Acute and Emergencies 🚑 Flashcards
F
1
Q
What is type 2 respiratory failure?
A
Low oxygen and high CO2
2
Q
What is type 1 respiratory failure?
A
Low oxygen and a low or normal CO2
3
Q
What are the causes of respiratory acidosis?
A
Airway obstruction (including asthma and COPD)
Head trauma
Opiates
Obstructive sleep apnoea
Obesity hypoventilation syndrome
GBS
Myasthenia gravis
Increased CO2 production
4
Q
How does respiratory acidosis occur?
A
Respiratory acidosis is caused by inadequate alveolar ventilation, leading to CO2 retention
5
Q
How is ventilation rate calculated?
A
Tidal volume X respiratory rate
(anything that reduces tidal volume or respiratory rate can affect the amount of CO2 retained)
6
Q
What ABG results will be seen in respiratory acidosis?
A
Low pH
Raised CO2
Possible raised bicarbonate (compensation)
7
Q
What are the causes of respiratory alkalosis?
A
CNS stimulation - anxiety, fever, pain, cerebral oedema, brain trauma, CNS infection
Hypoxia - asthma, anaemia, low FiO2
Stimulation of chest receptors - pneumothorax, PE, pulmonary oedema, pleural effusion, pneumonia
Sepsis
Hyperthyroidism
Liver disease
Pregnancy
8
Q
Why does respiratory alkalosis occur?
A
A raised respiratory rate causes excessive alveolar ventilation, which leads to too much CO2 being expired
9
Q
What ABG results will be seen in respiratory alkalosis?
A
High pH
Oxygen may be low or high
Low CO2
10
Q
What are the metabolic causes of metabolic acidosis?
A
Raised lactate
Raised ketones
Increased hydrogen ions
Reduced bicarbonate
11
Q
What conditions can cause metabolic acidosis?
A
Diabetic ketoacidosis
Uraemia
Methanol intoxication
Ethanol intoxication
Lactic acidosis
Diarrhoea
CKD
Rhabdomyolysis
Renal tubular acidosis
12
Q
What ABG results will be seen in metabolic acidosis?
A
Low pH
Low bicarbonate
13
Q
What ABG results will be seen in metabolic alkalosis?
A
High pH
High bicarbonate
14
Q
What are the causes of metabolic alkalosis?
A
Burns
Vomiting - loss of H+
Increased aldosterone activity
Loop and thiazide diuretics
Oedematous states - heart failure, nephrotic syndrome, cirrhosis
Hypokalaemia
Exogenous steroids
15
Q
What can cause increased aldosterone activity?
A
Conn’s syndrome
Liver cirrhosis
Heart failure
Loop diuretics
Thiazide diuretics
16
Q
What ABG results will chronic COPD show?
A
Respiratory acidosis with full compensation
17
Q
What ABG results will a life threatening asthma exacerbation show?
A
Respiratory alkalosis
18
Q
What ABG results will an opiate overdose show?
A
Respiratory acidosis (due to decreased respiratory drive)
19
Q
What ABG results will a PE show?
A
Respiratory alkalosis
20
Q
What is supraventricular tachycardia?
A
Where abnormal signals from above the ventricles cause tachycardia
21
Q
What is the pathophysiology of supraventricular tachycardia?
A
The electrical signals in the heart re-enter the atria from the ventricles - the electrical signal then travels down again through the AV node into the ventricles, causing a further ventricular contraction
22
Q
What type of tachycardia is SVT?
A
Narrow complex tachycardia (QRS complex has a duration of less than 0.12 seconds)
23
Q
What is paroxysmal SVT?
A
Where SVT reccurs and remits
24
Q
What are the four types of narrow complex tachycardia?
A
Sinus tachycardia
SVT
AF
Atrial flutter
25
How does SVT appear on ECG?
Appears as a QRS complex, followed by a T wave, followed by another QRS complex
There are P waves present, but are buried in the T waves, and therefore cannot be properly seen.
26
What are the three types of SVT?
AV node re-entrant tachycardia
AV re-entrant tachycardia
Atrial tachycardia
27
What is AV node re-entrant tachycardia?
Most common type of SVT - where electrical signals re-enter atria through AV node
28
What is AV re-entrant tachycardia?
Where the electrical signal re-enters the atria through an accessory pathway (Wolff-Parkinson-White syndrome)
29
What is atrial tachycardia?
Not caused by the signal re-entering the atria, but by an abnormal atrial electrical activity
30
What is the accessory pathway called in Wolff-Parkinson-White syndrome?
