Acute and critical care Flashcards
What are the prerequisites for a blood transfusion?
2 independent G&S taken by different people at different times
What blood group is given in an emergency?
What may be given in future? Why?
O negative
O positive. Save O negative for pregnant women to prevent rhesus disease.
If you have an obese person you need to given fluids to, to what weight do you calculate their fluid requirements?
Equations?
Ideal body weight.
Males = 0.9xH(cm)-88
Females = 0.9xH(cm)-92
If you are dealing with major trauma and the patient has massive haemorrhage, what are your fluid options? Which one first?
Red blood cells (first), FFP, Fluids (crystalloids)
Given the adult therapeutic dose and time for administration of:
- Red cells
- Platelets
- Cryoprecipitate
- FFP
Red cells = 1 bag over 2-3 hours
Platelets = 1 bag over 30 minutes (max)
Cryoprecipitate = 2 bags stat
FFP = 3 bags, 30 minutes max per bag (1.5hrs)
- What does TACO stand for?
- What are the signs and symptoms?
- Time frame for diagnosis?
- Investigation?
- Management?
1)Transfusion associated circulatory overload
2) Pulmonary oedema so: dyspnoea, wheezing, cough, cyanosis, tachypnoea
Heart overload: chest tightness, rapid increase in blood pressure, distended neck veins
Peripheral oedema
3) Within 24 hours of transfusion
4) CXR
5) Treatment = diuretics, (morphine), nitrates
Prevention = Giving single units, prophylactic diuretics, regular reviewing of patient
What is major trauma?
Serious and often multiple injuries where there is a strong possibility of death or disability
What is the Golden hour? Platinum 10 minutes?
Getting patients into hospital within 1 hour until their morbidity and mortality declines.
Life saving interventions should be implemented within 10 minutes of admission.
What are the steps of the primary survey of major trauma?
CABCDE Control catastrophic haemorrhage Airways and C-spine protection Breathing with ventilation Circulation with haemorrhage control Disability - neurological status (eyes, GCS/AVPU), glucose Exposure/ environment
What are possible mechanisms of injury in major trauma?
RTC Fall from standing height (elderly) Fall from height (>2 stories = bad) Assault - head injury, stamping Penetrating - knife, gun shot Crush injury - industrial/ building falling Blast injury - explosion
What are the ways that a blast injury can injure you?
Primary - blast wave disrupts gas filled structure
Secondary - impact of airborne debris
Tertiary - transmission of body
Quaternary - All other forces
What is the paramedic trauma handover?
ATMIST Age Time of injury Mechanism of injury Injuries Signs Treatments given already
What tool can you use to decide if a person needs a specialist major trauma centre?
Yorkshire major trauma triage tool
What to do in each of the CABCDE approach
C. 1) Direct, focussed pressure, keep pushing harder
2) Indirect pressure proximally
3) Torniquet - 3 inches above, another above if not sufficient
4) Haemostatic agents (ceelox)
A. Secure the airway - Immobilise the C-spine
Look listen feel for breathing
Suction, chin lift/jaw thrust, Guedel airway
Proceed to RSI/intubation if indicated
B. Give oxygen
Depends on causative issue:
- Tension pneumothorax - thoracocentesis/ thoracotomy + chest drain
- Massive haemothorax - Requires IV access + fluids before draining
- Cardiac tamponade - thoracotomy and drain
C. Stop catastrophic bleeding Pelvic binder Splint long bone fractures Permissive hypotension with fluid replacement (RBC, PLTs, FFP) Transexamic acid 1g over 10 mins the 1g infusion Emergent damage control surgery Interventional radiology Limit crystalloid
D. Prevent secondary brain injury
Secure airway in GCS less than 8 or control ventilation
Maintain normal - ICP, Glucose, Oxygen, CO2
E. Ensure patient is warm
Pain management
What is the time frame for securing an airway in major trauma upon arrival?
