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
2
Q
What are the pre-renal causes of AKI?
A
- Hypovolaemia (dehydration, bleeding)
- Septic shock
- Cardiogenic shock
3
Q
What are the renal causes of AKI?
A
- Acute tubular necrosis
- Glomerulonephritis
- Vasculitis
- Interstitial nephritis
- Tubular toxicity ie CT contrast
4
Q
What are the post renal causes of AKI?
A
-Urinary tract obstruction
>Intraluminal ie stone
>Extraluminal ie cancer compression on ureter
5
Q
What are the diagnostic criteria for AKI?
A
- Increase in serum creatinine >0.3mg/dl within 48 hours
- Or increase in serum creatinine 1.5x baseline
- Or urine volume <0.5ml/kg/hour for r6 hours
6
Q
What are the creatinine levels of stage 1 AKI?
A
-Creatinine 1.5-1.9x baseline
7
Q
What are the creatinine levels of stage 2 AKI?
A
-Creatinine 2.0-2.9x baseline
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
9
Q
What are the management aims for AKI?
A
- Treat underlying cause
- Prevent further damage by optimising renal blood flow with fluid challenge
10
Q
What forms the AKI management bundle?
A
- Restore prefusion
- Stop nephrotoxins
- Exclude obstruction
- Treat complications
11
Q
How is perfusion restored in AKI?
A
- Fluid challenge
- Consider vasoconstrictors or inotropes
12
Q
How do you exclude obstruction in AKI?
A
-Measure urine output
-Imaging
>CT - stones
>Renal USS - hydronephrosis
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
14
Q
How does septic shock cause a prerenal AKI?
A
-Sepsis causes leaky vessels and fluid moves into the interstitium from the vessels
15
Q
What is the main medical cause of acute interstitial nephritis causing AKI?
A
-NSAIDs
16
Q
What is a side effect of genatmycin? and which drugs interacts synergistically?
A
- Ototoxic
- Furosemide
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
18
Q
How is hyperkalaemia treated?
A
- Insulin
- Glucose
- Calcium gluconate (to stabilise the cardiac membranes)
- ECG
- RRT
19
Q
What are the complications of AKI?
A
- Uraemia
- Metabolic acidosis
- Fluid overload
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
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
22
Q
What are the features of acute liver failure?
A
- Jaundice
- Coagulopathy (^PTT)
- Hepatic encephalopathy
23
Q
What is the difference between acute liver failure and acute liver injury?
A
- Acute liver injury = prolonged INR and jaundice.
- NO encephalopathy
24
Q
What are classic signs of hepatic encephalopathy?
A
- Asterixis (liver flap)
- Unable to count back from 100 in 7s
25
How can acute liver failure be classified?
- Uses time from jaundice to encephalopathy
- Hyperacute: <7/7 (best prognosis)
- Acute: 8-28 days
- Subacute: 29days-12 weeks (worst prognosis)
26
What are the causes of acute liver failure?
- 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
27
What are some rarer causes of ALF?
```
-Viruses: HSV, CMV, EBV parvovirus
Ischaemic hepatitis
-Autoimmune hepatitis
-Wilson's disease
-Budd chiari syndrome
-Mushrooms
-Hepatectomy
```
28
Where is heptitis E caught from?
-Undercooked pork or shellfish
29
What is the difference between a single time point paracetamol overdose and a staggered overdose?
- Single time point: >4g paracetamol taken at once
| - Staggered: ingestion of 2+ supratherapeutic doses over 8 hours in a cumulative dose of >4g/day.
30
Which types of pts are increased risk of hepatotoxicity following paracetamol OD?
-Underweight
-Alcoholic
-Malnourished
>anorexia, CF, hep C, Cancer, HIV
-Staggered OD
-CLD
-Regular liver enzyme inducers
>rifampicin, phytoin, carbamazepine, St. John's wort
31
How should paracetamol OD be investigated?
