Acute Flashcards

Question

Acute Severe Asthma Presentation (and important History)

Answer 1

Acute breathlessness and wheee Hx: * Precipitant: infection, travel, exercise? * Usual and recent Rx? * Previous attacks and severity: ICU?

Answer 2

1. PEFR 2. ABG * PaO2 usually normal or slightly reduced * PaCO2 reduced * PaCO2 incresed-\> !! Send to ITU for ventilation 3. Bloods * FBC * U&E * CRP * Blood cultures

Answer 3

acute exacerbation of COPD Pneumothorax Pulmonary oedema

Answer 4

Admission Criteria: * life threatening attack * feature of severe attack persisting despite initial Rx * May discharge if PEFR \>75 1 hr after initial Rx Discharge when * Been stable on discharge meds fo 24hrs: * PEFR \>75 * With diurnal variability \<25%

Answer 5

**A**llergies **M**edication **P**ast medical history **L**ast meal **E**vents leading to revent

Answer 6

1. If **BP** unrecordable call the **cardiac arrest** team 2. **ABC** (including high flow oxygen) 3. **Raise foot of the bed** (unless cardiogenic) 4. **IV access** and 2 x large bore cannulae; get help if this takes \>2min 5. Assessment: 6. - rate/rhythm/ischaemia General- **cold/anaemic/dehydrated/features of anaphylaxis** 1. - HR, difference in BP between arms 2. 3. - trauma/aneurysm? 1. Identify and tx underlying cause: For **septic shock**- **gentamycin + antipseudomonal penicillin**. NB- if patient remains hypotensive despite fluids and vasopressors give low-dose steroids or recombinant human activated protein C. For **hypovolaemic shock**- **fluid replacement** titrated against BP, CVP, urine. If \>1L fluid needed then ?blood transfusion. For **heat exhaustion**- **tepid sponging and fanning**, 0.9% saline + hydrocortisone. ? chlorpromazine to stop itching. Stop cooling when temp \<39. 1. Give **crystalloid** fast to restore BP (unless cardiogenic shock) 2. **Seek expert help** early 3. **Invx-** FBC/U&E/glucose/CRP, X-match and clotting, blood/urine cultures, ECG, CXR, lactate, echo, abdominal CT, USS 4. Consider **arterial line, CV line, bladder catheter** 5. Tx underlying cause 6. **Fluid replacement** as dictated by BP/CVP/urine output 7. Don’t overload with fluids if cardiogenic shock 8. If persistently hypotensive **consider inotropes**

Answer 7

Blood loss * Trauma * GI bleeding (*haematemeisis, melaena*) * Ruptured AAA * Ruptured ectopic pregnancy Fluid loss / redistribution (‘third spacing’) * Burns * GI losses (vomiting, diarrhoea) * Pancreatitis * Sepsis

Answer 8

* ABCDE * Give high flow O2 by mask * Venous access * FBC, U&E, glucose, LFT, lactate, coagulation screen * Blood cultures if appropriate * Monitor vital signs * Pulse, BP, O2 * Check ABG * ECG and CXR * Insert urinary catheter and monitor urine output hourly * For shock associated with decreased effective circulating volume: * IV crystalloid (0.9% saline) 20ml/kg bolus * Give further IV fluids including colloid +/- blood * Aim for haemocrit \>30% * Look for the cause(s) of shock: * Echo * USS * CT Surgical intervention * Treat the specific cause of shock: * Laparotomy: Ruptured AAA, splenic or liver trauma, ruptured ectopic pregnancy, intra-abdominal sepsis * Thrombolysis / angioplasty: MI * Thrombolysis: PE * Pericardiocentesis/cardiac surgery: Cardiac tamponade * Antibiotics: Sepsis * Depends on perceived cause and local policies * If there is no obvious source, empirical combination therapy is advised (e.g. co-amoxiclav + gentamycin + metronidazole) * Obtain specialist microbiological advise early especially in neutropenic / immunocompromised patients * Inotropic and vasoactive therapy, assisted ventilation and invasive monitoring (including arterial and CVP lines) are often needed as part of goal directed therapy. Get specialist ITU help Early

Answer 9

1. Management: * C ABCDE * Haemorrhage control * Apply pressure to the wound

Answer 10

1. Definition: * Severe, life-threatening, systemic hypersensitivity reaction 1. Common Causes: * Food e.g. nuts * Most common cause in children * Drugs * Penicillin’s * Anaesthetic drugs * Contrast media * Blood products * Venom e.g. wasp stings

Answer 11

1. Early Signs: * Utricaria * Bronchospasm / stridor * Vomiting +/- diarrhoea * Flushing * Abdominal pain * Sense of impending doom 1. Worrying signs: * BP \<90mmHg systolic * Decreased O2 sats * Chest tightness * Stridor

Answer 12

1. Secure the airway- give **100% O2**. Intubate if respiratory obstruction 2. **Remove the cause**, **raise the feet of the bed** 3. **Adrenaline** IM 0.5mg, every 5mins as guided by BP/pulse/resp function 4. Secure **IV access** 5. **Chlorphenamine** 10mg IV and **hydrocortisone** 200mg IV 6. **IVI 0.9% saline** over 15mins (up to 2L may be needed); titrate against BP 7. **If wheeze, tx for asthma**; may require ventilator support 8. If still hypotensive, admit to ITU and give **IVI adrenaline +/- aminophylline** and **nebulized salbutamol**; get expert help 9. Admit to ward. Monitor ECG 10. Continue **chlorphenamine** 4mg/6h PO if itching 11. **Medic Alert bracelet** 12. Teach about **Epipen** 13. **Skin prick tests** to identify cause

Answer 13

1. **ABCDE** 2. Attach **ECG monitor** and **12 lead ECG** 3. **O2** 2-4L aim for SaO2\>95% (mask or nasal prongs) 4. **IV access**- bloods for FBC, U&E, glucose, lipids, cardiac enzymes 5. Brief assessment: **Hx** of CV disease; risk factors for IHD, contraindications to thrombolysis? **Examine**: pulse, JVP, cardiac murmurs, signs of heart disease, scars from previous surgery 1. **Aspirin** 300mg PO, +/- clopidogrel 2. **Morphine** 5-10mg IV + antiemetic e.g. **metoclopramide** 10mg IV 3. **GTN** sublingually or 2 puffs or 1 tablet PRN 4. **Primary PCI** (best if ongoing ischaemia and presentation within 12h) or **thrombolysis** (target time \<30mins. DO NOT thrombolyse if ST depression alone, T wave inversion alone or normal ECG). **Streptokinase** 1^st line for non-anterior MI 1.5million units 100mL 0.9% saline IVI over 1 hour. Tenecteplase IF anterior MI/ previous use of SK/ systolic BP\<100/ new LBBB. IF allergic reaction to SK give alteplase 5. **B-blocker** e.g. atenolol 5mg IV + **ACEi** 6. **DVT prophylaxis** until mobile 7. **Continue medication** except calcium channel antagonists 8. Admit for 48h of **bedrest and continous ECG** 9. **Daily examination** 10. **Aspirin** 75mg 11. **B-blockers for 1 year** to maintain HR\<60 12. **Continue ACEi** 13. Start **statin** 14. **Address risks**

