Acute and Emergency medicine Flashcards
When does Troponin rise and peak in ACS?
What does this tell you?
Within 3-12 hours
Peak 24-48 hours
Angina will have no trop rise; STEMI/NSTEMI will
When is myoglobin useful in ACS
Early rise at 1-4 hours
When is CK useful in ACS
Rise 3-12 hours
Peak 24 hours
Hyperacute (hours) and Acute (hours to days) changes on an ECG in ACS
Hyperacute- Tall T, ST elevation
Acute- T wave inversion, Pathological Q waves
Leads 11,111,avf on an ECG are…
Inferior heart
Leads 1,avl, V5, V6 on an ECG are…
Lateral heart
Leads V1, V2 on an ECG are…
Septal
Leads V3, V4 on an ECG are…
Anterior
Indications for primary percutaneous coronary intervention
ST rise >1mm (2 small squares) in 2 limb leads
ST rise of >2mm in 2 contralateral chest leads
LBBB
Must be within 120 minutes
What if a STEMI presents >120 minutes, how do you treat it?
Thrombolyse
If no effect then PCI
What does MONAT stand for in STEMI treatment?
Morphine 2.5-10mg slow IV bolus + Metoclopramide Oxygen 15L NRBM Nitrates GTN spray Aspirin 300mg PO Ticagrelor or clopidogrel
Treating an acute NSTEMI/Unstable angina
300mg Aspirin Nitrates Morphine Anti-thrombin therapy: 1- Fondaparinux 2- Ticagrelor (12 months)
What is the GRACE score
6 month future CV AE risk
if >3% then coronary angiography within 96 hours
What is the TIMI score
Mortality AE predictor post-MI
What can give a falsely high troponin
HF PE CKD Dialysis Arrhythmia SAH Seziure
What medications should someone be on post-MI
Beta blocker, aspirin, 12 month ticagrelor, ACEi
ECG signs for angina
ST depression, Flat/inverted T waves
Signs of past MI
When do you refer an anigina to a specialist
New angina of sudden onset
Recurrent and Hx of MI/CABG
Uncontrolled by drugs
What is the Well’s score; what action do you take if >4?
Likelihood of PE
> 4= High risk therefore CTPA
< 4= Low risk -> D-dimer= +ve = CTPA
What is a PERC score? Explain ‘HAD CLOTS’
Any of the criteria in this score are met then PE not ruled out
Hormone, Age >50, DVT/PE Hx, Cough blood Leg swelling, O2 neded, Tachycardia >100BPM, Surgery/Trauma
D-dimer has good sensitivity, what does this mean?
SNOUT
-VE= UNLIKELY TO BE PE
PE associated ECG changes
S1Q3T3
Large S wave in lead 1
Pathological Q wave in lead 3 (> 1 small box duration)
Inverted T wave in lead 3
Right axis deviation
What is the gold standard for PE Dx?
When can the above not be done?
CTPA
If renal impairment or pregnant therefore use V/Q scan
How do you identify a massive PE?
What do you treat this with?
Hypotension +/- Cardiac arrest
Alteplase (Thrombolysis)
How do you treat sub-massive or non-massive PEs
LMWH or fondaparinux for 5 days or until INR >2
Warfarin should be started within 24 hours
What are type A and Type B aortic dissections?
Type A- Ascending Aorta (MAJORITY) and highest mortality, caused by tamponade, interrupted flow, valve incompetence
Type B- Not in the ascending aorta
General features of Aortic dissection
Abrupt sharp tearing chest pain that is maximal at onset
Paraplegia, limb ischaemia, neuro deficit, syncope
Signs of Type A dissection vs type B
What are the pulses like? Any murmurs?
Type A- Hypotension
Type B- Hypertension
Asymmetry and absence of peripheral pulses
Aortic regurg murmur (Early diastolic decrescendo)
How do you confirm a Dx of Aortic dissection
BP both arms
CT angiography is gold standard
Transoes echo if haemodynamic instability
How do you treat aortic dissection
Type A= surgery
Type B= Iv labetalol to control HTN, conservative if uncomplicated
Presentation of pericarditis
Non prod cough, chest pain worse on lying flat, radiates to neck
ECG changes in pericarditis
Wide spread saddle shaped ST elevation
PR depression
T wave inversion
Treating pericarditis
NSAIDS (Naproxen) + PPI and cease phenytoin
Avoid antimicrobials
How gets primary and secondary pneumothorax?
Primary- young thin men
Secondary- Old with pre-existing lung disease
Criteria for chest drain in pneumothorax
> 2cm + SOB +/- > 50yrs
< 2cm + no SOB and primary ?Discharge
Which way is the mediastinum pushed in a tension pneumothorax
Contralaterally
How do you treat a tension pneumothorax?
Large bore needle 2nd ICS MCL
Syringe and saline- allow air to bubble through
Then chest drain
How does a tension pneumothorax cause cardiorespiratory arrest?
What are the signs of this
Great vein compression
Hypotension, neck vein distension, Cont. Tracheal deviation
What is a low/Int and high risk CURB-65 score?
Low- 0-1
Int- 2
High= 3-5
When would you consider an ICU admission for pneumonia?
Shock
Hypercapnia
Uncorrected hypoxia
Most common cause of an infective COPD exacerbation
H.Influenzae
+ S.Pneum, Morazella Catarrhalis
30% Viruses (Like Rhino virus)
Indications for admission of an infective COPD exacerbation
Cannot cope at home Deterioration Severe SOB/Cyanosis/Oedema LTOT Rapid onset Acidotic Sp02<90% Hypoxic CXR changes (Acute)
Treatment of an infective COPD exacerbation
Neb bronchodilators- Salbutamol and Ipratropium
30mg Pred
Amox/Tetra/Clarithro
Indications for Abx in a COPD exacerbation
Pyrexia
Purulent sputum
Consolidation on CXR
What would indicate a COPD exacerbation is needing NIV?
