Acute care Flashcards
Acute Exacerbation of COPD Mx
- Oxygen
○ Give titrated oxygen via a venturi mask, titrating to a target oxygen saturation of 88-92%
- Start with 24-28% oxygen if evidence that they are a CO2 retainer
○ If clinically uncertain, give high flow oxygen (15L/min) initially and titrate down depending on what response the PCO2 has- Nebulized salbutamol/atrovent (ipratropium) (if wheezy)
○ If patient is hypercapnic or acidotic, the nebuliser should be air driven not oxygen driven - give oxygen simultaneously via a nasal cannula if needed
○ Salbutamol can be given back to back 5mg nebs - PO prednisolone 30mg 7 day course
- Antibiotics
○ 5 days Amoxicillin, Doxycycline if allergic
○ Antibiotics should only be given if there is purulent sputum or clinical signs of pneumonia - Non Invasive Ventilation (same as BiPAP)
○ Indicated for patients with persistent respiratory acidosis refractory to initial treatments (escalate to ICU)
- Nebulized salbutamol/atrovent (ipratropium) (if wheezy)
- Intubation
- If still severely acidotic/hypercapnic with NIV
COPD Exacerbations 3 most common organisms
Haemophilus Influenzae
Streptococcus Pneumoniae
Moraxella Catarrhalis
Acute exacerbation of COPD Ix
Breathing
- ABG (important to monitor PO2 and PCO2)
- CXR (rule out pneumothorax/pneumonia)
Circulation
- Bloods (FBC, U&Es, CRP)
- ECG/cardiac monitor
- Blood cultures (if pyrexial)
Other
- Sputum culture
Types of pneumothorax
Primary/Spontaneous: Occurring in someone with no underlying lung pathology (young thin men)
Secondary pneumothorax: Occurring in someone with underlying lung pathology, or a patient >50 with a significant smoking Hx
Tension pneumothorax: Pneumothorax with air unable to escape causing midline shift and mediastinal compression, leading to compression of great veins and cardiorespiratory arrest
Causes/risk factors for pneumothorax
Spontaneous
Chronic lung disease: Asthma, COPD, Lung fibrosis, CF
Infection: TB, pneumonia
Trauma
Carcinoma
Connective tissue disorders: Marfan’s, Ehlers danlos
Iatrogenic: Chest drain, central line insertion
Pneumothorax Ix
*If tension pneumothorax suspected on A-E, don’t delay intervention with any investigations
Breathing
- CXR (to measure size)
- ABG (in those with chronic lung disease or hypoxic pts)
Pneumothorax Mx
Spontaneous
<2cm and not SOB: Discharge and FU in 2-4w
>2cm or SOB: Aspirate (then chest drain if aspiration unsuccessful)
Secondary
<1cm and not SOB: Admit for 24h observation with high flow oxygen
1-2cm and not SOB: Aspirate (then chest drain is unsuccessful)
>2cm or SOB: Chest drain
Tension
Immediate needle aspiration in 2nd intercostal space MCL, or triangle of safety
Then Chest drain
Pneumonia most common organisms
Typical
Strep Pneumoniae
Haem Influenzae
Moraxella Catarrhalis
Atypical (no cell wall)
Mycoplasma Pneumoniae
Chlamydia pneumophila
Legionella pneumophilia
Pneumonia Ix
Breathing
- ABG (important to monitor PO2 and PCO2)
- CXR (rule out pneumothorax/pneumonia)
Circulation
- Bloods (FBC, U&Es, CRP)
- ECG
- Blood cultures (if pyrexial)
Other
- Sputum culture
- Urine pneumococcal antigen
- Mycoplasma PCR/serology
Pneumonia Mx
- Oxygen
- Consider CPAP if still hypoxic on oxygen (/NIV if hypercapnic)
Risk stratification (CURB65)
- Confusion
- Urea >7
- RR >30
- BP <90/60
- > 65yo
0 or 1 = home treatment
2 or more = hospital abx therapy
3 or more = consider ICU referral
PE risk factors
- Immobilisation (long haul flights, surgery etc.)
