Acute care Flashcards by Sheryl O'Hare

What does a negative base excess indicate?

Excess acid

How well did you know this?

Not at all

Perfectly

Respiratory acidosis

pH is high/low
CO2 is high/low

pH low

CO2 high

How well did you know this?

Not at all

Perfectly

Metabolic acidosis

pH is high/low
bicarbonate is high/low

pH is low

bicarbonate is low

How well did you know this?

Not at all

Perfectly

Anion gap = (Na +K) - (Cl + HCO3)

true or false

True

How well did you know this?

Not at all

Perfectly

In COPD patients, raised PaCO2 with a NORMAL HCO3 suggests acute/chronic problem

Acute

How well did you know this?

Not at all

Perfectly

What is wells score used for?

Determining likelihood of PE

How well did you know this?

Not at all

Perfectly

If wells score is low, what does this mean and what do you do?

PE unlikely

D-dimers

How well did you know this?

Not at all

Perfectly

Hyperventilation causes which ABG pattern

Respiratory alkalosis

How well did you know this?

Not at all

Perfectly

panic attack causes which ABG pattern

Respiratory alkalosis

How well did you know this?

Not at all

Perfectly

Severe asthma typically causes which ABG pattern

Respiratory acidosis

How well did you know this?

Not at all

Perfectly

DKA typically causes which ABG pattern

Metabolic acidosis

How well did you know this?

Not at all

Perfectly

Severe vomiting causes which ABG pattern

Metabolic alkalosis

How well did you know this?

Not at all

Perfectly

Drug overdose (eg aspirin) typically causes which ABG pattern

Respiratory alkalosis

How well did you know this?

Not at all

Perfectly

Paient with renal colic. What is first line treatment?

Diclofenac

How well did you know this?

Not at all

Perfectly

What is the landmark for a cricothyroidotomy

Cricothyroid membrane

How well did you know this?

Not at all

Perfectly

unwell patient in ED. ECG shows narrow QRS complex which is regular. How do you manage?

Vagal manouevres

Then administer adenosine 6mg -> 12mg

How well did you know this?

Not at all

Perfectly

unwell patient in ED. ECG shows narrow QRS complex which is irregular. What is this likely to be and how do you manage in ED?

Likely AF

Rate control: B-blocker / diltiazem

How well did you know this?

Not at all

Perfectly

unwell patient in ED. ECG shows broad QRS complex which is regular. What is this likely to be and how do you manage in ED?

Amiodarone (300mg IV over 20-60 mins)

How well did you know this?

Not at all

Perfectly

Patient in ED wit bradycardia. What is first line management?

Atropine 500mcg IV

How well did you know this?

Not at all

Perfectly

Paeds CPR outline

5 rescue breaths

CPR 15:2

How well did you know this?

Not at all

Perfectly

Name 2 unshockable rhythms

PEA

Asystole

How well did you know this?

Not at all

Perfectly

Name 2 shockable rhythms

Pulseless VT

How well did you know this?

Not at all

Perfectly

When should you avoid head tilt chin lift manouvre

in trauma cases where there is concern about cervical spine injury

How well did you know this?

Not at all

Perfectly

Gudel is example of

oropharyngeal airway
nasopharyngeal airway

Oropharyngeal airway

How well did you know this?

Not at all

Perfectly

Size of nasopharyngeal airway equates to

diameter of patient's little finger

When might nasopharyngeal airway be contraindicated?

If ?base of skull fracture

Periorbial bruising Battles sign CSF rhinorrhoea What do these signs suggest

Base of skull fracture

Name 3 advanced airway techniques

``` Endotracheal Intubation Laryngeal mask airway Surgical airway (needle cricothyrotomy) ```

What should be used in ?c spine trauma? - head tilt chin lift - jaw thrust

Jaw thrust

Airway management: when may suction be used?

If there is complete or partial visible LIQUID obstruction in the airway

Airway management: when may mcGills forceps be used?

If there is complete or partial visible SOLID obstruction in the airway

Name 2 types of airway adjuncts?

Nasopharyngeal airway | Oropharyngeal airway

How do you size a Gudel airway?

From the incisors to the angle of the mandible

What is the final option for airway management where you have been unable to clear obstruction, open airway and ventilate patient?

Surgical airway | - cricothyrotomy

Flail chest

Segment of rib cage breaks due to trauma

Where are chest drains inserted?

4th / 5th ICS mid axillary line in the safety triangle

Why might you use a Kendrick leg splint?

Femoral fracture

Minimum score of GCS

GCS 3 components