Previous admin in 12 months DNACRP RR>30 PH<7.35 Hx NIV Abx/Steroids in last 12 months Decreased exercise tolerance Wx loss
Criteria for a Moderate Asthma exacerbation
PEFR 50-75%
RR<25
HR<110
Speech normal
Criteria for a severe Asthma exacerbation
PEFR 33-50%
Cannot complete sentences without taking a breath
RR>25/HR>110
Criteria for a life threatening Asthma exacerbation
PEFR <33% Sats <92% Rising PaCO2 Silent chest/Exhaustion Dysrhythmia/Bradycardia Hypotension Confusion
Managing acute asthma
Salbutamol- 5mg Neb w/o2 back to back Ipratropium- 500mcg- Neb w/o2- 4 hourly Hydrocortisone 200mg IV OR 40mg Pred orally Magnesium sulphate 2g IV over 20 mins IV Aminophylline 5mg/kg over 20 mins
Causes of cardiogenic pulmonary oedema
LHF leads to inc LV-end diastolic pressure; causes inc pulmonary hydrostatic pressure
MI/IHD/Arrhythmia/Cardiomegaly/-ve Inotropic drugs/Failed prosthetic valve
Causes of non-cardiogenic pulmonary oedema
ARDS, IV fluid overload, Hypoalbuminaemia, Toxins, Smoke inhalation
Signs of Pulmonary oedema on CXR
Batwing Hilar shadows
Kerley B lines (Interstitial space expansion)
Upper lobe diversion because of increased flow- upper lobe pulmonary veins resemble a stag’s antlers
Cardiomegaly
Treating an acute pulmonary oedema
IV furosemide 50mg Morphine GTN if BP<90 sys ICU if cardiogenic shock ?NIV
What type of crackles are heard upon auscultation in pulmonary oedema
Fine inspiratory crackles
Upon leg examination in ?DVT what signs are you looking for (3)?
Deep vein tenderness
Swelling 10cm distal to tibial tuberosity; Must be >3cm bigger than unaffected calf
Oedema- MAY BE PITTING
How do you interpret Well’s score for DVT?
2+= Likely= Proximal leg vein USS within 4 hours
D-Dimer +LMWH if cannot do above but get USS within 24 hours
=1 = Unlikely D-dimer; if +ve then USS within 4 hours
Treating DVT
1) LMWH/Fondaparinux until 5 days or INR>2
2) Warfarin within 24 hours continue for 6 months
3) Safety net- SOB/PAIN
In unprovoked DVT what should you check for?
Cancer
CR/FBC/Calcium/LFTs/Urinalysis
?Thrombophilia
Features of cellulitis
Red, warm, tender, swollen
Poorly defined margins
What is the Eron classification?
Classifies cellulitis
1- Afebrile
2- Febrile but no unstable cormobidities
3- Toxic appearance, unstable comorbids
4- Sepsis syndrome- Organ dysfunction, Not responding to fluid challenge
Admit for IV Abx if 3/4
How do you treat…
Localised cellulitis with no systemic upset
Cellulitis + Systemically unwell
Cellulitis of the face
Localised cellulitis with no systemic upset- Oral flucloxacillin or macrolide/Clinda if allergic
Cellulitis + Systemically unwell- IV Fluclox or Benzyl or Co-Amox
Cellulitis of the face- IV Abx + Optham referral
Define severe sepsis and septic shock
Severe sepsis= SIRS + Organ dysfunction
Septic Shock= SIRS + Hypotension despite fluid resus
What criteria are considered for SIRS
Temp, WCC, HR, RR, PAO2
What is the sepsis six
BUFALO
Complete within 1 hour
Signs of an acutely ischaemia limb (6 P’s)
Pale, Pulseless, Pain, Paralysis, Perishingly cold, Paraesthesia
Signs of critical limb ischaemia
Hangs leg out of bed Ulceration/Gangrene Intermittent claudication ABPI <0.5 Mottled
RF for gout
Diet Diuretics Renal failure Cytotoxics Myeloproliferative disease Chemo Aspirin
How do you confirm a Dx of gout
Diagnostic: Monosodium urate crystals in the synovial fluid or tophi
Therefore: 1) Joint aspiration 2) X-ray
Serum uric acid >360 u/mol is suggestive but not diagnostic
X-ray signs of gout
Punched out lesions in peri-articular bone
Preservation of joint space
No peri-articular osteopenia
Treatment of acute gout
Rest + NSAIDS +/- Colchine (+ PPI)
Prednisolone 15mg/day if above CI
If already on allopurinol do not alter!
Preventative drugs for gout
Allopurinol (May cause an initial acute attack)
Typical presentation of septic arthritis?
