Acute and Critical Care Flashcards
What are signs on A of ABCDE of a critically ill patient
Seesaw respiration
increased work of breathing
use accessory muscles
funny noises such as stidor, gurgling or silence
What are signs on B of ABCDE of a critically ill patient
Chest expansion reduced very high or very low respiration rate or this Nokia cyanosis added airway sounds such as wheeze and crackles deviation of trachea positive percussion
What are signs on C of ABCDE of a critically ill patient
external haemorrhage poor perfusion status mean arterial pressure less than 65 abnormal heart sounds low blood pressure (90>)
what are signs of poor perfusion status
capillary refill peripheral cyanosis oxygen saturation
What are signs on D of ABCDE of a critically ill patient
low GCS deranged blood glucose abnormal pupillary response
What are signs on E of ABCDE of a critically ill patient
mainly hypothermia think of the deadly triad
what is the management of A in ABCDE in critically ill patient
its tilt head chin left jaw thrust or intubation if necessary give suction for removing sputum or vomit
with airway is most commonly used in emergency management of airways
Guedel
what is a sign of fluid overload from boluses
new lung crackles
which type of IV should you use for fluid challenge
large ball
how much fluid challenge can you give before ICU is needed
2 L
what is major trauma
multiple serious injuries that could result in death and disability
what is the most common cause of major trauma
fall from standing height or road traffic accident
whereas the most common location for catastrophic haemorrhage
junctional arteries- femoral axillary carotid
what are common injuries which occur in road traffic accidents
C-spine blunt the racquetball cardiac trauma hollow viscous perforations solid organ perforation pelvic acetabulum or femoral injury
describe the ATMIST tool
age at time of injury mechanism of injury injuries found signs treatment given thus far
what other three mechanisms of injury
blunt trauma blast trauma sharper trauma
what terms described penetrating injuries
incisional from a blade laceration from debris gunshot
what is the management of catastrophic haemorrhage
clear any clots give direct pressure tourniquet haemostatic agents
what are the relative indications for intubation
unable to maintain own airway or to maintain breathing drive deteriorating GCS significant facial injury or seizure the: haemorrhagic shock metabolic acidosis agitated patients multiple painful injuries transfer to other area deep facial burns sit in airway
What is anaphylaxis
Set an onset of life-threatening airway +/or breathing +/or circulation problems with or without skin changes after exposure to a trigger
what are the criteria for anaphylaxis
acute onset of illness and sudden progression 2 Skin and all mucosal changes (flushing, urticaria, angio-oedema inc. periorbital)
Life-threatening airway and or breathing and all circulation problems
what airway symptoms can occur due to anaphylaxis
Airway
Tongue and throat swelling Horse voice
Strider
what are breathing signs and symptoms of anaphylaxis
Breathing
Increased respiratory rate Waze
Hyperoxia
Cyanosis – usually A late sign Respiratory arrest
what are circulatory signs of anaphylaxis
Circulation Signs of shock Tachycardia Hypertension Chest pain with ECG changes Braddy cardia and cardiac arrest
is confusion and LOC a sign of anaphylaxis
yes
describe the pathophysiology of anaphylaxis
Allergens activate IgE in the body these activate mast cells which release histamine inflammatory mediators was going to the blood circulation causing a systemic reaction
what is an anaphylactoid reaction
non-immune mediated without IgE. Allergens cause direct release of histamine and other inflammatory mediators from mast cells and does not cause degranulation
what is the immediate management of sus[ected anaphylaxisp
As soon as you suspect an anaphylactic reaction give IM adrenaline If initial dose wasn’t successful you can repeat
as well as IM adrenaline what else can you give in an anaphylaxis reaction
You should also start IV hydrocortisone
IV antihistamines
what should you do if you hear a wheeze in an anaphylaxis reaction
salbutamol
What shoud you do if you hear a stridor in an anaphylaxis reaction
neb. Adrenaline
what should you do if the patient begins to loose GCS in an anaphylaxis reaction
ntubation an IV adrenaline can be started
who should administer IV adrenaline
should only be given by those with experience
what are the risks of IV adrenaline
life-threatening hypertension tachycardia and arrhythmia
what are the indications for IV adrenaline
cardiac arrest
severe respiratory response
2 doses of IM adrenaline not working and a correct diagnosis
describe the discharge process of an individual who had an anaphylaxis reaction
> Patient who has suspected anaphylactic reaction should be treated and then observed for 6 hours they should
then be reviewed and a decision made about further observation
why do patients need to be monitored for 6h after an anaphylaxis reaction
incase of biphasic reaction
what are the risk factors for a biphasic reactions
Idoppathic reaction // severe asthmatic
possibility of continuing absorption allergen (like ingested stuff) previous history of biphasic reactions
presenting the evening at night (if asleep cant tell theyre re having a reaction)
- Patients in areas where they cannot access emergency services easily
whata are the most common causes for anaphylaxis
Stings, Nuts, Anaesthetics and antibiotics
what is C1 esterase deficiency
a condition which mimics anaphylaxis but is resistant to steroid antihistamines and adrenaline
how do you treat C1 esterase deficiency
C1 Estrace inhibitor concentrate or fresh frozen plasma
What investigation must you do in a patient with reduced GCS and in what timeframe?