Answer 14

1. **ABCDE** 2. Attach **ECG monitor and 12 lead ECG** 3. **O2** 2-4L aim for SaO2\>95% (mask or nasal prongs) 4. **IV access**- bloods for FBC, U&E, glucose, lipids, cardiac enzymes 5. Brief assessment: **Hx** of CV disease; risk factors for IHD, contraindications to thrombolysis? **Examine:** pulse, JVP, cardiac murmurs, signs of heart disease, peripheral pulses, scars from previous surgery 1. **Morphine** 5-10mg IV + **antiemetic** e.g. metoclopramide 10mg IV 2. **GTN** sublingually or 2 puffs or 1 tablet PRN 3. **Aspirin** 300mg PO, +/- **clopidogrel** 300mg (add clopidogrel IF increased troponin, ACS already on aspirin, ST depression on resting ECG, ACS after recent MI, patients being transferred for angioplasty, aspirin intolerant) 4. **Oral B blocker** e.g. metoprolol 50-100mg/8h (if CI give diltiazem 60-120u/kg/12h) 5. **Heparin** e.g. enoxaparin 1mg/kg/12h. If LMWH is unavailable give unfractionated heparin 5000IV bolus then IVI. Check APTT 6-hourly 6. **IV nitrate** if pain continues (e.g. GTN 50mg in 50mL 0.9% saline at 2-10mL/h) titrate to pain and maintain systolic BP\>100mmHg 7. Record **ECG in pain** 8. If patient high-risk (persistent or recurrent ischaemia, ST depression, diabetes, increased troponin) infuse a **GPIIb/IIIa antagonist** (e.g. tirofiban) and, ideally, **urgent angiography**. Add **clopidogrel**. Then optimise drugs- **B-blocker/Ca2+ channel antagonist/ACEi/nitrate**. Intensive **statin regimens,** start at top doses e.g. atorvastatin 80mg. If symptoms fail to improve, refer to a cardiologist for urgent angiography +/- PTCI or CABG 9. If the patient is low-risk (no further pain, flat or inverted T waves, or normal ECH and negative troponin), the patient may be **discharged if a repeat troponin (\>12h) is negative**. Treat medically and arrange further invx e.g. stress test, angiogram 10. **Wean off GTN** infusion when stabilised on oral drugs 11. **Start heparin** when pain-free for 24h but give at least 3-5 days of therapy 12. Check **serial ECGs, and troponin** \>12h after pain 13. **Address modifiable risk factors**: smoking, HTN, hyperlipidaemia, diabetes 14. **Gentle mobilisation**

Answer 15

**Narrow Complex Tachycardia:** * Regular: * Sinus tachy * Irregular: * Possible AF **Broad Complex Tachycardia:** * Regular * Assume VT * Irregular * AF with bundle branch block

Answer 16

* ABCDE * Haemodynamically unstable: Immediate cardioversion * Signs of heart failure (basal crepitations, raised JVP) * Signs of shock * Not-haemodynamically unstable: * Amiodarone * Ideally through a central line * If drug therapy fails: * Electrophysiological study * Implantable cardioverted-defibrillator

Answer 17

1. If **no pulse****à cardiac arrest** protocol 2. **ABCDE** 3. **O2, ECG and IV access** 4. Connect patient to **cardiac monitor** and have a defibrillator to hand 5. Assess if there are any adverse signs i.e. systolic BP\<90/chest pain/ heart failure/ HR\>150 6. If NO adverse signs: Correct **electrolyte problems** If regular rhythm **Amiodarone 300mg IV** over 20-60min, then 900mg over 24h. OR lidocaine If irregular rhythm the diagnosis is usually AF or pre-excited AF (amiodarone) or polymorphic VT e.g. torsade de points (Mg IVI) If this fails, get expert help **Sedation** **Synchronised DC shock**à 200J-300J-360J (monophasic) 1. If YES adverse signs Get **expert help** **Sedation** Synchronised **DC shock** 200J-300J-360J (monophasic) **Amiodarone** 300mg IV over 20-60min; then 900mg over 24h **K+ and Mg2+ correction** (up to 60mmol KCl at 30mmol/L and 4ml 50% MgSO4) **Further cardioversion** if needed For refractory cases consider: **lidocaine/procainamide/felcanide/overdrive pacing** 1. Establish the cause 2. IF VT occurs **after MI IV amiodarone**/lidocaine for 12-24h or amiodarone (if poor LV function). Can prevent recurrent VT using surgical **isolation of the arrhythmogenic area or an ICD**

Answer 18

Epidemiology: * Most common sustained cardiac arrhythmia * Present in about 5% of patients over aged 70-75 / 10% in patients aged 80-85 Types: * First detected episode * Recurrent: * 2\>= * If the episodes of AF terminate spontaneously = ***paroxysmal*** AF – Last less than **7** days (typically \< 24hr) * If not self-terminating then ***persistent*** AF is used (such episodes last \>**7** days) * Permanent AF: * Can't be cardioverted / or attempts are deemed inappropriate * Treatment goals are therefore rate control and anticoagulation if appropriate

Answer 19

* Symptoms: * Palpitations * Dyspnoea * Chest pain * Signs: * Irregularly irregular pulse * Investigations: * An ECG is essential to make the diagnosis as other conditions can give an irregular pulse, such as ventricular ectopics or sinus arrhythmia

Answer 20

* Seek immediate senior help * Treat shock * O2 * IV access * DC cardioversion * If unsuccessful – Amiodarone

Answer 21

* Interstitial oedema * Bat’s wing appearance * Upper lobe diversion (increased blood flow to the superior parts of the lung) * Kerly B lines * Pleural effusion * Cardiomegaly may be seen if there is a cardiogenic cause

Answer 22

1. **ABCDE** 2. 100% **oxygen** 3. **IV access and monitor ECG**; treat any arrythmias 4. Invx: **CXR, ECG, U&E, ‘cardiac’ enzymes, ABG, consider ECHO** 5. (during treatment monitor progress with BP/pulse/cyanosis/resp rate/JVP/urine output/ABG) 6. **Diamorphine 2.5-5mg** IV slowly- caution in liver failure and COPD 7. **Furosemide 40-80mg** IV slowly- larger doses in renal failure 8. **GTN** 2 puffs SL or 2 x 0.3mg tablets SL (NOT if BP\<90) 9. Necessary invx, examination and hx 10. If systolic **BP\>100 give isosorbide dinitrate 2-10mg/h** IVI; keep systolic BP\>90 11. If patient is worsening: further dose of **furosemide 40-80mg**. Consider **ventilation** (invasive or non-invasive e.g. CPAP; get help) or nitrate infusion. 12. If systolic **BP\<100mmHg, tx as cardiogenic shock** i.e. insert Swan Ganz catheter and inotropic support 13. **Daily weights; BP and pulse/6h**. Repeat CXR 14. Change to **oral furosemide or budesonide** 15. If on large doses of loop diuretic consider the addition of a **thiazide** e.g bendroflumethiazide 2.5-5mg daily PO 16. **ACE-i if LV failure**. If contraindicated/blackà hydralazine is better 17. Consider **B-blocker and spironolactone** 18. Is the patient suitable for **biventricular pacing and cardiac transplantation?** 19. Consider **digoxin and warfarin** esp if AF

