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IK6 - Exams > Acute care > Flashcards

Acute care Flashcards

1
Q

differentials for collapse

A

hypoglycaemia

cardiac: postural hypotension,
arrhythmias, outflow obstruction [HOCM, severe AS, massive PE], vasovagal syncope

seizure

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2
Q

Lucy attends A&E finding it hard to breath. her lips are swollen and she has a diffuse rash. Her friend says she had just eaten a snack and then suddenly couldn’t breathe.

How would you manage lucy?

A

ANAPHYLAXIS

  1. IM adrenaline 0.5ml 1mg/1ml 1:1000
  2. 10mg chlorphenamine (anti-histamine)
  3. 100mg hydrocortisone
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3
Q

what are the boundaries of the triangle of safety for chest drain?

A

the lateral border of pectoralis major anterior; the mid-axillary line posterior and the level of nipple inferior

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4
Q

management of anaphylaxis

A
  1. A-E, stop drug, senior help, anaesthetics if concerned airway
  2. Adrenaline 1:1000 IM
    1. anterolateral thigh
    2. 5 minutes apart, different thigh
    3. after 2 consider refractory + start more Tx
  3. additional meds
    1. cetirizine 10mg adult
    2. hydrocortisone 200mg
  4. monitoring - pulse oximetry, ECG, blood pressure
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5
Q

what is refractory anaphylaxis and how is it management?

A

no response to 2 x adrenaline

  • Peripheral low dose adrenaline IV infusion
    • 1 mg (1mL of 1mg/mL 1:1000) adrenaline in 100mLof 0.9% saline
    • Start at 0.5-1 mL/kg/hour rate
    • Should only be started by critical care/anaesthetics
    • Continue IM adrenaline every 5 minutes while this infusion is being set up to address ongoing ABC issues
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6
Q

how do you estimate surface area burned?

A
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7
Q

A-E assessment for burns

A

A-E assessment

  • A - assess for inhalation injury, consider pre-emptive intubation if high risk, C-spine protection
  • B - 100% O2, ABG, check carboxyhaemoglobin levels
    • Inhalation burns - high flow O2 15L and urgent anaesthetic review regarding intubation
  • C - 2 large bore IV, routine bloods, G&S, clotting, CK, aggressive fluid therapy, urinary catheter + UO monitoring
  • D - GCS, temperature (risk of hypothermia)
  • E - estimate percental burns, tetanus booster
    • Chemical burns - immediate irrigation of affected area
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8
Q

what is parkland’s formula

A
  • for fluid resus in burns
  • volume of crystalloid fluid to be given in first 24 hours
    • Adults - 4mL (Hartmann’s) x weight (kg) x % TBSA burned
    • Children - 3mL (Hartmann’s) x weight (kg) x % TBSA burned
    • Give 50% calculated in 8 hours post burn and 50% in remaining 16 hours
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9
Q

shockable rhythms?

A

ventricular fibrillation

pulseless ventricular tachycardia

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10
Q

what are the non-shockable rhythm?

A

PEA

asystole

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11
Q

what are the reversible causes of arrest?

A
  • H
    • Hypoxia
    • Hypothermia
    • Hyper/hypo-kalaemia
    • Hypovolaemia
  • T
    • Tension pneumothorax
    • Tamponade
    • Thrombosis
    • Toxins
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12
Q

management of non-shockable rhythm

A

PEA and asystole

  1. Start CPR - 30:2
  2. Adrenaline 1mg IM
    • Continue giving every other cycle of CPR e.g. 1, 3, 5 (every 3-5 minutes)
  3. Atropine 3mg IV if rate < 60bpm
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13
Q

management of shockable rhythms

A

Ventricular tachycardia or fibrillation, SVT

  1. Defibrillation shock (150 J)
  2. CPR - 2 minute cycle, 30:2
  3. Reassess rhythm
  4. Repeat steps 1-3 provided rhythm remains shockable

Drugs

  • 1mg IV/IO adrenaline after 3rd shock, then every 3-5 minutes
  • 300mg IV amiodarone bolus if shockable rhythm persisting after 3rd shock
    • Consider 150mg IV/IO amiodarone after 5 shocks
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14
Q

ECG features of hypothermia

A
  • bradycardia
  • “J” wave formation on ECG
    • Cardiac irritability starts around 33 degrees
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15
Q

what is hypothermia?

