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