Answer 23

1. **ABCDE** 2. **Oxygen** titrated to adequate arterial saturations 3. **Diamorphine** 2.5-5mg IV for pain and anxiety 4. **Invx-** ECG, U&E, cardiac enzymes, ABG, CXR, ECHO. IF indicated do CT thorax or V/Q scan 5. **Monitor- CVP, BP, ABG, ECG, urine output. 12 lead ECG** hourly until diagnosis. Consider **Swanz-Ganz catheter** for pulmonary wedge pressure and cardiac output, and an **arterial line** to monitor pressue. **Catheterise** for urine output. 6. Correct **arrhythmias, U&E abnormalities or acid-base disturbance** 7. **Optimise filling pressure** (if available measure pulmonary capillary wedge pressure) 8. IF PCWP\<15 fluid load-\> Give a **plasma expander** every 15min IV, aiming for PCWP 15-20. IF PCWP\>15-\> give **inotropic support e.g. dobutamine 2.5-10microgram/kg/min IVI**. Aim for systolic BP \>80mmHg 9. Consider **renal dose dopamine 2-5microgram/kg/min IV** initially 10. Consider **intra-aortic balloon pump** if you expect the underlying condition to improve or you need time awaiting surgery 11. Look for and tx any reversible cause e.g. thrombolysis for MI/PE, surgery for valve problems

Answer 24

*Note that a patient having any one of the life-threatening features should be treated as having a life-threatening attack*

Answer 25

* Follow the BTS/SIGN guidelines * ABCDE * High flow O2 * Put the bed back and rails up so the patient is sitting up and holding onto the side rails * To use pectoral muscles as accessory muscles * If patient cannot talk, start treatment but get senior ED and ICU help in case intubation and ventilation are required * Check trachea and chest signs for pneumothorax * Ask about previous admissions to ITU * Administer high dose nebulised beta-2 agonists * E.g. Salbutamol 5mg * Or 10 puffs salbutamol into a spacer device and face mask * For severe asthma or asthma that responds poorly to the initial nebuliser, consider continuous nebulisation * Give a corticosteroid * Prenisolone 40-50mg PO * Hydroxortisone 100mg IV * Add nebulised ipratropium bromide (500mcg) to beta-2 agonist treatment for patients with acute severe or life-threatening asthma or those with a poor initial response to beta-2 therapy * Magnesium sulphate recommended as next step for patients who are not responding * Consult with senior medical staff * E.g. 1.2-2g IV over 20 mins * Little evidence to support use of IV aminophylline (still mentioned in management plans) * If no response consider IV salbutamol * Consult with senior medical staff * Avoid ‘routine’ ABx * Repeat ABG within the hour * Hypokalaemia may be caused or exacerbated by beta-2 agonists and / or steroid therapy OR: 1. **Hx**- usual and recent tx, previous acute episodes, best PEFR, ITU admissions 2. **Assess severity** Severe- unable to complete sentences, RR\>25, HR\>110, PEFR\<50% Life-threatening- PEFR\<33%, silent chest, bradycardia/hypotension, exhaustion For severe attack: 01912817256, 07904144006, 07886420 1. Sit patient up at give **100% O2** via non-breathable bag 2. **Salbutamol 5mg plus ipratropium bromide 0.5mg** nebulised with O2 3. **Hydrocortisone 100mg IV or prednisolone 40-50mg** PO 4. **ABG, CXR, FBC, U&E** 5. **Monitor O2 sats, HR and resp rate** 6. IF life-threatening featuresà inform seniors and give **magnesium sulphate 1.2-2g IV** over 2 min. Give **salbutamol nebulisers every 15min** (with monitoring for arrhythmias) 7. IF patient improvesà **40-60% O2, prednisolone** 40-50mg/24h PO for 5 days, nebulised **salbutamol 4hourly** 8. IF patient doesn’t improve after 15-30mins, continue **100% O2 and steroids**, give **hydrocortisone 100mg IV** or prednisolone 30mg PO if not already given, **salbutamol nebulisers** every 15 mins, **continue ipratropium** 0.5mg every 4-6h 9. IF patient still doesn’t improve, discuss with seniors and ITU, **salbutamol nebulisers** every 15 mins, **magnesium sulphate** 1.2-2g IV over 20mins. Consider **aminophylline** 5mg/kg IVI over 20mins. If no improvement, transfer to ITU with doctor prepared to intubate. 10. Record PEFR pre- and post- B agonist in hospital at least 4 times 11. Once the patient is improving, wean down and **stop aminophylline** over 12-24h. **Reduce nebulised salbutamol** and switch to **inhaled B-agonist**. Initiate **inhaled steroids** and stop oral steroids if possible. Continue to monitor PEF. Look for deterioration on reduced treatment and beware early morning dips in PEF. Look for the cause. 12. Before discharge they must have been **stable on medication for 24h**, had **inhaler technique** checked, **PEFR\>75%,** **steroid and bronchodilator therapy, own a PEFR and management plan, GP appointment within 1 wk, Resp clinic appointment** within 4 weeks.

Answer 26

* Admit patients with any features of: * A life-threatening or near-fatal attack * Severe attack persisting after initial treatment

Answer 27

Refer any patient requiring ventilator support or with acute severe or life threatening asthma failing to respond to therapy, evidenced by: * Drowsiness, confusion * Exhaustion, feeble respiration * Coma or respiratory arrest * Persisting or worsening hypoxia * Hypercapnoea * ABG showing acidosis * Deteriorating peak flow

Answer 28

* Underlying rhythm is usually PEA * This may reflect one or more of the following: * Prolonged severe hypoxia * Hypoxia related arrhythmias * Tension pneumothorax * Give ATLS * Treat tension pneumothorax if present

Answer 29

* Most common bacterial organisms: * Haemophilus influenzae (most common cause) * Streptococcus pneumoniae * Moraxella catarrhalis * Respiratory viruses account for around 30% * Most important is the human rhino virus

Answer 30

* Worrying signs: * Low GCS * Rising CO₂ * Symptoms: * Breathlessness * Cough * Increased sputum * Tight chest * Confusion * Decreased exercise tolerance * Signs: * Wheeze * Cyanosis * Barrel-chest * Poor expansion * Tachypnoea

Answer 31

* ABG * Often deranged in COPD * Compare with previous sample * Pay close attention to FiO2 * Repeat after 30 mins * CXR: * Hyper-expanded chest * Flat diaphragm * Spirometry: * Decreased FEV1 * Decreased FEV1:FVC ratio (\<70%)