BM for hypoglycaemia within 30minutes
what investigations should you perform on someone with reduced GCS
BM / ECG / ABG VBG cultures + septic screen U+E
what are ine indications for performing a head CT
GCS < 13 on initial assessment -
!GCS < 15 at two hours after the injury on assessment
Suspected open or depressed skull fracture
Any sign of basal skull fracture Post-traumatic seizure.
Focal neurological deficit
More than one episode of vomiting OR ^%+ Hx of bleeding or clotting disorders dangerous mechanism of injury more than 30 min retrigrade amnesia
what are signs of opioid overdose
Constricted pupils
Slowed respiration rate of less than 12 Altered mental status
what is the management of opioid overdoese
Naloxone slowly infure until breathing properly
what should you do before adminisetring naloxone
ventilate the patient in case of the risk of precipitating RDS due to high CO2
What are the common types of head trauma
Subdural :Epidural
Basil skull fracture
what are signs of a basil skull fracture
Raccoon eyes
CSF leak from nose or Ear
Bleeding for nose or ear
CSF can look like yellow crusting around a blood clot or a yellow halo around blood on a pillow
why might someones typanic membrane being purple indicate basil skull fracture
Bleeding from the ear requires tympanic membrane rupture so if you look at the tympanic membrane and it appears purple/bruised it means bleeding is present however it has not passed through
What are ways to manage aspiration in reduced GCS
Clear the air way:
logrolling may be possible as this keeps C-spine in line Or oropharyngeal suctioning
If there was no risk of the spine injury then you could try postural drainige then intubation and ventilation
what are indications for C Spine X Ray
Anyone at risk of having had a spinal-cord injury this includes this is split into high low and no risk
what would be classified as high risk for having had C-spine injury
HIgh risk: aged 65 or over dangerous mechanism of injuries Paris easier in the upper or lower limbs,
what will be classified as having low risk for having had C-spine injury
low risk: low impact rear end motor vehicle collision sitting in a comfortable position ambulatory at any time since injury no mid cervical spine tenderness delayed onset of neck pain unable to rotate the neck at 45°
what is defined as no risk for c spine injury
if they are low risk but are able to rotate the neck at 45°
while the indications for full in-line spinal immobilisation and imaging
anyone whose high risk or low risk and unable to move their neck 45°
when incubating a patient to prevent aspiration what else should be done simultaneously
insert NG tube to empty stomach
one word and end due to be contraindicated in major trauma
in basilar skull fractures or severe facial trauma as the tube can go into the brain
what are the indications for intubation and ventilation
Coma – GCS8 or less
Loss of protective laryngeal reflexes
Ventilatory insufficiency O2 <13 on oxygen or CO2 >6 Spontaneous hyperventilation causing CO2 <4 Irregular respirations
what are relative indications for intubation and ventilation
Significantly deteriorated and consciousness of 1 + on the motor score Unstable fractures of the facial skeleton
Lots of bleeding into mouth for example from skull base fracture Seizures
what drugs facilitate intubation
Muscle relaxants Analgesias
Sedation short acting
how do you prepare for an incoming trauma
Ask for help of other clinical staff Get a team together Get a copy of the guidelines Assign a task to each member Prepare any medication equipment they may be needing Mentally run through the scenario and prepare yourself
what signs should you be aware o fin ABCDE assessment of fitting patient
Signs of obstruction - like tongue in fits Ensure you listen to lungs even if the fitting Get IV access ASAP
Quick neurological exam – pupils GCS/AVPU Establish pregnancy if possible
what may comprimise airway in fitting patient
Might be compromised due to XS secretions blood vomit tongue or jawlock
what airway should you use in a fitting patient and why
nasopharyngeal is a good option
They are always tolerable even when conscious so it is a good long-term management of someone who is likely to regain consciousness
what are possible causes of status epilipticus
anticonvulsants nonadherence or withdrawal Alcohol withdrawal Cerebral oedema Drug overdose Metabolic abnormalities – hyponatraemia Infections Hypoglycaemia Hypoxia Tumour Eclampsia
