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FINALS > Acute and Critical Care > Flashcards

Acute and Critical Care Flashcards

1
Q

What are signs on A of ABCDE of a critically ill patient

A

Seesaw respiration
increased work of breathing
use accessory muscles
funny noises such as stidor, gurgling or silence

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2
Q

What are signs on B of ABCDE of a critically ill patient

A

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

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3
Q

What are signs on C of ABCDE of a critically ill patient

A

external haemorrhage poor perfusion status mean arterial pressure less than 65 abnormal heart sounds low blood pressure (90>)

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4
Q

what are signs of poor perfusion status

A

capillary refill peripheral cyanosis oxygen saturation

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5
Q

What are signs on D of ABCDE of a critically ill patient

A

low GCS deranged blood glucose abnormal pupillary response

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6
Q

What are signs on E of ABCDE of a critically ill patient

A

mainly hypothermia think of the deadly triad

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7
Q

what is the management of A in ABCDE in critically ill patient

A

its tilt head chin left jaw thrust or intubation if necessary give suction for removing sputum or vomit

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8
Q

with airway is most commonly used in emergency management of airways

A

Guedel

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9
Q

what is a sign of fluid overload from boluses

A

new lung crackles

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10
Q

which type of IV should you use for fluid challenge

A

large ball

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11
Q

how much fluid challenge can you give before ICU is needed

A

2 L

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12
Q

what is major trauma

A

multiple serious injuries that could result in death and disability

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13
Q

what is the most common cause of major trauma

A

fall from standing height or road traffic accident

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14
Q

whereas the most common location for catastrophic haemorrhage

A

junctional arteries- femoral axillary carotid

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15
Q

what are common injuries which occur in road traffic accidents

A

C-spine blunt the racquetball cardiac trauma hollow viscous perforations solid organ perforation pelvic acetabulum or femoral injury

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16
Q

describe the ATMIST tool

A

age at time of injury mechanism of injury injuries found signs treatment given thus far

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17
Q

what other three mechanisms of injury

A

blunt trauma blast trauma sharper trauma

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18
Q

what terms described penetrating injuries

A

incisional from a blade laceration from debris gunshot

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19
Q

what is the management of catastrophic haemorrhage

A

clear any clots give direct pressure tourniquet haemostatic agents

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20
Q

what are the relative indications for intubation

A

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

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21
Q

What is anaphylaxis

A

Set an onset of life-threatening airway +/or breathing +/or circulation problems with or without skin changes after exposure to a trigger

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22
Q

what are the criteria for anaphylaxis

A

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

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23
Q

what airway symptoms can occur due to anaphylaxis

A

Airway
Tongue and throat swelling Horse voice
Strider

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24
Q

what are breathing signs and symptoms of anaphylaxis

A

Breathing
Increased respiratory rate Waze
Hyperoxia
Cyanosis – usually A late sign Respiratory arrest

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25
Q

what are circulatory signs of anaphylaxis

A 
Circulation
Signs of shock
Tachycardia
Hypertension
Chest pain with ECG changes Braddy cardia and cardiac arrest
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26
Q

is confusion and LOC a sign of anaphylaxis

A

yes

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27
Q

describe the pathophysiology of anaphylaxis

A

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

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28
Q

what is an anaphylactoid reaction

A

non-immune mediated without IgE. Allergens cause direct release of histamine and other inflammatory mediators from mast cells and does not cause degranulation

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29
Q

what is the immediate management of sus[ected anaphylaxisp

A

As soon as you suspect an anaphylactic reaction give IM adrenaline If initial dose wasn’t successful you can repeat

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30
Q

as well as IM adrenaline what else can you give in an anaphylaxis reaction

A

You should also start IV hydrocortisone

IV antihistamines

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31
Q

what should you do if you hear a wheeze in an anaphylaxis reaction

A

salbutamol

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32
Q

What shoud you do if you hear a stridor in an anaphylaxis reaction

A

neb. Adrenaline

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33
Q

what should you do if the patient begins to loose GCS in an anaphylaxis reaction

A

ntubation an IV adrenaline can be started

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34
Q

who should administer IV adrenaline

A

should only be given by those with experience

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35
Q

what are the risks of IV adrenaline

A

life-threatening hypertension tachycardia and arrhythmia

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36
Q

what are the indications for IV adrenaline

A

cardiac arrest
severe respiratory response
2 doses of IM adrenaline not working and a correct diagnosis