Answer 32

* ABCDE * Sit the patient up * Give oxygen to maintain sats \>/ 88% * Aim for PaO2 ~8kPa * Give salbutamol 5mg +/- ipratropium 500mg nebs * Drive by **air** * Leaving **nasal O2 cannulae on under mask if necessary** * Steroids * Add prednisolone 30mg PO * Or hydrocortisone 200mg IV * Sputum for M, C & S * ABG * CXR * Portable if unwell * *Use ABG results and clinical observation to guide further management:* * Normal ABG (for them) continue current O2 and give regular nebs * Worsening hypoxaemia increased FiO2, repeat ABG \<30 min, watch for confusion which should prompt for ABG sooner, consider NIV * Increasing CO2 retention or worsening GCS, request senior help urgently, consider: * ICU input/assessment * Aminophylline 5mg/kg bolus over 20 min unless the patient us on oral aminophylline or theophylline * NIV * Consider prescribing ABx if the patient has increased *SOB, fevers, worsening cough, purulent sputum or focal changes on CXR* *OR* 1. **ABC** 2. **Hx**- usual/recent tx, smoking status, exercise capacity 3. PEFR, ABG, CXR, FBC, U&E, CRP, ECG, Blood cultures, sputum culture 4. **Controlled O2** therapy, starting at 24-28%. Aim for PaO2\>8 5. **Nebulised bronchodilators** Salbutamol 5mg/4h and ipratropium 500 microgram/6h 6. **Steroids** IV hydrocortisone 200mg and oral prednisolone 30-40mg (continue for 7-14d) 7. **Abx** if evidence of infection e.g. amoxicillin 500mg/8h PO 8. **Physiotherapy** to aid sputum expectoration 9. If no responseà **repeat nebulisers and consider IV aminophylline** 10. If no responseà **consider NIPPV** if resp rate \>30 or pH\<7.35 11. Consider intubation and ventilation if pH\<7.26 and PaCO2 is rising 12. Consider a **respiratory stimulant** drug e.g. doxapam 1.5-4mg/min IV 13. Prior to discharge liaise with GP regarding **steroid reduction, domiciliary oxygen, smoking and vaccines** 1. For stable COPD: advice stop smoking, exercise, tx poor nutrition/obesity, influenza, vaccines. For mild diseaseà short acting B-agonist or ipratropium bromide PRN. For moderateà regular short acting B2 agonist +/or ipratropium. Consider steroid trial. For severe diseaseà combination therapy with regular short-acting B agonist and ipratropium. Consider steroid trial and assess for home nebulisers. 2. For more advanced disease- consider pulmonary rehabilitation and long term oxygen therapy if O2\<7.3. Surgery if recurrent pneumothoraces, isolated bullous disease, volume reduction surgery. Assess the social circumstances and support required. Air travel may be hazardous.

Answer 33

Definitions: * Primary = No underlying lung disease * Secondary = Underlying lung disease Risk Factors: * Primary = Tall, thin, male, Marfan’s, recent central line, pleural aspiration or chest drain * Secondary = COPD, asthma, infection, trauma, mechanical ventilation

Answer 34

* Symptoms: * Breathlessness * +/- Chest pain * Signs: * Hyper-resonant * Reduced air entry on affected side * Tachypnoea * Tracheal deviation * Investigations: * CXR

Answer 35

* General Management: * ABCDE * Sit patient up * Give O2 * Primary Pneumothorax (BTS Recommendations): * If rim of air is \<2cm and the patient is not short of breath then discharge should be considered * Otherwise aspiration should be attempted * If this fails (defined as \>2cm or still SOB, then a chest drain should be inserted) * Patients should be advised to avoid smoking to reduce the risk of further episodes * Secondary Pneumothorax: * If the patient is \>50 years old and the rim of air is \>2cm and/or the patient is SOB then a chest drain should be inserted * Otherwise aspiration should be attempted if the rim of air is between 1-2cm * If aspiration fails then a chest drain should be inserted * All patients should be admitted and observed for at least 24hrs * If \<1cm then the BTS guidelines suggest giving O2 and observing for 24hrs

Answer 36

* Less likelihood of recurrence than spontaneous pneumothorax * Majority will resolve with observation, if treatment is required then aspiration should be used * Ventilated patients need chest drains, as may some with COPD

Answer 37

* Mechanism: * Air trapped in the pleural space is under +ve pressure * Mediastinal shift may occur, compressing the contralateral lung and reducing venous return * Signs: * Hypotensive * Circulatory shock is the single most reliable sign of tension pneumothorax * Tachycardia * Tachypnoea * Unilateral hyper-resonance * Reduced air entry * Raised JVP * Tracheal deviation

Answer 38

* *This is an emergency and will worsen if not treated* * ABCDE * Sit the patient up and give 15L oxygen * Treat prior to CXR * Thoracocentesis - Insert large cannula (orange / grey) into the 2^nd intercostal space, midclavicular line * Listen for a hiss * Leave in situ * Insert a chest drain on the same side (with an underwater seal)

Answer 39

* Bacterial (80-90%) * Streptococcus pneumoniae = Most common cause of community acquired pneumonia * Others include mycoplasma pneumoniae, haemophilus influenzae, legionella * Always consider TB, particularly in chronic alcoholism, poor social circumstances, immigrants and those travelling to developed countries * Immunosuppressed patients (e.g. HIV, steroid therapy) are at increased risk of TB and Pneumocystis jirovecii * Viral (10-20%):

Answer 40

* Some patients with ‘mild’ illness, good social circumstances and no significant co-morbidity may be safely discharged with appropriate antibiotics (e.g. amoxicillin 0.5-1g PO tds), simple analgesia and GP follow up * Patients with a CURB-65 score \>= 3 have severe pneumonia with a high risk of death (-\>ITU) * Patients who score 2 are at increased risk of death and should be considered for inpatient treatment or hospital supervised outpatient care * Patients with a CURB-65 score of 0-1 are suitable for home treatment

Answer 41

* Patients deemed suitable for discharge: * Simple analgesia * Oral ABx * GP follow up * Patients admitted but not severely unwell * Oral: Either amoxicillin 0.5-1g PO tds + erythromycin 500mg PO qds (or clalithromycin 500mg bd) * IV: Ampicillin 500mg IV qds + erythromycin 500mg IV qds (or clalithromycin 500mg bd) * Monitor SpO2 and provide O2 accordingly * Provide simple analgesia * Patients with sepsis or severe sepsis: * IV crystalloid fluids * Take blood cultures * Administer IV ABx * E.g. co-amoxiclav + clalithromycin * Contact ITU and make preparations for arterial line, central line and urinary catheter insertion

Answer 42

* Pulmonary oedema * Pulmonary infarction * Pulmonary vasculitis * SLE PAN, Churg-Strauss and Wegner’s * Aspergillosis * Allergic alveolitis * Bronchial or alveolar cell carcinoma

Answer 43

Causes: An exudate is diagnosed if the pleural fluid:serum protein \>0.5, fluid:serum LDH \>0.6 or the fluid LDH is \>2/3 the upper limits of lab normal value * Exudates: * Pneumonia (bacterial, viral, mycoplasma) * Malignancy (bronchial carcinoma, mesothelioma, lymphoma) * TB * PE, with pulmonary infarction * Transudates: * Cardiac failure * Nephrotic syndrome * Hepatic failure * Ovarian hyperstimulation * Ovarian fibroma (Meig’s syndrome)

Answer 44

* Symptoms: * Usually due to underlying disease process * A mild dull ache * Dyspnoea (initially at exercise and later at rest) may occur if large * A history of vomiting followed by chest pain points to a ruptured oesophagus – a surgical emergency * Signs: * Not apparent until \>500ml is present * Dyspnoea * Stony dull to percussion * Absent breath sounds over the effusion are characteristic * Bronchial breathing may be heard just above the effusion * Very large unilateral effusion may produce evidence of mediastinal shift * Investigations: * CXR can demonstrate pleural effusions as small as 250ml * Blunting of the costrophrenic angle

Answer 45

* Provide O2 and resuscitate as necessary, according to the underlying pathology * Emergency therapeutic pleural aspirations are rarely required in the ED except where haemothorax is suspected * Refer to medical team for further investigation * US gluided diagnostic pleural aspiraton

Answer 46

* Pleuritic chest pain * Dyspnoea * Haemoptysis * Patients can present with virtually any cardio / respiratory symptom