``` Eye opening (4 max) Verbal response (5 max) Best motor response (6 points) ```

Eye opening - GCS

4 - eye opens spontaneously 3 - eye opens to voice 2 - eye opens in response to painful stimulus 1 - eye does not open

Verbal response - GCS

``` 5 - talking normally 4 - confused conversation 3 - inappropriate words 2 - incomprehensible sounds 1 - no speech ```

Best motor response - GCS

``` 6 - normal movements, obeys commands 5 - moves towards painful stimulus 4 - normal flexion 3 - abnormal flexion 2 - extension 1 - no movement ```

Fasting before surgery - food - liquid

Fast for 6 hours before surgery (food) Can drink water up to 2 hours before surgery

Anticoagulants need to be stopped before surgery. True or false?

True

How long before surgery do DOACs need to be stopped for?

24 hours before surgery

How long does COCP need to be stopped before surgery?

4 weeks

Surgery tends to increase/decrease blood sugar levels?

Increase | - due to the stress body is under

What are the 4 pillars of consent

Understand Retain Weigh up Communicate decision

After an operation, what do patients complain of most?

Post op nausea and vomiting

When is clopidogrel stopped before operation ?

7 days

What are the 2 standard colours of adult cannulas?

Blue | Pink

3 pillars of general anaesthesia

Pain free Not aware (patient is asleep) Paralysis (not in all GA)

What % of air is oxygen?

21%

Where in the body is energy generated (which structure)?

Mitochondria

How much oxygen does a standard person USE per minute? - 250ml/min - 500ml/min - 750ml/min - 1000ml/min

250ml/min

What is the functional residual capacity?

Expiratory reserve volume + residual volume

In anaesthesia, why is pre-oxygenation used (ie hold oxygen mask to patient's face for 3 mins)

This replaces the functional residual capacity with 100% oxygen (instead of 21% oxygen) so it essentially buys time by increasing oxygen in the lungs

Who should not receive a laryngeal mask airway (LMA) ?

Patient's with reflux | - it doesn't protect their airway

Patients with reflux should have which airway?

Endotracheal tube | - it has a cuff to protect the airway

For patient about to have surgery, which CARDIAC medications should be stopped on day of surgery? (and why?)

ACE inhibitor Angiotensin receptor blocker Thiazide diuretic being anaesthetised causes hypotension but these drugs will cause prolonged hypotension

How long should aspirin be stopped before surgery?

7-10 days

How long should DOACs be stopped before surgery?

24-48 hours

Warfarin and surgery

Stop warfarin 5 days before surgery Day 3 before surgery start LMWH injections for 2 days After op restart LMWH injections + warfarin When INR normal, stop LMWH injections

Patient 7 hr post op complains of pain despite having an epidural pre-operatively. What should be done first?

Check sensory block height

``` Patient develops broad complex tachycardia HR 160 BP 80mmHg systolic What should be done? - adenosine - amiodarone - synhronised DCCV - CPR ```

Got a pulse so CPR not required. | However, he is unstable so 3 x synchronised DCCV required first line

``` Patient develops broad complex tachycardia HR 120 BP 100mmHg systolic What should be done? - adenosine - amiodarone - synhronised DCCV - CPR ```

Amiodarone IV infusion

What ECG features do you need to diagnose STEMI

over 2mm in 2 contiguous chest leads OR over 1mm in 2 contiguous limb leads OR New LBBB

Identify a STEMI what is the management plan

``` Morphine Oxygen (only if needed) Nitrates Aspirin Ticagrelor ``` IV heparin (if going onto PCI) PCI

In MONA + C what is used instead of clopidogrel now

Ticagrelor

Why does infection cause increased resp rate

Pain | Fever

If you need to fluid resuscitate a patient but there is a risk that the patient could get fluid overloaded, what do you do>

250ml (instead of 500ml) IV fluids (crystalloid) | frequent reassessment is crucial

All COPD patients have 88-92% oxygen range target. True or false ?

True | - even if not normally a CO2 retainer

How can you tell if someone is a CHRONIC CO2 retainer or an acute CO2 retainer?

If chronic, there will be metabolic compensation on the ABG

What is the treatment for acute exacerbation of COPD