45 minutes
Absolute indications for intubation
Inability to maintain airway Inability to maintain adequate oxygenation upon less invasive manoeuvres Inability to maintain normocapnia Deteriorating conscious level Significant facial injuries Seizures
What are the indications for intubation with burns?
Deep facial burns, hypoxia or hypercapnia, full thickness neck burns.
Early intubation before swelling and fluid builds up
Relative indications for intubation
Haemorrhagic shock
Agitated patient
Multiple painful injuries
Transfer to another area of hospital/ expected clinical course
Indications for c-spine immobilisation?
High force mechanism of injury with a reduced consciousness level
Life threatening injuries on primary survey
ATOM FC Airway obstruction Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Cardiac tamponade
Textbook signs of tension pneumothorax
In reality
1.Diminished breath sounds Hyperesonance Distended neck veins Deviated trachea Hypoxia Tachycardia Hypotension
- Air hunger/agitation
Hypoxia
Hypotension
Immediate management of tension pneumothorax
Thoracocentesis in 2nd intercostal space mid-clavicular line
Thoracotomy with large bore chest drain
Define massive haemothorax
Signs
Management
- Over 1.5L blood into the chest cavity
- Reduced air sounds, hyporesonance (contrasts tension)
- Obtain IV access because when you drain it they can bleed more into the space causing hypotension
Thoracotomy (indications >1.5L blood loss or >200ml/hr)
What is an open pneumothorax?
Wound to chest wall communicating with the pleural cavity. Needs to be 2/3 aperture of trachea. Air moves inwards but wound closes on way out creating a 1 way valve
Define flail chest
Fracture of 2 or more ribs in 2 or more places.
This creates a floating rib section that move paradoxically. This severely impairs ventilation.
Signs of a cardiac tamponade
Pathophysiology
Investigation?
Treatment?
Beck’s triad:
1) Hypotension
2) Diminished heart sounds
3) Distended neck veins
Penetrative trauma into the pericardium (cardiac box) which blood collects and compresses the heart causing the triad
USS
Thoracotomy and incision of the pericardium (removing fluid)
Life changing injuries on secondary survey
Simple pneumothorax Aortic injuries Diaphragmatic injuries Fractured ribs Lung contusion Cardiac contusion
Most accurate signs to show a bleeding patient in hypovolaemic shock
Others?
Tachypnoea
Pale
Sweaty
Anxious/ confused Tachycardiac Narrow pulse pressure CRT Hypotension Bradycardia - terminal sign
Sites for massive haemorrhage
Blood on the floor (external haemorrhage) and four more:
- Chest
- Abdomen
- Long bones
- Pelvis
Causes of abdominal bleeding
Signs
Investigation required
Treatment + indications
Blunt force trauma/ penetrating
Not always obvious. Peritonism is a late sign so scan
CT abdo required
Laparotomy/ interventional radiology Peritonism Radiological evidence of free air GI haemorrhage Persistant/ resistant haemodynamic instability
Treatment of pelvic fractures
Pelvic binders to push it back together
What is permissive hypotension?
Numbers?
Allow lower BP
MAP 50mmHg
Systolic 90mmHg
Why are crystalloids not used in trauma?
It doesn’t carry oxygen
High chloride content so causes hyperchloraemic acidosis
Indications for fluid administration in trauma?
Systolic pressure <90mmHG
HR >130mmHg
Reduced consciousness level
Obvious massive ongoing blood loss
How are patients volume resuscitated in trauma?
1 unit RBC
1 unit platelet
1 unit FFP
What is the sequence of management in massive haemorrhage?
Stop catastrophic bleeding Pelvic binder Splint long bone fractures Permissive hypotension Transexamic acid 1g over 10 mins the 1g infusion Emergent damage control surgery Interventional radiology Limit crystalloid
How is neurology assessed on the primary survey?
AVPU
GCS - particularly motor for outcomes
Pupillary response
Sensory level if able
What is the Cushing’s reflex?