- Blood paracetamol levels
- ABG (metabolic acidosis)
- Prothrombin time
- ALT (high = paracetamol)
32
What are the complications of acute liver failure?
- Encephalopathy
- Renal failure
- Sepsis (bacterial and fungal infections)
- Malnourishment
33
Define shock
- Circulatory failure
- Tissue hypo-perfusion
- Energy defecit
- Accumulation of metabolites (lactate)
34
What are the causes of shock?
- Septic
- Hypovolaemic
- Anaphylactic
- Cardiogenic
- Neurogenic
35
What are the 3 basic components that can go wrong to cause shock?
- Fluid
- Pumps
- Pipes
36
What are the fluid causes of shock?
- Haemorrhage
- Dehydration
- Burns
- DKA
37
What are the pump causes of shock?
- Tension pneumothorax
- Pulmonary embolism
- Cardiac tamponade
- Ischaemia
- Arrhythmias
38
What are the pipe causes of shock?
- Neurogenic ie spinal cord lesion
- Endocrine ie Addisonian crisis
- Septic (leaky fluid)
- Anaphylactic (leaky fluid)
39
How is an episode of shock managed?
- Help
- ABCDE
- o2.
- Treat underlying cause
40
What medications treat hypovolaemia?
- Fluids
| - Vasopressors
41
What medications manage septic shock?
- Fluids
- Antibiotics
- Adrenaline
42
What medications manage anaphylactic shock?
- IM adrenaline 1:1000
- Fluids
- Vasopressors
43
What medications manage cardiogenic shock?
- Inotropes (increases contractility)
| - NOT vasopressors>increases resistance for heart to pump against
44
Where are the 5 areas blood can accumulate?
- Blood on the floor and 4 more
- Thorax
- Abdomen
- Pelvis
- Long bones
45
What are the immediate steps in managing AAA or aortic dissection?
- Help
- ABCDE
- Crossmatch blood
- Call surgeon
46
Which drugs should manage a small and big PE?
- Small: LMWH
| - Big: alteplase
47
How should broad complex tachycardia be managed immediately?
-HELP
-ABCDE
-Repeat ECG
>wide and fast = bad
48
What are the main endocrine emergencies?
- Hyponatraemia
- Addisonian crisis
- Phaeochromacytoma
- Pituitary apoplexy
- Thyroid storm
- Myxoedema coma
- Hypercalcaemia
- DKA
49
What is the biochemical definition for hyponatraemia?
-Sodium <135mmol/L
50
What are the 3 main categories of causes of hyponatraemia?
- Hypervolaemic
- Euvolaemic
- Hypovolaemic
51
What are the causes of hypervolaemic hyponatraemia?
- Congestive heart failure
- Renal failure
- Nephrotic syndrome
- Cirrhosis/liver failure
- Hyperglycaemia
52
What are the causes of euvolaemic hyponatraemia?
-Diuretics
-SIADH
-Primary polydipsia
-Low Na intake
-Advanced renal failure
-Hormonal insufficiency
>Addison's
>Hypothyroidism
>Pregnancy
53
What are the causes of hypovolaemic hyponatraemia?
```
-Renal causes:
>diuretics, Addisons, nephropathy
-GI causes:
>D+V
-Other:
>Burns
>Rhabdomyolysis
>pancreatitis
>peritonitis
```
54
What are the clinical features of hyponatraemia?
- Confusion
- Lethargy
- Seizures
- Coma
55
How is acute hyponatraemia treated?
-3% saline. 150ml bolus over 20 minutes
56
What is the general rule for treating endocrine emergencies?
-Treat on clinical suspicion and don't wait for test results
57
What are the symptoms of acute adrenal failure (Addisonian crisis)?
- Pain (lower back, abdo, legs)
- Severe D+V
- Low BP
- Loss of consciousness
- Hyperkalaemia
- Hyponatraemia (confusion, lethargy, coma)
58
What are the causes of an Addisonian crisis?