- Hypercoagulability (Factor V leiden, APLS, Cancer)
- Pregnancy
- Prev. DVT
PE Ix
Breathing
- ABG
- CXR
Circulation
- Bloods (FBC, U&E, CRP, D-dimer, clotting screen)
- ECG (R Heart strain = S1Q3T3, most commonly sinus tachy)
Other
- Well’s score
>4 = CTPA
4 or below = D-dimer
PE Mx
If haem unstable with low BP: Thrombolysis w/ alteplase
Breathing
- Oxygen
Circulation
- Empirical treatment dose DOAC
- IV morphine + metoclopramide
Definitive management
- Pharmacological: DOAC/LMWH
- Interventional: IVC filter (can be temporary in people who can’t have anticoagulation, or permanent in people with recurrent PE)
- Thrombolytic: Medical or mechanical thrombolysis
Meningitis Causative Organisms
Bacteria Neisseria Meningitidis Haemophilus Influenzae Strep Pneumoniae Listeria Monocytogenes (in elderly)
Viral (more common)
HSV
VZV
Enteroviruses
Meningitis Ix
Circulation
- Bloods (FBC, U&Es, CRP, Glucose (if drowsy), blood cultures)
- Basic obs (fluid resus as necessary)
- LP
Meningitis Mx
If septic: Initiate sepsis 6, delay LP until stable
If meningitic with no raised ICP: Give IV ceftriaxone + IV dexamethasone (after taking cultures and bloods), fluids as necessary and do LP <1h
If raised ICP (papilloedema, focal neurology, seizures): Escalate, give IV ceftriaxone + IV dexamethasone (after taking cultures and bloods)
Encephalitis differentials
Encephalopathy (without infectious prodrome):
- Hypoglycaemia
- Hepatic encephalopathy
- DKA
- Drugs
- Hypoxic Brain injury
- Uraemic encephalopathy
Encephalitis Ix
Bloods: FBC, Blood cultures, viral PCR
Contrast CT: Focal temporal lobe enhancement = HSV encephalitis (MRI if contrast allergic)
LP: After CT
Encephalitis Mx
IV acyclovir
Cerebral Abscess Ix
Bloods: FBC, U&Es, CRP, blood cultures
Imaging: CT head (ring enhancing lesion)
Cerebral abscess Mx
Control ICP
Urgent neurosurgical referral
Status epilepticus/prolonged seizure causes
Infection
- Meningitis/encephalitis
Malignancy
- SOL
Metabolic
- Hypoglycaemia
- Electrolyte abnormalities (check Ca)
- Overdose/drug toxicity
Status Epilepticus Mx
Investigations
- Circulation
- Monitor BP and ECG when on phenytoin - Time seizure
Interventions
- Breathing
- Oxygen + suction - Circulation
- Take bloods (FBC, U&E, LFTs, VBG (for glucose),
Ca, Tox screen
- IV lorazepam/Buccal Midazolam
- IV phenytoin if seizure continuing after 2
benzo doses
- (Thiamine/glucose if necessary)
Contact anaesthetics early (<20 mins)
Head Injury Mx
Immobilise C-spine until cervical spine injury ruled out
Stabilise Airway, Breathing and Circulation early using standard measures
Assess GCS - if <8, anaesthetic input for intubation
Involve neurosurgeons if low GCS or suspected raised ICP
- Bloods
FBC, U&E, LFT, glucose, blood alcohol, tox screen, clotting
Secondary survey
- Neuro exam
- Brief Hx
- Check for evidence of basal skull fracture
- Palpate neck for tenderness
Indications for CT head <1h in head injury
- Evidence of basal skull fracture
- Raccoon eyes/Battle sign
- Rhinorrhoea/Otorrhea - GCS <15 after 2h
- GCS <13 on admission
- Vomiting >1 time
- Focal neurological deficit
- Post traumatic seizure
Indications for CT head <8h in head injury
Loss of consciousness or amnesia AND:
- > 65yo
- Coagulopathy
- Dangerous mechanism
- Retrograde amnesia >30mins
Indications for CT Cervical Spine <1h in head injury
- GCS <13 on initial assessment
- Patient has been intubated
- Definitive diagnosis required before urgent surgery
- If other parts of the body are being scanned anyway
Clinical suspicion of cervical spine injury AND:
- > 65yo
- Dangerous mechanism of injury
- Focal neurological deficit