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37
Q

describe the discharge process of an individual who had an anaphylaxis reaction

A

> 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

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38
Q

why do patients need to be monitored for 6h after an anaphylaxis reaction

A

incase of biphasic reaction

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39
Q

what are the risk factors for a biphasic reactions

A

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

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40
Q

whata are the most common causes for anaphylaxis

A

Stings, Nuts, Anaesthetics and antibiotics

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41
Q

what is C1 esterase deficiency

A

a condition which mimics anaphylaxis but is resistant to steroid antihistamines and adrenaline

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42
Q

how do you treat C1 esterase deficiency

A

C1 Estrace inhibitor concentrate or fresh frozen plasma

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43
Q

What investigation must you do in a patient with reduced GCS and in what timeframe?

A

BM for hypoglycaemia within 30minutes

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44
Q

what investigations should you perform on someone with reduced GCS

A

BM / ECG / ABG VBG cultures + septic screen U+E

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45
Q

what are ine indications for performing a head CT

A

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

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46
Q

what are signs of opioid overdose

A

Constricted pupils

Slowed respiration rate of less than 12 Altered mental status

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47
Q

what is the management of opioid overdoese

A

Naloxone slowly infure until breathing properly

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48
Q

what should you do before adminisetring naloxone

A

ventilate the patient in case of the risk of precipitating RDS due to high CO2

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49
Q

What are the common types of head trauma

A

Subdural :Epidural

Basil skull fracture

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50
Q

what are signs of a basil skull fracture

A

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

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51
Q

why might someones typanic membrane being purple indicate basil skull fracture

A

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

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52
Q

What are ways to manage aspiration in reduced GCS

A

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

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53
Q

what are indications for C Spine X Ray

A

Anyone at risk of having had a spinal-cord injury this includes this is split into high low and no risk

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54
Q

what would be classified as high risk for having had C-spine injury

A

HIgh risk: aged 65 or over dangerous mechanism of injuries Paris easier in the upper or lower limbs,

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55
Q

what will be classified as having low risk for having had C-spine injury

A

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°

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56
Q

what is defined as no risk for c spine injury

A

if they are low risk but are able to rotate the neck at 45°

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57
Q

while the indications for full in-line spinal immobilisation and imaging

A

anyone whose high risk or low risk and unable to move their neck 45°

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58
Q

when incubating a patient to prevent aspiration what else should be done simultaneously

A

insert NG tube to empty stomach

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59
Q

one word and end due to be contraindicated in major trauma

A

in basilar skull fractures or severe facial trauma as the tube can go into the brain

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60
Q

what are the indications for intubation and ventilation

A

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

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61
Q

what are relative indications for intubation and ventilation

A

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

62
Q

what drugs facilitate intubation

A

Muscle relaxants Analgesias

Sedation short acting

63
Q

how do you prepare for an incoming trauma

A 
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
64
Q

what signs should you be aware o fin ABCDE assessment of fitting patient

A

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

65
Q

what may comprimise airway in fitting patient

A

Might be compromised due to XS secretions blood vomit tongue or jawlock

66
Q

what airway should you use in a fitting patient and why

A

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

67
Q

what are possible causes of status epilipticus

A 
anticonvulsants nonadherence or withdrawal Alcohol withdrawal
Cerebral oedema
Drug overdose
Metabolic abnormalities – hyponatraemia Infections
Hypoglycaemia
Hypoxia
Tumour
Eclampsia
68
Q

what investigations are important in status epilepticus

A

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

69
Q

what are the complications of status epilepticus

A 
Focal neurological deficits
Cognitive dysfunction mostly memory Behavioural problems
Aspiration pneumonia
Pulmonary oedema
Cardiac arrhythmia
70
Q

describe the stages of managing a seizure

A

Buccal midazolam (PR diazapam in young children) –> Lorazepam IV –> phenytoin IV –> propofol IV

71
Q

what are side effects of benzodiazepines

A

Bradycardia hypotension respiratory depression

72
Q

why is respiratory depression especially dangerous in fitting patient

A

In a fitting patient respiratory depression is very bad fitting patients get hypoxic and acidotic quickly and easily

73
Q

what are side effects of phenytoin

A

cardiac arrhythmias

74
Q

what should you do when administering phenytoin IV

A

check for history of heart conditions give continuous ECG checking for arrhythmias bradycardia second or 3rd° heart block

75
Q

what can you use the phenytoin if it is contraindicated

A

Levatarastam aka Capra most common Phenobarbital

Valproic acid IV

76
Q

which type of muscle relaxant should you use in status epilepticus and why

A

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

77
Q

what are causes of tachycardia in majour trauma?

