Summary of BDZ poisoning

A

Effects potentiated if taken another CNS depressant such as alcohol or opioids

XS sedation
Impaired mental state, attention or memory (esp loss of anterograde memory)
Inappropriate behav or judgement + labile mood
Drowsiness, slurred speech, ataxia
Diminished postural stability + reflexes
Nystagmus

ECG: transient 1st degree heart block, 2nd degree HB, QT prolongation
CK: elevated rhabdomyolysis
Poss met acidosis

Supportive
Observe pt for min of 4hrs
Activated charcoal if present within 1hr
Flumazenil: risk of seizures

18
Q

Summary of beta blocker poisoning

A

CVS: hypotension, bradycardia, AV block
Bronchospasm, breathing trouble (SOB, gasping), wheezing (asthma)
Stupor, coma, weakness, nervousness, XS sweating, drowsiness, confusion, fever, delirium, syncope

Hypoglycaemia
Hyperkalaemia

Fluid, secure airways 
Salbutamol 
Atropine 
Bicarb for met acidosis, dialysis
Glucagon if resistant
19
Q

Summary of salicylate overdose

A

Direct stim of resp centre, overbreathe, resp alkalosis. Kidney attempts to compensate by excrete alkali to give met acidosis
Inhibits normal met pathways so get failure of normal met of carbs, fats + proteins. Build up of organic acids, ketones, lactate + pyruvate

V/N, dehydration 
Vertigo
Sweating, pyrexia 
Bounding pulses
HTN 
Hyperventilation 
Lethargy 
Hyper/hypoglycaemia

Resp alkalosis 1st, then met acidosis
In kids met acidosis predominant
Reg VBG

Supportive
Activated charcoal <1hr
IV Na Bicarb: strict supervision
Haemodialysis: ITU, in severe LT overdose. Serum conc >700, met acidosis resistant IV bicarb, acute resp failure, pul oedema, seizure, coma.

20
Q

Summary of lithium poisoning

A

Narrow therapeutic index (0.4-1mmol/L) + long plasma ½ life. 2 = serious toxicity
Toxicity precipitated by: dehydration, RF, drugs (thiazides, other diuretics, ACEi, ARB, NSAIDs, deterioration of renal functions, infection, metronidazole

Coarse tremor: fine tremor in therapeutic levels 
Hyperreflexia 
Acute confusion, apathy, restlessness
Polyuria, V/D
Ataxia, weakness 
Dysarthria 
Muscle twitching

Volume resus
Haemodialysis
IV bicarb: urinary alkalisation promotes lithium excretion

21
Q

Tx of warfarin overdose

A

vit K, prothrombin complex

22
Q

Tx of heparin overdose

A

protamine sulphate

23
Q

Tx of iron overdose

A

desferrioxamine, chelating agent

24
Q

Tx of lead overdose

A

dimercaprol, Ca edetate, EDTA, DMSA

25
Q

Tx of cyanide overdose

A

hydroxycobalamin, amyl nitrite, Na nitrite, Na thiosulfate.

26
Q

Summary of suxameth apnoea

A

Plasma cholinesterase def, can’t metabolise sux
Not apparent until try to wake pt
Genetic or acquired

Can’t be awakened: pulse BP rise, sweating, dilation of pupils, pt is becoming aware but still paralysed

If paralysed need to anaesthetise + ventilate

27
Q

Summary of malignant hyperpyrexia

A

AD, disorder of skeletal muscle metab, abnormality in ryanodine receptor in SR, XS release of Ca from SR
Increased muscle activity + metab, XS heat production, temp rise 2 degrees an hr
Trigger: exposure to inhaled anaesthesia, sux, antipsychotics (neuroleptic malig syndrome)
Young adults, minor surgery

Increase in end tidal CO2 
Tachycardia 
Increasing O2 requirement = falling SpO2 despite increased O2
Progressive (often late) rise in temp 
Tachypnoea 
Muscle rigidity

Met acidosis
CK raised
Contracture tests with halothane + caffeine

Stop volatile agent, replace w total IV
Hyperventilate with 100% O2
High flow flush to flush anaesthetic agent from pt
Dantrolene Na, inhibit Ca release from SR
Acute cooling, cold 0.9 saline, surface cooling (ice over axilla + fem a, wet sponging)
ICU: monitor temp, monitor urine myoglobin

28
Q

CT head guidelines - criteria for within 8 hours?

A

Within 8 hrs: some LOC/ amnesia + 1+ of:
>65
Hx of bleeding/ clotting disorder
dangerous MOI (pedestrian/ cyclist hit by car, ejected from car, fall from >1M/ 5 stairs)
>30 min retrograde amnesia of events before injury, anticoag.
if on warfarin and no other indications

29
Q

CT head guidelines - paediatric criteria?

A

Paeds: initial GCS <14 for >1
<15 for <1
<15 2hrs post injury
Skull # or tense fontanelle
Suspected NAI
Post traumatic seizure
Focal neurological deficit.
<1 + bruising/ swelling/ lac >5cm.
witness LOC >5 mins,
amnesia >5 mins.
Abnormal drowsiness 3+ vomiting.
Dangerous MOI.

30
Q

When are escharotomies indicated?

A

circumferential full thickness burns to the torso or limbs

Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)

Acute (2 decks)

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