Inflammed joint with sudden fast onset >50% knee No movement Joint held in position of most comfort- usually flexion Fever, shaking, rigors
What would a septic arthritis X-ray look like
Initially may be normal
Later on there is a loss of landmarks and soft tissue swelling with displacement of the capsular flat planes
Diagnosis of septic arthritis
Clinical Hx/Exam +/- X-ray
Joint aspiration (MOST RELIABLE) -> Culture
?CT/MRI
Treatment of septic arthritis
STAT IV flucloxacillin or clindamycin
+ Orthopaedic referral
(VANCOMYCIN IF MRSA)
What are the 4 I’s of DKA
Infection, Infarction, Insufficient insulin, Intercurrent illness
DKA presentation
Osmotic diuresis (Polyuria) leads to hypoperfusion, hypotension, and shock
Polydipsia
SOB
KUSSMAL breathing
Dehydration- Cap refill, dry mouth, dec skin turgor, weak pulse
3 Diagnostic criteria for DKA
Acidaemia PH<7.3 HCO3<16mmol/L
Ketonaemia/uria Urine ketones ++ or Cap ketones >3 mmol/L
Hyperglycaemia (or known T1DM) CBG >11mmol/L
Treatment of DKA
IV insulin 0.1 units/kg/hr
0.9% Saline 1L over 1 hr > 2 hrs > 2hrs > 4 hrs> 4 hrs> 6 hrs
Treat Hypokalaemia 20mmols if <5 + 40mmols <4.5
Hourly CBG/ketones/bicarb/K+
Indications of DKA resolution
PH >7.3 ketones <0.3 mmol/L
Stop IV
? Start SC insulin
When would you consider giving glucose in DKA
Once Glucose <14mmol/L
5% Dextrose
or add 10% glucose 125ml/hr
Indications for Critical care in DKA
Bicarb < 5 Pregnancy (Big DKA RF) Drowsy HF Anuria/Oliguria K+ <3.5 on admin Sats <92%
Potential complications of DKA
Arrhythmias Gastric stasis Thromboembolism Cerebral oedema ARDS AKI
What is Whipple’s triad of hypoglycaemia
Plasma hypoglycaemia
Concurrent symptoms
Resolution with correction of low glucose
Treating hypoglycaemia
Quick acting carbohyrate/Glucose 10-20g orally
If unconscious/uncooperative then IV glucose 10-20% E.G 150mls 10% Dextrose/15 mins
If no IV then IM Glucagon
Prolonged hypoglycaemic coma- IV Mannitol + Dexamethasone + Iv glucose
What is HHS?
Sevre uncorrected hyperglycaemia causes osmotic diuresis and volume depletion resulting in blood hyperviscosity
Presentation of HHS
How do you distinguish this from DKA?
Onset is days- weeks
WATERY= Poluria, thirsty, dehydrated, urgdency
WEAK= Fatigue, LoC
PAIN- Headaches, Papilloedema
HHS- Slower onset, Elderly, likely T2DM, Hyperglycaemia is more pronounced, Ketacidosis less pronounced
Dx criteria of HHS
Hypovolaemia
Plasma osmolarity >320 mOsmol/kg
Hyperglycaemia > 30mmol/L
Management of HHS
IV 0.9% saline aim for +ve balance of 3-6L by 12 hours
Once hydrated then give insulin, if given too soon this can precipitate CV collapse; 0.05 units/KG/Hr if ketonaemia
TARGET GLUCOSE 10-15mmol/L
Complications of HHS
Higher mortality than DKA…
Ischaemia, Infarction, VTE, DIC, ARDS, Multi-organ failure, Rhabdomyolysis, Cerebral oedema, Central Pontine Myelinolysis,Over-administration of insulin
ECG findings on 1st degree AV block
PR consistently prolonged
ECG findings on 2nd degree MOBITZ 1 AV block
Progressive PR prolongation then a QRS block
ECG findings on 2nd degree MOBITZ 2 AV block
Normal PR
P wave not followed by QRS at a constant ratio
+? Wide QRS
ECG findings on 3rd degree AV block
No PR interval
P wave does not relate to QRS
Heart block pharmacological interventions?
When would you use this?
0.5mg Atropine IV can repeat 3 times
Adrenaline
Syncope, Shock, MI, Ischaemia, HF (ADVERSE FEATURES)
Cerebral perfusion pressure formula
CPP= MAP - ICP
Initial features of increased ICP post-head injury?
What does this progress to?
Decreased consciousness
Ipsilateral pupillary dilatation as temporal lobe herniation causes occulomotor compression
Contralateral hemiparesis, Cardio-respiratory arrest, Cushing’s response
What is cushing response following head injury
Reflex increase in BP with bradycardia
+ irregular breathing
Signs of a basal skull fracture
Bilateral orbital bruising (Panda eyes) Subconjunctival haemorrhage Haemotypanum CSF rhinorrhea/otorrhoea Battle's sign (Brusing over mastoid process over days)
Indications for an immediate CT scan post-head injury
GCS<13 (or < 15 in the ED) Basal skull fracture Seizure Focal neurological deficit >1 episode of vomiting
Normal sequlae of head injury
Mild headache
Nausea
Cannot concentrate
Anxiety
Indications for non-urgent CT post-head injury (8 hours)
Some LoC/Amnesia
+(65+, Clotting problems, Dangerous mechanism, > 30 mins retrograde amnesia)
ALWAYS IF ON WARFARIN
How is recovery in Syncope Vs seizure
Syncope is likely to be a rapid full recovery
What is Todd’s paresis?
May follow seizures
focal deficit or hemiparesis lasting 24 hours
What do all new onset seizures need?
BRAIN IMAGING
Indications for an emergency CT post-seizure
Focal signs Head injury HIV ?Intracranial infection No improvement in consciousness
When is it appropriate to discharge a seizure presentation?
Normal neuro/cardio exams
ECG/electrolytes normal
Single seizure
Refer to epilepsy clinic
If already an epileptic then discharge if no change in seizure pattern
What is status epilepticus?
> 30 mins
Generalised seizure
Doesn’t regain consciousness
Treating Status epilepticus
Lorazepam 1-2mg IV slow bolus repeat 5 mins (or 10mg Diazepam) Buccal midazolam if no IV
Then if they continue… 20 mg/kg IV Phenytoin
Get ICU help. RSI if continued seizures.
3 features of vasovagal syncope
Sudden
LoC
Spont.Recovery
When would you consider a cardiac referral for syncope?
When would you consider a neurology referral?
