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Phase 3B > Acute and critical care > Flashcards

Acute and critical care Flashcards

1
Q

What are the risk factors for AKI?

A
  • Age >65
  • Diabetes
  • Hypertension
  • Dehydration
  • Nephrotoxic medications
  • CKD
  • Chronic CVD/Heart failure
  • Rhabdomyolysis
  • Renal tract obstruction
  • Myeloma
  • Liver disease
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2
Q

What are the pre-renal causes of AKI?

A
  • Hypovolaemia (dehydration, bleeding)
  • Septic shock
  • Cardiogenic shock
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3
Q

What are the renal causes of AKI?

A
  • Acute tubular necrosis
  • Glomerulonephritis
  • Vasculitis
  • Interstitial nephritis
  • Tubular toxicity ie CT contrast
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4
Q

What are the post renal causes of AKI?

A

-Urinary tract obstruction
>Intraluminal ie stone
>Extraluminal ie cancer compression on ureter

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5
Q

What are the diagnostic criteria for AKI?

A
  1. Increase in serum creatinine >0.3mg/dl within 48 hours
  2. Or increase in serum creatinine 1.5x baseline
  3. Or urine volume <0.5ml/kg/hour for r6 hours
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6
Q

What are the creatinine levels of stage 1 AKI?

A

-Creatinine 1.5-1.9x baseline

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7
Q

What are the creatinine levels of stage 2 AKI?

A

-Creatinine 2.0-2.9x baseline

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8
Q

What are the creatinine levels of stage 3 AKI?

A
  • Creatinine 3x baseline
  • or Increase in serum creatinine to >4mg/dl
  • or initiation of renal replacement therapy
  • or decrease in eGFR <35ml/min per 1.73m^2 in <18 years
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9
Q

What are the management aims for AKI?

A
  • Treat underlying cause

- Prevent further damage by optimising renal blood flow with fluid challenge

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10
Q

What forms the AKI management bundle?

A
  • Restore prefusion
  • Stop nephrotoxins
  • Exclude obstruction
  • Treat complications
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11
Q

How is perfusion restored in AKI?

A
  • Fluid challenge

- Consider vasoconstrictors or inotropes

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12
Q

How do you exclude obstruction in AKI?

A

-Measure urine output
-Imaging
>CT - stones
>Renal USS - hydronephrosis

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13
Q

What are some nephrotoxic drugs?

A 
-ACEi/ARBs
>reduce perfusion to kidneys
-NSAIDs
-Aminoglycosides ie gentamycin
-Contrast media
-Furosemide and some other diuretics
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14
Q

How does septic shock cause a prerenal AKI?

A

-Sepsis causes leaky vessels and fluid moves into the interstitium from the vessels

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15
Q

What is the main medical cause of acute interstitial nephritis causing AKI?

A

-NSAIDs

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16
Q

What is a side effect of genatmycin? and which drugs interacts synergistically?

A
  • Ototoxic

- Furosemide

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17
Q

What metabolic abnormalities occur from an AKI and why?

A
  • Hyperkalaemia
  • Metabolic acidosis
  • The transporters work less effectively causing a build up of H+ and K+ and a loss of Na
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18
Q

How is hyperkalaemia treated?

A
  • Insulin
  • Glucose
  • Calcium gluconate (to stabilise the cardiac membranes)
  • ECG
  • RRT
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19
Q

What are the complications of AKI?

A
  • Uraemia
  • Metabolic acidosis
  • Fluid overload
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20
Q

What is the role of the liver?

A
  • Synthesis of: -protein, clotting factors, bile, glucagon
  • Detox: alcohol, drugs, ammonia, bilirubin
  • Storage: energy, vitamins (ADEK), minerals
  • Part of the immune system
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21
Q

What is acute liver failure?

A
  • Rapid onset of hepatocellular dysfunction leading to a variety of systemic complications
  • A complex multisystem illness which occurs after an insult to the liver
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22
Q

What are the features of acute liver failure?

A
  • Jaundice
  • Coagulopathy (^PTT)
  • Hepatic encephalopathy
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23
Q

What is the difference between acute liver failure and acute liver injury?

A
  • Acute liver injury = prolonged INR and jaundice.

- NO encephalopathy

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24
Q

What are classic signs of hepatic encephalopathy?

A
  • Asterixis (liver flap)

- Unable to count back from 100 in 7s

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25
Q

How can acute liver failure be classified?

A
  • Uses time from jaundice to encephalopathy
  • Hyperacute: <7/7 (best prognosis)
  • Acute: 8-28 days
  • Subacute: 29days-12 weeks (worst prognosis)
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26
Q

What are the causes of acute liver failure?

A
  • Paracetamol overdose
  • Alcohol
  • Viral hepatitis (A, B or E)
  • Acute fatty liver of pregnancy
  • Unknown cause (females, 20-40)
  • Anabolic steroids
  • Chinese and herbal drugs
  • Allergic reaction to drugs
  • Recreational drugs ie cocaine, legal highs
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27
Q

What are some rarer causes of ALF?

A 
-Viruses: HSV, CMV, EBV parvovirus
Ischaemic hepatitis
-Autoimmune hepatitis
-Wilson's disease
-Budd chiari syndrome
-Mushrooms
-Hepatectomy
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28
Q

Where is heptitis E caught from?