A

temp < 35

mild 32-25, moderate 30-28, severe < 28

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16
Q

what are the components of the qSOFA score?

A
  • > 2 indicates higher risk of mortality, used outside ICU
    • Respiratory rate > 22/min
    • Altered mentation (GCS < 15)
    • Systolic BP < 100 mmHg
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17
Q

what are the sepsis 6?

A

to be achieved within the 1st hour

  • Take: blood culture, lactate, urine output
  • Give: O2, IV antibiotics, fluid challenge
18
Q

immediate management of high risk sepsis patient?

A
  • Initial
    • immediate senior review
    • Bloods - VBG, cultures, FBC, CRP, U&Es, creatinine, clotting screen
    • Broad spectrum antibiotics
    • Oxygen
  • Fluid resuscitation
    • If lactate > 4 mmol/L or SBP < 90mmHg
      • IV fluid bolus of 500ml in 15 minutes, if fluid overloaded give 250ml
      • ICU r/v, consider central venous access, inotropes or vasopressors
    • If lactate 2-4 mmol/L
      • IV fluid bolus of 500ml in 15 minutes, if fluid overloaded give 250ml
    • Consider fluid bolus if lactate < 2 mmol/L
    • No response to initial bolus → repeat
    • No response after 2 boluses → consultant to review
  • Monitoring
    • Maximum interval of every 30 minutes
    • GCS/AVPU
    • Vital signs
    • Urine output - catheterise if required
  • Failure to response in 1 hour of initial antibiotics or fluid resuscitation → senior review
    • Signs of failed response - SBP < 90 mmHg, ↓ GCS, RR > 25 or new need for mechanical ventilation, lactate fails to ↓ 20% in first hour
19
Q

types of shock summaries

20
Q

acute management of pulmonary embolism - haemodynamically unstable

A

Haemodynamically unstable

  • Resuscitation - O2 + mechanical ventilation + IV fluids (crystalloid if SBP < 90)
  • Thrombolysis - tissue plasminogen activator if imminent/in arrest
  • Surgical - embolectomy (if thrombolysis is CI)

Supportive measures

  • Oxygen
  • Ventilation
  • Fluid resuscitation
  • Analgesia
21
Q

management of PE - haemodynamically stable

A

Haemodynamically stable

  • Anticoagulation
    • Direct oral anticoagulants - apixban or rivaroxaban, OP setting
    • Warfarin + LMWH heparin cover
      • LMWH heparin for at least 5 days and until 48 hours of therapeutic INR (> 2)
    • Dabigatran or edoxaban with 5 days LMWH heparin prior → alternative to DOAC and warfarin
  • Duration of treatment
    • Provoked i.e. identifiable RF - 3 months
    • Unprovoked - 6 months
    • Ongoing cause e.g. thrombophilia - life-long treatment

Supportive measures

  • Oxygen
  • Ventilation
  • Fluid resuscitation
  • Analgesia
22
Q

management of upper GI bleed - NICE general principles

A
  • A-E assessment + resuscitation
    • C - 2 cannula, bloods (FBC, U&E, LFT, glucose, clotting)
    • Crossmatch 4-6 units
    • Rapid IV crystalloid, give RBC if grade III/IV shock
    • Correct clotting abnormalities
  • Transfusion + managing bleeding risk
    • RBC - in context of clinical picture, definitely if Hb < 70
    • Platelet if active bleeding and platelets < 50
    • FFP if active bleeding and PT or APTT > 1.5 c of normal
    • Cryoprecipitate if fibrinogen level < 1.5 g/L despite FFP transfusion
    • Prothrombin complex concentrated if on warfarin
  • Endoscopy
    • Severe acute upper GI bleed → immediate after resuscitation
    • All others within 24 hours (if > 1 Blatchford)
23
Q

when to give blood products?