Answer 47

* All patients with symptoms or signs suggestive of a PE should have a history taken, examination performed and a CXR to exclude other pathology * If a PE is still suspected then a two-level Wells score should be performed * \> 4 = PE likely * PE likely: * Arrange an immediate computed tomography pulmonary angiogram (CTPA) * If there is a delay in getting the CTPA then give low-molecular weight heparin until the scan is performed PE unlikely: * Arrange a D-dimer test * If positive arrange an immediate CTPA * If there is a delay in getting the CTPA then give low-molecular weight heparin until the scan is performed If patient has an allergy to contrast media, V/Q scan should be arranged instead

Answer 48

* S1Q3T3 * Large S wave in lead I * A large Q wave in lead III * An inverted T wave in lead III * Right bundle branch block and right axis deviation are also associated with PE * Sinus tachycardia may also be seen

Answer 49

* Low molecular weight heparin (LMWH) or fondaparinux should be given initially after a PE is diagnosed * An exception to this is for patients with a massive PE where thrombolysis is being considered * In such a situation, unfractionated heparin should be used * A vitamin K antagonist e.g. warfarin should be started within 24 hours of diagnosis * The LMWH or fondaparinux should be continued for at least 5 days or until the INR is 2.0 or above for at least 24 hours, whichever is longer * Warfarin should be continued for at least 3 months * At 3 months, NICE recommend that clinicians should assess the risks and benefits of extending treatment * NICE advise extending warfarin beyond 3 months for patients with an unprovoked PE * This essentially means that if there was no obvious cause or provoking factor (surgery, trauma, significant immobility) it may imply the patient has a tendency to thrombosis and should be given treatment longer than the norm of 3 months * For patients with active cancer, NICE recommend LMWH for 6 months Thrombosis: * Thrombolysis is now recommended as first-line treatment for massive PE where there is circulatory failure e.g. hypotension

Answer 50

* If a patient is suspected of having a DVT, a two-level DVT Wells score should be performed: * Clinical probability simplified score: * 2 points or more = DVT likely * 1 point or less = DVT unlikely * DVT likely (2 points or more) * Proximal leg vein USS should be carried out within 4 hours and, if the result is negative, a D-dimer test * If a proximal leg vein USS cannot be carried out within 4-hours, a D-dimer test should be done and LMWH administered whilst waiting for a proximal leg vein USS (which should be performed within 24 hours) * DVT unlikely (1 point or less) * Perform a D-dimer and if positive manage: * A proximal leg USS within 4 hours * If a proximal leg vein USS cannot be carried out within 4-hours, a D-dimer test should be done and LMWH administered whilst waiting for a proximal leg vein USS (which should be performed within 24 hours)

Answer 51

* LMWH or fondaparinux should be given initially after a DVT is diagnosed * A vitamin K antagonist (e.g. warfarin) should be given within 24 hours of the diagnosis * The LMWH or fondaparinux should be continued for at least 5 days or until the INR is 2.0 or above for at least 24 hours * I.e. LMWH or fondaparinux is given at the same time as warfarin until the INR is in the therapeutic range * Warfarin should be continued for at least 3 months * At 3 months NICE say you should review the risks and benefits of continuing treatment * Consider extending warfarin over 3 months for patients with unprovoked proximal DVT if their risk of VTE is high and there is no additional risk of major bleeding * For patients with active cancer, NICE recommend using LMWH for 6 months

Answer 52

**_Investigation for malignancy:_** * Both malignancy and thrombophilia are obvious risk factors for DVT * NICE make recommendations on how to investigate patients with unprovoked clots * Offer all patients diagnosed with unprovoked DVT or PE who are not already known to have cancer the following investigations for cancer: * A physical examination (guided by the patient’s full history) * A CXR * Blood tests (FBC, serum calcium, LFTs) and urinalysis * Consider further investigations for cancer with an abdomino-pelvic CT scan (and mammogram for women) in all patients aged over 40 years with a first unprovoked DVT or PE **_Thrombophilia screening:_** * Not offered if patients are on lifelong warfarin (e.g. wont alter management) * Consider testing for antiphospholipid antibodies if unprevoked DVT or PE * Consider testing for hereditary thrombophilia in patients who have had an unprevoked DVT or PE and who have a first degree relative who has had a DVT or PE

Answer 53

Each ED requires a rapid initial assessment of head-injury patients * Exact system will depend on local policy * It must enable urgent treatment of those patients liable to complications * Experienced nursing staff can quickly identify those patients in need of urgent attention based upon: * Mechanism of injury * History from ambulance crew * An assessment of vital signs * Consciousness according to GCS * Limb power * Pupil responses * BMG * Patients who are heamodynamically stable, alert and orientated * Take full history

Answer 54

* **0-3 months** * Group B Streptococcus * E.Coli * Listeria monocytogenes * **3 months – 6 years** * Neisseria meningitides * Streptococcus pneumoniae * Haemophilus influenzae * **6 years – 60 years** * Neisseria meningitides * Streptococcus pneumoniae * **\> 60 years** * Streptococcus pneumoniae * Neisseria meningitidis * Listeria monocytogenes * **Immunosuppressed** * Listeria monocytogenes

Answer 55

* Bloods: * FBC * CRP * Coagulation * Blood culture * Whole blood PCR * Blood glucose * Blood gas * Lumbar puncture * No signs of raised ICP * CSF Analysis * *The Ziehl-Neelsen stain is only 20% sensitive in the detection of tuberculous meningitis and therefore PCR is sometimes used (sensitivity = 75%)* * *\*mumps is unusual in being associated with a low glucose level in a proportion of cases. A low glucose may also be seen in herpes encephalitis*

Answer 56

* All patients should be transferred to hospital urgently * If patients are in a pre-hospital setting (e.g. GP) and meningococcal disease is suspected then IM benzylpenicillin may be given if it does not delay the transit to hospital * Antibiotics: TABLE * If the patient has a history of immediate hypersensitivity reaction to penicillin or to cephalosporins the BNF recommends using **chloramphenicol** * n.b manage contacts

Answer 57

* Prophylaxis needs to be offered to household and close contacts of patients affected with meningococcal meningitis * Oral ciprofloxacin or rifampicin may be used * The risk is highest for the first 7 days but persists for at least 4 weeks * Meningococcal vaccination should be offered to close contacts when serotype results are available, including booster doses to those who had the vaccine in infancy * For pneumococcal meningitis no prophylaxis is generally needed * There are however exceptions to this

Answer 58

* 85% are due to rupture of berry aneurysms * Conditions associated with berry aneurysms: * Adult polycystic kidney disease * Ehlers-Danlos syndrome * Coarctation of the aorta * AV malformations * Trauma * Tumours

Answer 59

symptoms: * Rapid onset (\<2mins), severe, continuous (\>2hr) headache * Occipital * ‘Hit around the head’ * Vomiting * Dizziness * +/- seizures Signs: * LOC * Most concerning * Neck stiffness * Drowsy / Decreased GCS * Photophobia * Focal neurology

Answer 60

CT: Negative in 5% LP: after 12hrs (allow time for xanthochromia to develop)

Answer 61

* Cerebral ischaemia * Rebleeding (in 30%) * Obstructive hydrocephalus (due to blood in ventricles) * Vasospasm leading to cerebral ischaemia * Death

Answer 62

* ABCDE * 15L/min O2 * Analgesia * Codeine 30mg PO * 5mg morphine IV * Anti-emetic: * Metoclopramide 10mg IV/IM * Reassess often and request neurological observations * Lie patient flat and advise not to get up or eat * Involve anaesthetist and neurosurgeon early and consider transfer to ICU if low GCS * Neurosurgical option * No clear evidence over early surgical intervention against delayed intervention * Post-operative ***nimodipine*** * Has been shown to reduce the severity of neurological deficits but doesn’t reduce rebleeding