A

-Undercooked pork or shellfish

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29
Q

What is the difference between a single time point paracetamol overdose and a staggered overdose?

A
  • Single time point: >4g paracetamol taken at once

- Staggered: ingestion of 2+ supratherapeutic doses over 8 hours in a cumulative dose of >4g/day.

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30
Q

Which types of pts are increased risk of hepatotoxicity following paracetamol OD?

A

-Underweight
-Alcoholic
-Malnourished
>anorexia, CF, hep C, Cancer, HIV
-Staggered OD
-CLD
-Regular liver enzyme inducers
>rifampicin, phytoin, carbamazepine, St. John’s wort

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31
Q

How should paracetamol OD be investigated?

A
  • Blood paracetamol levels
  • ABG (metabolic acidosis)
  • Prothrombin time
  • ALT (high = paracetamol)
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32
Q

What are the complications of acute liver failure?

A
  • Encephalopathy
  • Renal failure
  • Sepsis (bacterial and fungal infections)
  • Malnourishment
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33
Q

Define shock

A
  • Circulatory failure
  • Tissue hypo-perfusion
  • Energy defecit
  • Accumulation of metabolites (lactate)
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34
Q

What are the causes of shock?

A
  • Septic
  • Hypovolaemic
  • Anaphylactic
  • Cardiogenic
  • Neurogenic
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35
Q

What are the 3 basic components that can go wrong to cause shock?

A
  • Fluid
  • Pumps
  • Pipes
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36
Q

What are the fluid causes of shock?

A
  • Haemorrhage
  • Dehydration
  • Burns
  • DKA
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37
Q

What are the pump causes of shock?

A
  • Tension pneumothorax
  • Pulmonary embolism
  • Cardiac tamponade
  • Ischaemia
  • Arrhythmias
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38
Q

What are the pipe causes of shock?

A
  • Neurogenic ie spinal cord lesion
  • Endocrine ie Addisonian crisis
  • Septic (leaky fluid)
  • Anaphylactic (leaky fluid)
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39
Q

How is an episode of shock managed?

A
  • Help
  • ABCDE
  • o2.
  • Treat underlying cause
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40
Q

What medications treat hypovolaemia?

A
  • Fluids

- Vasopressors

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41
Q

What medications manage septic shock?

A
  • Fluids
  • Antibiotics
  • Adrenaline
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42
Q

What medications manage anaphylactic shock?

A
  • IM adrenaline 1:1000
  • Fluids
  • Vasopressors
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43
Q

What medications manage cardiogenic shock?

A
  • Inotropes (increases contractility)

- NOT vasopressors>increases resistance for heart to pump against

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44
Q

Where are the 5 areas blood can accumulate?

A
  • Blood on the floor and 4 more
  • Thorax
  • Abdomen
  • Pelvis
  • Long bones
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45
Q

What are the immediate steps in managing AAA or aortic dissection?

A
  • Help
  • ABCDE
  • Crossmatch blood
  • Call surgeon
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46
Q

Which drugs should manage a small and big PE?

A
  • Small: LMWH

- Big: alteplase

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47
Q

How should broad complex tachycardia be managed immediately?

A

-HELP
-ABCDE
-Repeat ECG
>wide and fast = bad

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48
Q

What are the main endocrine emergencies?

A
  • Hyponatraemia
  • Addisonian crisis
  • Phaeochromacytoma
  • Pituitary apoplexy
  • Thyroid storm
  • Myxoedema coma
  • Hypercalcaemia
  • DKA
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49
Q

What is the biochemical definition for hyponatraemia?

A

-Sodium <135mmol/L

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50
Q

What are the 3 main categories of causes of hyponatraemia?

A
  • Hypervolaemic
  • Euvolaemic
  • Hypovolaemic
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51
Q

What are the causes of hypervolaemic hyponatraemia?

A
  • Congestive heart failure
  • Renal failure
  • Nephrotic syndrome
  • Cirrhosis/liver failure
  • Hyperglycaemia
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52
Q

What are the causes of euvolaemic hyponatraemia?

A

-Diuretics
-SIADH
-Primary polydipsia
-Low Na intake
-Advanced renal failure
-Hormonal insufficiency
>Addison’s
>Hypothyroidism
>Pregnancy

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53
Q

What are the causes of hypovolaemic hyponatraemia?

A 
-Renal causes:
>diuretics, Addisons, nephropathy
-GI causes:
>D+V
-Other:
>Burns
>Rhabdomyolysis
>pancreatitis
>peritonitis
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54
Q

What are the clinical features of hyponatraemia?

A
  • Confusion
  • Lethargy
  • Seizures
  • Coma
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55
Q

How is acute hyponatraemia treated?

A

-3% saline. 150ml bolus over 20 minutes

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56
Q

What is the general rule for treating endocrine emergencies?

A

-Treat on clinical suspicion and don’t wait for test results

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57
Q

What are the symptoms of acute adrenal failure (Addisonian crisis)?