- Can be 1st presentation
- Sepsis or Sx can cause acute exacerbation of chronic insufficiency
- Steroid withdrawal
59
How is addisonian crisis managed?
- 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
60
What is extreme hypertension and tachycardia until proven otherwise?
-Phaeochromacytoma
61
What is emergency management of phaeochromacytoma?
- Alpha blocker (doxazocin or phenoxybenzamine)
| - Then Beta blocker (propanolol) if required
62
What can precipitate a phaeochromacytoma crisis?
- Exercise
- Beta blockers
- Abominal pressure
- Stress
- Emotional trauma
63
What is pituitary apoplexy?
-Sudden enlargement of pituitary tumour secondary to haemorrhage/infarction
64
What are the features of pituitary apoplexy?
-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
65
How is pituitary apoplexy managed?
- MRI ?Poss surgery
| - IV hydrocortisone
66
What are the symptoms of a thyroid storm?
- Tremor
- Vomiting
- Hypertension
- Thyrotoxicosis symptoms
67
How is a thyroid storm managed?
- Propylthiouracil
- Propanolol
- Lugol's idoine
- Cholestryamine
- Fluids and supportive therapy
68
What are the features of hypercalcaemia?
- Painful bones, renal stones, abdominal groans and psychic moans
- corneal calcification, shortened QT, hypertension
69
What are the 2 main causes of hypercalcaemia?
- Primary hyperparathyroidism
| - Malignancy (bony mets, myeloma)
70
What are some other causes of hypercalcaemia?
- Sarcoidosis
- Vit D intoxication
- Acromegaly
- Thyrotoxicosis
- Drugs: thiazides, calcium containing antacids
- Dehydration
- Addison's disease
- Paget's disease of the bone
71
How is hypercalcaemia managed?
- Rehydration with normal saline (3-4l/day)
- Bisphosphonates
- Can use calcitonin
72
What fluid volume is needed for daily maintenance in adults?
- 30ml/kg
| - 70kg person: 30x70 =2100mls
73
How much sodium and potassium is needed per day in fluid maintenance?
- NA: 1-2mmol/kg
| - K: 1mmol/kg
74
What are the sources of sensate fluid loss?
- Urine output
- Drainage from a body part
- Bleeding
75
What are the sources of insensate fluid loss?
- Water vapour lost by breathing
| - Third spacing ie ascites
76
What are the signs indicating some dehydration?
- Restless, irritable
- Sunken eyes
- Thirsty, drinks eagerly
- Skin turgor returns slowly
77
What are signs of severe dehydration?
- Drowsy, unconscious
- Sunken eyes
- Drinks poorly, not able to eat or drink
- Skin turgor returns slowly
78
What is the general approach to fluid prescribing?
- Calculate defecit
- Ongoing maintenance
- Monitor results of therapy
79
What is the definition of major trauma?
-Serious and othern multiple injuries where there is a strong possibility of death or disability
80
What is the injury severity score?
- Looks at the different injuries a pt has and scores them
| - >15 = major trauma
81
What are the main categories of injury?
- Blunt ie lacerations
- Sharp ie incisions
- Penetrating ie stab, gunshot wound
- Burns including electrical burns
82
Which radiological imaging should be done in a primary survey for trauma?
- Xray
- FAST USS: free fluid in abdomen
- CT scanning
83
When does a pt get a whole body CT?
- 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
84
What mechanisms of injury require a CT?
- >1 body system
- RTC with fatalities
- Falls from height
- Falls from a horse
- Findings on plain film/USS
85
What are the signs of a patient bleeding?
-Visual blood loss
-Tachycardia
>be aware of beta blockers, elderly, children, pregnant women, fitness athletes
-Prolonged cap refill time
-Hypotension
86
What is the lethal triad of trauma?
- Hypothermia
- Acidosis
- Coagulopathy
87
What is the difference between primary and secondary head injury?