A
  • RBC - in context of clinical picture, definitely if Hb < 70
  • Platelet if active bleeding and platelets < 50
  • FFP if active bleeding and PT or APTT > 1.5 c of normal
  • Cryoprecipitate if fibrinogen level < 1.5 g/L despite FFP transfusion
24
Q

management of variceal bleed

A
  • A-E resuscitation
  • Blood transfusion
  • Vitamin K, FFP and platelet transfusions as needed
  • At presentation
    • All varices:
      • Terlipressin (IV, 5 days)
      • Antibiotics (IV, as per local guidelines, quinolones)
    • Gastric varices:
      • 1st line - endoscopic injection
      • 2nd line - TIPS
    • Oesophageal varices:
      • 1st line- band ligation
      • 2nd line - Sengstaken-Blakemore tube + TIPSS
  • Urgent OGD once stable for it, ideally within 24 hours
    • Variceal band ligation = treatment of choice
  • Management - prevention
    • Non-selective beta-blockers e.g. PO propranolol (40mg, BD, PO)
    • Variceal band ligation
    • TIPSS
25
Q

indications for CT head adult (immediate)

A
  • Initial A&E GCS < 13
  • GCS < 15 at 2 hours after the injury
  • Suspected open or depressed skull fracture
  • Any sign of basal skull # - haemotympanum, “panda” eyes, CSF leak from ear or nose, Battle’s sign
  • Focal neurological deficit
  • Post-traumatic seizure
  • More than 1 episode of vomiting
26
Q

indications for head CT within 8 hours (adult)

A
  • 65 +
  • Hx of bleeding or clotting disorder
  • On anti-coagulants
  • Dangerous mechanism of injury
  • > 30 minutes retrograde amnesia of events immediately prior to head injury
27
Q

indications for CT c spine

A
  • GCS < 13, intubated
  • plain x-ray inadequate/abnormal,
  • definitive diagnosis required urgently
  • head being scanned
  • suspicion of cervical injury + > 65/dangerous mechanism/focal neuro deficit/paraesthesia
28
Q

management of status epilepticus

A
  • A-E
  • 5 minutes - 4mg lorazepam IV or 10mg IM/buccal midazolam
  • 15 minutes - repeat benzo
  • 20/30 minutes - IV phenytoin, IV levetiracetam, IV fosphenytoin
  • 30/40 - GA with RSI using Propofol + continuous EEG monitoring
29
Q

aspirin/salicyclate OD management

A
  • < 125 mg/kg OD aSx → 6hr observe, d/c with safety net
  • Larger dose or uncertain quantity:
  • Oral activated charcoal - consider if < 1 hour
  • Gastric lavage - > 500mg/kg (life-threatening) within 1 hr of ingestion
  • IV sodium bicarbonate - for urinary alkalinisation
  • Emergency haemodialysis - indicated if:
    • Salicylate levels > 900 mg/L
    • Salicylate levels > 700 mg/L with metabolic acidosis
    • Coma due to overdose
  • Supportive care
    • Fluids. hypokalaemia, hyperthermia (dantrolene)
30
Q

indication for NAC in paracetamol OD

A
  • Immediate prescription
    • staggered OD or doubt over time of ingestion
    • Consider if those likely to have glutathione depletion so high risk of toxicity - AN, HIV, malnutrition
    • If estimated OD is > 150mg/kg and cannot act on blood results within 8 hours of ingestion
  • If 4 hour paracetamol level over treatment line on nomogram
31
Q

NAC regime

A

1 bag over 1 hour

1 bag over 4 hours

1 bag over 16 hours

32
Q

what criteria mean NAC treatment should continue?

A
  • ALT more than doubled admission measurement
  • ALT over 2 x the upper normal limit
  • INR > 1.3 (in absence of other cause e.g. warfarin)
33
Q

criteria for consideration of liver transplant after paracetamol OD

A

Criteria for liver transplant:

  • Arterial pH < 7.3 24 hours after ingestion
  • PT > 100 seconds and creatinine > 300 umol/L and grade III/IV encephalopathy
34
Q

antidote for benzodiazepine

A

flumazenil

35
Q

management of beta-blocker OD

A

IV atropine

IV glucagon

36
Q

management of cyanide OD

A

dicobalt edentate

oxygen

37
Q

management of ethylene glycol poisoning

A

fomepizole

38
Q

management of iron ID

A
  • desferrioxamine IV (systemic toxicity management)
  • cardiac monitoring
  • whole bowel irrigation if > 60mg/kg ingested
  • surgical/endoscopic removal of tablets if lethal ingestion or WBI not feasible
39
Q

management of organophosphate poisoning

A
  • atropine
  • pralidoxime
40
Q

management of TCA OD

A

sodium bicarbonate

IK6 - Exams (24 decks)

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