Altered cardiac functioning from raised ICP (pre-coning and a very bad sign)
Raised ICP = Raised BP = baroreceptor stimulation = bradycardia
Management of head injuries
Prevent secondary brain injury
Secure airway in GCS less than 8 or control ventilation
Maintain normal - ICP, Glucose, Oxygen, CO2
What are the respiratory differences in the elderly?
Weak respiratory muscles Kyphotic T spine Rigid chest wall Reduced alveolar exchange surface area Impaired central response to hypoxia
What are the cardiovascular differences in the elderly?
Total body water reduces (preload)
Reduced vascular compliance and increased rigidity (afterload)
Myocardium becomes fat and collagen reducing contractility
All the above lead to reduced stroke volume
What drugs can cause falls?
Antihypertensives Opioids NSAIDs Sedatives Steroids Beta-blockers Anticoagulants (higher risk of bleeds on fall)
Diagnostic criteria for a UTI in the elderly?
New urinary symptoms or fever with:
- Change in urinary character
- or haematuria
- or loin tenderness
What are the types of pelvic fractures?
Which one is made worse by pelvic binders?
Lateral compression fracture - worse with pelvic binder
AP compression/ open book fracture
Vertical shear
What angles are required for a c-spine fracture?
How to structure interpretation
AP, lateral, odontoid peg (requires opening of mouth)
ABCS A - alignment of bony structures B - bones (any fractures) C - cartilage (any widening of spaces) S - Soft tissue
Indications for a CT head
GCS <13 at presentation
GCS<15 at 2 hours after injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture
Post-traumatic seizure
Focal neurological deficit
More than one episode of vomiting since injury
What radiological method is used to rapidly assess for trauma?
What does it look at?
FAST scan (Focused assessment with Sonography in Trauma)
Cardiac region
Left upper quadrant - spleen
Suprapubic region - fluid in peritoneal cavity
What are the three core features of acute liver failure?
Epidemiology?
Jaundice, coagulopathy (INR>1.5), hepatic encephalopathy (absence of chronic disease and within 12 weeks for diagnosis)
Rare but serious
How to assess for hepatic encephalopathy
Hands outstretched and they start to flap
What are the classifications of acute liver disease?
What causes fit into each?
Worst prognosis?
Hyperacute - within 7 days:
- Paracetamol, drugs, viral hepatitis
Acute - 1 to 4 weeks:
- Viral hepatitis, ischaemic hepatitis
Sub-acute - 4-12 weeks (Worst prognosis):
- Seronegative hepatitis
- Autoimmune hepatitis
What are the causes of acute liver failure?
How does this change by area of the world?
Paracetamol overdose - most common in UK
Viral hepatitis - A, E (commonest worldwide), B
Other drugs
What drugs can cause acute liver failure?
General causes
Commoner - Paracetamol, isoniazid, NSAIDs, sodium valproate, carbamazepine
Rarer - TCA, phenytoin, allopurinol, amiodarone
Ischaemic hepatitis Autoimmune hepatitis Acute fatty liver of pregnancy Wilson's disease Budd chiari syndrome Mushrooms (amanita phalloides) Post-hepatectomy
What is the upper limit of paracetamol dose per day?
Max dose per day in chronic liver disease or weight <50kg?
4g
2-3g
What investigations need doing in acute liver failure?
Management?
Drug concentrations - paracetamol
Immunoglobulins - IgM, IgG
Autoantibodies
Ultrasound - fatty liver
Stop causative drug Reverse if possible - NAC IV fluids Abx and antifungals Liver transplant
Risk factors for paracetamol overdose
Staggered overdose
Alcohol excess
Malnutrition
Chronic liver disease
What compound is deficient in acute liver failure?
Glutathione - it is used up
Investigations in a paracetamol overdose?
Management?
Paracetamol levels
INR
U/E
Liver function tests
N-acetyl cysteine
IV fluids
Antibiotics and antifungals
What is the earliest indicator of hepatitis B?
Management?