- Primary: actual trauma to the white matter
| - Secondary: caused by hypoperfusion, acidosis etc. A result of a process elsewhere in the body
88
How should a significant head injury be managed?
-Imaging
-Early referral to neurosurgery
-Ensure perfusion of brain
>hypercarbic can increase cerebral blood flow
89
How can raised intracranial pressure be managed?
- Cerebral dehydration: mannitol, hypertonic saline
| - Reduce cerebral blood volume: ensure well oxygenated, normal co2 levels
90
How can the c spine be immobilised?
- Collar
- Blocks
- Tapes
91
What are the supratnetorial causes of unconsciousness?
- Head injury
| - Stroke
92
What are the infratentorial causes of unconsciousness?
- Brain stem damage
| - Herniation
93
What are the metabolic causes of unconsciousness?
- Resp: Hypoxia, hypercabia
- Hypo/hyperglycaemia
- Hyponatraemia
- Hepatic encephalopathy (high ammonia)
- Severe renal failure: high urea
- Sepsis
- Toxins, drugs
94
What are the important features of neuro exam to check in head injuries/LOC?
- GCS
- Pupils
- Cranial nerves
- Lateralising signs
- Focal deficits
95
Define sepsis:
-Life threatening organ dysfunction caused by a dysregulated host response to infection
96
What are common sites of infection that lead to sepsis?
- Chest
- Abdomen
- UTI
- CNS
- MSK
- Line infections on ITU
97
What are signs of end-organ dysfunction in sepsis?
- Hypotension
- Hypoperfusion
- Hypoxia
- Renal (oligurla, raised Cr)
- Marrow and clotting issues
98
What are the sepsis 6?
- BUFALO
- Blood cultures + septic screen
- Urine output hourly
- Fluid resus
- Antibiotics IV
- Lactate
- Oxygen
99
In what time does sepsis 6 need to be performed?
-Within the hour especially antibiotics!
100
What is an easy way of remembering the GCS scores?
-EVM, 4,5,6
101
Which component of GCS is arguable the most important?
-Motor score
102
What are the scores for eyes in GCS?
- 4: Spontaneously open
- 3: Open to voice
- 2: Open to pressure
- 1: None
103
What are the scores for voice in GCS?
- 5: orientated
- 4: confused
- 3: inappropriate words
- 2: uncomprehensible sounds
- 1: none
104
What are the scores for motor in GCS?
- 6: obeys commands
- 5: localises pain
- 4: Normal flexion to pain
- 3: Abnormal flexion to pain
- 2: Extension to pain
- 1: none
105
How should motor function be assessed in GCS?
-Stick tongue out. (central nervous system so won't be using spinal reflexes)
106
What is a VQ mismatch?
-A mismatch of perfusion and ventilation
| ie blood flow through areas of the lung where no gas exchange occurs
107
What are common causes of VQ mismatch?
- Chest infections
| - Heart failure
108
What partial pressure of oxygen is regarded as resp. failure?
-<8 pO2
109
What is type 1 resp failure?
-Normal or decreased CO2 and low O2
110
What is type 2 resp failure?
-High CO2 and low O2
111
What resp failure should BiPAP be used to manage?
-Type 2 resp failure.
| >Increases inspiratory and expiratory pressure.
112
What resp failure should CPAP be used to manage?
-Type 1 resp failure
| >Used to treat hypoxia
113
What is non-invasive ventilation?
-BiPAP & CPAP
114
What are the indications for Non-invasive ventilation?
- Post op
- COPD
- Oedema
- CPAP for obstructive sleep apnoea
115
What are the contra-indications for non invasive ventialtion?
- ASTHMA
- Pneumothorax
- Agitation
- Airway loss
116
Which method should ABGs be reviewed?
- PO2 ->are they in resp. failure?
- PCO2 -> T1RF or T2RF?
- PCO2 -> respiratory acidosis or alkalosis?
- BE -> metabolic acidosis (2)
- pH -> compensated vs decompensated
117
What would T2RF look like on an ABG?