Answer 63

Definition * Also known as cerebrovascular accident (CVA) * Sudden interruption of the vascular supply to the brain * Remember that neural tissue is completely dependent on aerobic metabolism so any problem with oxygen supply can quickly lead to irreversible damage Epidemiology * Significant cause of morbidity and mortality * In the UK alone there are over 150000 strokes per year with over 1.2 million stroke survivors * 4^th largest cause of death in the UK

Answer 64

* Ischaemic * \<24 hours = Transient ischaemic attack * \>24 hours = Ischaemic stroke * Haemorrhagic

Answer 65

* Rapidly developing clinical signs of focal (at times global) disturbance of cerebral function lasting more than 24hrs or leading to death with no apparent cause other than that of vascular origin * WHO * Features include: * Motor weakness * Speech problems (dysphasia) * Swallowing problems * Visual field defects (homonymous hemianopia) * Balance problems * Cerebral hemisphere infarcts may have the following symptoms: * Contralateral hemiplegia * Initially flaccid then spastic * Contralateral sensory loss * Homonymous hemianopia * Dysphagia * Brainstem infarction: * May result in more severe symptoms including quadriplegia and locked in syndrome * Lacunar infarcts: * Small infarcts around the basal ganglia, internal capsule, thalamus and pons * This may result in pure motor, pure sensory, mixed motor and sensory signs or ataxia

Answer 66

* The following criteria should be assessed: * Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg * Homonymous hemianopia * Higher cognitive dysfunction e.g. dysphagia * Whilst symptoms alone cannot be used to differentiate haemorrhagic from ischaemic strokes, patients who’ve suffered haemorrhages are more likely to have: * Decreased level of consciousness: seen in upto 50% of patients with haemorrhagic stroke * Headache is also more common in haemorrhagic stroke * Nausea and vomiting is also common * Seizures occur in upto 25% of patients

Answer 67

* Face – Has their face fallen on one side, can they smile? * Arms = Can they raise both arms and keep them there * Speech = Is their speech slurred * Time = Time to call 999 if you see any single one of these signs

Answer 68

* Patients with suspected stroke need to have emergency neuroimaging * The main cause for urgency is to see whether a patient may be suitable for thrombolytic therapy to treat early ischaemic strokes * The two types of neuroimaging used in this setting are CT and MRI

Answer 69

* If stroke is ischaemic and certain criteria are met, the patient should be offered thrombolysis * Example criteria include: * Patients present within 4.5 hours of onset of stroke symptoms * The patient has not had a previous intracranial haemorrhage, uncontrolled HTN, pregnant * Once haemorrhagic stroke has been excluded, patients should be given aspirin 300mg as soon as possible and antiplatelet therapy should be continued nb: contraindications to thrombolyrsis

Answer 70

* The treatment of TIAs focus on reducing their risk of further attacks * ABCD2 prognostic score TABLE * This gives a total score ranging from 0-7 * \>= 4 – Higher risk of stroke should be given: * Aspirin 300mg daily, started immediately * Specialist assessment and investigation within 24 hours of onset of symptoms * Measures for secondary prevention introduced as soon as the diagnosis is confirmed including discussion of individual risk factors * \<= 3 * Specialist assessment within 1 week of symptom onset, including decision on brain imaging * If vascular territory or pathology is uncertain, refer for brain imaging * \>= 2 episodes in one week (crescendo TIA) should be treated as being at high risk of stroke, even though they may have a ABCD2 score of \<=3

Answer 71

* Neurosurgical consultation to advise further management * Vast majority of patients are not suitable for surgical intervention * Management is therefore supportive for haemorrhagic stroke * Anticoagulants e.g. warfarin and antithrombotic agents e.g. Clopidogrel should be stopped to minimise further bleeding * If a patient is anticoagulated then this should be reveres as quickly as possible * Trials have shown improved outcomes in patients who have their blood pressure lowered acutely and this is now part of protocols of haemorrhagic strokes

Answer 72

* Definition: * Convulsive status epilepticus is defined as a convulsive seizure which lasts for a prolonged period * \> 5 mins * Or when convulsive seizures occur one after the other with no recover in between

Answer 73

* \< 5 years * Elderly * Genetic predisposition * Intellectual disability * Structural brain pathology

Answer 74

* Hypoxia/cardiac arrest * Hypoglycaemia * Metabolic (low Ca, high/low Na) * Trauma * Meningitis, encephalitis, malaria * Raised ICP and CVA * Drug overdose * Hypertension / eclampsia (pregnancy)

Answer 75

* ABCDE * A = Check airway is patent, consider manoeuvers / adjuncts * B = If no respiratory effort, call arrest team * C = If no palpable pulse, call arrest team * D = If GCS 8, call anaesthetist * Call for senior help * Start timing * 15l oxygen for all patients * Keep patients safe and put into recovery position is possible * Monitor: * HR, O2 sats, BP, cardiac trace, temp. * Venous access (after 3-4 mins). Take bloods: * FBC, U&E, LFT, Ca2+, glucose, blood cultures, anticonvulsant levels * Check glucose: * If \<3.5mmol/l give 100ml 20% glucose STAT * Priority is termination of the seizure: * 1^st line = Benzodiazapines such as diazepam or lorazepam * Lorazepam IV 4mg over 2 min, repeat every 10 min if no effect * Diazepam 10mg PR, repeat every 10 min if no effect upto 30mg total * Buccal midazolam if unable to secure immediate IV access If ineffective within 10 mins… * 2^nd line = Phenytoin, sodium valproate, phenobarbital * Phenytoin 20mg/kg IV at \<50mg/min * If taking phenytoin: phenobarbital 10mg/kg IV over 10 min If no response within 30 minutes: * 3^rd line = Induction of GA

Answer 76

Definition: * Clouding of consciousness leading to an acute confusional state * Also known as: * Acute confusional state * Acute organic brain syndrome

Answer 77

* Infection (UTI, chest, meningitis): * Fever * Dysuria * Cough +/- sputum * Headache, photophobia, neck stiffness * Withdrawal: * Alcohol * Drugs * Acute metabolic: * Hypoglycaemia * Failures (cardiac, respiratory, renal or liver) * Trauma: * Falls * Accidents * CNS lesion: * Fits, faints or funny turns * Vision * Hypoxia: * Shock / haemorrhage * Deficiency * B1 * B6 * Diagnosed with dementia before * Endocrine: * Thyroid * Adrenal * Acute vascular insult: * Stroke in the past * Smoker * HTN or high cholesterol * Toxins: * Prescribed drugs account for 40% * New medications * Changed doses of any medications recently * Heavy metals:

Answer 78

* What is the most important risk factor for delirium? * Underlying cognitive impairment * Epidemiology: * Affects upto 30% of elderly patients admitted to hospital

Answer 79

* Memory disturbances (loss of short term \> long term) * May be agitated or withdrawn * Disorientation * Mood change * Visual hallucinations * Disturbed sleep cycle * Poor attention

Answer 80

* Treat the underlying cause * Modification of environment * Clock for orientation * Photographs * Calendar * Side room * Good lighting * Low noise levels * Sedative * Avoid if possible * Haloperidol 0.5mg