``` Oxygen Nebulisers: salbutamol 5mg Nebulisers: Ipatropium bromide Amoxicillin Prednisolone 40-50mg ```

Non invasive ventilation is the same as BiPAP. True or false/

True

Explain how NIV works

Patient inhales themselves and BiPAP mask supplements with bursts of pressure and pushes air into the lungs

T wave inversion on an ECG suggests

Ischaemia | - NSTEMI

What is the management of NSTEMI

``` Morphine Oxygen (if required) Nitrates Aspirin Ticagrelor ``` + FONDAPARINEUX

Key points to ask in history of head injury

``` MECHANISM of injury loss of consciousness vomiting (one off vomit is ok) visual disturbance associated injuries seizures amnesia ```

Suspicious of base of skull fracture, what airway adjunct should you avoid?

Nasopharyngeal airway

Reduced GCS Unequal pupils What does this potentially suggest?

Raised intracranial pressure

Battles sign suggests

Base of skull fracture

Where should you test for pain (if needed) in GCS?

Trapezius squeeze

GCS 8 or less equates to what on AVPU

Response to Pain (P)

3rd nerve palsy: dilated/constricted pupil?

DILATED pupil

Name 4 base of skull fracture signs

Battle's sign (behind the ear) CSF leak from nose Racoon / panda eyes (bilateral bruising around the eyes) Haemotympanum

Hypertension Bradycardia Irregular breathing

CUSHINGS TRIAD caused by reduced brain stem perfusion

Raised ICP causes increased/decreased cerebral blood flow

Decreased

Anyone with a GCS less than 13 and a head injury should have a CT scan within which time frame?