-Respiratory acidosis
118
What would a panic attack look like on an ABG?
-Respiratory alkalosis
119
What are the anatomical factors that cause loss of airway patency?
- Large tongue
- Neck flexion
- Obesity
- Adenotonsillar hypertrophy
- Oedema (burns/infection)
120
What are reduces the tonic contraction of pharyngeal muscles which causes loss of airway patency?
- REM sleep
- Alcohol
- Other sedative drugs
- Coma
121
What are the 4 causes of ventilatory failure?
- 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
What are signs of large airway obstruction?
- Partial: noisy
- Complete: Silent
- Increased resp drive initially
- Paradoxical chest/abdo movement
- Suprasternal/intercostal/subcostal recssion
- Lack of misting on O2 mask
123
What manoevers are use for basic airway management?
- Head tilt
| - Jaw thrust
124
What are type of artificial airways?
- Nasal airway
- Oral (Guedel) airway
- Laryngeal mask airway
- Endotracheal tube
125
What requirements do you need for an intubation technique?
- 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
What factors predict difficult intubation?
- Short neck
- Small, immobile mandible
- Prominent upper teeth
- Fixed neck flexion
- Limited mouth opening
- Soft tissue swelling
127
Which 3 specific factors predict a difficult intubation?
- Thyromental distance
- Assess mouth opening
- Neck extension
128
What is the definition of clearance (pharmacokinetics)?
-A measure of the renal excretion ability (may also depend on hepatic metabolism)
129
What is first order kinetics?
-Rate of elimination is proportional to concentration
130
What is zero order kinetics?
-Rate is independent of concentration ie constant amount is eliminated
131
What are the indications for central venous access?
- Monitoring central venous pressure
- Pacing
- Administration of drugs that can not be infused peripherally ie TPN, chemo, KCL, vasopressors
- Haemodialysis
- Poor peripheral access
132
What are absolute contraindications for central venous access?
- Patient refusal
| - Infection at site
133
What are relative contraindications for central venous access?
- Coagulopathy
- Evidence of vein thrombosis
- Access likely to be impossible ie surgery, trauma, neck immobilised in hard collar
134
What are the potential sites for central venous access?
- Internal jugular
- Subclavian
- Femoral
- PICC (peripherally inserted central catheter)
135
What site is most commonly used for central venous access?
-Right internal jugular
136
What are early complications of central venous access?
- Arrhythmias
- Pneumothorax
- Haemothorax
- Cylothorax
- Bleeding/haematoma
- Damage to the artery
- Air embolism
- Nerve damage
137
What are late complications of central venous access?
- Thrombosis
- Phlebitis
- Catheter-related sepsis
138
What is carbon monoxide poisoning due to?
-Exposure to gaseous products of incomplete combustion ie house fire, faulty gas fire
139
Why does carbon monoxide cause hypoxia?
- 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
Does CO or O2 have a higher affinity to Hb?
-CO is 200 x higher affinity than 02
141
What are symptoms of CO?
- Headache
- Malaise
- Nausea
- Ataxia
- Syncope
- Seizures
- Coma
142
What are the signs of CO?
- ^HR
- ^RR
- Hypotension
- MI
- Rhabdomyloysis
- Cherry red skin (rare)
143
What would lab tests show in CO poisoning?
- raised creatinine kinase (muscle, cardiac damage)
| - Metabolic acidosis
144
How is CO managed?
- 100% O2 until COHb <5%
- ?Fluids, inotropes
- Organ toxicity monitoring > ECG, cardiac enzymes, urinalysis, serum creatinine
145
How does calcium exist in the blood?
- Bound to albumin
- Bound to anions eg phosphate, citrate
- Free (unbound) ionised
146
Which form of calcium is physiologically active?
-Ionised calcium (unbound)
147
What is normal blood calcium?
| What is ionised calcium?
