ACUTE Flashcards
SEPSIS
- Sepsis 6
- Define SIRS (2/4)
- Define sepsis
- Define septic shock
A-E
3 out, 3 in
1. Blood cultures
2. Lactate (VBG, ABG)
3. Urine output (0.5ml/kg/hr)
4. Oxygen (non-rebreathe mask, 15l/min)
5. IV Fluids (0.9% NaCl 500ml or 250ml if HF/RF)
6. IV Abx (broad spec, as per Trust Guidelines)
Systemic inflammatory response syndrome:
* if 2+ of - HR<90, temp <36 or >38.3, RR >20 or PaCO2 <4.3, WCC <4 or >12
Sepsis - SIRS + known/suspected infection
Septic shock - hypotension (BP<90) or lactate >4 persists despite fluid challenge, requires inotropes (escalate to ITU)
Emergency drugs
* Anaphylaxis
* ACS
* Opioid overdose
* Status epilepticus
* PE
* Bradyarthytmia (adverse features)
* Hypoglycaemia
* Addisonian crisis
* Severe asthma attack
* Further management asthma attack
* DKA
*
- Im Adrenaline 500mcg, 1:1000 (0.5ml)
- IV Morphine (5mg), GTN spray (2 puffs/5min), O2
- IV Naloxone 400mcg (max 10mg)
- IV Lorazepam 4mg (max 12mg)
- Apixaban - doac therapeutic dose or LMWH
- IV Atropine 500mcg, max 3mg
- IM Hydrocortisone 100mg
- 200ml of 10% glucose IV or 100ml 20% glucose IV, or IM glucagon
- Salbutamol 5mg (nebs through O2, every 15 mins), Prednisolone PO 50mg (or IV), Ipatropium (0.5mg, add to nebs). Senior mx - IV MgSo4 –> aminophylline.
- Fluids, fixed rate insulin infusion, then once glucose return to normal:glucose infusion, +/-K+
Emergency drugs - adults
Anaphylaxis
Status epilepticus
Opioid overdose
Bradyarrhythmia
Acute pulmonary oedema
Myocardial infaraction
- IM Adrenaline 500mcg of 1:1000 (0.5ml)
- IV Lorazepam 4mg (max every 5mins, up to 12)
- IV Naloxone 400mcg
- IV Atropine 500mcg (every 5 mins, max 3mg)
- IV Furosemide (40-120mg)
- IV Morphine (5mg), O2 15l non-rebreathe mask, GTN spray 2puffs 5min, Aspirin 300mg PO
A-E Assessment
AIRWAY
Assessment
* Patency?
* Yes - speaking
* No - no sounds; gurgling, stridor, snoring
Action
* Blood/vomit/secretions? - suction
* Head tilt, chin lift; jaw thrust
* –> airway adjuncts (NP, OP)
* –> Call anaesthetist
Reassess
BREATHING
Assessment
* L - Obs - O2 sats, RR, ?cyanosis
* F - Resp exam - Tracheal deviation; lung expansion; percussion
* L - Auscultate - equal air entry/added or absent sounds
Action
* Low O2 - 15l O2 via non-rebreathe mask
* New O2 requirement? - ABG
* Other ix - CXR/CTPA
CIRCULATION
Assessment
* L - OBS - Pulse RRC, CRT, BP, JVP
* L - Auscultate heart
Action
* IV Access - 2 x wide bore cannula
* Take bloods (now/later) - FBC, U&E, Coags, Group & Save, trop, LFTs, VBG, cultures
* ECG - 3 lead/12 lead
* Measure urine output
* Fluids - 500ml 0.9% NaCl bolus (250ml if cardiac/renal failure); RBC for acute haemorrhage
Reassess
DISABILITY
Assessment
* Consciousness - AVPU/GCS
* Pupils (PERL)
* Blood Glucose - CBG/VBG
Action
* Consciousness - Airway protect if GCS less than 8; left lateral position
* Pupils - pinpoint - antidote; unequal - CT head
* Glucose - hypo if < 4 mmol/l –> 100ml 20% glucose IV
EXPOSURE
Assessment
* L - Obs - temperature
* Fully expose body - wounds, haemorrhage, #s, rash
* F - Abdo palpation, Calf tenderness, ankle swelling
Action
- depending on findings
Indentification of sepsis
1. NEWS Score
2. QSOFA
3. Sepsis red flags
- > 5 or >3 in one parameter
- > 2 is high risk: BP< 100, New onset confusion, RR>22
- Rash, RR>35, BP<90, lactate >2, <0.5ml/kg/hr urine output, recent chemo 2-3wk ->neutropenic sepsis
ANAPHYLAXIS
definition (resus council)
- life-threatening condition
- Sudden onset and rapid progression of symptoms
- which compromise ABC airways, breathing and circulation
+/- skin/mucosal changes in 80%
Anaphylaxis: A-E
SUSPECT ANAPHYLAXIS –> CALL FOR HELP!!!!!!!!!!!