HBV C IgM
Tenofovir
Daily INR, U/E, LFT
Call transplant team
What are the complications of acute liver failure?
Encephalopathy - high levels of ammonia
Cardiorespiratory disease - infections, ARDS
How is fluid distributed in the body?
Rule of thirds
2/3 intracellular
1/3 extracellular - 2/3 interstitial, 1/3 intravascular
What fluid is utilised to fluid resus a patient?
Why?
Hartmann’s
It is closest to normal physiological values
What are daily fluid requirements per kg?
Water - 30mls
Na - 1-2 mmols
K - 1 mmol
Energy - 30Kcal
What are the types of fluid loss?
Give examples of each?
Sensible - measureable
- Haemorrhage
- Urine output
Insensible - not measurable
- Breath
- Sweat
- Stool
What are the signs of dehydration?
What percentage dehydration does thirst indicate?
Restlessness/ irritability
Sunken eyes
Thirsty
Reduced skin turgor
Thirst = 10% dehydration
How do fluids need to be monitored?
Why?
Minimum 12 hourly U/Es (more frequently really)
IV fluids do not constitute normal blood constituents and therefore, derangement of electrolytes is common
How do you calculate fluid requirements?
Example: 56kg woman, on floor for 48 hours and is confused and lethargic
100/50/20 per 24 hours or 4/2/1 per hour
Correct deficit = 96mls for every hour she has been on the floor = 4,608ml over 12-24 hours
Maintenance = 96mls/hr whilst NBM
Features of shock
Tissue hypo-perfusion
Energy deficit
Build up of metabolites
Types of shock
The fluid - Hypovolaemic, haemorrhagic
The pump - Obstructive (Tension ptx, PE, tamponade), cardiogenic (ischaemic, arrhythmia)
The pipes - Distributive (neurogenic, endocrine), septic, anaphylactic
Management of shock
Call for help A,B,C Give oxygen Cannulate a vein ECG, BP, SpO2 Treat underlying cause: - Hypovolaemic - IV fluids - Septic/anaphylactic - Abx, fluids, vasopressors (adrenalin) - Cardiogenic - inotropes (dopamine)
75 year old man post-surgery has a urine output of 5mls over 2 hours, BP 120/70, HR 50
What finding is abnormal?
Likely cause?
Low urine output
Low BP (most likely has a baseline much higher)
Low HR
Post-surgical bleeding causing shock
At what BP would you define hypotension?
What is a better measure and what is the definition using this?
<90 systolic or a drop of more than 40mmHg from baseline
Mean arterial pressure (MAP) - <65mmHg
Define respiratory failure
What are the types? Pathophysiological cause of each?
pO2<8
Type 1 = hypoxia without hypercapnia - V/Q mismatch
Type 2 = hypoxia with hypercapnia - failure of ventilation
Patient with asthma presents with hypoxia without hypercapnia, are you concerned?
Yes, normal CO2 is considered life threatening
How can you support breathing in respiratory failure?
What are the different types and for what are they used?
Non-invasive ventilation
ePAP (expiratory) - type 1 RF - oedema, anaesthesia, pneumonia
iPAP (inspiratory) - type 2 RF
ePAP + iPAP = BiPAP
ePAP = cPAP
Contraindications to non-invasive ventilation
Asthma - air trapping
PTX
Agitation
Airway loss
Classification of AKI?
Stage 1 - Creatinine 1.5x, Urine output <0.5ml/kg/hr for > 6hrs
Stage 2 - Creatinine 2x, UO <0.5ml/kg/hr for >12hrs
Stage 3 - Creatinine 3x, UO <0.3ml/kg/hr for >24hrs, Anuria > 12hrs
Causes of AKI?
Prerenal - shock (hypovolaemic, septic, cardiogenic), pressure optimisation (low BP)
Renal - toxins (NSAIDs, Acute interstitial nephritis, contrast, gentamicin)
Postrenal - Obstruction
Renal complication of shock? Why?