- Normal: 2.12-2.62 mmol/l
| - Ionised: 1.16-1.31mmol/l
148
What are the common causes of hypocalcaemia?
- Hypoparathyroidism
- Vitamin D deficiency
- Chronic renal disease
149
What are the symptoms of hypocalcaemia?
- Neuromuscular irritability (tetany)
- Bronchospasm
- ECG changes
- Seizures
150
Why does hypocalcaemia cause neuromuscular symptoms?
- Decreased interaction of calcium with sodium channels.
- Inhibits depolarisation of nerve and muscle fibres.
- Diminished calcium lowers the threshold for depolarisation = neuromuscular symptoms
151
What are the symptoms of hypocalcaemia using the mneumonic CATS go numb?
- Convulsions
- Arrhythmias
- Tetany/numbness/paraesthesia in hands, feet, around the mouth
152
What are the ECG changes caused by hypocalcaemia?
- Intermittent QT prolongation
| - Causes life threatening cardiac instability --> risk ^ of Torsades de Point
153
How does alkalosis affect calcium?
- 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
What is the definition of hypothermia?
-Fall in core temp of <2 degrees below normal
155
What is the CNS pathophysiology that occurs when a patient falls below 35c?
- Hypothermia causes CNS depression
- Temperature dependent enzymes don't function properly
- Causes impaired judgement, slurred speech, LOC
156
What is the CVS pathophysiology that occurs when a patient falls below 35c?
- 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
What is the resp pathophysiology that occurs when a patient falls below 35c?
- Initially stimulated and it's then diminished as metbaolism becomes depressed
- Resp rate and CO2 production halve
- Resp arrest at 24 degrees
158
What is the renal pathophysiology that occurs when a patient falls below 35c?
- Initial large diuresis caused by impaired ADH sensitivity)
| - Renal blood flow decreases
159
What is the coagulation pathophysiology that occurs when a patient falls below 35c?
- Depressed enzymatic function
| - Coagulopathy treated by rewarming
160
What are the predisposing facotrs for hypothermia?
- Extremes of age
- Hypopituitarism/hypothyroidism
- Malnutrition
- Burns/skin diseases
- Lack of acclimatisation to cold
- Alcohol ie vasodilation, impaired shivering
- Drugs ie benzos, narcotics
161
How should hypothermia be managed and which methods should be used when?
- Sudden onset/ severe needs active method
| - Slow onset/ mild-moderate needs passive method
162
When should the passive method be used for hypothermia?
- 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
When should active warming be used and what does it involve for hypothermia?
- 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
What should you be cautious of when warming someone who is hypothermic?
-Rapid rewarming can cause cardiac and metabolic instability
165
What are some potential complications following hypothermia?
- Drugs can have toxic effect
- Hyperkalaemia
- Possible renal failure due to hypoperfusion
- Frostbite
166
How does local anaesthetics work?
-Prevent pain by causing reversible block of conduction along nerve pathways
167
What is the local anaesthetics mode of action?
-Enter axon, block sodium channels from inside axon, prevents spread of depolarisation wave
168
What are the different type of local block?
- 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
What are some common uses for local anaesthetics
- 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
What are some potential complications for local anaesthetic use?
- 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
Local anaesthetic toxicty signs on CNS and CVS?
- Numbness of mouth/lips, lightheadedness
- Convulstions
- Pupil dilation, coma, apnoea
- Bradycardia, hypotension, asystole
172
What does a 1% solution of lignocaine contain?
-10mg/ml.
| Should not exceed 5mg/kg with no adrenaline or 7mg/kg with adrenaline
173
What is the most common cause of maternal sepsis?
-Community acquired Beta haem strep group A
174
What is the criteria to diagnose SIRS?
```
-Diagnosed by 2+ of:
>fever/hypothermia
>tachycardia >90
>tachypnoea >20
>WBC >12 or <4
```
175
What is the definition of sepsis?
-SIRS in the presence of infection
176
What is the definition of severe sepsis?