A
  • Pain (lower back, abdo, legs)
  • Severe D+V
  • Low BP
  • Loss of consciousness
  • Hyperkalaemia
  • Hyponatraemia (confusion, lethargy, coma)
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58
Q

What are the causes of an Addisonian crisis?

A
  • Can be 1st presentation
  • Sepsis or Sx can cause acute exacerbation of chronic insufficiency
  • Steroid withdrawal
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59
Q

How is addisonian crisis managed?

A
  • Hydrocortisone 100mg IV or IM
  • 1L normal saline infused over 30-60mins
  • Hydrocortosione 6hrly until pt stable
  • Oral replacement after 24 hrs and reduced to maintenance over 3/4 days
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60
Q

What is extreme hypertension and tachycardia until proven otherwise?

A

-Phaeochromacytoma

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61
Q

What is emergency management of phaeochromacytoma?

A
  • Alpha blocker (doxazocin or phenoxybenzamine)

- Then Beta blocker (propanolol) if required

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62
Q

What can precipitate a phaeochromacytoma crisis?

A
  • Exercise
  • Beta blockers
  • Abominal pressure
  • Stress
  • Emotional trauma
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63
Q

What is pituitary apoplexy?

A

-Sudden enlargement of pituitary tumour secondary to haemorrhage/infarction

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64
Q

What are the features of pituitary apoplexy?

A

-Sudden onset headache (similar to SAH)
-Vomiting
-Neck stiffness
-Visual field defects (bitemporal superior quadrantic defect)
-Extra-ocular nerve palsies
-Features of pituitary insufficiency
ie hypotension due to hypoadrenalism

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65
Q

How is pituitary apoplexy managed?

A
  • MRI ?Poss surgery

- IV hydrocortisone

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66
Q

What are the symptoms of a thyroid storm?

A
  • Tremor
  • Vomiting
  • Hypertension
  • Thyrotoxicosis symptoms
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67
Q

How is a thyroid storm managed?

A
  • Propylthiouracil
  • Propanolol
  • Lugol’s idoine
  • Cholestryamine
  • Fluids and supportive therapy
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68
Q

What are the features of hypercalcaemia?

A
  • Painful bones, renal stones, abdominal groans and psychic moans
  • corneal calcification, shortened QT, hypertension
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69
Q

What are the 2 main causes of hypercalcaemia?

A
  • Primary hyperparathyroidism

- Malignancy (bony mets, myeloma)

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70
Q

What are some other causes of hypercalcaemia?

A
  • Sarcoidosis
  • Vit D intoxication
  • Acromegaly
  • Thyrotoxicosis
  • Drugs: thiazides, calcium containing antacids
  • Dehydration
  • Addison’s disease
  • Paget’s disease of the bone
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71
Q

How is hypercalcaemia managed?

A
  • Rehydration with normal saline (3-4l/day)
  • Bisphosphonates
  • Can use calcitonin
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72
Q

What fluid volume is needed for daily maintenance in adults?

A
  • 30ml/kg

- 70kg person: 30x70 =2100mls

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73
Q

How much sodium and potassium is needed per day in fluid maintenance?

A
  • NA: 1-2mmol/kg

- K: 1mmol/kg

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74
Q

What are the sources of sensate fluid loss?

A
  • Urine output
  • Drainage from a body part
  • Bleeding
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75
Q

What are the sources of insensate fluid loss?

A
  • Water vapour lost by breathing

- Third spacing ie ascites

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76
Q

What are the signs indicating some dehydration?

A
  • Restless, irritable
  • Sunken eyes
  • Thirsty, drinks eagerly
  • Skin turgor returns slowly
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77
Q

What are signs of severe dehydration?

A
  • Drowsy, unconscious
  • Sunken eyes
  • Drinks poorly, not able to eat or drink
  • Skin turgor returns slowly
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78
Q

What is the general approach to fluid prescribing?

A
  • Calculate defecit
  • Ongoing maintenance
  • Monitor results of therapy
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79
Q

What is the definition of major trauma?

A

-Serious and othern multiple injuries where there is a strong possibility of death or disability

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80
Q

What is the injury severity score?

A
  • Looks at the different injuries a pt has and scores them

- >15 = major trauma

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81
Q

What are the main categories of injury?

A
  • Blunt ie lacerations
  • Sharp ie incisions
  • Penetrating ie stab, gunshot wound
  • Burns including electrical burns
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82
Q

Which radiological imaging should be done in a primary survey for trauma?

A
  • Xray
  • FAST USS: free fluid in abdomen
  • CT scanning
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83
Q

When does a pt get a whole body CT?

A
  • In most significant trauma events
  • When suspect occult injuries that are not clinically detectable
  • CT chest, abdo, pelvis
  • Assess vsicera, vessels, spaces, bones
  • Haemodynamically unstable
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84
Q

What mechanisms of injury require a CT?

A
  • > 1 body system
  • RTC with fatalities
  • Falls from height
  • Falls from a horse
  • Findings on plain film/USS
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85
Q

What are the signs of a patient bleeding?

A

-Visual blood loss
-Tachycardia
>be aware of beta blockers, elderly, children, pregnant women, fitness athletes
-Prolonged cap refill time
-Hypotension

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86
Q

What is the lethal triad of trauma?