Acute tubular necrosis
Low circulatory pressure or leaky vessels (sepsis) causes avascularisation of the renal tubules and therefore, necrosis occurs
What two ions are in excess intravascularly in AKI?
Why?
K+, H+
The transporters K-3Na and H-Na don’t function leaving potassium and hydrogen ions in circulation
Interpret this ABG: pH 7.37 PaCO2 7* PaO2 8.1* HCO3 32* BE 3*
Type 2 respiratory failure
Respiratory acidosis with renal compensation (chronic)
This is a classic picture of a patient with COPD
Algorithm for interpreting an ABG?
pO2 - in resp failure? pCO2 - type 1 vs type 2 pCO2 again - respiratory acidosis/alkalosis BE/HCO3 - metabolic goes with the pH pH - acidosis/alkalosis/compensated
Define sepsis
What is the scoring system for it?
Scoring used more in practice?
Life threatening organ dysfunction caused by a dysregulated host response to infection
SOFA scoring
NEWS
Indicators of organ dysfunction
- Hypotension - BP<90, MAP <65
- Renal - oliguria <0.5 mls/kg/hr for 2 hrs, creatinine >177mcmol/L
- Hypoperfusion - serum lactate >2
- Marrow and clotting - plts <100, INR>1.5, aPPT>60s
- Hypoxia - SpO2<90% or needing O2
Define septic shock
Sepsis + hypotension unresponsive to fluid
Management of sepsis
BUFALO - within 1 hour of admission Blood cultures Urine output IV fluid Abx Lactate Oxygen
Causes of coma
CNS - seizure, infection, SOL, CVA
CVR - Low CO state
Resp - hypoxia, hypercapnia, CO poisoning
MET - uraemia, hepatic encephalopathy, hypoglycaemia, hypo/hypernatraemia, hypothyroidism, hypothermia
Drugs - opiates, benzo’s, TCA
How do you assess disability in an ABCDE assessment?
AVPU/ GCS
Glucose
Pupillary response
What are the features of the GCS?
EVM 456
- Eyes: 4 spontaneous, 3 to speech, 2 to pressure, 1 none
- Verbal: 5 orientated, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none
- Motor: 6 obeys commands, 5 localises, 4 normal flexion to pain, 3 abnormal flexion to pain, 2 extension to pain, 1 none
A patient has a CT head with an extradural evident, what do you do?
Regular monitor (30 mins) of neurological signs Call a neurosurgeon Anaesthetic referral - for intubation/ airway securing
Patient with a head injury suddenly develops a fixed dilated pupil, what has happened?
Intracranial bleed (EDH,SDH) causing raised ICP.
Raised ICP causes uncal herniation.
This compresses on the oculomotor nerve causing the fixed dilated pupil
What factor do you monitor to optimise cerebral perfusion?
Equation?
Target value?
In what circumstance would you consider a lower value?
Mean arterial pressure (MAP)
Cerebral perfusion pressure (CPP) = MAP - ICP
MAP = 85mmHg
If there is another massive area of haemorrhage (therefore, undergoing permissive hypotension), you need to weigh up which one is going to be more detrimental
Methods to reduce ICP
Cerebral dehydration - mannitol or hypertonic saline
Reduction of cerebral blood volume:
- Head up 30 degrees
- Correct hypercapnia (pCO2 4.5-5) and hypoxia (pO2>8.5)
What grading system is used to assess their disease burden/ risk in anaesthetics?
ASA 1-Normal 2- Mild systemic disease 3- severe systemic disease 4 - above + threat to life 5 - Not expected to survive 24hrs without surgery 6 - brain dead E - emergency
What is pre-optimisation?
What may be done?
Optimising the patient physiologically and obtaining sufficient access to allow best outcomes in theatre
Invasive blood pressure monitoring
Urinary catheter
Central venous access - pulmonary arterial flotation catheter
Inotropic support - BP will drop on anaesthesia
Cardiac output monitoring
Maximise oxygen delivery
Surgery school/ fit-4-surgery (lifestyle advice) - elective cases
What preoperative measures are usually undertaken?