Airway
A- stridor
A- Adrenaline 500mcg IM (0.5ml of 1:1000), every 5 mins if nec
Breathing
A - RR, sats monitor
A - O2 15l non-rebreathe mask
Circulation
A - BP, ECG
A - stop causative fluids, IV Access, +/-500ml IV Fluids, lie patient flat
Disability
A: AVPU, glucose (VBG), pupils
Exposure
A: temp, rash, abdo pain, swelling
A: other investigations
Ix after stabilisation
- Mast cell tryptase within 6hr
- Observation 6hrly
- Anti-histamines e.g. Chlorphenamine
- Further review/allergy clinic/adrenaline auto-injector prescription
- Discharge
- 2hrs (respond to single dose adrenlaine, complete sx resolution)
- 6hrs (2 doses x adrenaline or previous reaction)
- 12hrs+ (2x doses/severe/ongoing sx/presentation at night)
DKA diagnosis:
* Hyperglycaemia >11mmol/l
* Ketonaemia/kentonuria >3mmol/l or >2
* Acidosis ph<7.3
Management (FIGP-ICK)
Further management
Mangement:
1. Fluid replacement (NaCl 0.9% 500ml)
2. Insulin (infusion at 0.1u/kg/hr)
3. Once glucose <14mmol/l add 10% glucose in addition to infusion
4. Correct electrolytes: add K+ if necessary
5. Monitoring (glucose, ketones)
Further management: fixed rate insulin infusion
Anaphylaxis: discharge guidelines
- fast track (2hrs)
- 6hrs
- 12hrs
What must be arranged for all patients after first presentation of anaphylaxis?
- f\good response to adrenaline, ull symptom resolution, received and understood autoinjector
- previous biphasic reaction or 2 doses IM adrenaline needed
- ## patient presented at night, biphasic reaction, ongoing symptoms, required more than 2 doses IM adrenaline, severe asthma, lives in area far from emergency services
Hypoglycaemia
Normal CBG >3.5
Management if
1. Low GCS
3. Normal GCS
Underlying causes?
Low GCS hypoglycaemia
A - airway adjunct
B - 15l/min O2 if sats <94
C - IV Access; glucose 10% 200ml stat.
IF INSULIN OVERDOSE –> glucagon
D - CBG monitoring every 30min-1hr
E - everything else
Normal GCS
Glucogel 10g
Monitor CBG 1-2hr until stable
If persistent –> 1l 10% glucose 6-8hr IV
Underlying causes
Insulin overdose or oral antidiabetic overdose
Sepsis
Addisonian crisis
Alcohol excess
Acute liver failure
Major trauma - difference between primary and secondary survey
Primary - cAcBCDE
* Catastrophic haemorrhage
* Airway
* C-spine protection
* Breathing
* Circulation (haemorrhage control)
* Disability
* Exposure & Environmental control
Secondary - full assessment, post stabilisation, e.g. after CT and reassess of A-E: AMPLE and systematic evualation (head–>toes)
* allergies
* medications
* past illness
* last meal
* events/environment/MOI
Thoracic trauma
List the “Deadly Dozen” - Lethal 6 (requires treatment during primary survey) and Hidden 6 (detected during secondary survey)
Lethal 6 : ATOMFC
1. Airway obstruction
2. Tension pneumothorax
3. Open pneumothorax
4. Massive haemothorax
5. Flail chest (technically not lifethreatening)
6. Cardiac tamponade
Hidden 6 - contusions, disruptions & tears
1. Pulmonary contusions
2. Myocardial contusions
3. Thoracic **aortic **disruption
4. **Traceobronchial **disruption
5. Oesophageal disruption
6. Traumatic diaphragmatic tear
Tension pneumothorax
- hole in chest –>trapped air within the pleural cavity causing a one-way valve of air entry into chest without air exit (inc. thoracic pressure)
- On affected side:unilateral pleuritic pain; shock, O/E hyperinflation, hyperresonance (percussion), tracheal deviation away from aff. side
- requires urgent decompression (needle thoracentesis)
- furhter mngmt by chest drain
Options of sites for urgent thoracentesis for tension pneumothorax
- 5th ICC mid-axillary line
- 2nd ICC mid clavicular line
Open/traumatic pneumothorax - “sucking chest wound” - definition and treatment before surgical repair
- obvious chest wound –> respiratory depression & bubbling of wound
- 3-way occlusive dressing (air out, not in) –> chest drain
Massive haemothorax: definition, sx, signs, CXR findings, acute treatment and indications for thoracotomy (by amount of blood loss)