A
  • Hypothermia
  • Acidosis
  • Coagulopathy
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87
Q

What is the difference between primary and secondary head injury?

A
  • Primary: actual trauma to the white matter

- Secondary: caused by hypoperfusion, acidosis etc. A result of a process elsewhere in the body

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88
Q

How should a significant head injury be managed?

A

-Imaging
-Early referral to neurosurgery
-Ensure perfusion of brain
>hypercarbic can increase cerebral blood flow

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89
Q

How can raised intracranial pressure be managed?

A
  • Cerebral dehydration: mannitol, hypertonic saline

- Reduce cerebral blood volume: ensure well oxygenated, normal co2 levels

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90
Q

How can the c spine be immobilised?

A
  • Collar
  • Blocks
  • Tapes
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91
Q

What are the supratnetorial causes of unconsciousness?

A
  • Head injury

- Stroke

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92
Q

What are the infratentorial causes of unconsciousness?

A
  • Brain stem damage

- Herniation

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93
Q

What are the metabolic causes of unconsciousness?

A
  • Resp: Hypoxia, hypercabia
  • Hypo/hyperglycaemia
  • Hyponatraemia
  • Hepatic encephalopathy (high ammonia)
  • Severe renal failure: high urea
  • Sepsis
  • Toxins, drugs
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5
Perfectly
94
Q

What are the important features of neuro exam to check in head injuries/LOC?

A
  • GCS
  • Pupils
  • Cranial nerves
  • Lateralising signs
  • Focal deficits
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95
Q

Define sepsis:

A

-Life threatening organ dysfunction caused by a dysregulated host response to infection

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96
Q

What are common sites of infection that lead to sepsis?

A
  • Chest
  • Abdomen
  • UTI
  • CNS
  • MSK
  • Line infections on ITU
97
Q

What are signs of end-organ dysfunction in sepsis?

A
  • Hypotension
  • Hypoperfusion
  • Hypoxia
  • Renal (oligurla, raised Cr)
  • Marrow and clotting issues
98
Q

What are the sepsis 6?

A
  • BUFALO
  • Blood cultures + septic screen
  • Urine output hourly
  • Fluid resus
  • Antibiotics IV
  • Lactate
  • Oxygen
99
Q

In what time does sepsis 6 need to be performed?

A

-Within the hour especially antibiotics!

100
Q

What is an easy way of remembering the GCS scores?

A

-EVM, 4,5,6

101
Q

Which component of GCS is arguable the most important?

A

-Motor score

102
Q

What are the scores for eyes in GCS?

A
  • 4: Spontaneously open
  • 3: Open to voice
  • 2: Open to pressure
  • 1: None
103
Q

What are the scores for voice in GCS?

A
  • 5: orientated
  • 4: confused
  • 3: inappropriate words
  • 2: uncomprehensible sounds
  • 1: none
104
Q

What are the scores for motor in GCS?

A
  • 6: obeys commands
  • 5: localises pain
  • 4: Normal flexion to pain
  • 3: Abnormal flexion to pain
  • 2: Extension to pain
  • 1: none
105
Q

How should motor function be assessed in GCS?

A

-Stick tongue out. (central nervous system so won’t be using spinal reflexes)

106
Q

What is a VQ mismatch?

A

-A mismatch of perfusion and ventilation

ie blood flow through areas of the lung where no gas exchange occurs

107
Q

What are common causes of VQ mismatch?

A
  • Chest infections

- Heart failure

108
Q

What partial pressure of oxygen is regarded as resp. failure?

109
Q

What is type 1 resp failure?

A

-Normal or decreased CO2 and low O2

110
Q

What is type 2 resp failure?

A

-High CO2 and low O2

111
Q

What resp failure should BiPAP be used to manage?

A

-Type 2 resp failure.

>Increases inspiratory and expiratory pressure.

112
Q

What resp failure should CPAP be used to manage?

A

-Type 1 resp failure

>Used to treat hypoxia

113
Q

What is non-invasive ventilation?

A

-BiPAP & CPAP

114
Q

What are the indications for Non-invasive ventilation?

A
  • Post op
  • COPD
  • Oedema
  • CPAP for obstructive sleep apnoea
115
Q

What are the contra-indications for non invasive ventialtion?

A
  • ASTHMA
  • Pneumothorax
  • Agitation
  • Airway loss
116
Q

Which method should ABGs be reviewed?

A
  • PO2 ->are they in resp. failure?
  • PCO2 -> T1RF or T2RF?
  • PCO2 -> respiratory acidosis or alkalosis?
  • BE -> metabolic acidosis (2)
  • pH -> compensated vs decompensated
117
Q

What would T2RF look like on an ABG?

A

-Respiratory acidosis

118
Q

What would a panic attack look like on an ABG?

A

-Respiratory alkalosis

119
Q

What are the anatomical factors that cause loss of airway patency?

A
  • Large tongue
  • Neck flexion
  • Obesity
  • Adenotonsillar hypertrophy
  • Oedema (burns/infection)
120
Q

What are reduces the tonic contraction of pharyngeal muscles which causes loss of airway patency?

A
  • REM sleep
  • Alcohol
  • Other sedative drugs
  • Coma
121
Q

What are the 4 causes of ventilatory failure?