Give oxygen
Give fluids
Give regular medications
What drugs need to be omitted pre-op
ACEi - 24-72hrs
ARBs - 24-72hrs
Anti-TNFs - 2 weeks
Platelet inhibitors - aspirin, clopidogrel - 7-10 days
DOACs - 4 days (reversal agent available, Praxbind)
Why are NSAIDs avoided in anaesthesia?
Which one may be used?
Increased risk of intraoperative bleeding
Parecoxib
What are patients given intraoperatively?
Oxygen Fluids Blood/ blood products Antibiotics Anaethesia Analgesia - morphine Muscle relaxation
How is anaesthesia induced?
Maintained?
Why is there a shift in the method of maintenance?
Propofol
Inhalation agent - sevaflurane, desflurane
TIVA - total intravenous anaesthesia (propofol throughout)
The inhalation agents are strong greenhouse gases (desflurane)
How do anaesthetics work?
They increase the action of GABA on the reticular activating system preventing consciousness
What muscle relaxants are used?
How do they work?
How can they reversed?
Depolarising - suxamethonium - rapid action, short duration (so used in RSI)
Non-depolarising - rocuronium, atracurium
Depolarisation - Interacts with the nicotinic receptors on the post-synaptic membrane of the NMJ causing depolarisation and fasciculations
Non-depolarisation - inhibits the nicotinic receptors of NMJ. Takes a while as it is a competitive inhibitor but takes a while to wear off (20-40 mins)
Sugammadex - encapsulates the drugs and reverses it (within 1.5mins)
What are patients given post-operatively?
Analgesia - simple, opioids or regional analgesia
Epidural - may be controlled by the patient
Fluids/ blood products
Inotropes/ vasopressors
Anti-emetics/ anticoagulants/ abx
Why is patient controlled epidural analgesia safe?
Usually knock yourself out before you can press the button enough to give yourself respiratory depression
What are the two types on local anaesthetics used?
What type of procedure are each used in?
Lidocaine - cuts and lacerations b/c immediate onset and lasts about 15 minutes
Bupivicaine - in regional anaesthesia, spinals and epidurals. 10 minutes onset and lasts 2 hours
What type of drugs is usually utilised in epidurals?
Opioids (therefore don’t give more b/c you’ll OD them)
What are the two types of sedation maintenance?
Give examples of each
Inhalational - desflurane, sevoflurane (quick offset is the benefit, greenhouse gas is negative)
Total intravenous anaesthesia (TIVA) - propofol or thiopenthal in the emergency situation
What are the types of simple airway?
Face mask
Oropharyngeal (guedel)
Nasopharyngeal
What are the types of advanced airways?
What is the definition of a definitive airway?
What of the above are in this category?
Laryngeal mask
Endotracheal (Definitive)
Tracheostomy (definitive)
A definitive airway is one that is placed below the laryngeal inlet
What are the types of non-invasive ventilation?
In what situation is each used?
Why?
CPAP: Used in type 1 resp failure. Problem with oxygenation because airway collapse of expiration therefore, positive pressure keeps them open
BiPAP: Used in type 2 resp failure. This is a failure of ventilation so pressure is applied in both inspiratory and expiratory phases
What are the two type of invasive ventilation?
What are the two type of control that can be used?
When is each control method used?
Endotracheal tube
Tracheostomy
Pressure controlled - pressure increases until target TIME is reached. Used in ITU almost exclusively
Volume controlled - volume increases until target VOLUME is reached. Used in theatres
How do anticholinergic medications act on the heart?
Examples?
Beta-agonists?
Examples?
Inhibits the vagus nerve preventing parasympathetic action and therefore, increasing heart rate
Atropine, glycopyrrolate
Stimulates the myocardium so increases heart rate and contractility
Dobutamine
Used in ITU mostly for heart failure
How do alpha-agonists work?