Bundle of Kent
31
What are the ECG changes in Wolff-Parkinson-White syndrome?
Short PR interval
Wide QRS complex
Delta wave
32
What are the stages of acute SVT management?
Stage 1 - vagal manoeuvres
Stage 2 - adenosine
Stage 3 - verapamil or beta blocker
Stage 4 - Synchronised DC cardioversion
33
What are vagal manoeuvres?
Manoeuvres that stimulate the vagus nerve, increasing activity in the parasympathetic nervous system
34
What are examples of vagal manoeuvres?
Blowing hard against resistance
Carotid massage (on one side only) - contraindicated in carotid artery stenosis
35
How is adenosine given to patients with SVT?
Given as an IV rapid bolus into a central or alrge vein - as it only acts for approx. 10 seconds
36
Which patients is adenosine avoided in?
Asthma
COPD
Heart failure
Heart block
Hypotension
37
What dose of adenosine is given in SVT?
Initially 6mg
then 12mg
then 18mg
38
What are the three types of ACS?
Unstable angina
STEMI
NSTEMI
39
Where does the right coronary artery supply?
Right atrium
Right ventricle
Inferior aspect of left ventricle
Posterior septal area
40
What does the left coronary artery split into?
Circumflex artery
LAD (left anterior descending artery)
41
Where does the circumflex artery supply
Left atrium
Posterior aspect of left ventricle
42
Where does the LAD supply?
Anterior septal area
Anterior aspect of left ventricle
43
What are the symptoms of ACS?
Pain radiating to jaw or arms
Nausea and vomiting
Sweating/clamminess
Feeling of impending sense of doom
Shortness of breath
Palpitations
44
For when and how long do symptoms occur in ACS?
At rest for more than 15 minutes
45
What ECG changes are seen in a STEMI?
ST-segment elevation
New left bundle branch block
46
What ECG changes are seen in an NSTEMI?
ST segment depression
T wave inversion
47
What ECG leads correspond to the left coronary artery?
I, aVL, V3-6
48
What ECG leads correspond to the LAD?
V1-4
49
What ECG leads correspond to the circumflex artery?
I, aVL, V5-6
50
Which ECH leads correspond to the right coronary artery?
II, III, aVF
51
What can cause a raised troponin?
ACS
CKD
Sepsis
Myocarditis
Aortic dissection
PE
52
What investigations should be performed in someone with suspected ACS?
Troponin
ECG
FBC, U&E, LFTs, lipids, glucose
CXR
Echocardiogram
53
How is a STEMI diagnosed?
When the ECG shows new LBBB or ST elevation
54
How is a STEMI diagnosed?
Rising troponin
A normal ECG or other ECG changes (ST depression or T wave inversion)
55
How is unstable angina diagnosed?
When symptoms suggest ACS, but:
- Troponin is normal
- Normal ECG or other ECG changes (ST depression or T wave inversion)
56
What is the initial management of ACS?
CPAIN
C - call an ambulance
P - perform an ECG
A - aspirin 300mg
I - IV morphine
N - nitrate (GTN spray)
57
What is the management of a STEMI?
PCI (percutaneous coronary intervention) - within 2 hours
Thrombolysis - within 12 hours
58
What agents are used in thrombolysis?
Alteplase
Streptokinase
Tenecteplase
59
What is the management of an NSTEMI?
BATMAN
B - base decision about angiography and PCI on GRACE score
A - aspirin 300mg
T - ticagrelor 180mg
M - morphine
A - antithrombin therapy with fondaparinux
N - nitrate
60
When should you give oxygen in ACS?
If someone's saturations drop below 95% (in someone without COPD)
61
When should angiography for an NSTEMI be considered?
If patients have a GRACE score above 3%
62
What is the GRACE score?
The 6 month probability of death after having an STEMI
63
What medications are used for secondary prevention of ACS?
6As
- Aspirin 75mg
- Another antiplatelet (ticagrelor or clopidogrel) for 12 months
- Atorvastatin 80mg
- ACE inhibitors
- Atenolol
- Aldosterone antagonist (for those with clinical heart failure)
64
What are the complications of MI?
DREAD mnemonic
D - death
R - rupture of heart septum or papillary muscles
E - oEdema (heart failure)
A - arrhythmia and aneurysm
D - Dressler's syndrome
65
What is Dressler's syndrome?
Pericarditis that occurs 2-3 weeks after an acute MI
66
How does Dressler's syndrome present?