- Paraesthesia in upper/lower limbs
Indications for cervical spine X-ray <1h in head injury
Patient can’t actively rotate head 45 degrees left or right
OR
No low-risk feature for C-spine injury present:
- Comfortable in sitting position
- Ambulatory since injury
- No midline cervical spine tenderness
- Delayed onset of neck pain
Cushing’s triad of raised ICP
Hypertension
Bradycardia
Fluctuating RR
Raised ICP Mx
Raise head of bed to 30-40 degrees Hyperventilate to reduce PCO2 Osmotic agents e.g. mannitol Steroids (only if SOL to reduce oedema, otherwise doesn't work) Fluid restriction
Neurosurgery intervention e.g. craniotomy, Burr hole
DKA Mx
- Fluids (4-6L over first 24h, 1st L over 1st hour - if shocked, give 500ml bolus)
- start 5% dextrose alongside saline once glucose <14
- Potassium (add from the second bag as long as K is <5.5 (40mmol/L), do regular 4-hourly VBGs/cap glucose to monitor)
- Insulin (Fixed rate insulin infusion 50U at 0.1U/kg/hour - continue patient’s long acting insulin as normal. Continue until blood ketones <0.6
- Monitor Urine output with catheter
- Search for underlying cause
- Best to monitor Ketones for resolution of DKA
- Tox screen
- Infection screen
Hypoglycaemia Mx
If conscious, alert and able to swallow: Oral glucose tablets or carb snack and recheck in 15 mins
If conscious but uncooperative: Glucose gel/buccal
If impaired consciousness: 20% IV glucose 200ml/h if conscious, 200ml/15 mins if unconscious OR IM glucagon
Long acting carbohydrate once stable
HHS vs DKA
Longer Hx
marked dehydration
Glucose normally >30mmol, osmolality >320
No ketones
Addisonian Crisis Mx
Bloods (FBC, U&E, cortisol, ACTH) Monitor Glucose (danger of hypoglycaemia)
IV hydrocortisone 100mg IV, then infusion
IV 0.9% saline bolus
IV glucose if hypoglycaemic
Acute poisoning Mx
Take bloods (FBC, U&E, LFT, glucose, tox screen, always check paracetamol/salicylate levels)
Empty stomach if appropriate (gastric lavage - only if recommended by toxbase)
Activated charcoal (is <1h post ingestion)
Specific antidote (check toxbase if unsure)
Haemodialysis
Monitoring: Vital signs, blood glucose, cardiac monitor
Psych assessment
General investigation pairings
Resp: CXR + ABG
Metabolic: Glucose + tox screen
Surgical: G+S + X-match + clotting
Anaphylaxis Mx
Airway
- Secure w/ adjunct if necessary/intubate
Nebulised salbutamol
Remove allergen
IM adrenaline 1:1000 500mcg (repeat after 5mins if necessary - after 2 goes if still not good can have IV adrenaline on HDU/ITU)
Elevate legs
IV fluids
IV Chlorphenamine
IV hydrocortisone
After acute phase: admit ECG Continue chlorphenamine if itching Teach epipen use Arrange referral to allergy clinic
Anaphylaxis Precipitants
Must suspect if rapid onset airway/breathing/circulatory compromise
Drugs e.g. penicillin, contrast
Allergens e.g. peanuts, eggs
Drowsiness/reduced GCS differentials
Stroke
Encephalitis
Trauma (EDH/SDH,SAH)
SOL
Hypoglycaemia
Encephalopathy
Dyspnoea differentials
Pneumothorax Pneumonia PE Asthma COPD Pulmonary Oedema
Abdo pain differentials
Surgical
Acute abdomen
Bowel obstruction
Medical Basal pneumonia MI DKA Gastroenteritis
Chest pain differentials
Stable angina
Unstable angina
MI
Aortic dissection
Stroke Hyperacute Mx
CT + CT angiogram
Aspirin 300mg
Thrombolysis (if haemorrhage ruled out on CT, and BP controlled) - IV alteplase within 4.5h - give aspirin 24h after thrombolysis
Thrombectomy - If thrombolysis contraindicated, within 6h, only if CT angio has confirmed occlusion of the proximal anterior circulation
Repeat CT head after 48h to rule out haemorrhagic transformation
Stroke acute Mx