A
  • Central respiratory depression (loss of drive)
  • Mechanical impairment (muscle weakness/flail chest)
  • V/Q mismatch/shunt (pneumonia, COPD)
  • Obstruction (small airway-asthma, large airway)
122
Q

What are signs of large airway obstruction?

A
  • Partial: noisy
  • Complete: Silent
  • Increased resp drive initially
  • Paradoxical chest/abdo movement
  • Suprasternal/intercostal/subcostal recssion
  • Lack of misting on O2 mask
123
Q

What manoevers are use for basic airway management?

A
  • Head tilt

- Jaw thrust

124
Q

What are type of artificial airways?

A
  • Nasal airway
  • Oral (Guedel) airway
  • Laryngeal mask airway
  • Endotracheal tube
125
Q

What requirements do you need for an intubation technique?

A
  • Unconscious patient
  • Proper monitoring and assistance
  • Pillows adequate to potition head
  • Laryngoscope with bright ligh
  • ETT of correct diameter and length
  • Syringe
  • Suction
  • Tape
  • Aids ie bougie
126
Q

What factors predict difficult intubation?

A
  • Short neck
  • Small, immobile mandible
  • Prominent upper teeth
  • Fixed neck flexion
  • Limited mouth opening
  • Soft tissue swelling
127
Q

Which 3 specific factors predict a difficult intubation?

A
  • Thyromental distance
  • Assess mouth opening
  • Neck extension
128
Q

What is the definition of clearance (pharmacokinetics)?

A

-A measure of the renal excretion ability (may also depend on hepatic metabolism)

129
Q

What is first order kinetics?

A

-Rate of elimination is proportional to concentration

130
Q

What is zero order kinetics?

A

-Rate is independent of concentration ie constant amount is eliminated

131
Q

What are the indications for central venous access?

A
  • Monitoring central venous pressure
  • Pacing
  • Administration of drugs that can not be infused peripherally ie TPN, chemo, KCL, vasopressors
  • Haemodialysis
  • Poor peripheral access
132
Q

What are absolute contraindications for central venous access?

A
  • Patient refusal

- Infection at site

133
Q

What are relative contraindications for central venous access?

A
  • Coagulopathy
  • Evidence of vein thrombosis
  • Access likely to be impossible ie surgery, trauma, neck immobilised in hard collar
134
Q

What are the potential sites for central venous access?

A
  • Internal jugular
  • Subclavian
  • Femoral
  • PICC (peripherally inserted central catheter)
135
Q

What site is most commonly used for central venous access?

A

-Right internal jugular

136
Q

What are early complications of central venous access?

A
  • Arrhythmias
  • Pneumothorax
  • Haemothorax
  • Cylothorax
  • Bleeding/haematoma
  • Damage to the artery
  • Air embolism
  • Nerve damage
137
Q

What are late complications of central venous access?

A
  • Thrombosis
  • Phlebitis
  • Catheter-related sepsis
138
Q

What is carbon monoxide poisoning due to?

A

-Exposure to gaseous products of incomplete combustion ie house fire, faulty gas fire

139
Q

Why does carbon monoxide cause hypoxia?

A
  • Carbon monoxide binds to haemaglobin and is very stable
  • Oxygen does not have enough room to bind to haemaglobin
  • CO can be in up to half of Hb
140
Q

Does CO or O2 have a higher affinity to Hb?

A

-CO is 200 x higher affinity than 02

141
Q

What are symptoms of CO?

A
  • Headache
  • Malaise
  • Nausea
  • Ataxia
  • Syncope
  • Seizures
  • Coma
142
Q

What are the signs of CO?

A
  • ^HR
  • ^RR
  • Hypotension
  • MI
  • Rhabdomyloysis
  • Cherry red skin (rare)
143
Q

What would lab tests show in CO poisoning?

A
  • raised creatinine kinase (muscle, cardiac damage)

- Metabolic acidosis

144
Q

How is CO managed?

A
  • 100% O2 until COHb <5%
  • ?Fluids, inotropes
  • Organ toxicity monitoring > ECG, cardiac enzymes, urinalysis, serum creatinine
145
Q

How does calcium exist in the blood?

A
  • Bound to albumin
  • Bound to anions eg phosphate, citrate
  • Free (unbound) ionised
146
Q

Which form of calcium is physiologically active?

A

-Ionised calcium (unbound)

147
Q

What is normal blood calcium?

What is ionised calcium?

A
  • Normal: 2.12-2.62 mmol/l

- Ionised: 1.16-1.31mmol/l

148
Q

What are the common causes of hypocalcaemia?

A
  • Hypoparathyroidism
  • Vitamin D deficiency
  • Chronic renal disease
149
Q

What are the symptoms of hypocalcaemia?

A
  • Neuromuscular irritability (tetany)
  • Bronchospasm
  • ECG changes
  • Seizures
150
Q

Why does hypocalcaemia cause neuromuscular symptoms?

A
  • Decreased interaction of calcium with sodium channels.
  • Inhibits depolarisation of nerve and muscle fibres.
  • Diminished calcium lowers the threshold for depolarisation = neuromuscular symptoms
151
Q

What are the symptoms of hypocalcaemia using the mneumonic CATS go numb?