Abnormal ECG, LoC on exertion, HF, >65 with no prodrome, murmur
Bitten tongue, Amnesia, Unresponsive, Unusual psoturing, Prodrome, Post-ictal confusion
Examples of…
Reflex mediated syncope
Orthostatic hypotension related syncope
Cardiac syncope
Vasovagal, Situational, Cardiac sinus syncope
Primary or secondary AN failure, Alcohol, diuretics, AD, Volume depletion
Bradycardia, SVT, Cardiomyopathy, MI, Valvular, PE, Aortic dissection
3 main classifications of syncope
Reflex mediated
Orthostatic hypotension
Cardiac
What scores you 1 point in the Rosier Stroke score? What scores -2 points?
+1= Asymmetrical Arm, face or leg weakness, speech disturbance or visual field defects
-2= LoC, Syncope, Seizure
UNLIKELY IF 0 or less
Indications for an urgent CT scan in ?Stroke
Presents within 4 hours of onset On anticoagulation GCS <13 Progressive/Fluctuating symptoms Papilloedema Neck stiffness Fever
Main Categories of symptoms to ask about in ?Stroke (7)
Motor Sensory Meningism Pain Speech Cognition/Consciousness Sight
Does a normal CT rule out an ischaemic stroke?
No
Initial CT may be normal
Do CT angiogram
Managment of an ischaemic stroke
300mg Aspirin
Thrombolyse if within 4.5 hours of onset
Mechanical thrombectomy if within 6 hours
STROKE WARD
On the HUNT & HESS scale for SAH severity what would indicate a more severe event?
Stupor, Hemiparesis
What do you do in suspected SAH?
Emergency CT scan (detects >90%)
Then admit for lumbar puncture (typically regardless of CT result) as it takes 12 hours for xanthochromia to develop
Once an SAH is confirmed what can be done to investigate causative pathology
Aniogram
How do you control BP in SAH and what is the target?
BP<160
Nimodepine (also prevents vasospasm)
How do you treat raised ICP in SAH
IV Mannitol (Increases blood plasma osmolarity, driving water into plasma from the cerebral tissues)
If an ?SAH is unconscious what do you do?
ET tube
Arterial line
Catheter
Neurosurgical team
Complications of SAH
30% Rebleed Vasospasms Hyponatraemia Seizures Hydrocephalus Death
Key ‘later’ features of meningitis
Meningism Kernig's and Brudzinski's signs Decreased consciousness Seizures Focal CNS Petechial or purpuric non-blanching rash
Signs of meningococcal septicaemia
Later features of meningitis +
Slow cap refill
Hypotension
Unusual skin colour
Signs of septicaemia without meningitis
Hypotensive + infective signs
NO KERNIG’S BRUDZINSKI’S NOR FOCAL NEURO DEFICITS
Gold standard Dx for meningitis
Lumbar puncture with CSF culture
Lumbar puncture signs suggesting bacterial meningitis
> 1.5g of proteins
CSF glucose <50% Plasma glucose (SAME IN VIRAL)
Cloudy fluid (CLEAR IN VIRAL)
RELEASE PROTEINS, USE GLUCOSE, NEUTROPHILLIC
Treatment of bacterial mengingits in secondary care
IV ceftriaxone immediately + IV Amox/Ampicillin if >60/Immunocomp/<3 months
Analgesia, Antipyretics, Hydration
IV Dexamethasone 10mg/4Xday
Best Abx for strep.Pneum meningitis
Benzylpenicillin + Vanco/Ceph/Rifampicin
Dependent on local sensitivities
Key signs of a space occupying lesion
Headche worse on lying/Bending/Coughing Vomiting, papilloedema, Dec GCS Focal neurology Blackout, personality change, Amnesia Seizures
4 features indicating a secondary headache (SAH, Lesion) vs a primary (Tension, Migraine)
Sudden onset
Focal neurology
Systemic features
>50
Key diagnostic criteria for temporal arteritis
> 50 New pain Temporal artery abnormality ESR>50mm/hour Abnormal artery biopsy
NEED 3/5
What visual signs can you get in temporal arteritis
Rapid + profound
diplopia Amaurosis fugax
What does the optic disc look like in temporal arteritis
Pale, Waxy, Elevated disc, Splinter haemorrhages
Treatment of temporal arteritis
High dose prednisolone
IV mehtylpred if visual symptoms
+ Osteoporosis prophylaxis
Low dose aspirin
Onset of venous sinus thrombosis?
Onset is days-weeks NOT SUDDEN
What must you exclude in venous sinus thrombosis
SAH and Meningitis
What can be used to Dx venous sinus thrombosis
MRI T2 weighted to visualise thrombus
CT/MRI/Venography
What are the features of cavernous sinus thrombosis
periorbital oedema
6th CN palsy
Transverse sinus thrombosis
Headache mastoid pain, focal neurology, papilloedema
Saggital sinus thrombosis
Seizures, Hemiplegia, Papilloedema
Sigmoid sinus thrombosis causes lots of what
Opthalmic symptoms- oedema, proptosis pain
What size defines an arterial enlargement as aneurysmal?
When is said aneurysm at low chance of rupture?
> 3cm
<5cm
What imaging technique composes the initial assessment of AAA?
What then shows anatomical details?
USS 3mm accuracy (initial assessment and follow up)
CT
Signs of AAA rupture?
Sudden abd pain/back pain -> Loin groin sudden collapse Expansile mass Shock Hypotension Absent pulses PEA
Management of a ruptured AAA
STABILISE High flow O2 2X large bore cannulas Emergency cross match IV analgesia Cyclizine Vascular surgeon
When would preventative AAA surgery be considered
> 5.5cm
USS monitoring for AAA
3-4.4cm= Annual USS 4.5+= 3 monthly USS
What is Rovsing’s signs
Pain in RIF when pressing LIF
McBurney’s point
1/3rd from ASIS to umb
Pain and guarding when ?Appendicitis
Key investigations to do if ?Appendicitis
Urinalysis +/- pregnancy test- RULE OUT UTI
USS (FAST) can exclude pelvis pathology and show free fluid
CT has high sensitivity and specificity
Pre-surgical Abx for appendicitis
Metronidazole and cefuroxime
Appendicitis complications
Perforation Wound infection Mass Abscess paralytic ileus Adhesion Maternal mortality in pregnancy
Best imaging for gall stones
USS
What is acute cholecystitis?