Pleuritic chest pain
Low grade fever
Pericardial rub on auscultation
67
How is Dressler's syndrome diagnosed?
ECG - global ST elevation and T wave inversion
Echo - pericardial effusion
Raised CRP and ESR
68
What is the management of Dressler's syndrome?
NSAIDs
Steroids
Pericardiocentesis to remove fluid from heart if there is a significant pericardial effusion
69
What is AKI?
A rapid drop in kidney function diagnosed by measuring serum creatinine
70
What are the criteria for diagnosis of an AKI?
A rise in creatinine of 26 micromol/L or greater within 48 hours
A 50% or greater rise in serum creatinine in 7 days
A fall in urine output to less than 0.5ml/kg/hour for more than 6 hours
71
What are the risk factors for AKI?
Older age
Sepsis
CKD
Heart failure
Diabetes
Liver disease
Cognitive impairment - reduced fluid intake
Medications
Radiocontrast agents
72
What medications commonly cause AKI?
NSAIDs
Gentamicin
Diuretics
ACE inhibitors
73
What are the pre-renal causes of AKI?
Dehydration
Shock
Heart failure
74
What are the renal causes of AKI?
Acute tubular necrosis
Glomerulonephritis
Acute interstitial nephritis
Haemolytic uraemic syndrome
Rhabdomyolysis
75
What are the post-renal causes of AKI?
Kidney stones
Tumours
Ureteral or urethral stricture
BPH
Neurogenic bladder
76
What is the most common intrinsic cause of AKI?
Acute tubular necrosis
77
What is acute tubular necrosis?
The damage and death of epithelial cells of the renal tubules (due to hypoperfusion or nephrotoxins)
78
What investigations are performed in suspected AKI?
Serum creatinine
Urinalysis
Ultrasound of urinary tract (to determine post-renal cause)
ABG
Bloods - FBC, U&E, LFTs, glucose, CK, CRP
ECG - hyperkalaemia
CXR - pulmonary oedema
79
What is a stage 1 AKI?
Rise of >26micromol or more within 48 hours
Rise in creatinine of more than 50% in 7 days
Urine output less than 0.5ml/kg/hour for more than 6 hours
80
What is a stage 2 AKI?
More than 100% rise in creatinine in 7 days
Urine output less than 0.5ml/kg/hour for more than 12 hours
81
What is a stage 3 AKI?
More than 200% rise in creatinine in 7 days
Urine output less than 0.3ml/kg/hour for 24 hours
Anuria for 12 hours
82
What is the management of AKI?
IV fluids
Withhold medications that may worsen the condition
Withhold/adjust medications that may accumulate with reduced renal function
Relieve obstruction in post-renal AKI
Dialysis
83
What are the complications of AKI?
Fluid overload
Heart failure
Pulmonary oedema
Hyperkalaemia
Metabolic acidosis
Uraemia
84
What is a tension pneumothorax?
A pneumothorax that causes displacement of the mediastinal structures, and compromises cardiopulmonary function
This is due to a one way valve that causes air to enter the lungs, but not exit
85
What are the causes of pneumothorax?
Iatrogenic
Spontaneous
Trauma
Lung pathologies e.g asthma, COPD, infection
86
What is the investigation of choice for a simple pneumothorax?
Erect CXR
87
What are the symptoms of pneumothorax?
Pleuritic chest pain
Sudden onset shortness of breath
Reduced chest expansion
Reduced or absent breath sounds
88
What kinds of medical conditions can cause pneumothorax?
Connective tissue disease
- Marfan's disease
- Ehlers-danlos syndrome
Obstructive lung disease
- COPD
- Asthma
Infective lung disease
- TB
- Pneumonia
Fibrotic lung disease
- CF
- Idiopathic pulmonary fibrosis
Neoplastic disease
89
What are the signs of pneumothorax on examination?
On the affected side:
Reduced or absent breath sounds
Reduced chest expansion
Hyper-resonant percussion
Reduced vocal resonance
90
What are the additional signs of a tension pneumothorax on examination?
Deviated trachea
Tachycardia
Hypotension
91
When is a pneumothorax managed conservatively?
If a patient is asymptomatic (regardless of size)
<2cm in size, and no high risk characteristics
92
What are the high risk characteristics of a pneumothorax?
Haemodynamic instability
Significant hypoxia
Bilateral pneumothorax
Underlying lung disease
50 or older with significant smoking history
Haemopneumothorax
93
What are the management options for pneumothorax?