1 hour

Indications for CT imaging within 1 hour (5)

``` GCS less than 13 Any sign of base of skull fracture Focal neurological deficit Post-traumatic seizure More than 1 episode of vomiting ```

For adults who have sustained a head injury and have any of the following risk factors, perform a CT cervical spine scan within 1 hour of the risk factor being identified. Name 2 risk factors

GCS less than 13 | Patient that has been intubated

Acute blood on a CT scan is what colour?

white

Subdural haemorrhage crosses suture lines. True or false?

True

Subdural haemorrhage often sudden/insidious?

Insidious

Extradural haematoma - caused by which artery usually?

Middle meningeal artery

Management of an extradural haematoma

Causes significant pressure | Neurosurgical theatre - burr hole

Young people -> brief LOC -> lucid interval -> rapid deterioration

Extradural haematoma

What is a spondylolisthesis?

When one of the vertebrae slips out of place onto the vertebrae below it

Low backache, worse after activity, relieved by rest. What does this make you think of ?

spondylolisthesis

Traumatic twisting injury to the knee when the leg is bent, and being unable to straighten knee (locked) suggests

medial meniscal injury

Patient miscalculated stairs, put full weight on right leg with knee straight. Clinical haemarthrosis, tenderness maximally laterally, straight leg raise causes significant tenderness. What is most likely? - patellar fracture - tibial plateau fracture - quadraceps tendon rupture - ACL rupture

Tibial plateau fracture

Which ligament is the most commonly injured in inversion injuries - anterior talofibular - posterior talofibular - calcaneofibular - tibionavicular

Anterior talofibular

Septic artthritis suspected. What is best investigation?

Aspiration of synovial fluidd

50 year old patient with a fracture following a fall. Has had previous total hysterectomy and bilateral salpingectomy. What is the appropriate management? - oestrodiol - alendronic acid - calcitriol - tibolone

Alendronic acid

Young male with asthma. 4-6 attacks of migraine with aura per month. Needs prophylactic treatment. What treatment do you advise?

topiramate | would be propranolol but he is asthmatic

pain that runs from the buttock through the back of the thigh and into the calf and outside of the foot (ie all down the leg). Numbness on lateral aspect of foot. What is likely nerve involved? - common peroneal nerve - L5 radiculopathy - S1 radiculopathy - cauda equina compression

S1 radiculopathy

Someone with paracetamol overdose turns up to the ED within 1 hour. What do you do?

Give activated charcoal

What is the antidote for paracetamol?

N-acetylcystine | Methionine

What is the antidote for beta blockers?

Glucagon

What is the antidote for opioids?

Naloxone

Paracetamol is converted by which system to ____

Paracetamol is converted by the Cytochrome P450 system to NAPQI

What are the common EARLY features of paracetamol poisoning?

Nausea and vomiting

Delayed presentation of paracetamol poisoning (2-3 days later) features may include

features of hepatic necrosis - right subcostal pain - nausea and vomiting - jaundice

When should blood paracetamol levels be checked?

4 hours

How is N-acetylcystine given?

IV | given over 20 hours

If blood paracetamol levels are checked at 4 hours and it is above the treatment line, what is used?

N-acetylcystine

If the patient's blood paracetamol level is elevated at 4 hours and they need treatment, what blood work is done after the treatment? and if the blood work is abnormal what is done?

INR LFT U+E If these are abnormal - continue with N-acetylcystine

What is rapid sequence induction?

A way of inducing anaesthesia in patients at risk of aspiration of gastric contents

In CPR, after how many shocks do you start administering drugs ?

after 3rd shock

What are the reversible causes of cardiac arrest?

4H's and 4Ts - hypovolaemia - hypothermia - hypoxia - hypo/hyper kalaemia Tension pneumothorax Cardiac tamponade Toxins Thrombus

After 3rd CPR shock which 2 drugs do you administer

Adrenaline 1mg Amiodarone 300mg Repeat adrenaline every 3-5 mins

30 yo male, painful red eye for a week, worst at night. long sighted. What is likely diagnosis?

Acute angle closure glaucoma

Eye trauma with suspected penetrating injury. What is the first line investigation?

CT orbits

Patient develops acute muscle spasms after being treated with halloperidol yesterday. What is first line treatment? - baclofen - diazepam - procyclidine

Procyclidine

Which colour of cannula is 22 gauge?

blue

Name the colours of cannula from smallest to biggest

Blue - 22 Pink - 20 Green - 18 Grey - 16

What colour of cannula is the 'go to' for non-emergency patients?

Pink

Chronic pain is pain lasting longer than _____

Lasts longer than 3 months

Which type of pain is being described here: burning, shooting, numbness, pins and needles, not well localised

Neuropathic pain

What are the 4 steps involved in pain physiology

Periphery Spinal cord Brain Modulation

Pain signals travel in which 2 nerves to the spinal cord

A-delta nerve fibres | C nerves

Which part of the spinal cord is involved in pain: dorsal horn or ventral horn

Dorsal horn

In which part of the brain does pain perception occur? - cortex - limbic system - brainstem

Cortex

WHO pain ladder (3 steps)

1. Paracetamol +/- anti inflammatory (iboprufen, diclofenac) 2. Codeine 3. Morphine, oxycodone

Drug (and non-drug) treatments for nociceptive pain (at periphery level)

R.I.C.E Anti-inflammatory (ibuprofen, diclofenac) Local anaesthetic

Drug (and non-drug) treatments for nociceptive pain (at spinal cord level)

Acupuncture Local anaesthetic Opioid Ketamine

Drug (and non-drug) treatments for nociceptive pain (at brain level)

Paracetamol Codeine Morphine Amitryptiline

What is the biggest disadvantage of paracetamol

Liver damage in overdose

Codeine is better for acute or chronic pain?

Acute

Addiction is rare/common in acute pain?

Rare

What is a good medication to use for post-operative pain?

Morphine

Oral dose of morphine is 2-3 times IV / IM / SC dose. Why is this?

Due to tolerance | - increased doses needed over time

Tramadol is a controlled drug. True or false?

False

What are the disadvantages of using amitryptiline?

Anti-cholinergic side effects (dry mouth, constipation)

What is a good medication for chronic cancer pain?

Morphine

Patient with chronic pain presents with worsening pain. What do you do?

Continue normal opioids | add extra opioids to cover acute pain

Which pain medications should be avoided in renal failure?

NSAIDs

Paracetamol mechanism of action?

Inhibits prostaglandin synthesis in the CNS

Management of opioid induced respiratory depression

Give oxygen Adjust dose or stop delivery of opioid Give naloxone if necessary

Tramadol is a strong/weak opioid?

Weak

Patient is on anticoagulants. This means epidural cannot be administered. True or false?

True

Name an antihistamine used in nausea and vomiting?

Cyclizine

Name a 5HT3 antagonist?

Odansetron

Name 3 different classes of anti-emetics

Antihistamine 5HT3 antagonist Anti-dopaminergic

What is the first line treatment for a raised INR ?

Vitamin K

It is very important to know that medication can be given (with a sip of water) to patients that are fasted for theatre. true or false?

True

Emergency treatment of coagulopathy?

FFP

INR ___ and below then it is ok to proceed with operation?

1.5 and below

Standard PCA (patient controlled analgesia) prescription is what?

1mg morphine bolus, 5 min lockout

Who goes to HDU, who goes to ICU ?

HDU - one failing organ ICU - over one failing organ

If you need invasive ventilation, where do you go? Ward HDU ICU

ICU

Define inotrope

A substance that affects the force of muscular contraction in the heart

Define vasopressor

A hypOtensive agent (used to raise blood pressure)

Inotropes must always be given by infusion through a central venous catheter. True or false?

true

Name 2 examples of inotropes

Adrenaline | Dobutamine

What 2 groups of antacids are commonly prescribed?

PPI (omeprazole) | H2RA (Ranitidine)

Can antacids be given on the morning of surgery?

Yes

Which drug is commonly used prior to induction of anaesthesia?

Midazolam

Benzodiazepines bind to which receptor?

GABA receptor

Name 3 IV anaesthetic agents

Propofol Ketamine Sodium thiopentate

Name 3 volatile anaesthetic agents

Sevoflurane Desflurane Isoflurane

Why are neuromuscular blocking drugs administered in anaesthesia?

To relax / paralyse muscles | Facilitate intubation

Name 1 depolarising neuromuscular blocking agent?

Suxamethonium

What has quicker onset of action - depolarising neuromuscular blocking agent - non-depolarising neuromuscular blocking agent

depolarising neuromuscular blocking agent

Name 4 opioids

morphine fentanyl Alfentanil Remifentanil

name 2 topical anaesthetics used in paediatrics

EMLA | Ametop

Different intravenous fluids cause different effects on body fluid compartments. If you infuse: 1 litre 0.9% Saline or Hartmann's (crystalloid). You get an increase in - ICF - ECF - both

ECF (interstitial fluid + plasma)