- extensive blood loss within pleural cavity –> Shock
- O/E - dull to percussion, signs of hypovolaemia
- CXR - loss of mirror image
- IV Fluids +/- blood products +/- chest drain if bleed seen on CXR
- Thoracotomy if >1500ml bleed or >200ml/2hrs
Flail chest: definition, associated commonly with which other complication
- series of 3+ # ribs, fress section of chest wall & paradoxical breathing
- O2 & supportive care before ?surgery
- pulmonary contusion
Cardiac tamponade:
definition,
symptoms triad,
acute treatment,
further treatment
Fluid/blood build up in pericardial cavity (haemopericardium) –> Pericardial effusion –> increased pressure on heart –> reduced CA and SV –> haemodynamic compromise:
Beck’s triad
* Raised JVP (raised venous p)
* Hypotension (reduced arterial p)
* Muffled heart sounds (effusion)
and pulsus paradoxus (pulse fades on inspiration)
* thoracotomy or pericardiocentesis
can be caused by as little as 100ml blood due to pericardial sac not being distensible
Hidden 6
* most common cause of death following RTA/falls, widened mediastinum on XR, persistent hypotension, tracheal deviation and depression of bronchus
* most common potentially lethal chest injury
* which is usually associated with blunt trauma
* not silent 6 but a typical site for disruption caused by sudden deceleration injury
- Aortic transection (thoracic aortic disruption) - deceleration injury, near-complete tear through all layers of aorta, contained haemoatoma
- pulmonary contusion
- diaphragmatic disruption
- duodeno-jejunal flexure disruption (abdo tenderness and intra-abdo fluid on CT)
Define:
1. crush injury
2. compartment syndrome
3. rhabdomyolysis
Both are systemic injuries from polytrauma.
* Crush injury - from prolonged pressure on large muscles causes disnitegration of muscles.
* Compartment syndrome - increase in pressure within a confined space –>tissue necrosis and metabolic acidosis (severe pain particuarlly passive flexion of toes, pallor, paralysis, pulselessness, paraesthesia)
* rhabdomyolysis - breakdown of skeletal muscle cells, releasing contents into circulation
Compartment syndrome immediate management
removal of cast if present
fasicotomy
analgesia
fluids
rupture of interventricular septum
- complication following?
- patients at risk
- causes hypotension and biventricular failure - largely right sided - finding?
post MI
left anterior descending
right sided heart failure - raised JVP and harsh/holosytolic murmur
Features of rhabdo:
1. General
2. Electrolyte derangement
3. Urinary findings
4. Treatment
- AKI with disproportionately raised creatinine
- Hyperkalaemia, Hyperphosphataemia (from myocytes) Elevated CK at least x5
Hypocalcaemia - Urine: myoglobinuria (brown/red urine)
- IV FLuids +/- bicarb
Fat embolism:
* vast majority associated with:
* presents - hrs after initial injury
* affects which 3 systems
* key inv finding
* mngmnt
* prevention
- trauma, or #s
- 24-72hrs
- resp (SoB, tachypnoea, hypoxia), neuro (drowsiness), derm (ptechial rash in conjunctiva + oral mucosa + neck)
- lipuria (urinalysis)
- supportive + DVT proph
- early immobilisation of #s
Acute respiratory distress syndrome:
* Define
* Causes
* Sx
* Ix
* Mx - location
- non-cardiogenic pulmonary edema
- trauma to lung, infection, blood transfusion, smoke inh, pancreatitis, CP bypass, COVID
- acute SOB, tachycardia, hypotension
- bilateral lung crackles
- CXR (bilateral infiltrates) ABG
- ITU
What is the FAST scan used for in trauma?
A point-of-care ultrasound to establish presence of free fluid (4 areas) - investigates extent of free fluid in pneumothorax
trauma + persistent hypotension
internal bleeding?
could be contained haematoma?
e.g. aortic disruption
Signs of basal skull fracture
- Panda eyes
- Battle’s sign (bruising over mastoid)
- Haemotympanum
- CSF Rhinorrhoea/Otthorhea
- LMN facial nerve palsy
Head + Spinal Injury - when would you immobilise the neck?