-Sepsis with organ dysfunction, hypotension or hypoperfusion
177
What is the definition for septic shock?
-Sepsis + refractory arterial hypotension despite adequate fluid resuscitation
178
What are features of severe sepsis?
- Hypotension
- Hypoxia
- Raised lactate
- Acute oliguria (<0.5ml/kg/hr)
- Deranged renal/hepatic function
- Altered mental state
- Coagulation abnormality
- Hyperglycaemia (with no diabetes)
179
What are the early, later and very late signs of sepsis?
- Early: tachypnoea/tachycardia
- Later: hypotension, poor urine output
- Very late: pale, clammy, cool periphery, altered consciousness
180
What is the management of sepsis?
- Fluid challenge of 1000ml crystalloid
| - Antibiotics - early, broad spec.
181
What antibiotics should be used for sepsis?
-Augmentin and Metronidazole
or
-Cefuroxime and metronidazole
-Penicillin allergy: clindamycin and gentamycin
-Severe sepsis: ciprofloxacin, gentamycin, metronidazole
182
What is the CURB management for pneumonia?
1: Amoxicillin PO
2: Co-amoxiclav
3: IV co-amoxiclav and PO clarithromycin
183
What are the functions of the skin?
- Keeps water in
- Keeps infections out
- Thermoregulator
- Vitamin D production
- Sensory organ
- Identity
184
What are the causes of burns?
- Dry heat (fire/hair straighteners)
- Wet heat (scald)
- Chemical >alkali and acid
- Electrical
185
How are acidic burns different from alkaline?
- 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
What type of acid is so dangerous it can burn bone?
-Hydrofluoric acid
187
How is a hydrofluroric acid burn treated?
-Calcium gel, eyewash, s/c calcium gluconate
188
How can you estimate a size of a burn?
- 1% is a patient's palm
| - Rule of 9s. Body surface area.
189
If a pt has been managed using BUFALO and is being transferred to ITU, what interventions will be done?
- Arterial line: measure BP
| - Central line: for access
190
What drugs can be used to reverse hypotension as a result from septic shock?
- Metaraminole (alpha agonist)
- Phenylephrine (alpha agonist)
- Adrenaline
- Noradrenaline
- Vasopressin
- Debutamine
- Steroids
191
What are some examples of drugs that can cause a metabolic acidosis?
- Metformin
| - Acetazolamide (Rx for benign intracranial hypertension)
192
What imaging can be done to view pneumothoraces?
- USS
- CXR
- CT
193
What dose of propofol should be given to a pt?
2-3mg/kg (of ideal body weight)
194
How do fevers behave if the source is from an abscess?
-Waves of feeling feverish and then normal
195
What defines a staggered overdose?
- 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
What site is really useful for patients that have ODd?
-Toxbase
197
What are some drugs that can cause airway obstruction if they are overdosed?
- Opioids
- Benzodiazapines
- Alcohol
198
What are some drugs that can cause arrhythmias if they are overdosed?
- Local anaesthetics
- Tricyclic antidepressents
- Beta blockers, Calcium channel blockers
199
What are some drugs that can cause hypothermia if they are overdosed?
- Alochol
| - Barbituates (anticonvulsants - phenoarbital)
200
What are some drugs that can cause hyperthermia if they are overdosed?
-Amphetamines (ie cocaine, LSD, MDMA)
201
What drugs cause Miosis (constricted pupils)?
- Alcohol
- Benzodiazapines
- Opiates
202
What drugs cause mydriasis (dilated pupils)?
- Amphetamines
| - Tricyclic antidepressents
203
What can be given to prevent further absorption of a drug in an OD?
- Activated charcoal
- Gastric lavage
- Haemodialysis
204
How does activated charcoal work?
-Drug binds to charcoal instead of being absorbed and is transported through GIT
205
What are the early symptoms of a paracetmaol overdose?
- Asymptomatic
| - Nausea
206
What are the symptoms after 24 hours of a paracetamol OD?