Inflammation of the gallbladder wall likely because of Impaction of the neck of the gallbladder
Murphy’s sign (2 fingers, pain on insp, not on LUQ)
RUQ pain
Fever
N&V
Treating Acute cholecystitis
NBM Analgesia Fluids IV cefuroxime Laparoscopic cholecystectomy
What is Ascending cholangitis?
Infection and stasis of the biliary tree
What is Charcot’s triad?
What is Reynold’s pentad?
RUQ pain, Fever/Rigors/ Jaundice
Pentad= Above + CNS distrubance and Hypotension
BOTH SEEN IN ASC CHOLANGITIS
4 F’s of biliary colic
Female, Fat, Forty, Foetus
Classificiation of bowel obstruction
Extrinsic
Intramural
Intraluminal
Important bowel obs Qs
Any bowel disease Recent surgery Hernias RT Cancers
From a Hx how do you distinguish SBO from LBO
In SBO…
Faeculent vomiting is earlier, colicky pain is worse, constipation is later, and distension is central
What are haustra
Do not cross full diameter of LB
What are valvulae conniventes
Cross full diameter of small bowel
What is the 3, 6, 9 rule for bowel obstruction?
Abnormal if…
SB= >3cm
LB= >6cm
Caecum= >9cm
SBO vs LBO on an AXR
SBO= Central gas shadows, valvulae conniventes, no gas in LB
LBO= Constant pain. Peripheral gas shadows, not in rectum, Coffee bean sign if volvulus.
What does a barium swallow + x-ray determine
Level of obstruction in SBO
Classic presentation of diverticulitis
Tender colon with peritonism \+ Change in bowel habit \+ Older \+ LUTS \+ N&V
CXR sign of perforated bowel
Pneumoperitoneum
4 major complications of diverticuliutis
Abscess (use CT with contrast) then USS guided drainage
Perforation
Haemorrhage
Fistulae
When would you admit diverticulitis
Cannot tolerate oral fluids
Pain intolerable
Not improved for 72 hours
Basic treatment principles of diverticulitis
Analgesia NBM IV fluids \+/- Abx Avoid colonscopy as may cause perforation
Best imaging for an ovarian cyst
Transabdominal/vaginal USS
Then MRI if >7cm
Always rule out UTI and pregnancy
When must you always consider ectopic pregnancy as a DDx?
Young women Abdomen pain Vaginal bleeding Syncope Look for hypovolaemic shock!
Diagnosis of Ectopic pregnancy
USS (Vaginal>Abdominal)
Pregnancy test
What are Cullen’s and Grey Turner’s signs?
Periumbillical bruising= Cullen’s
Flank bruising= Grey Turner’s
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Surgery Mumps AI Scorpion sting Hypercalcaemia/Lipidaemia/Hypothermia ERCP Drugs
By how much is serum amylase raised in acute pancreatitis?
3x (or more)
Serum lipase better
Best imaging for pancreatitis
CT least ambiguous and good for severity and Px (post-72 hours)
USS can see gallstones
MRI good for severity
How does glucose and calcium change in pancreatitis?
Hypocalcaemia
Hyperglycaemia
What is the Ranson/Glasgow score
Pancreatitis severity- PANCREAS
Pao2 <8kpa Age >55 Neutrophils/WCC >15 x 10^9 Calcium <2mmol/L Renal urea >16 mmol/L Enzymes= LDH >600 IU AST >200 IU/L Albumin <32 g/L Blood sugars >10
> 3 points in the 1st 48 hours means severe pancreatitis
Systemic complications of pancreatitis
Respiratory oedema, effusion, consolidation, ARDS Hypovolaemia and shock DIC Low calcium, High glucose, Low Mg Haemorrhage, Ileus Renal dysfunction
What effect does eating have on duodenal ulcers
Pain relief upon eating (Gastric is worse after eating)
Most common type of peptic ulcer
Duodenal ulcer
Indications for endoscopy if ? Peptic ulcer
> 55 + 1st presentation
Anaemia/Wx loss/Chronic blood loss/Bleeding/Progressive dysphagia/Persistent vomiting/Mass
What are... Melaena Haematemesis Coffee ground-vomit Haematochezia
Melaena- Black tarry stools= UGIB
Haematemesis= Bright red indicates active haemorrhage
Coffee ground-vomit= Bleeding ceased
Haematochezia= Fresh blood, LGIB
What happens to urea in a GI bleed
Increases
In what time frame do you do an endoscopy for UGIB
Within 24 hours
If unstable then immediately
What is the Blatchford score?
Informs whether someone needs an endoscopy
What is the Rockall score?
Predicts outcomes in GI bleed
Key investigations for renal colic
CT KUB within 14 hours
Urinalysis and MSU- LOOK FOR BLOOD
What analgesia is best for renal stones?
IV opioids with oral NSAID like diclofenac or Ketorolac
When would you give immediate Abx for otitis media?
Perforation or discharge
Systemically unwell
> 4 days of symptoms
< 2 yrs and bilateral
AMOXICILLIN
Signs of a Quinsy? What do you do?