And how? (3)
Risk factors:
1) >65
2) Known spinal condition
3) Dangerous MOI
4) Note sx - Limb paraesthesia
Technique:
hard collar, blocks and tape
keep back straight, log rolling only
GCS Scoring:
Eyes (4)
Speech (5)
Motor (6)
Eyes
4 - open
3- open to voice
2 - open to pain
1 - not
Verbal
5 - orietated, fully responsive
4 - confused
3 - inappt words
2 - inappt sounds
1 - no sound
Motor
6 - obeys commands
5 - localises to pain
4 - flexes to pain - withdraw
3 - abnormal flexion to pain
2 - decerebrate
1 - no response
CT Head NICE Guidlines for Head Injury
* within 1 hour
* within 8 hours
1 hour
* GCS <13 or drop below 15 2hrs post injury
* focal neurological deficit
* 2+ episode of vomiting
* evidence of BSF, or open/depressed skull #
* seizure
8 hours
* Loc/Amnesia + bleeding disorder/dangerous MOA/retrograde amnesia more than30 mins, or head injury + blood thinner
general principle of the Monroe-Kelly Doctrine re brain volume, CSF and intracranial blood:
- compensation
- decompensation
Compensation
increase in volume in one fluid will cause a decrease in the other 2 by venous drainage into sinuses
Decompensation
once mass reaches a certain size, decompensation –> small rise in intracranial volume results in exponential rise in ICP
Traumatic brain injury
- Can be focal (contusion or ICH) or diffuse; axonal (acc-decel, shearing forces)
- Can be primary or secondary: distinguish the 2
**Primary TBI: **damage done at time of incident: contusion, diffuse axonal injury, skull fractures
**Secondary TBI: **damage to the brain from complications after initial injury: hypoxia, ischemia, raised ICP, hypo/hyperglycaemia, infection, pyrexia, herniation
Symptoms of foramen magnum/tonsillar herniation - and late sign (triad)
- Decreased GCS
- Decorticate posturing
- Irregular resps
- Bilateral fixed dilated pupils
-
Cushing’s response:
1. Hypertension
2. Bradycardia
3. Abnormal breating
Types of brain haemorrhage: location/vascular supply, clinical presentation, key associations, CT Scan appearance
1. Subarachnoid haemorrhage
- If CT scan negative, next line invesitgation (within 12hr of symptom onset)? Findings (3)?
- If spontaneous SAH confirmed - further diagnostic tests? (2)
SAH
* non-traumatic: rupture of cerebral aneurysm (CoW), or traumatic
* thunderclap headache (occipital, strenous activity)
* cocaine use, sickle cell anaemia
* Non-contrast CT Head: hyperattenuation around CoW (around ventricles if severe)
* LP - xanthochromia, elevated bilirubin from blood breakdown, normal/raised opening pressure
* Spontaneous - ?aneursysm/AVM: CTA or MRA
Spontaneous subarachnoid haemorrhage
Mx of confirmed aneurysmal SAH:
Conservative, medical. surgical
Complications?
Spontaneous SAH Mx:
* Supportive (bed rest, analgesia, VTE proph)
* prevent vasospasm - delayed cerebral ischemia 7-14 days after onset (Nimodopine)
* prompt intervention within 24hrs - coil
Complications:
- rebleed
- delayed ischemia
- siadh ; hyponatremia
- seizures
- hydrocephalus
Types of brain haemorrhage: location/vascular supply, clinical presentation, key associations, CT Scan appearance
2.Extradural haemorrhage
Extradural
* meningeal artery, temporal/parietal post major head injury
* skull # +** lucid interval** + rapid decline (raised ICP)
* convex/lentiform; does not cross suture lines
Types of brain haemorrhage: location/vascular supply, clinical presentation, associations, CT Scan appearance
3.Subdural haemorrhage
Subdural
* rupture of bridging veins, parietal lobes, post trivial injury
* slower onset + fluctuating consciousness
* elderly, alcoholics due to vein atrophy (more prone to rupture)
* concave/crescent shape
Types of brain haemorrhage: location/vascular supply, clinical presentation, coup or contrecoup, associations, CT Scan appearance
3. Intracerebral haemorrhage
Intracerebral
* any lobe, like stroke
* sx depend on location
* coup = region affected directly related to site of exernal injury. Contrecoup = region affected is opposite
* hyperdensity w/in brain substance
Spinal cord injury
Causes and signs of
1. Complete
1b - Complete if above T6
2. Incomplete (hemisection)
3. Cauda equina
- complete loss of sensation/paralysis below level of injury: trauma; transverse myelitis.