what investigations are important in status epilepticus
Do blood cultures possibly a lumbar puncture consider antibiotics or antivirals (and cephalitis) Take BM give glucagon or IV dextrose
CT head for haemorrhage or tumour give dexamethasone
check temperature and give cooling that
what are the complications of status epilepticus
Focal neurological deficits Cognitive dysfunction mostly memory Behavioural problems Aspiration pneumonia Pulmonary oedema Cardiac arrhythmia
describe the stages of managing a seizure
Buccal midazolam (PR diazapam in young children) –> Lorazepam IV –> phenytoin IV –> propofol IV
what are side effects of benzodiazepines
Bradycardia hypotension respiratory depression
why is respiratory depression especially dangerous in fitting patient
In a fitting patient respiratory depression is very bad fitting patients get hypoxic and acidotic quickly and easily
what are side effects of phenytoin
cardiac arrhythmias
what should you do when administering phenytoin IV
check for history of heart conditions give continuous ECG checking for arrhythmias bradycardia second or 3rd° heart block
what can you use the phenytoin if it is contraindicated
Levatarastam aka Capra most common Phenobarbital
Valproic acid IV
which type of muscle relaxant should you use in status epilepticus and why
best to start using a short acting paralytic agent
If using long acting paralytic agents you cannot tell if they are fitting cerebrally so you must use EEG monitoring
With short acting if they’re again fitting again you know they are fitting and add another drug
what are causes of tachycardia in majour trauma?
Clot/pulmonary embolus Physical strain Hypothermia Pneumothorax
Anxiety and pain Drugs Hyperventilating Arrhythmias
what are signs of anaphylactic shock
tachycardia tachyopnea hypotension flushed swollen itchy skin no change in temp reduced urine output
what are signs of cardiogenic shock
tachycardia tachyopnea hypotension pale cold clammy skin no change in temp reduced urine output
what are signs of hypovoluemic shock
tachycardia tachyopnea hypotension pale cold clammy skin no change in temp reduced urine output
what are signs of obstuctive shock
tachycardia tachyopnea hypotension pale cold clammy extremities low body temp reduced urine output
what are signs of neurogenic shock
bradycardia tachyopnea hypotension flushed dry skin temp can be raised or lowered no bladder control
what are signs of septic shock
tachycardia tachyopnea hypotension flushed –> pale cold clammy skin temp ++ or – increased urine output
what is a FAST SCAN and when is it used
in major trauma , A fast scan is a quick and easy task to perform and is an ultrasound scan to show any serious intra-abdominal events and free fluid
what are indications for rapid requence induction
GCS less than eight Falling GCS
Hyperoxia
Respiratory failure Transfer to other hospital Multiple injuries
what imaging should you do after FAST SCAN
whole body CT should be performed to fully assess the extent of injuries
what are indications for whole body CT
High-speed motor vehicle collision Nontrivial motorcycle collision
Death at the scene
Four from a height of over 2 m
Other concerning mechanisms of injury Abnormal fast or trauma chest or pelvis x-ray
Abnormal vital signs
what are indications for emergancy laperotomy
And emergency laparotomy is usually not necessary unless there are signs of haemodynamic instability peritonitis or diffuse abdominal tenderness
is a fracture is found on whole CT Is further imaging then required
usually no
what are DD for tension pneumothorax and how would you differentiate these
haemothorax cardiac tapenade
what is the pathophysiology of a tension pneumothorax
s increasing interest the IT pressure eventually displaces mediastinal structures
- This interferes with Venus return of the heart
:The vena caval is blocked causing cardiovascular collapse in shock
what is the management of a tension pneumothorax
Management of this is a chest decompression using an IV cannula in the second intercostal midclavicular line then fitting a thoracostomy and a chest drain
what are the lethal 6
Airway obstruction Tension pneumothorax Open pneumothorax / Massive haemothorax Flail chest Cardiac tapenade –
how do you manage an open pneumothorax