Unilateral pain
Deviated uvula
Cannot open mouth
Contact ENT + IV benzylpenicillin
Criteria for oral Abx in Tonsillitis
Fever
Exudative
Tender Ant.Cervical lympthadenopathy
Absent cough
PENICILLIN
What is croup
Viral URTI that causes inflammatory spread to the larynx/trachea
URTI symptoms lead to stridor/resp distress/hoarseness
Give Dex +/- Adrenaline
Westley clinical scoring of croup
Insp stridor Intercostal recession Air entry Cyanosis Consciousness
> 6 severe
Sepsis criteria considers…
Infection + 2 or more of:
TEMP, CAP REFILL, HR, RR, WCC, LACTATE
In ALS when do you assess the rhythm?
After every 2 min cycle of CPR
What do you do if the rhythm is shockable (VF, Pulseless VT)
1 shock
Resume CPR for 2 min
What do you do if the rhythm is non-shockable (PEA/Asystole)
Resume CPR for 2 mins
When do you give adrenaline during CRP?
1mg every 3-5mins IV/IM
When do you give amiodarone during CPR?
300Mg after 3 shocks
The reversible causes of Cardiac arrest
Hypoxia
Hypothermia
Hypovolaemia
Hypo/perkalaemia
Tension Pneumo
Thrombosis
Tamponade
Toxins
What are adverse features in an tachycardic adult with a pulse?
Shock
MI
Syncope
HF
In a tachycardic adult who is unstable what do you do?
Synchronised DC shock up to 3 attempts
300mg amiodarone/10-20mins
Expert help
Repeat shock then 900mg amiodarone over 24 hours
Broad complex tachycardia?
VT
Narrow complex tachycardia?
SVT
AF
Flutter
Re-entry paroxysmal SVT
Treating Fast AF <48 hours onset
Heparinise
Cardioversion
Treating AF >48 hours onset
Beta blocker or CCB
CHADVAS2 >2= Anticoagulation
Indications for emergency electrical cardioversion in AF?
Shock, syncope, Acute HF, Ischaemia
Agents used for chemical cardioversion
Flecainide if no structural disease
Otherwise: Amiodarone
ECG signs of Flutter
Regular atrial beat
Sawtooth pattern as constant atrial depolarisation
Treating Flutter
Cardioversion (even if >48 hours)
Radiofrequency ablation
Carotid sinus massage and adenosine
SVT ECG findings
Narrow QRS <3 small Sq
Rate >100 BPM
Treating SVT
Vagal maneouvres
IV adenosine or DC cardioversion
Cardiology referral
ECG findings in VT
Rate >100BPM
Broad QRS >3 small squares
Precordial leads unlikely to have both R + S
Treating VT
If BP<90, CHEST PAIN OR HF THEN…
Immediate synchronised cardioversion, shock if acutely unwell
If not then can use Amiodarone via central line
Treating VF
ALS algorithm
Causes of Hyponatraemia
Hypovolaemic- D+V, Diuretics, renal failure, adrenocortical suppression
Euvolaemic- SIADH, Acute water load
Hypervolaemic- CCF, Cirrhosis, Nephrotic syn, Renal failure
SIADH Criteria
Serum hypo-osmolarity <275
Urine osmo >100
Urine Na+ > 30
Causes of SIADH
Malignancy, Diuretics, PPIs, SSRIs, ACEi, Loop diuretics
How do you treat Hyponatraemia
If Hypovolaemic then 0.9% Saline
If Euvolaemic/SIADH then fluid restrict +/- Demeclocycline
Hypernatraemia causes
Dehydration, GI loss, Urinary loss, Hyperaldosteronism, Diabetes insipidus
Treatment of hypernatraemia
Isotonic 0.9% saline
Causes of hyperkalaemia
1) Renal
2) Extracellular shift
Renal- AKI/CKD/Amiloride/Spiro/ACEi,/NSAIDS/Addison’s
Extracellular shift- DKA, Digoxin, Theophylline
Hyperkalaemia ECG changes
Tall Tented T waves
Small P waves
Polonged PR
Wide QRS
When do you treat hyperkalaemia
> 6 + ECG changes
>6.5
In hyperkalaemia how do you…
1) Stabilise the cardiac membrane
2) Shift K+ into cells
3) Remove K+ from body
1) 10% 10mls IV Calcium gluconate every 10 min
2) 50mls 50% glcuose with 10 units soluble insulin +/- 5mg Sal back to back
3) 15g calcium resonium
Hypokalaemia causes
Diuretics Conn's D+V Laxatives CUSHINGS ALKALOSIS Salbutamol/Ins/Glucose
Causes of hypocalcaemia with
Low PTH
High PTH
Other
Low PTH- Iatrogenic, PT destruction, AI
High PTH- Vit D deficiency
Other- Pancreatitis, Bisphosphonates, Malignancy
Chvostek’s and Trousseau’s sign?
Chvostek’s- Tap facial nerve to elicit muscle spasm
Trousseau’s- Inflating BP cuff elicits Carpopedal spasm
HYPOCALCAEMIA
What is severe hypocalcaemia
<1.9
Signs of hypocalcaemia
Tetant, Seizures, Carpopedal spasm, Inc QT, Paraesthesia
3 key diseases to exclude with hypocalcaemia
Acute pancreatitis, CKD, Rhabdomyolysis
When do you treat hypocalcaemia; what with?