1b - autonomic dysreflexia (HTN, sweating in response to pain) - partial loss of sensation/paralysis below level of injury: Brown-Seqard
- damage to cauda equina: bowel or bladder sx - incontinence and saddle anaesthesia
ICU - Levels of Care (0-3)
0 - ward care
1 - at risk of deterioating, acute ward with advice from critical care
2 - e.g. single-organ failure; HDU, 2:1 nursing
3 - multi–organ failure or advanced resp support, 1:1 nursing
advanced resp support = ventilator+sedation
Respiratory support –> from least to most advanced (5)
- Oxygen therapy (e.g.15l via non-rebreathe mask - up to 80%)
- Nasal high flow (provides 60l/min, up to 95%)
- Non-Invasive Ventilation (CPAP, BiPAP)
- I+V
- ECMO
Non-invasive ventilation
* basics
* CPAP or BiPAP
- both provide positive end expiratory pressure (PEEP) air pressure to prevent collapse of alveoli during expiration
- patient still required to breathe by themselves, PEEP supports breaths
- CPAP - provides expiratory support online
- BiPAP - provides expiratory AND inspiratory support (EPAP + IPAP)
*
Mechanical Ventilation (I+V)
* which level of care?
* intubation method?
* potential problems
- level 3 (HDU)
- endotracheal tube to charena, connected to ventilator
- hypotension, arrythmia, sleep problems, airway trauma, muscle wasting
ECMO
* stands for?
* what is it?
* what access does it require?
- extra-corporeal membrane oxygenation
- cardiac bypass machine
- heart still beating but machine acts as artificial lung - O2 in and CO2 out
- large central vein access (femoral vein)
Renal replacement therapy
Acute: haemodialysis (intermittent) or filtratrion (continous)
Chronic: haemodialysis or peritoneal dialysis
* Indications for Acute RRT (AEIOU)
A: severe metabolic acidosis
E: electrolyte abnormalities - severe hyperkalaemia not already treated
I: intoxication/overdose - toxin removal
O: refractory fluid overload
U: uraemia: pericarditis, encephalopathy - seizures, reduced GCS
Anaesthesia: local, regional and general.
Regional:
- Peripheral
- Central (spinal/epidural)
Distinguish the difference between the types:
Peripheral: LA injection into area surrounding a particular nerve: paraesthesia of region supplied by that nerve (entire limb); e.g. interscalene (brachial plexus)
Central - spinal: LA injection into subarachnoid space (CSF) in lumbar spine (e.g. L3/L4) to avoid damage to cord. 1-3hrs.
Central - epidural: analgesia during labour/post op laparotomy. LA injection via catheter inserted into epidural space - tissues and spinal nerve roots. Typically Levobupivicaine +/- fentanyl
Typical side effects of central nerve blockades
Both spinal and epidural: nausea as BP drops; loss of bladder control, pruritus
Adverse effects of epidural- headache if “dural tap”, hypotension, motor weakness, nerve damage, meningitis, haematoma
OPERATIVE CARE
What is the ASA Grading system?
- Fitness to undergo anaesthetic
- Higher score = increased chance of post-op complications
- Score 1-5
- 5 - not expected to survive with or without surgery
OPERATIVE CARE - DIABETES
Increased chance of periop site infection, AKI, pneumonia. Trust Guidelines depend on nature of surgery (elective/emergency), insulin compliance, comorbidities, length of surgery.
Generally - 1st on waiting list to minimise fasting time.
* Hba1c Aim
* Type of Insulin during op? not always necesary though
- <69
- Variable Rate Insulin
PERIOPERATIVE CARE: DIABETES
*General rules: *
- Good glycaemic control: Take as normal or modifications to current treatment
- Poor glycaemic control, renal risk factors, >1meal to be missed - VRIII
Oral antidiabetics - rules for:
1. Metformin/Sulfonylureas
2. DPPVIs, GLPAs
3. SGLT2Is
4. Long acting insulin (once daily)
5. BIphasic regiments (twice daily)
*Eg multiple dose regiment - take the evening dose as normal and then (as starving) - omit the morning dose if to have operation that morning *
1. Take as normal on day of surgery, may need to adjust lunchtime dose (depending on regimen eg OD, BD, TDS)
2. Take as normal
3. Omit on day of surgery
4. Reduce dose by 20% (starting from day before)
5. Reduce morning dose by 50% (starting from day before), evening stays same
PERIOPERATIVE CARE: HEART FAILURE
- Echo (AS- high risk)
- Lee Cardiac Risk Index
- Aim HR<100
- BP<180/120
PERIOPERATIVE CARE: MEDICATION CONSIDERATIONS
- Stop meds on day of surgery with risk of perioperative hypotension (4)
- Anticoagulants: Balance between risk of clots and risk of bleeding - DOACS? Clopidogrel?
- Antiplatelets - Aspirin?
- Betablockers?