A

Clot/pulmonary embolus Physical strain Hypothermia Pneumothorax
Anxiety and pain Drugs Hyperventilating Arrhythmias

78
Q

what are signs of anaphylactic shock

A

tachycardia tachyopnea hypotension flushed swollen itchy skin no change in temp reduced urine output

79
Q

what are signs of cardiogenic shock

A

tachycardia tachyopnea hypotension pale cold clammy skin no change in temp reduced urine output

80
Q

what are signs of hypovoluemic shock

A

tachycardia tachyopnea hypotension pale cold clammy skin no change in temp reduced urine output

81
Q

what are signs of obstuctive shock

A

tachycardia tachyopnea hypotension pale cold clammy extremities low body temp reduced urine output

82
Q

what are signs of neurogenic shock

A

bradycardia tachyopnea hypotension flushed dry skin temp can be raised or lowered no bladder control

83
Q

what are signs of septic shock

A

tachycardia tachyopnea hypotension flushed –> pale cold clammy skin temp ++ or – increased urine output

84
Q

what is a FAST SCAN and when is it used

A

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

85
Q

what are indications for rapid requence induction

A

GCS less than eight Falling GCS
Hyperoxia
Respiratory failure Transfer to other hospital Multiple injuries

86
Q

what imaging should you do after FAST SCAN

A

whole body CT should be performed to fully assess the extent of injuries

87
Q

what are indications for whole body CT

A

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

88
Q

what are indications for emergancy laperotomy

A

And emergency laparotomy is usually not necessary unless there are signs of haemodynamic instability peritonitis or diffuse abdominal tenderness

89
Q

is a fracture is found on whole CT Is further imaging then required

A

usually no

90
Q

what are DD for tension pneumothorax and how would you differentiate these

A

haemothorax cardiac tapenade

91
Q

what is the pathophysiology of a tension pneumothorax

A

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

92
Q

what is the management of a tension pneumothorax

A

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

93
Q

what are the lethal 6

A 
Airway obstruction 
Tension pneumothorax
Open pneumothorax  / Massive haemothorax 
Flail chest 
Cardiac tapenade –
94
Q

how do you manage an open pneumothorax

A

– use a three sided dressing to help maintain lung negative pressure like a valve

95
Q

how do you manage a massive haemothorax

A

– chest drain and give blood to replace

96
Q

how do you manage a flail chest

A

– give CPAP and surgery to fix the ribs

97
Q

how do you manage a cardiac tamponade

A

thoracotomies or pericardiocentesis

98
Q

what is permissive hypotensive resus

A

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

99
Q

when would you use permissive hypotensive resus

A

if there is continuing bleeding during an acute period of injury avoiding diluted coagulopathy and acceleration of haemorrhage

100
Q

when is permisive hypotensive resus contraindicated and why

A

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

101
Q

how do youinitially deliver blood products

A

fixed ratio until you get back the lab results of that coagulation studies where you can change things to more specific management

102
Q

in a major trauma a patient has abdominal tenderness but no guarding what should you ba wary of

A

peritonitis due to haemorrhage can take a while to manifes

103
Q

What should you elicit from a overdose history

A

why what when what else was taken route how much DHx psychiatric Hx Age and weight

104
Q

what is classed as an overdose of paracetamol

A

> 10 g or > 200 mg / kg

105
Q

at what dose of paracetamol OD can you expect hepatic necrosis and liver failure

A

> 250 mg/kg

106
Q

describe the timeline of paracetamol OD

A

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

107
Q

what are the stages of paracetamol OD

A

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

108
Q

what are the sympyoms of stage 2 paracetamol OD

A

Resolution or nausea and vomiting Right upper quadrant pain and tenderness

109
Q

what bloods would suggest stage 2 paracetamol OD

A

Progressive elevation of transaminases, Bilirubin and prothrombin time

110
Q

after paracetamol OD how long does it take to retun to normal liver architechture (if untreadted0

A

3months

111
Q

what are the riskfactors of major liver damage from paracetamol OD

A

Underlying hepatic impairment Microsomal enzyme induction Acute glutathione depletion states:

112
Q

what drugs can predispose you to major liver damage from paracetamol OD

A

Phenobarbitone Carbamazepine Phenytoin
Rifampicin
Oral contraceptive pill

113
Q

what causes acute gluthione depletion states

A

acute illness with decreased nutrient intake Anorexia bulimia malnutrition
Chronic alcoholism
HIV