Tetany/Seizures <1.9
Calcium gluconate slow IV
Hypercalcaemia
Primary hyperPTH
Maligancy
Thiazides
Primary adrenal insufficiency
Hypercalcaemia symptoms
BONE STONES MOANS GROANS
Pain, vomiting, polyuria, Polydipsia, weakness, constipation, Dec QT, Pancreatitis, Fatigue, Depression, cog impairment
Hypercalcaemia + Inc Alk Phos could indicate pain
Bony mets
Hypercalcaemia treatment
Fluids and bisphosphonates
Key Q in paracetamol OD
Number of tablets Dose When and how long over Taken with anything else Psych Hx
Biochemistry seen in Paracetamol OD
Deranged LFTs ALT>1000 Acidaemia Inc INR Inc creatinine ?Renal failure Hypoglycaemia Tachycardia
Risk factors for severe liver damage in paracetamol OD
> 150 mg/kg
12 g (24 tabs)
Inducers of P45O (CBZ, Pheny, Rif, Barbit)
Treating Paracetamol OD... <1 hour <4 hours <4-8 hours >8 hours Staggered OD
<1 hour- Charcoal
<4 hours- Wait until 4 hours for paracetamol level
4-8 hours- Use level and if above line give NAC
>8 hours- Give NAC and review with curve
Staggered OD- Give NAC, Graph useless
How is NAC given in Paracetamol OD
IV infusion in 5% glucose 3 consecutive doses/24 hours
150 mg/kg in 200ml glu over 1 hour 50mg/kg in 500ml glu/4 hrs 100mg/kg in 1L /16 hours (1hr-> 4hr-> 16hr) Stop if INR <1.3 ir ALT<2X upper limit of normal
Common side effect of NAC?
Anaphalactoid reaction therefore give antihistamine
When would you admit a patient with acute alcohol withdrawal?
Safeguarding Delirium Tremens (or Hx of this) Seizures <18yrs AN over-activity Wernicke's
What is pabrinex?
Prophylactic treatment of thiamine deficiency
Opiate OD causes what result on an ABG
Respiratory acidosis
Treatment of Opiate OD
Naloxone
400mcg
short half life so may need to repeat
ABG result caused by TCA OD
metabolic acidosis
ECG changes on TCA OD
Prolonged QT
Widening of QRS PR
Polymorphic VT Torsades de pontes
Broad complex tachy
Treating TCA OD
IV Bicarb
IV lipid emulsion
Amphetamine OD presentation
Hyperreflexia Tachycardia Dilated pupils Delirium Agitation MDMA- Polydipsia, hyponatraemia, Convulsions
Treating Amphetamine OD
Activated charcoal
Benzo to treat convulsions
3 Diagnostic criteria for anaphylaxis
Sudden onset/Rapid progression
Life threatening airway/breathing/circulatory compromise
Skin and mucosal changes
Key enzyme test for anaphylaxis Dx
Triptase
Once stable, 4 hour level and then 24 hour for baseline
Most important drug to give first in anaphylaxis
Adrenaline
Reverses vasodilation and bronchoconstriction but more importantly ameliorates mast cell degranulation
Adrn-> Repeat -> Fluids -> Chlor + Hydro
3 drugs to give in anaphylaxis
0.5mls 1:1000 Adrenaline IM; repeat every 5 mins
10mg Chlorpenamine IV
200mg Hydrocortisone IV
(Watch for biphasic/prolonged reaction therefore admit)
4 key complications of AKI
Hyperkalaemia
Pulmonary oedema
Pericarditis
Metabolic acidosis
Indications for RRT in AKI
Pulmonary oedema
Persistently high K+
PH <7.15
Ecephalopathy, OD, Pericarditis
How do you use serum creatinine and urine output to detect AKI?
26umol rise in SC in 48 hours (or 50% in 7/7)
Urine output <0.5ml/kg/hr in 6 hrs (or 8 hrs in children)
What are the 3 stages of AKI?
1) Creatinine inc 1.5x or UO<0.5 for 6 hrs
2) Creatinine inc 2-2.9 baseline or UO<0.5 for >12 hrs
3) Creatinine inc 3x baseline or UO <0.3 for > 12 hours or Anuria for > 12 hours
What is STOP AKI
Sepsis- BUFALO
Toxins- DIAMOND HAL
Optimise BP
Prevent harm (Hyperkalaemia, Pul oedema, Acidosis, Pericarditis)
Key symptoms distinguishing delirium from confusion
Delirium will have fluctuations in consciousness and a short attention span therefore they cannot concentrate
Thinking is also disordered
USE 4AT
Key aetiologies of delirium
Systemic infection, intracranial infection, Drugs, Withdrawal, Metabolic, Hypoxia, Vascular, Head injury, Epilepsy, Nutritional
Common causes of unconsciousness
Hypoglycaemia Drug OD Head injury Stroke SAH Convulsion Alcohol intoxication
Key causes not to miss in a patient with collapse/syncope
PE
GI bleed
Ectopic pregnancy
Ruptured AAA
The San Francisco Syncope rule says to admit a patient with syncope if they have…THINK CHESS
[CHESS= CHF, Haematocrit<30%, ECG, SOB, SBP<90]
CHF
Haematocrit <30% (Total red blood cells as % of total volume)
Abnormal ECG
SoB
Sys BP <90
Indications for an MRI in a patient with back pain
>55 Systemically unwell Hx trauma or malignancy Infection Fracture Cauda equina
Back pain red flags
<20 or >50 Hx malignancy Night pain Fever Hx trauma Systemically unwell
Ottawa ankle rules of x-ray
Aim is to exclude a fracture
Cannot Wx bear for 4 steps post injury and NOW
Tenderness over posterior surface or malleoli
Lower threshold if extremes of age or intoxicated
Remember a crack or snap does not mean there was a fracture
Advice for ankle injury
RICE
Crutches if cannot Wx bear
Encourage mobilisation
If X-ray not needed then come back in 5 days if you still cannot Wx bear
Describe a Colle’s and Smith’s wrist fracture
Colle’s is FOSH ‘dinner fork’ with the radius displaced downwards and hand displaced dorsally
Smith’s is fall onto flexed wrist, Palmar angulation of distal bone fragment ‘Garden spade’
What is a Galeazzi fracture
Wrist fall on outstretched arm with elbow flexed
Distal radius fracture with disolaction of distal radioulnar joint
What is a Barton’s fracture
Dislocation of the radial-carpal joint
Important X-ray advice for fractures
Always get 2 views!