– use a three sided dressing to help maintain lung negative pressure like a valve
how do you manage a massive haemothorax
– chest drain and give blood to replace
how do you manage a flail chest
– give CPAP and surgery to fix the ribs
how do you manage a cardiac tamponade
thoracotomies or pericardiocentesis
what is permissive hypotensive resus
Managing trauma patients by restricting the amount of resuscitation fluids to when only carotid pulse can be felt and maintaining blood pressure is lower than the normal range
when would you use permissive hypotensive resus
if there is continuing bleeding during an acute period of injury avoiding diluted coagulopathy and acceleration of haemorrhage
when is permisive hypotensive resus contraindicated and why
Do not do this if there’s a head injury- as if the ICP rises you need the systolic pressure to rise in match it
how do youinitially deliver blood products
fixed ratio until you get back the lab results of that coagulation studies where you can change things to more specific management
in a major trauma a patient has abdominal tenderness but no guarding what should you ba wary of
peritonitis due to haemorrhage can take a while to manifes
What should you elicit from a overdose history
why what when what else was taken route how much DHx psychiatric Hx Age and weight
what is classed as an overdose of paracetamol
> 10 g or > 200 mg / kg
at what dose of paracetamol OD can you expect hepatic necrosis and liver failure
> 250 mg/kg
describe the timeline of paracetamol OD
Cellular toxicity occurs at around 10–12 hours without treatment
Liver dysfunction occurs after that and this is when symptoms tend to present
Liver failure occurs around 48 hours if enough has been ingested and no treatment
what are the stages of paracetamol OD
stage 1- 0-24h asymptomatic or GI upset / Stage 2- 24-48h symptoms / stage 3 - 48-96 h hepatic failyre stage 4 - 96h+ death or normalisation
what are the sympyoms of stage 2 paracetamol OD
Resolution or nausea and vomiting Right upper quadrant pain and tenderness
what bloods would suggest stage 2 paracetamol OD
Progressive elevation of transaminases, Bilirubin and prothrombin time
after paracetamol OD how long does it take to retun to normal liver architechture (if untreadted0
3months
what are the riskfactors of major liver damage from paracetamol OD
Underlying hepatic impairment Microsomal enzyme induction Acute glutathione depletion states:
what drugs can predispose you to major liver damage from paracetamol OD
Phenobarbitone Carbamazepine Phenytoin
Rifampicin
Oral contraceptive pill
what causes acute gluthione depletion states
acute illness with decreased nutrient intake Anorexia bulimia malnutrition
Chronic alcoholism
HIV
what s used to decide if to treat paracetamol OD
normogram
should you wait for paracetamol levels to come back if patient is jaundiced or hepatotoxic
no just treat them
a patient presenta having taken less than 75mg/kg paracetamol in last 24 h do they need treating
not unless high risk - even then check paracetamol levels
what bloods should you check in paracetamol OD
FT INR : U+E creatininebicarbonate FBC paracetamol levels
what are the steps for investigating paracetamol OD
bloods at admission and again at 4 hours to see if safe four discharge, always checking normogram
what would indicate patient who took paracetamol >75mg/kg is safe for discharge
Paracetamol concentration < 10 mg/L
ALT within normal range
INR < 1.3
The patient has no clinical features suggesting liver damage
can you use activated charcoal in paracetamol OD
yes if ingested less than 1h ago
what is a commonside effect of NAC and what is management
Allergic reactions are common with NAC
if this happens stop NAC and administer IV antihistamine then restart NAC If they are very allergic give methiamine PO
how do investigations and management differ if OD was staggered > 1h
if more than 75mg/kg then start NAC empirically and then check U+E LFT and INR on arrival - you treat fully for 21h unless if no detected levels of paracetamol and bloods are normal and patient is I asymptomatic NAC can be stopped
What are common ‘benign’ causes of chest pain
GORD
MSK
Stable angina Anxiety Pericarditis Oesophageal spasm
what are potentially fatal causes of chest pain
Aortic deception Pneumothorax Endocarditis
MI
Unstable angina PE
what is a good way to differentiate between MSK causes of chest pain and other types in a history