Answer 81

* Recent falls: Subdural haematoma * Incontinence: Normal pressure hydrocephalus * Rapid fluctuations: Lewy Body Dementia * Hypertension: Ischaemic Heart Disease * Sexual contact HIV & Syphilis * Family History: Huntington’s

Answer 82

* Non-variceal * Oesophagitis/gastritis * Mallory-Weiss * Peptic ulcer disease * Malignancy * Drugs * Variceal * Decompensated liver disease

Answer 83

* Gastric irritant medications (NSAIDs) * Lack of gastro-protective medication * Ulcers * Alcohol / ALD * Reflux / GORD * Persistent vomiting * Endoscopy / stenting procedures * Past abdo surgery

Answer 84

* What to ask on the phone? * Is the patient alert and talking? * Blood streaked in the vomit or vomiting blood * Urine output? * Has he been drinking recently * On any anticoagulants? * Is he cannulated? * Ask the nurse: * Do repeat set of observations including lying and standing BP * Leave his notes and drug chart on the desk * If he is not cannulated, prepare kit * If he is not catheterised, get the catheter kit ready * If he gets worse put out the appropriate MET call (medical emergency team)

Answer 85

Initial Assessment * AVPU * ABCDE * IV access for fluid resus and bloods * Call senior * Major haemorrhage protocol/Bleed reg Investigations: * Bloods: * FBC, VBG (lactate), LFTs, clotting screen, X-match 4-6 units * Consider: * ECG * Perforation? * Erect CXR, surgical input early * Urgent endoscopy if significant drop in Hb or significantly low Hb (\<70) * Gastroenterology/Bleed reg

Answer 86

* 15L of high flow oxygen * Continuous monitoring * FBC, U&E, LFT, CRP, Clotting, X-match 4-6U * Give O- in an emergency (discuss with transfusion lab) * In the meantime: * Careful fluid resus STAT – Care diluting Hb and clotting factors * Transfuse blood if haemodynamically unstable or Hb less than 70 * PPI: * Omeprazole 80mg IV STAT – Then 8mg/hr IVI for 72hrs * Variceal bleeding: * Terlipressin 2mg IV QDS 24hr then 1mg IV QDS if bleeding settled * Endoscopy: * GBS, Rockall score * Urgent if active bleeding, significant drop/low Hb * Within 24hrs for all else

Answer 87

* Withhold: * All anticoagulants * NSAIDs * Consider: * Antiemetic * PPI (lansoprazole is indicated for patients on aspirin and Clopidogrel, omeprazole if not) * Reverse anti-coagulation (10mg Vit K for warfarin, protamine (1mg/100units)

Answer 88

* Past GI bleeds * Dyspepsia / known ulcers * Known liver disease / oesophageal varices * Dysphagia * Vomiting * Drugs * Alcohol * Serious comorbidity

Answer 89

* Risk- stratification * Mortality * Re-bleeding risk * Pre-endoscopy * Glasgow-Blatchford * Predicts treatment needs * Most useful for discharge with score 0 * Rockall (pre-endoscopy) * During-endoscopy * Forrest score * Best for re-bleeding risk * Post-endoscopy * Rockall * Good at looking at mortality from UGIB

Answer 90

* Medication: * Analgesia – Diclofenac * IM / oral * ??Alpha-adrenergic blockers * Aid ureteric stone passage * Imaging: * USS 1^st line * Sensitivity = 45% * Specificity = 90% * Complications such as hydronephrosis can be quickly identified * Con-contrast CT * Confirm diagnosis

Answer 91

* Stones \<5mm will usually pass spontaneously * Lithotripsy and nephrolithotomy may be used for severe cases

Answer 92

* Main cause: * Alcohol * Gallstones * Causes: GET SMASHED * Gallstones * Ethanol * Trauma * Steroids * Mumps (other viruses include Coxsackie B) * Autoimmune (e.g. polyarteritis nodosa) * Scorpion venom * *Hypertriglyceridaemia*, *Hypercalcaemia*, *Hypercholomicronaemia*, *Hypothermia* * ERCP * Drugs * Azathioprine * Mesalazine * Frusemide

Answer 93

Features * Severe epigastric pain * Vomiting is common * Rarely: Temporary or permanent blindness * Iscaemic (Purtscher) retinopathy Examination * Tenderness * Ileus * Low grade fever * Periumbilical discolouration * Turners sign * Rare * Flank discolouration * Grey-Turners * Rare

Answer 94

* Diagnosis: * Serum lipase \> serum amylase * More sensitive and specific * Longer t1/2 * Does not correlate with disease severity * Assessment of severity: * Glasgow, Ransorn scoring systems and *APACHE II* * Biochemical scoring e.g. using CRP

Answer 95

* ABCDE * Nutrition: * Rationale is it helps prevent bacterial translocation * Use of ABx therapy * Some surgeons give * Surgery * Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy * Patients with an obstructed billary system due to stones should undergo early ERCP * Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement * Patients with infected necrosis would undergo either radiological drainage or surgical necrosectomy

Answer 96

* Definition: * Inflammation of the gallbladder * Cause: * Gallstone in cystic duct * -\>Bile stasis * -\>Bacteria overgrowth -\> ascending cholangitis * Features: * Mid-epigastric \> *_RUQ pain_* * Nausea and vomiting * *_Fever_* * Murphy’s sign of examination * Occasionally mildly deranged LFTs * Especially if Mirizzi syndrome * Increased ALP * Increased conjugated bilirubin _Charcot's cholangitis triad_ is the combination of *jaundice*; *fever*, usually with rigors; and *right upper quadrant abdominal pain*. It occurs as a result of ascending cholangitis (an ***infection*** of the bile duct in the liver). * * *

Answer 97

* Investigations: * USS * Sonographic Murphy’s sign * Gallbladder wall thickening * Sludge * Distension of GP and bile duct

Answer 98

Management: * ABCDE * Supportive * Analgesia * Fluids * ABx * Cholecystectomy * Usually within 48 hours of presentation Complications: Rupture and peritonitis

Answer 99

* Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (like benzodiazepines) and inhibits the NMDA-type glutamate receptors * Alcohol withdrawal is thought to lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)

Answer 100

* Symptoms start at 6-12 hours * Tremor * Sweating * Tachycardia * Anxiety * Peak incidence of seizures at 36 hours * Peak incidence of delirium tremens is at 48-72 hours: * Coarse tremor * Confusion * Delusions * Auditory and visual hallucinations * Fever * Tachycardia

Answer 101

* 1^st line = Benzodiazepines e.g. chlordiazepoxide * Usually part of a reducing dose protocol * Carbamazepine also effective in treatment of alcohol withdrawal AND prevent Korsakoffs with pabrinex (B1 thiamine)

Answer 102

Pathophysiology: * Absolute or relative decrease in insulin levels * A high plasma glucose causes an osmotic diuresis with Na and water loss * Hypotension * Hypo-perfusion * Shock Precipitating: * *Infection* – Commonly UTI, RTI, skin * *Infarction* – MI, stroke, GI tract * *Insufficient insulin* - Missed insulin doses * *Intercurrent illness* - Presentation * May be a complication of existing T1DM * May be a first presentation * Features: * Abdominal pain * Polyuria, polydipsia, dehydration * Kussmaul breathing (deep hyperventilation) * Acetone-smelling breath (‘pear drops smell’)