``` Different intravenous fluids cause different effects on body fluid compartments. If you infuse: 1 litre 5% Glucose. you get an increase in - ICF - ECF - both ```

Both

Frail 82 year old lady who broke her ankle and was found lying on the floor a day later. She is drowsy with dry mucous membranes. Urea and creatinine are raised. What fluid should you give? - crystalloids - 5% glucose

5% glucose | This lady has been lying on the floor and is dehydrated. She needs water which can be provided by 5% glucose.

16 year old female involved in a road traffic accident. She has an open femoral fracture which is bleeding profusely. She is pale, tachycardic but normotensive. Which fluid should you give? - crystalloids - 5% glucose

This lady is hypovolaemic because of blood loss and again needs a fluid that will restore her circulating volume. Crystalloid is a good initial choice in this situation. Colloid, although not offered as a choice in this tutorial, would also be an acceptable choice for treating haemorrhagic shock. Ultimately, of course, this patient may require blood.

If bradycardia is accompanied by life-threatening adverse signs, what is the treatment a. Electrical Synchronised DC Shock b. Amiodarone 300mg IV Infusion c. Adrenaline 2-10 mcg min IV Infusion d. Atropine 500mcg IV until max of 3 mg e. Adrenaline 0.5mg 1M repeated until a response

d. Atropine 500mcg IV until max of 3 mg

SVT not responding to vagal manouvres. What do you do? a. Adrenaline 2-10 mcg min IV Infusion b. Electrical Synchronised DC Shock c. Amiodarone 900 mg IV Infusion over 24 hr d. Adenosine 6 mg bolus rapid IV injection e. Adenosine 12 mg bolus rapid IV injection

D | 6mg -> 6mg -> 12mg

Prior to completion of N-acetyl cystine infusion, which bloods should you check?