- ACE-Is, ARBs, Diuretics, Alpha Blockers (antihypertensives)
- Anticoagulants - note DOACS unable to be reversed; Clopidogrel stopped 1 wk before elective
- Stop aspirin 1 wk before (except if had vascular stenting)
- Continue beta blockers
PERIPERATIVE CARE: FASTING GUIDELINES
NBM: Solids vs Liquids
Solids 6 hrs
Clear Fluids 2 hrs
ANAESTHESIA
Timeline:
Pre-oxyenation
Pre-medication (3)
1. Induction - awake to anaesthetised state (airway management + options for analgesia/hypnosis and for muscle relaxant)
2. Maintenance: keep pt unconcious
3. Emergence ( 4 requirements)
4. Recovery
Pre-meds:
1. Analgesia: opiates (Fentanyl)
2. Muscle relaxation: bennzos (Midazolam)
3. Sedation: alpha-2 agonists (Clonidine)
Induction:
1. Analgesia and hypnosis: IV propofol or INH O2/NO2 or Sevo
2. Muscle relaxant: depolarising or non-depolarising
Maintenance:
1. Iv Propofol or INH Sevo
2. May require other drugs e.g. Epineprin for hypotension, abx for infection proph
Emergence:
1. Analgesia
2. Anti-emetics (Ondansetron)
3. Ensure muscle relaxant has been restored then switch off maintenance agents
4. Extubation
Recovery
- Monitoring, check breathing for themselves
What is accidental awareness?
How can this be tested for prior to emergence?
If hasn’t worn off what meds can be used?
- When the paitent regains consciousness whilst paralysed
- nerve stimulator
- e.g. ulnar nerve stimulates thumb twitching
- Neostigmine or Sugammadex
ANAESTHETIC AGENTS: HYPNOSIS
Iv agents - 3-4 key points for each:
1. propofol
2. Sodium thiopentate
3. Ketamine
4. Etomidate
- GABA-receptor agonist, Rapid onset and recovery, also analgesic and anti-emetic, can be used for maintenance
- Barbiturate, rapid onset but slow recovery, risk of hypotension, x analgesic/maintenace
- NMDA receptor antagonist, used for pains or pre-hospital care, risk of hallucinations/dissociative anaesthesia
- rarely used, less chance of hypotension/ good cardiac safety, suitable for maintenance, requires steroids for next few days, can cause post-op vomiting and painful on injection
ANAESTHETIC AGENTS: INHALED
1. Volatile liquids: Sevoflurane, Isoflurane, Desflurane
- how are they administered?
- When is Iso used over Sevo?
2. NO2
- can be used for induction in which group?
- given in vaporisers in O2/N2 and O2
- Sevo generally, but Iso preferred in obstetrics and asthmatics
- NO2 - paeds (no cannulation required)
MUSCLE RELAXANTS
Name examples and their reversal agents
Both compete with ACh at the NMJ
1. Depolarising:
2. Non-depolarising
- Suxamethonium - Neostigmine: cholinesterase inhibitors
- Atracurium, Vecuronium, Rocuronium - Sugammedex
AIRWAY INTERVENTIONS
1. OP (Guedel)
2. NP
3. . Endotracheal tube ETT
4. . Supraglottic airway device SAD (Igel)
5. . Bag valve mask (Ambu-bag)
6.. Tracheostomy
- most often used when ventilating via face mask prior to SAD; induces gag reflex
- used in emergency, CId in suspected basal skull #
- x
- tue inserted through vocal cords to trachea (20-24cm); use laryngoscope to visualise positioning +/- bougie. PROTETCS AIRWAY
- Alternative to ETT - AIRWAY NOT PROTECTED
- Self inflating resuscitator: provides oxygen and ventilation prior to placement of definitive airway
- temporary or permanent (e.g. resp failure where long term ventilation is reqd; bypass upper airway: cricothyroidectomy, surgical tracheostomy
Central venous catheters: location and uses:
1. Central line
2. Vas-Cath
3. PICC line: peripherally inserted central catheter
4. Hckman line: Tunnelled central venous catheter
5. PortaCath
- insertion: large vein (internal jugular, SC or femoral) with tip in VC. For meds too irritating for peripheral cannula
- short term haemodialysis
- similar to central line but narrower in diameter; lower risk of infection; medium term IV access
- similar to central line but tunnelled through S/C; adhesion of skin; longer term IV access
- Like hickmann but with port to access device; longest lasting option - fully internalised by skin
Pain ladder:
* Chronic pain
* Acute, nociceptive pain
General/chronic pain
1. Mild pain: simple analgesics
2. Moderate pain: mild opioids (codeine, tramadol) + simple analgesiccs
3. Severe pain: strong opiods (morphine) + simple analgesics
*Alongisde: Adjuvant medications for neuropathic pain
Acute nociceptive pain
REVERSE PAIN LADDER: 3 to 1
PALLIATIVE CARE PAIN RELIEF
Strong opioids (Level 3 of Pain Ladder):
* 1st to 3rd line options
* If GFR less than 30?