A way to differentiate between MSK and true chest pain is if there is tenderness associated with the chest wall However remember to problems can be concommitment
what does pain taking in a big breath suggest
PE
what oes pain in chest when doing a stretching motion suggest
MSK
what blood tests are involved in a cardiac workup
FBC Cardiac troponins CRP Cardiac isoforms : CK- MB Creatine kinase
what Ix apart from bloods is required in a cardiac work up
ECG for any ?DD: CXR CTPA
is a normal ECG grounds for saying MI not present
no - MI don’t always have clear ECG changes so even if serial ECG is normal MI could still be present
why is creatine kinase measured
general and can be produced from breakdown of any muscle (inc. heart in heart attack) however is a good marker of renal function for comorbidities and for indications of what drugs to use
why Is CK-MB measured what are its limitations
specific to myocyte muscle breakdown however still not as sensitive as troponins
what is the mbest cardiac marker
tropoins
when should you measure troponins
Low sensitivity troponins peak at 24–48 hours
whereas high sensitivity can be done after three hours of onset
describe the Ix/Mx pathway for a ?MI
Patient presents with chest pain
Perform ECG and full cardiac work up
At 3 hour mark of onset do HS Troponin
If indeterminate or definite MI is occurring admit to
hospital
Take serial Troponin hourly if result is indeterminate
Once troponin level is reached the definite of MI level
start treatment
Also do serial ECGs as they can show useful changes
what is initail management for MI
M(O only if <92%) NA
what are definitive manageement options for MI
primary PCI or Fibrinolysis/Thrombolysis
when should primary PCI be performed
Should be performed within 12 hours from onset of symptoms and within two hours from diagnosis
If a patient no longer has chest pain will PCI still work
no- A good indication of if PCI will be effective is if there is still chest pain
This is because if the tissue is dead there will not be any pain
what drugs can you give in fibrinolysis/thrombilysis
Altepase /tenecteplase/ streptokinase
what are severe complications of fibrilolysis/thrombolysis
Haemorrhage especially GI and intercranial Recurrent ischaemia
what are contraindications to fibrinolysis/thrombolysis
Acute pancreatitis
Aneurysm
Aortic dissection
AV malformations Bacterial endocarditis
when would you ise CT-CA as an investigation
Although you can perform a CT angiography for diagnosis this is usually not used in the acute setting
rather in stable chest pain
In PCI you view the blockage anyway
What is the most common mechanism of injury in elderly people
falling from a standing height
what changes in the respiratory system predispose the elderly to chest infections
Respiratory muscles are weaker
There is kyphosis of the thoracic spine
There is chest wall rigidity
There is an impaired central response to hyperoxia There is reduced Alviolar gas exchange surface There is a smaller physiological reserve to injury
describe how pharmacokinetics are affected in the elderly
In elderly patients there is a smaller total body of water so less preload Peripheral vasculature becomes more rigid so Resistance remains the same and doesn’t accommodate preload
MyoCardium is replaced by fat and collagen so it’s less contractile
There is autonomic and baroreceptor dysfunction
There is atrial pacemaker atrophy
The cardiac output is changed
The elderly usually have some degrees of hypertension so a blood pressure that is normal for younger people is considered hypotensive in the elderly
what drugs should you be wary of prescribingi in the elderly
A CEI Opiates Sedatives/benzodiazepines Steroids NSAIDS Beta-blockers – cannot physiologically compensate for bleed so if in a fall there is no tachycardia Anticoagulant
why are NSAIDs relatively CI in the elderly
– renal injury, causing impaired function and hypotension
why are Beta Blockers relatively CI in the elderly
cannot physiologically compensate for bleed so if in a fall there is no tachycardia
why might signs of head trauma be less obvious in the elderly
atrophy which occurs there is a greater space for blood to accumulate
what do rib injuries pose a risk for in the elderly
Over three rib fractures plus any other fracture in the rib carries significant mortality
Increased risk of developing pneumonia if rib injury