Conservative management
Pleural vent ambulatory device
Needle aspiration or chest drain
94
What is a pleural vent ambulatory device?
A catheter that is inserted into the pleural space, which allows air to exit, but not return
This can be worn as an outpatient until the pneumothorax has resolved
95
Where is a chest drain inserted?
Into the triangle of safety - formed by:
- 5th intercostal space
- Midaxillary line
- Anterior axillary line
The drain is inserted just above the rib, to avoid the neurovascular bundle that runs below the rib
96
How does a chest drain work?
One end of the drain is inserted into the chest, and the other is placed in water - this allows air to exit the chest and bubble through the water, but not re-enter the chest
97
What are the complications of a chest drain?
Air leaks around drain site
Surgical emphysema (air collects in the subcutaneous tissue)
98
When will a patient require surgical management for a pneumothorax?
A chest drain fails to treat pneumothorax
There is persistent air leak of the drain
The pneumothorax reoccurs
99
What is the emergency management of a tension pneumothorax?
ABCDE assessment
Give high flow oxygen via a non-rebreather mask
Chest drain and open thoracostomy if available
OR needle decompression
100
How is needle decompression carried out in tension pnemothorax?
16 gauge cannula, inserted into the fifth intercostal space, mid-axillary line on the affected side
101
What are some possible causes of anaphylaxis?
Insect stings
Nuts
Other foods
Antibiotics
IV contrast agents
Other medications
102
What type of hypersensitivity reaction is anaphylaxis?
Type 1 hypersensitivity
103
What is the presentation of anaphylaxis?
Urticaria
Angioedema
Abdominal pain
Itching
Tachycardia
Shortness of breath
Wheeze
Swelling of the larynx (and stridor)
Hypotension
104
How can anaphylaxis be confirmed?
Serum levels of mast cell tryptase, taken after the patient is stabilised
105
What is the emergency management of anaphylaxis?
Remove trigger
ABCDE
Oxygen
IM adrenaline
Chlorphenamine and hydrocortisone
IV fluid chanllenge if hypotensive
106
What is the adult dose of adrenaline given in anaphylaxis?
500 micrograms IM
107
What is a biphasic reaction?
The recurrence of symptoms soon after the initial episode
108
What are the eye response scores for GCS?
4 - spontaneous eye opening
3 - eye opening to speech
2 - eye opening to voice
1 - no eye opening
109
What are the movement scores for GCS?
6 - obeys commands
5 - localises pain
4 - withdraws from pain
3 - flexion to pain
2 - extension to pain
1 - no motor response
110
What are the verbal scores for GCS?
5 - oriented
4 - confused
3 - inappropriate words
2 - incomprehensible sounds
1 - no verbal response
111
What GCS score warrants an assessment by the anaesthetic team?
GCS < 8
112
What are the features of an acute COPD exacerbation?
Worsening breathlessness
Increased sputum production and purulence
Cough
Wheeze
Increased respiratory and heart rate
Fever without an obvious source
113
What are the clinical signs of a COPD exacerbation?
Breathlessness
Tachypnoea
Use of accessory muscles or pursed lip breathing
New onset cyanosis
Peripheral oedema
Acute confusion or drowsiness
114
What is the management of an acute COPD exacerbation in hospital?
Oxygen
Antibiotics
Steroids
Bronchodilators
115
What is the target oxygen sats range for patients with COPD?
88-92%
116
What bronchodilators are given in acute COPD exacerbation?
Salbutamol 5mg/4h
Ipatropium 0.5mg/6h
117
What steroids can be given in acute COPD exacerbation?
IV hydrocortisone 200mg
Prednisolone PO 40mg for 7-14 days
118
What further treatment is given in an acute COPD exacerbation when there is no response to initial treatment?
Repeat nebulised bronchodilators
IV aminophylline
Consider BiPAP
Consider invasive ventilation
119
What dose of adrenaline is given to children in anaphylaxis?
<6 months old - 100-150mcg
6 months to 6 years - 150mcg
6 - 12 years - 300mcg
120
Where is adrenaline given into?
The anterolateral aspect of the middle third of the thigh
121
Which drugs should be stopped in AKI?
NSAIDs
ACE inhibitors
ARBs
Aminoglycosides
Diuretics
122
What ABG results will an acute COPD exacerbation show?
Respiratory acidosis with partial compensation
123
What ABG results will hyperventilation show?
Respiratory alkalosis