"post parvolex bloods" - LFT, INR, U+E

If 'post parvolex bloods' are normal, what do you do?

Discharge patient and psycho input if required

If 'post parvolex bloods' are abnormal, what do you do?

Continue acetylcysteine at the dose and infusion rate used in the 3rd treatment bag

How long is the current N-acetyl cystine infusion?

21 hours

Signs of ANTICHOLINERGIC toxicity

Dilated pupils Dry mucous membranes Confusion

What is the antidote for anticholinergic toxicity

sodium bicarbonate

What is the antidote for propranolol

Glucagon

``` 72 year old female. Known insulin dependent diabetic. Found unconscious at home. GCS 3, P 80, RR 15, BP 154/83. Pale, sweaty and clammy. Paramedics BM 14.1, Repeat BM 1.7. What is best immediate management? A Give IV dextrose 5% 500mls B Give IV Naloxone C Give IV dextrose 10% 200mls D Give IV flumazenil 200 micrograms E Commence bag and mask ventilation F Perform RSI and CT head ```

C - IV dextrose 10% 200mls

78 year old female. Thin and frail but mentally alert. Simple fall onto R hip which is painful on any movement. Distressed by pain. How do you manage pain?

IV morphine + fascia iliaca block

Treatment of complete heart block

Atropine 0.5mg bolus up to 3mg

In which 2 situations do you need to be cautious about giving adenosine?

Asthmatics - bronchospasm | if patient is on CCB (prolongs half life)

18 year old male. Has just eaten a takeaway kebab. Sudden onset lip and facial swelling. Feels his throat is tight and has difficulty breathing. P120 reg BP 85/40 sats 98% What is your immediate treatment? (include dose)

IM adrenaline 500mcg | 0.5mls of 1:1000

23 year old male. Crushed between heavy machinery at work. Painful pelvis. P120 reg, BP 76/50, sats 100%. Pelvic X-ray shows open book pelvic fracture. What do you do in the ED department

``` ABCDE Pelvic binder O negative blood Tranexamic acid Morphine ```

How do you manage a depressed skull fracture?

Requires referral to neurosurgery for elevation of the bone fragments and wound care

Which drug is used in the cute management of thyroid storm?

IV propranolol

``` Patient with hashimotos thyroiditisi comes for check up after being started on thyroxne 75mcg OD. What is the single most important blood test to assess response to treatment? Free T4 Total T4 Free T3 TSH ESR ```

TSH

``` The correct dose and route of adrenaline for administration during cardiac arrest is 1mg IM 0.1mg IV 0.5mg IV 1mg IV 0.5mg IM ```

1mg IV

Salbutamol causes tachycardia or bradycardia?

Tachycardia | - because it works on B2 receptors in the heart. Don't need to treat it

1g oral paracetamol 6 hourly as required OR regular oral paracetamol 1g (4 times daily) Which is best

regular oral paracetamol 1g (4 times daily)

Type 1 diabetic going for day case short minor surgery. What should be done

Aim for 'first on the list' Omit all diabetes meds and insulin (APART FROM LONG ACTING INSULIN) on the morning of surgery Restart all meds with first meal post op (apart from metformin)

Salbutamol causes tachycardia or bradycardia?

Tachycardia

Should you give fluids in acute asthma attack?

Yes if patient is dry

What is the minimum acceptable urine output?

>0.5ml/Kg/hour

Sepsis leads to inappropriate vasodilation and hypotension. True or false?

Truee

Cardiac output sum

HR x SV

BP = ? x ?

BP = CO x SVR

What is the minimum acceptable urine output?

>0.5ml/Kg/hour

Which of the following retains fluid - oncotic pressure - hydrostatic pressure

Oncotic pressure

Which of the following forces fluid out of vessel - oncotic pressure - hydrostatic pressure

Hydrostatic pressure