A
  • Convulsions
  • Arrhythmias
  • Tetany/numbness/paraesthesia in hands, feet, around the mouth
152
Q

What are the ECG changes caused by hypocalcaemia?

A
  • Intermittent QT prolongation

- Causes life threatening cardiac instability –> risk ^ of Torsades de Point

153
Q

How does alkalosis affect calcium?

A
  • Hydrogen ions and calcium ions bind to serum albumin
  • In alkalosis, there are less hydrogen ions so there is more room for calcium to bind to albumin so free calcium levels decrease
154
Q

What is the definition of hypothermia?

A

-Fall in core temp of <2 degrees below normal

155
Q

What is the CNS pathophysiology that occurs when a patient falls below 35c?

A
  • Hypothermia causes CNS depression
  • Temperature dependent enzymes don’t function properly
  • Causes impaired judgement, slurred speech, LOC
156
Q

What is the CVS pathophysiology that occurs when a patient falls below 35c?

A
  • Cold stress causes ^^ in myocardial O2 consumption, ^HR, vasoconstriction.
  • As get colder = bradycardia
  • Progressive fall in CO and BP.
  • SAN and AVN depression = ectopics, AF,
  • Poor respinse to atropine, DC shock, lidocaine
157
Q

What is the resp pathophysiology that occurs when a patient falls below 35c?

A
  • Initially stimulated and it’s then diminished as metbaolism becomes depressed
  • Resp rate and CO2 production halve
  • Resp arrest at 24 degrees
158
Q

What is the renal pathophysiology that occurs when a patient falls below 35c?

A
  • Initial large diuresis caused by impaired ADH sensitivity)

- Renal blood flow decreases

159
Q

What is the coagulation pathophysiology that occurs when a patient falls below 35c?

A
  • Depressed enzymatic function

- Coagulopathy treated by rewarming

160
Q

What are the predisposing facotrs for hypothermia?

A
  • Extremes of age
  • Hypopituitarism/hypothyroidism
  • Malnutrition
  • Burns/skin diseases
  • Lack of acclimatisation to cold
  • Alcohol ie vasodilation, impaired shivering
  • Drugs ie benzos, narcotics
161
Q

How should hypothermia be managed and which methods should be used when?

A
  • Sudden onset/ severe needs active method

- Slow onset/ mild-moderate needs passive method

162
Q

When should the passive method be used for hypothermia?

A
  • If core temp >32 in elderly or >30 in young
  • Dry warm environment, layers, splace blanket, warm drinks
  • Use own body heat
  • Consider IV fluid if hypotensive
163
Q

When should active warming be used and what does it involve for hypothermia?

A
  • Use if v low temp as pts body heat inadequate or persistently hypotensive
  • External: skin-to-skin, warm bath, warm air
  • Internal: warm IV fluid, gastric/peritoneal/bladder lavage. Thoracic lavage warm tap water and 2 chest drains
164
Q

What should you be cautious of when warming someone who is hypothermic?

A

-Rapid rewarming can cause cardiac and metabolic instability

165
Q

What are some potential complications following hypothermia?

A
  • Drugs can have toxic effect
  • Hyperkalaemia
  • Possible renal failure due to hypoperfusion
  • Frostbite
166
Q

How does local anaesthetics work?

A

-Prevent pain by causing reversible block of conduction along nerve pathways

167
Q

What is the local anaesthetics mode of action?

A

-Enter axon, block sodium channels from inside axon, prevents spread of depolarisation wave

168
Q

What are the different type of local block?

A
  • Individual nerve axons (1-2minutes)
  • Small nerves (3-5 minutes)
  • Large nerves (5-10cm) ie femoral, sciatic
  • Nerve plexus ie brachia (20mins)
  • Central neuraxial ie spinal/epidulra (10/20 mins)
169
Q

What are some common uses for local anaesthetics

A
  • Minor ops: vasectomy, cysts, skin suturing
  • Major ops: C section, hernia repair
  • Post-op pain relief: epidurals, catheters around nerve plexuses
  • Trauma pain relief: multiple rib fractures,
  • Procedures: chest drain insertion, AV fistula formation
170
Q

What are some potential complications for local anaesthetic use?

A
  • Difficult anatomy
  • Deep nerves
  • Anatomical variation
  • Obesity
  • Inadequate dose
  • Not waiting long enough
  • Young child
  • Dementia
  • Surgery too extensive/prolonged
  • Pt anxious
  • Pain when effects wears off
  • Vessel damage
  • Nerve damage
  • Infection
  • Hypotension
  • Headache
  • Toxicity
171
Q

Local anaesthetic toxicty signs on CNS and CVS?

A
  • Numbness of mouth/lips, lightheadedness
  • Convulstions
  • Pupil dilation, coma, apnoea
  • Bradycardia, hypotension, asystole
172
Q

What does a 1% solution of lignocaine contain?

A

-10mg/ml.

Should not exceed 5mg/kg with no adrenaline or 7mg/kg with adrenaline

173
Q

What is the most common cause of maternal sepsis?

A

-Community acquired Beta haem strep group A

174
Q

What is the criteria to diagnose SIRS?