What are they used for?
Examples?
They stimulate alpha receptors found in peripheral blood vessels and therefore, cause vasoconstriction.
Used to treat hypotension
Peripheral - phenylephrine, metaraminol
Central - Noradrenaline
What is the function of filtration?
What are the indications?
To act like the kidneys, removing metabolites and maintaining fluid, electrolyte balance
Indications: fluid overloads, uraemia, severe metabolic acidosis, hyperkalaemia, poisoning
How do NSAIDs work?
What is the results of this?
What are the other places it acts on? Causing?
They prevent the conversion of arachidonic acid (derived from phospholipase A2) into prostaglandins by COX. Prostaglandins are involved in peripheral inflammation therefore, NSAIDs reduce this
Stomach acid - peptic ulcers
Renal blood - acute kidney injury
Platelets - blood thinning (why they are rarely used in anaesthetic situations)
What are the three anti-emetic receptors and where are they?
Give medications that act on each?
5-HT3 found in GI tract, solitary tract nucleus and area postrema - Ondansetron
Dopamine-2 found in GI tract, solitary tract nucleus and area postrema - domperidone
Histamine found in cerebellum (acting on area postrema) and chemoreceptor trigger zones - cyclizine - causes motion sickness
Features of hyponatraemia?
Management? (in a fit person without any chronic onset)
Drowsiness, agitation, urinary incontinence
3% saline 150ml bolus over 20 mins - not usually done this quick
Usually 0.9% saline over 24 hours
Features of Addison’s disease?
Management?
Lethargy, nausea, loss of appetite (features of hypothyroidism up to now), weight LOSS.
Postural hypotension.
Hyponatraemia with high urine sodium. High TSH (lacking cortisol which usually inhibits TSH synthesis)
Hydrocortisone and .9% saline
Causes of hyponatraemia?
Indicators of each?
Management in each scenario?
Hypervolaemic (dilutional):
- CCF, nephrotic syndrome, cirrhosis of liver
- Low urine sodium, oedematous
- Fluid restrict (<1L/24hrs)
Euvolaemic:
- Hypothyroidism (check TSH), adrenal insufficiency (9am cortisol), drugs, SIADH (High urine osmolarity and sodium)
- Fluid restriction
Hypovolaemic:
- Vomiting/ diarrhoea, burns, pancreatitis
- Diuretics, Addison’s, salt-wasting nephropathy
- Replacement saline
Dose and route of hydrocortisone acutely
100mg IM
What cortisol level excludes adrenal insufficiency?
300/350 mg/L
Management of adrenal insufficiency?
Measure cortisol and ACTH
IV .9% saline
Hydrocortisone 100mg IM 6 hourly until eating and drinking
Treat precipitant
Resolving: hydrocortisone 20 mg PO TDS
Maintenance: hydrocortisone 5/10 mg and fludrocortisone 0.1/0.2mg/day (for primary)
Young adult presents with systolic BP>200 and tachycardia. Initial management?
Diagnosis?
Start alpha blocker (phenoxybenzamine) - need to bring down BP
Measure plasma catecholamines and urine metanephrines. ?plasma aldosterone
Pheochromocytoma
What do you need to measure if you suspect pheochromocytoma?
What are each of these compounds?
Plasma catecholamines - noradrenalin, adrenalin
Urine metanephrines - catecholamine breakdown products
Patient is found to have a pituitary mass on CT scan, what should you give immediately and why?
IV hydrocortisone to prevent adrenal insufficiency
Main causes of hypercalcaemia? How do you differentiate?
Investigations + findings?
Management?
Primary hyperparathyroidism (High/ normal PTH as you would expect it to be low with high calcium) Malignancy (low PTH)
Adjusted calcium
PTH
Phosphate, ALP, renal function
ECG - short QT
.9% 4-6L/24 hours IV bisphosphonates - zoledronic acid Glucocorticoids Calcimimetics - Cinacalcet Denosumab