What causes an acromioclavicular dislocation
Direct blow to top of the shoulder in young athletes
Adduction= pain
Tender over AC joint
Most common form of glenohumeral dislocation
Anterior
Look for military badge numbness
What is ‘light bulb’ sign on an X-ray
Loss of normal half moon overlap (Humerus and scapula)
Suggests posterior dislocation
LOOK FOR LOSS OF EXT.Rotation
Sign of a fractured neck of femur
Shortened leg and externally rotated
In a ?Hip fracture when are you most concerned about infringement on blood supply?
Score 3-4 on Garden system
Complete fracture + Either partially displaced or bony disruption
(2= Complete + non displaced)
(1= Incomplete)
How do you confirm a Dx of urinary retention
USS of bladder
>300cc
Classic presentation of testicular torsion
Sudden severe pain radiating to lower abdomen Vomiting Red, tender and swollen Upwards retraction No cremasteric reflex Pain NOT eased by elevation
Causes of airway obstruction
CNS depression Foreign body Trauma Swelling Laryngospasm/Bronchospasm Blocked tracheostomy
Causes of breathing problems
CNS depression
Muscle weakness
Disorders of lung function
PE, ARDS, Oedema
Causes of circulatory problems
Primary cardiac- MI, Arrhythmia, Tamponade, HF, Myocarditis, HOCM
Secondary cardiac- Asphyxia, Tension Pneumo, Blood loss, Hypoxia, Hypothermia, Septic shock, Hyperthermia, Rhabdomyolysis
Trauma triad of death
Coagulopathy
Metabolic acidosis
Hypothermia
What injury severity score indicates major trauma
> 15
Sign of an obstructed airway
Quiet
No movement
Injuries causing Airway compromise
ATOMFC
Airway obstruction Tension pneumothorax Open pneumothorax (defect 1/3rd diameter of trachea) Massive haemothorax (>1500mls) Flail chest Cardiac tamponade
Assessing circulation/End organ perfusion with HEP B
Hands- Temp, sweating, CRT
End organ perfusion- UO, Conscious level
Pulse- Rate quality, regular
BP- Hypotension?
What does on the floor and 4 more refer to?
Blood loss…
External wound
Chest cavity
Abd.Cavity
Pelvic cavity
Long bone fracture
What are the 4 types of shock
Hypovolaemic/Haemorrhagic
Obstructive (Tamponade)
Cardiogenic
Distributive (Sepsis, Anaphylaxis, Neurogenic)
Define Hypotension
> 40 decrease in baseline MAP
SYS<90
MAP<60
Eye opening in GCS (4)
4- Spontaneous
3- To speech
2- To pain
1- None
Verbal response in GCS (5)
5- Orientated 4- Confused 3- Inappropriate words 2- Sounds 1- None
Motor response in GCS (6)
6- Obeys commands 5- Localises to pain 4- Withdraws from pain 3- Abn. Flexion 2- Abn.Extension 1- None
What GCS scores is minor, moderate and severe
Minor 13-15
Moderate 9-12
Severe 3-8
(<8 always intubate)
What are the Canadian C-Spine rules?
Trauma criteria for whether someone needs imaging
If they meet any of the low risk factors they do not need imaging
What low risk factors are considered in the Canadian C-spine rules?
Comfortable sitting Ambulatory Rear-end motor collision Delayed onset neck pain No midline cervical spine tenderness
High risk criteria for a ?C-spine injury
> 65 Years
Dangerous mechanism (Fall>1m, High speed collision, horse riding injury etc)
Paraesthesia in extremities
Signs of a trauma induced spinal injury
Diaphramatic breathing Neurogenic shock Priapsim Responds only to pain above clavicles Fixed position of upper limb Flacid areflexia LoS/Function Tender/Swelling on leg roll
When is a trauma induced spinal injury unlikely? When do you decide whether there is a spinal injury?
No Neuro deficit + No pain along spine
1 week post-injury
What is the Monro-Kellie doctrine?
Compensatory mechanisms maintain normal ICP for change in volume <100-120ml
After this ICP inc and you can get coning
Shape of a subdural haematoma?
What vessel system is likely involved?
Crescent moon shaped
Venous
Shape of a extradural haematoma?
What vessel system is likely involved?
Lemon shaped/Lens shaped
Arterial
Key principles in preventing secondary brain injury
Prevent hypoxia and hypercapnia Maintain BP Look for decompensation Prevent hypoglycaemia CT early Senior input
Venous saturation and pressure targets in Sepsis
CVP= >8mmhg
SVO2>70%
In septic shock (or lactate >4) what is it important to do within 6 hours (think veins)?
CVP and central venous oxygenation
Rule of 15% in collapse
PE Aortic dissection ACS Ectopic Ruptured AAA SAH
What 4 key themes must be explored in collapse Hx?
HEAD- Hypoxia, Hypoglyc, Epilepsy
HEART- IHD, Emboli (AF?), Arrhythmia, AS
VESSELS- Vasovagal, situaitonal, Ectopic
DRUGS- Anti-HTN, Beta-blockers
What is the OESIL RISK score?
Assesses risk of cardiac death post-syncope/collapse
>65, Hx CVD, No prodrome, Abn ECG
What are the 6 parameters of a NEWS SCORE
RR 02 sats Temp Sys BP HR Consciousness
Explain how different NEWS Scores impact management
0= Min 12 hour obs
1-4= Min 4-6 hourly obs, Assess by Reg.Nurse
>5 or 3 in one parameter= Min 1 hour obs, inform Med team, clinical assessment
>7= Vital sign monitoring continuously, assessed by team with critical care competencies