A 
-Diagnosed by 2+ of:
>fever/hypothermia
>tachycardia >90
>tachypnoea >20
>WBC >12 or <4
175
Q

What is the definition of sepsis?

A

-SIRS in the presence of infection

176
Q

What is the definition of severe sepsis?

A

-Sepsis with organ dysfunction, hypotension or hypoperfusion

177
Q

What is the definition for septic shock?

A

-Sepsis + refractory arterial hypotension despite adequate fluid resuscitation

178
Q

What are features of severe sepsis?

A
  • Hypotension
  • Hypoxia
  • Raised lactate
  • Acute oliguria (<0.5ml/kg/hr)
  • Deranged renal/hepatic function
  • Altered mental state
  • Coagulation abnormality
  • Hyperglycaemia (with no diabetes)
179
Q

What are the early, later and very late signs of sepsis?

A
  • Early: tachypnoea/tachycardia
  • Later: hypotension, poor urine output
  • Very late: pale, clammy, cool periphery, altered consciousness
180
Q

What is the management of sepsis?

A
  • Fluid challenge of 1000ml crystalloid

- Antibiotics - early, broad spec.

181
Q

What antibiotics should be used for sepsis?

A

-Augmentin and Metronidazole
or
-Cefuroxime and metronidazole
-Penicillin allergy: clindamycin and gentamycin
-Severe sepsis: ciprofloxacin, gentamycin, metronidazole

182
Q

What is the CURB management for pneumonia?

A

1: Amoxicillin PO
2: Co-amoxiclav
3: IV co-amoxiclav and PO clarithromycin

183
Q

What are the functions of the skin?

A
  • Keeps water in
  • Keeps infections out
  • Thermoregulator
  • Vitamin D production
  • Sensory organ
  • Identity
184
Q

What are the causes of burns?

A
  • Dry heat (fire/hair straighteners)
  • Wet heat (scald)
  • Chemical >alkali and acid
  • Electrical
185
Q

How are acidic burns different from alkaline?

A
  • Acidic: instantly painful, wash it off straight away

- Alkaline: Not as painful straight away, absorbs more before try and wash it off as doesn’t seem to be a problem

186
Q

What type of acid is so dangerous it can burn bone?

A

-Hydrofluoric acid

187
Q

How is a hydrofluroric acid burn treated?

A

-Calcium gel, eyewash, s/c calcium gluconate

188
Q

How can you estimate a size of a burn?

A
  • 1% is a patient’s palm

- Rule of 9s. Body surface area.

189
Q

If a pt has been managed using BUFALO and is being transferred to ITU, what interventions will be done?

A
  • Arterial line: measure BP

- Central line: for access

190
Q

What drugs can be used to reverse hypotension as a result from septic shock?

A
  • Metaraminole (alpha agonist)
  • Phenylephrine (alpha agonist)
  • Adrenaline
  • Noradrenaline
  • Vasopressin
  • Debutamine
  • Steroids
191
Q

What are some examples of drugs that can cause a metabolic acidosis?

A
  • Metformin

- Acetazolamide (Rx for benign intracranial hypertension)

192
Q

What imaging can be done to view pneumothoraces?

A
  • USS
  • CXR
  • CT
193
Q

What dose of propofol should be given to a pt?

A

2-3mg/kg (of ideal body weight)

194
Q

How do fevers behave if the source is from an abscess?

A

-Waves of feeling feverish and then normal

195
Q

What defines a staggered overdose?

A
  • Overdose taken over an hour

- Be wary of plasma levels as some of the drug may have been metabolised so may not be an accurate blood level

196
Q

What site is really useful for patients that have ODd?

197
Q

What are some drugs that can cause airway obstruction if they are overdosed?

A
  • Opioids
  • Benzodiazapines
  • Alcohol
198
Q

What are some drugs that can cause arrhythmias if they are overdosed?

A
  • Local anaesthetics
  • Tricyclic antidepressents
  • Beta blockers, Calcium channel blockers
199
Q

What are some drugs that can cause hypothermia if they are overdosed?

A
  • Alochol

- Barbituates (anticonvulsants - phenoarbital)

200
Q

What are some drugs that can cause hyperthermia if they are overdosed?

A

-Amphetamines (ie cocaine, LSD, MDMA)

201
Q

What drugs cause Miosis (constricted pupils)?

A
  • Alcohol
  • Benzodiazapines
  • Opiates
202
Q

What drugs cause mydriasis (dilated pupils)?

A
  • Amphetamines

- Tricyclic antidepressents

203
Q

What can be given to prevent further absorption of a drug in an OD?

A
  • Activated charcoal
  • Gastric lavage
  • Haemodialysis
204
Q

How does activated charcoal work?

A

-Drug binds to charcoal instead of being absorbed and is transported through GIT

205
Q

What are the early symptoms of a paracetmaol overdose?

A
  • Asymptomatic

- Nausea

206
Q

What are the symptoms after 24 hours of a paracetamol OD?

A
  • Can be asyptomatic
  • Gastric pain
  • Increased nausea
207
Q

What are the symptoms after 2-3 days of paracetamol OD?