Answer 103

* Check to confirm diagnosis and possible underlying cause(s) * Check BMG and test urine for glucose and ketones * Send bloods for U&E, blood glucose, creatinine, osmolality * ABG to check for metabolic acidosis +/- respiratory compensation * FBC and CXR to look for pneumonia * Blood cultures and if appropriate, throat or wound swabs * Urine/sputum microscopy and culture

Answer 104

* ABCDE * If altered consciousness/coma is present, provide and maintain a patent airway * Give high FiO2 * Fluid replacement: * Most patients with DKA are deplete around 5-8 litres * Normal / isotonic saline is used initially (0.9% NaCl) * 1L over 0.50-1hr * 500ml/hr for next 2-3 hours * Persistent hypo-perfusion may require increased infusion rate or colloids * Avoid over-rapid infusion with the risk of pulmonary oedema and ARDS especially in the elderly * Insulin: * Fixed rate IV infusion at 0.1 U/kg/hour * Check plasma glucose levels every hour * Once blood glucose is \<15mmol/l an infusion of 5% dextrose should be started * Correction of hypokalaemia * Monitor urine output (most accurate with urinary catheter) * Arrange admission to ICU, HDU or acute medical admissions unit

Answer 105

* Signs of infection: * Often masked * Temperature is rarely raised * If in doubt treat with broad spectrum ABx * Over-rapid fluid replacement: * Can cause cardiac failure, cerebral oedema and ARDS * Especially in elderly or those with cardiac disease * CVP monitoring may be needed * Clotting: * Hyperglycaemia causes a hypercoagulable state * DVT or PE may occur * Administer prophylactic anticoagulation with LMWH in DKA

Answer 106

* Definition: * Reduction in renal function following an insult to the kidneys * Incidence: * Around 15% of patients admitted to hospital develop AKI * Risk factors: * Chronic kidney disease * Other organ failure / chronic disease e.g. heart failure, liver disease, DM * History of AKI * Use of drugs with nephrotoxic potential (e.g. NSAIDs, aminoglycosides, ACE inhibitors, ARBs, diuretics) within the past week * \>65 years

Answer 107

* Pre-renal * Hypovolaemia secondary to diarrhoea/vomiting * Renal artery stenosis * Renal * Glomerulonephritis * Acute tubular necrosis * Acute interstitial nephritis * Rhabdomyolysis * Tumour lysis syndrome * Post-renal * Kidney stone in ureter or bladder * Benign prostatic hyperplasia * External compression of the ureter

Answer 108

* A reduced urine output. * The term **oliguria** is defined as a urine output less than 0.5ml/kg/hr * Fluid **Overload** * A raise in molecules that the kidney normally excretes / maintains a careful balance of: * **Potassium**, **urea** and **creatinine**

Answer 109

Symptoms & signs: * Many patients with early AKI experience no symptoms. * However, as renal failure progresses the following may be seen: * Reduced urine output * Pulmonary and peripheral oedema * Arrhythmias (secondary to changes in potassium and acid-base balance) * Features of uraemia (e.g. pericarditis or encephalopathy)

Answer 110

Detection * Detect AKI in line with the (p)RIFLE, AKIN or KDIGO definitions by using any of the following criteria: * A raise in serum creatinine 20 micromoles/L or greater within 48 hours * A 50% or greater rise in serum creatinine known or presumed to of occurred within the past 7 days * *A fall in urine output less than 0.5ml/kg/hr for more than 6 hours in adults* Investigations: * All patients with suspected AKI should have urinalysis * Imaging: * If patients have no identifiable cause for the deterioration or are at risk of urinary tract obstruction they should be offered a USS within 24 hours of assessment

Answer 111

* Largely supportive * Careful fluid balance to ensure that the kidneys are properly perfused but not excessively to avoid fluid overload * Medication review: TABLE * Manage hyperkalaemia: * Renal replacement therapy e.g. haemodialysis * Used when the patient is not responding to medical treatment of complications e.g. hyperkalaemia, acidosis and uraemia

Answer 112

Normal range for [K+]: 3.5-5.5mM Causes: * Ineffective elimination: * AKI/CKD * Medications * K+ sparing diuretics * ACE-I * AT-2 blockers * Spirinolactone * Mineralocorticoid deficiency * Excessive cellular release * Transcellular shift: acidosis (DKA), beta-blockers, suxamethonium * Rhabdomyolysis * Burns * Tumour lysis syndrome * Excessive intake * Potassium supplements * Laxatives containing K+ (Movicol) * Pseudohyperkalaemia: * Tourniquet time * Test tube haemolysis

Answer 113

* What to ask: * Are they alert and talking? * Any chest pain? * Urine output? * New or old problem? * Ask nurse to: * Do an ECG * Gather notes and drug chart on the desk * If they are not cannulated, prepare kit * If they are not catheterised, prepare kit

Answer 114

* Initial approach: * AVPU * ABCDE * ECG * Unwell or stable? * Fluid balance? * History: * Acute? / Chronic accumulation? * Patient have CKD? * Cardiac history? Eplerenone, are they being diuresed? * Look at fluid charts? * Is patient diabetic? * Symptoms: * Palpitations / dizziness

Answer 115

* Investigations: * Repeat sample if unsure of accuracy of hyperkalaemia e.g. haemolyis * ABG/VBG * Helpful if you suspect a spurious result * ECG signs: * \>5.5 * Tall, peaked T waves * \>6.5 * Flat P waves * Prolonged PR segment * \>7.0 * Bizarre QRS * Conduction block * Sinus bradycardia / AF * Sine wave * VF

Answer 116

* Follow trusts hyperkalaemia protocol * Treat if K+ \> 6.5 or if K+ \>5.5 with K+ related ECG changes * Stabilise the myocardium: * Calcium gluconate * 30mls 10% over 10 min * Shift K+ into cells: * Insulin and glucose * Activates Na+/K+ ATPase * 10 units Actrapid in 100mls 20% dextrose * IV fluids if dehydrated * Salbutamol * Similar effect to insulin * 5mg NEB * 2-hourly * Effect reduced if on dialysis, beta-blocker or digoxin * Lower total body potassium: * Stop drugs that increase K+ * Advise on diet * No chocolate, fruit juice, bananas until dietician review * Calcium resonium: * If K+ rebounds

Answer 117

* K+ and H+ can be thought of as competitors * Hyperkalaemia tends to be associated with acidosis because as the potassium levels rise, fewer hydrogen ions enter cells * Hypokalaemia with alkalosis: * Vomiting * Diuretics * Cushing’s syndrome * Conn’s syndrome * Hypokalaemia with acidosis: * Diarrhoea * Renal tubular acidosis * Acetazolomide * Partially treated DKA

Answer 118

* Hypokalaemia with HTN * Cushing’s syndrome * Conn’s syndrome (primary hyperaldosteronism) * Liddle’s syndrome * 11-beta hydroxylase deficiency * 21-hydroxylase deficiency, which accounts for 90% of congenital adrenal hyperplasia, is not associated with HTN * Hypokalaemia without HTN * Diuretics * GI loss (diarrhoea, vomiting) * Renal tubular acidosis (types 1 and 2) * Bartter’s syndrome * Gitelman syndrome

Answer 119

* Muscle weakness * Hypotonia * Hypokalaemia predisposes patients to digoxin toxicity * Care should be taken if patients are on diuretics * ECG Features: * U waves (see below) * Small or absent T waves * Prolonged P-R * ST depression Management: SLOWLY correct electrolyte imbalance