- Can be asyptomatic
- Gastric pain
- Increased nausea
207
What are the symptoms after 2-3 days of paracetamol OD?
- Jaundice
- Oedematous change
- Drowsiness
- Confusion
- Ataxia
- DIC
- Liver capsular pain due to swelling
208
Which enzyme pathway metabolises paracetamol?
-Cytochrome p450
209
Why can you wait for up to 8 hours after the overdose to treat?
-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
What level of paracetamol needs to be treated?
-Paracetamol >150mg/kg
211
Which blood test becomes abnormal first in a paracetaol overdose?
-INR
>becomes abnormal within 6-12 hours.
>Other blood tests may still be normal
212
What 5 things need to be done to manage a human bite?
- Antibiotics if bite is over a joint > clindamycin and ciprofloxacin
- Blood sample for storage
- Tetanus
- Hepatits B
- Irrigation
213
What is the definition of major trauma?
-Any injury(ies) that are life threatening or life changing that requires multiple resources to manage
214
What are the different types of major trauma?
- Blunt force trauma ie RTC, falls, assaults
- Penetrating trauma ie Knife wounds, gunshot wounds
- Burns
- Blast injuries
215
What is the most common cause of major trauma?
-Falls from less than 2m
216
Which acronym is commonly used in emergency trauma as a handover?
- ATMIST
- Age
- Timing
- Mechanism
- Injury
- Signs
- Treatment
217
How should a primary survey be done and in what order?
- Catastrophic haemorrhage
- Airway and C spine
- Breathing and ventilation
- Circulation and blood loss
- Disability (GCS and motor movement)
- Environment (body temp)
218
Where can blood collect?
```
-On the floor and 4 more:
>Chest
>Abdomen
>Pelvis
>Longbones
```
219
What are the deadly 6?
```
-Trauma that can cause death within the hour
>ATOM-FC
-Airway obstruction
-Tension pneumothorax
-Open pneumothorax
-Massive haemothorax
-Flail chest
-Cardiac tamponade
```
220
How will a pt present if they have a tension pneumothorax?
- Panicking pt
- Air hungry - can't catch a breath
- CV compromise (increased intrathoracic pressure causes there to be reduced preload)
- Hypoxic
221
How should a tension pneumothroax be managed?
-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
How should a massive haemothorax be managed?
- Chest drain
- Replace blood volume
- Stop bleeding
223
How does a traumatic cardiac tamponade present?
- High index of suspicion if a wound in the cardiac box
| - Hypotension, muffled heart sounds, dilated neck veins
224
How is cardiac tamponade managed?
-Pericardialcentesis and resuscitive thoracotomy
225
Which abx should be used to treat severe CAP?
-Co-amoxiclav and clarithromycin
226
Which abx should be used to treat HAP?
- 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
How is cellulitis treated?
Amoxicillin or flucloxacillin
| >clarithromycin if penicillin allergic)
228
How is a complicated UTI treated?
-Ciprofloxacin and gentamycin
229
How is meningitis treated?
-Ceftriaxone
230
How is toxic shock syndorme treated?
-Flucloxacillin
231
Which antibiotics are used to treat bowel infections?
- Metronidazole
| - Co-amoxiclav
232
Which abx is used for Infective endocarditis?
-Gentamycin
233
How is necrotising fasciitis treated?
-Clindamycin
234
What are red flags of sepsis?
- 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
How do depolarising muscular relaxants work?
-Binds to nicotinic acetylcholine receptors resulting in persistent depolarisation of the motor end plate
236
What are the adverse effects of a depolarising muscular relaxant?
- Malignant hyerthermia
| - Transient hyperkalaemia
237
How do non-depolarising muscle relaxants work?
-Competitive antagonist of nicotinic ACh receptors
238
What is a side effect from depolarising muscle relaxants?
-Hypotension
239
How are depolarising muscle relaxants reversed?
-Neostigmine