114
Q

what s used to decide if to treat paracetamol OD

A

normogram

115
Q

should you wait for paracetamol levels to come back if patient is jaundiced or hepatotoxic

A

no just treat them

116
Q

a patient presenta having taken less than 75mg/kg paracetamol in last 24 h do they need treating

A

not unless high risk - even then check paracetamol levels

117
Q

what bloods should you check in paracetamol OD

A 
FT
INR : U+E
creatininebicarbonate
FBC
paracetamol levels
118
Q

what are the steps for investigating paracetamol OD

A

bloods at admission and again at 4 hours to see if safe four discharge, always checking normogram

119
Q

what would indicate patient who took paracetamol >75mg/kg is safe for discharge

A

Paracetamol concentration < 10 mg/L
ALT within normal range
INR < 1.3
The patient has no clinical features suggesting liver damage

120
Q

can you use activated charcoal in paracetamol OD

A

yes if ingested less than 1h ago

121
Q

what is a commonside effect of NAC and what is management

A

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

122
Q

how do investigations and management differ if OD was staggered > 1h

A

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

123
Q

What are common ‘benign’ causes of chest pain

A

GORD
MSK
Stable angina Anxiety Pericarditis Oesophageal spasm

124
Q

what are potentially fatal causes of chest pain

A

Aortic deception Pneumothorax Endocarditis
MI
Unstable angina PE

125
Q

what is a good way to differentiate between MSK causes of chest pain and other types in a history

A

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

126
Q

what does pain taking in a big breath suggest

A

PE

127
Q

what oes pain in chest when doing a stretching motion suggest

A

MSK

128
Q

what blood tests are involved in a cardiac workup

A 
FBC
Cardiac troponins
CRP
Cardiac isoforms : CK- MB
Creatine kinase
129
Q

what Ix apart from bloods is required in a cardiac work up

A

ECG for any ?DD: CXR CTPA

130
Q

is a normal ECG grounds for saying MI not present

A

no - MI don’t always have clear ECG changes so even if serial ECG is normal MI could still be present

131
Q

why is creatine kinase measured

A

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

132
Q

why Is CK-MB measured what are its limitations

A

specific to myocyte muscle breakdown however still not as sensitive as troponins

133
Q

what is the mbest cardiac marker

A

tropoins

134
Q

when should you measure troponins

A

Low sensitivity troponins peak at 24–48 hours

whereas high sensitivity can be done after three hours of onset

135
Q

describe the Ix/Mx pathway for a ?MI

A

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

136
Q

what is initail management for MI

A

M(O only if <92%) NA

137
Q

what are definitive manageement options for MI

A

primary PCI or Fibrinolysis/Thrombolysis

138
Q

when should primary PCI be performed

A

Should be performed within 12 hours from onset of symptoms and within two hours from diagnosis

139
Q

If a patient no longer has chest pain will PCI still work

A

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

140
Q

what drugs can you give in fibrinolysis/thrombilysis

A

Altepase /tenecteplase/ streptokinase

141
Q

what are severe complications of fibrilolysis/thrombolysis

A

Haemorrhage especially GI and intercranial Recurrent ischaemia

142
Q

what are contraindications to fibrinolysis/thrombolysis

A

Acute pancreatitis
Aneurysm
Aortic dissection
AV malformations Bacterial endocarditis

143
Q

when would you ise CT-CA as an investigation

A

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

144
Q

What is the most common mechanism of injury in elderly people

A

falling from a standing height

145
Q

what changes in the respiratory system predispose the elderly to chest infections

A

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

146
Q

describe how pharmacokinetics are affected in the elderly

A

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

147
Q

what drugs should you be wary of prescribingi in the elderly

A 
A CEI
Opiates
Sedatives/benzodiazepines
Steroids
NSAIDS Beta-blockers – cannot physiologically compensate for bleed so if in a fall there is no tachycardia
Anticoagulant
148
Q

why are NSAIDs relatively CI in the elderly

A

– renal injury, causing impaired function and hypotension

149
Q

why are Beta Blockers relatively CI in the elderly

A

cannot physiologically compensate for bleed so if in a fall there is no tachycardia

150
Q

why might signs of head trauma be less obvious in the elderly

A

atrophy which occurs there is a greater space for blood to accumulate

151
Q

what do rib injuries pose a risk for in the elderly

A

Over three rib fractures plus any other fracture in the rib carries significant mortality
Increased risk of developing pneumonia if rib injury

FINALS (24 decks)

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