A
  • Jaundice
  • Oedematous change
  • Drowsiness
  • Confusion
  • Ataxia
  • DIC
  • Liver capsular pain due to swelling
208
Q

Which enzyme pathway metabolises paracetamol?

A

-Cytochrome p450

209
Q

Why can you wait for up to 8 hours after the overdose to treat?

A

-Glutathione stores take around 8 hours to be used up completely. Allows time to take blood tests and determine whether paracetamol levels are over the treatment line

210
Q

What level of paracetamol needs to be treated?

A

-Paracetamol >150mg/kg

211
Q

Which blood test becomes abnormal first in a paracetaol overdose?

A

-INR
>becomes abnormal within 6-12 hours.
>Other blood tests may still be normal

212
Q

What 5 things need to be done to manage a human bite?

A
  • Antibiotics if bite is over a joint > clindamycin and ciprofloxacin
  • Blood sample for storage
  • Tetanus
  • Hepatits B
  • Irrigation
213
Q

What is the definition of major trauma?

A

-Any injury(ies) that are life threatening or life changing that requires multiple resources to manage

214
Q

What are the different types of major trauma?

A
  • Blunt force trauma ie RTC, falls, assaults
  • Penetrating trauma ie Knife wounds, gunshot wounds
  • Burns
  • Blast injuries
215
Q

What is the most common cause of major trauma?

A

-Falls from less than 2m

216
Q

Which acronym is commonly used in emergency trauma as a handover?

A
  • ATMIST
  • Age
  • Timing
  • Mechanism
  • Injury
  • Signs
  • Treatment
217
Q

How should a primary survey be done and in what order?

A
  • Catastrophic haemorrhage
  • Airway and C spine
  • Breathing and ventilation
  • Circulation and blood loss
  • Disability (GCS and motor movement)
  • Environment (body temp)
218
Q

Where can blood collect?

A 
-On the floor and 4 more:
>Chest
>Abdomen
>Pelvis
>Longbones
219
Q

What are the deadly 6?

A 
-Trauma that can cause death within the hour
>ATOM-FC
-Airway obstruction
-Tension pneumothorax
-Open pneumothorax
-Massive haemothorax
-Flail chest
-Cardiac tamponade
220
Q

How will a pt present if they have a tension pneumothorax?

A
  • Panicking pt
  • Air hungry - can’t catch a breath
  • CV compromise (increased intrathoracic pressure causes there to be reduced preload)
  • Hypoxic
221
Q

How should a tension pneumothroax be managed?

A

-Needle decompression with large cannula into the 4th/5th intercostal space in midaxillary line
>used to be the 2nd intercostal space in the midclavicular line, but due to obesity, the tissue is often too thick for the needle to penetrate to the lungs

222
Q

How should a massive haemothorax be managed?

A
  • Chest drain
  • Replace blood volume
  • Stop bleeding
223
Q

How does a traumatic cardiac tamponade present?

A
  • High index of suspicion if a wound in the cardiac box

- Hypotension, muffled heart sounds, dilated neck veins

224
Q

How is cardiac tamponade managed?

A

-Pericardialcentesis and resuscitive thoracotomy

225
Q

Which abx should be used to treat severe CAP?

A

-Co-amoxiclav and clarithromycin

226
Q

Which abx should be used to treat HAP?

A
  • Third-generation cephalosporins (eg, cefotaxime, ceftriaxone and ceftazidime)
  • Broad-spectrum penicillins (eg, piperacillin/tazobactam)
  • Fluoroquinolones (eg, ciprofloxacin and levofloxacin)
  • Aminoglycosides (eg, gentamicin)
  • Carbapenems (eg, imipenem and meropenem)
227
Q

How is cellulitis treated?

A

Amoxicillin or flucloxacillin

>clarithromycin if penicillin allergic)

228
Q

How is a complicated UTI treated?

A

-Ciprofloxacin and gentamycin

229
Q

How is meningitis treated?

A

-Ceftriaxone

230
Q

How is toxic shock syndorme treated?

A

-Flucloxacillin

231
Q

Which antibiotics are used to treat bowel infections?

A
  • Metronidazole

- Co-amoxiclav

232
Q

Which abx is used for Infective endocarditis?

A

-Gentamycin

233
Q

How is necrotising fasciitis treated?

A

-Clindamycin

234
Q

What are red flags of sepsis?

A
  • GCS <12
  • 18 hours of <0.5mls/kg/hour urine output
  • HR >130
  • RR >25
  • O2 required to remain sats of >92%
  • Mottled, cyanotic, non-blanching rash
  • Systolic BP <90
  • Lactate >2
  • Recent chemotherapy
235
Q

How do depolarising muscular relaxants work?

A

-Binds to nicotinic acetylcholine receptors resulting in persistent depolarisation of the motor end plate

236
Q

What are the adverse effects of a depolarising muscular relaxant?

A
  • Malignant hyerthermia

- Transient hyperkalaemia

237
Q

How do non-depolarising muscle relaxants work?

A

-Competitive antagonist of nicotinic ACh receptors

238
Q

What is a side effect from depolarising muscle relaxants?

A

-Hypotension

239
Q

How are depolarising muscle relaxants reversed?

A

-Neostigmine

Phase 3B (14 decks)

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