* if GFR less than 15?
* in severe renal impairment?
* what should be prescribed in adjunct with all strong opiods?
- Morphine/Diamorphine - oral/subcut (e.g. Zomorph)
- Oxycodone (1st line if GFR less than 30)
- Fentanyl (1st line if GFR less than 15)
- Alfentanil, Buprenorphine - in severe renal impairment
- Laxatives
PALLIATIVE
Morphine dosing
* breakthrough dose calcuation?
* increased dose %?
Breakthrough = 1/6 of total background dose/24hrs
Increasing dose = by 30-50%
PALLIAITVE
Opioid conversions
Oral
1. Oral Codeine/tramadol –> Oral Morphine
Subcut.
1. Oral morphine –> SC morphine
2. Oal morphine –> SC diamorpphine
3. Oral oxycodone –> SC diamorphine
Transdermal
4. 30mg oral morphine = fentanyl ?mcg patch
5. 24mg oral morphine = buprenoprhine ?mcg patch
- Moderate –> strong = /10
- /2
- /3
- /1.5
- 12mcg
- 10mcg
PALLIAITVE Nausea and vomiting - choice of anti-emetic for each indication
1. Reduced gastric motility
2. Chemically mediated (hypercalcaemia, chemo/opioid related)
3. Visceral/serosal (constipation, oral candidiasis)
4. Raised ICP (cerebral mets)
5. Vesibular (H1R activation, opioid/motion related)
6. Cortical (anxiety, pain, fear, H1R and GABA-R activated)
7. Second line/multifactorial
- Metoclopramide/Domperidone
- Ondansetron/Haloperidol
- Cyclizine
- Cyclizine/Dexamethasone if headche
- Cyclizine, Hyoscine Hydrobromide
- Lorazepam
- Levopromazine
How can true seizures be distinguished from psuedoseziures (non-epileptic attack disorder- NEAD)?
Prolactin:
Elevated 10-20mins post episode –> more likely pseudoseizure
GCS: Eyes
- No response
- Eyes open to pain
- ” To voice
- ” Spontaneous
GCS: Verbal
- No noise
- Sounds only
- Inappt words
- Converses but confused
- Orientated
GCS: Motor
- Decerebrate posturing (abnormal extension to pain)
- Decorticate posturing (abnormal flexion to pain)
- Withdraws from pain
- Localises to pain
- Obeys commands
4 rapidly reversible causes of altered LOC
- Dehydration
- Heat stroke
- Hypoglycaemia
- Hypoxia
TOXIDROMES:
Describe changes in HR, RR, temp, pupils, bowel sounds, diaphoresis
For:
Anticholinergic overdose
Atopine
Oxybutinin
Antihistamines
Antipsychotics
Antispasmodics
Anticholinergic –> fight or flight symptoms
1) Tachycardic
2) Tachypnoeic
3) Hyperthermic
4) Mydriasis
5) Reduced/absent
6) Dry/reduced secretions
TOXIDROMES:
Describe changes in HR, RR, temp, pupils, bowel sounds, diaphoresis
For:
Cholinergic overdose
ACHIs e.g. Donepezil, Neostigmine -
pilocarpine
- Normal
- Normal
- Normal
- Miosis - pinpoint
- Normal
- Sweating
TOXIDROMES:
Describe changes in HR, RR, temp, pupils, bowel sounds, diaphoresis
For:
Opioid overdose
Codeine
Tramadol
Morphine
Oxycodone
Heroin- Diamorphine
Fentanyl
Methadone
Diphenoxylate
- Bradycardic
- Resp depression
- Hypothermic
- Miosis - pinpoint pupils
- Dry, reduced secretions
TOXIDROMES:
Describe changes in HR, RR, temp, pupils, bowel sounds, diaphoresis
For:
Sympathomimetic overdose - aka stimulant
Cocaine
Amphetamine
Adrenaline
Noradrenaline
Ritalin
LSD, MDMA
Theophylline
1) Tachycardic
2) Tachypnoeic
3) Hyperthermic
4) Mydriasis - pupil dilation
5) Present bowel sounds
6) Sweating
TOXIDROMES:
Describe changes in HR, RR, temp, pupils, bowel sounds, diaphoresis
For:
Sedative/hypnotic
Benzodiazepines: Diazepam, Lorazepam
Midazolam
Anxiolytics
Z-drugs
Muscle relaxants
- Bradycardic
- Resp depression
- Hypothermic
- Normal pupils
- Absent/reduced bowel sounds
- Dry/reduced secretions
Main distinction between opioid overdose and sedative/hypnotic overdose
opioids - pinpoint pupils
sedative/hypnotic - no change
ANTIDOTES
Prior to antidotes what can be given within 1 hr of ingestion?
* Opioids
* Insulin/sulphonylureas
* Calcium channel blockers
* Organophosphates (muscarinic)
* Paracetamol
* Benzos
* Betablockers
- activated charcoal
- Naloxone
- Glucose
- Calcium gluconate
- Atropine
- N-Acetyl cysteine
- Flumenazil (only if severe; risk of seizures)
- Atropine (anticholinergic)
ANTIDOTES
Tricyclic antidepresants
* Give X if
* ph is less than
* ECG changes:
* or:
Give Sodium Bicarbonate if ph<7.1 (acidotic);
ECG changes - broad complex tachycardia (widened QRS >160ms)
- hypotension
Paracetamol overdose guidelines
- what dosage is potentially fatal
- threshold for starting NAC after checking pct levels
- in which situations would you start NAC before results come back (3)?
- 150mg/kg (24 tablets)
- NAC if above treatment line = if levels are >100mg/l at 4 hrs (or 15mg/l at 15)
Start NAC when
1. Staggered overdose (taken across multiple hours)
2. Outside of 8hr window (8-24hrs)
3. >24s with signs/symptoms of liver damage
Salicylate poisoning
* Findings on blood gas
* Presentation - key symptom
* Management
- Mixed respiratory alkalosis (initial stages as CO2 blown off) and metabolic acidosis (as aspirin dissolves into a weak acid)
- Tachycardic, tachypnoeic, sweating, tinnitus, vomiting, dehydration
- Urinary alkalinsation with IV Bicarb
Other overdoses
name the antidote
* Warfarin
* Heparin
* Methanol
* CO
* Iron
* Cyanide
* Lead
* Digoxine
* Ethylene glycol (antifreeze)
- Vitamin K; prothrombin coplex
- Protamine sulfate
- Fomepizole/Ethanol
- Hyperbaric oxygen; 100% target sats
- Desferroxamine
- Hydroxycobalamin
- Dimercaprol
- Digiband
- Fomepizole/Ethanol
BURNS
Rule of 9s
- Each region: 9% x 11 + 1% (perineum)
Classifying burns (new phrases and appearance):
1st degree
2nd degree (2 types)
Third degree
1. Superficial epidermal - red/painful
2. Partial thickness: superficial dermal: pink/blistering or deep dermal - white/n-b erythema/reduced sensation
3. Full thickness - no pain/blisters. White/brown/black
Factors that would raise suspicion for inhalation injury
- Hoarse voice
- Deep facial burns
- Resp distress/stridor
- Hx of burns in an enclosed space
- carbonaceous sputum
Define eschar and escharotomy
- Reduced elastisity of burnt tissue
- Tissue becomes constrictive
- Procedure to cut the skin to reduce constrictive effect on chest/region
Indication for fluid resus for burns
- which types of burn?
- how much TBSA (adults/kids)?
- Full thickness
- Partial thickness deep dermal
- > 15% TBSA Adults
- > 10% TBSA Children
What is the Parkland Equation for Burns Resus Fluids?
1. Total = in 24hrs
2. What % is given in the first 8 hours?
3. The resus endpoint is defined as a urine output of
4. After 24hrs
- Total = 2-4mls x %BSA of burn x weight (kg), over 24hrs
- 50%
- 0.5ml/kg/hr
- Maintenance crystalloids / colloids
BURNS: Guidelines for referral to secondary care
- All deep dermal and full thickness
- Superficial dermal if >3% TBSA adult or 2% children
- Inhalation, electrical or chemical injury
- Suspicion of NAI
Malignant hyperthermia
* AD inherited condition due to mutation encoding skeletal muscle, causes hypermetabolism - tachy, hyperthermia, high potassium, metabolic acidosis
* Presentation - typical feature
* Causative drugs (2)
* Management (2)
*
- Muscle rigidity in masseter
- Suxamethonium and inhaled anaesthetics - sevo & isoflurane
- cooling and dantrolene to lower ca2+ release
Local Anaesthetic Systemic Toxicity (LAST)
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treatment
paraesthesia, restlessness, vertigo –> seizures and cardiovascular instability
lipid emulsion therapy (sequesters LA away from tissues)