Bloods - FBC, U&E, G+S, X-match
Imaging - Urgent CT head, CXR, ECG
If non-AF: Aspirin 300mg (+PPI if get dysphagia with aspirin) 14 days then switch to Clopidogrel 75mg OD lifelong, + secondary CV prevention
If AF: Aspirin 300mg 14 days then start anticoagulation according to CHADSVASC
If Stroke + DVT/PE: give anticoagulation in preference to aspirin
Haemorrhagic stroke Mx
Stop causative meds
Reverse anticoagulation (PCC + Vit.K if on warfarin)
Control BP
Call neurosurgery
TIA Mx
Aspirin 300mg OD
Secondary CV prevention
Refer to specialist TIA clinic - MRI, carotid doppler
Anticoagulant vs antiplatelet rule
Arterial thrombosis = antiplatelet
Venous thrombosis (e.g. DVT) = Anticoagulant
Signs of HHS/differences from DKA
Glucose >30 Osmolality >320 pH >7.3 Ketones <3 Hx is longer (>1 week)
Mx of HHS
Slow rehydration with IV saline over 48h
Introduce insulin slowly at 0.05U/kg/hr if glucose not falling by 5mmol/L/hr
Keep glucose at 10-15mmol over first 24h to avoid cerebral oedema
VTE prophylaxis, look for cause
DKA Ix
Breathing
- CXR
- ABG (if hypoxic)
Circulation
- Bloods (FBC, U&E, LFT, CRP, Blood cultures, VBG, capillary glucose)
- ECG
Urine dipstick and MSU
DKA presentation
Drowsiness Vomiting Abdo pain Polyuria Polydipsia
DKA triggers
Infection MI Pancreatitis New medication Non-compliance/wrong insulin dose
Differentials for refractory acidosis
Aspirin overdose DKA Lactic acidosis (especially in diabetics)
Signs of severe DKA requiring early ITU input
Blood ketones >6 pH <7 Sats <92 Systolic BP <90 after bolus K <3.5 on admission GCS <12
In what conditions is secondary CV prevention indicated
Angina - aspirin 75mg
Stable angina undergoing PCI/CABG - aspirin + clopidogrel
ACS - DAPT (aspirin + ticagrelor) 1 year then aspirin 75mg
Stroke/TIA - clopidogrel 75mg
AF - DAPT if not tolerant of anticoagulation
PAD - clopidogrel 75mg + high dose statin
AF Ix
Rule out secondary causes
ECG
Bloods (FBC, U&E, CRP, TFTs, clotting, troponin)
ECHO - check for valvular heart disease
How do you assess the area of a burn
Wallace’s Rule of Nines: head + neck = 9%, each arm = 9%, each anterior part of leg = 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%, anterior abdomen = 9%, posterior abdomen = 9%
Mx of different kinds of shock
Septic shock: Sepsis 6
Haemorrhagic shock: Replace lost volume
Neurogenic shock: Vasopressors
Anaphylactic shock: IM adrenaline
Mx of STEMI
Aspirin 300mg
IV Morphine + Metoclopramide
Oxygen
Nitrates (SL or IV)
Determine whether patient is for PCI (can it be done within 120mins of time when fibrinolysis can be done)
If presentation is >12h after symptom onset, consider PCI for sure
If yes:
- give Prasugrel
- Transfer for PCI
- Patient gets heparin and glycoprotein 2b/3a inhibitor at PCI
If no (for fibrinolysis):
- Give fondaparinux
- Do fibrinolysis
- Patient gets ticagrelor afterwards
- Repeat ECG after 30 mins to assess for ongoing ischaemia requiring PCI
What is in a confusion screen?
Septic screen (look for source of infection anywhere)
Metabolic (haematinics, U&Es, glucose, TFTs, Blood gas)
Toxicology
Confusion Mx
Conservative
- Stop contributory meds
- Orientation (family members, well lit side room, don’t leave unattended
- Sleep hygiene
- fluids and nutrition
Medical
Treat underlying cause
Sedation (last resort)
Blatchford score vs Rockall score
Blatchford: Pre-endoscopy scoring system that stratifies into low risk and high risk (score of 0 = suitable for outpatient Mx)
Rockall: Post-endoscopy scoring system for risk of re-bleeding and mortality
When to do an endoscopy in UGI bleed
Straight after resus if unstable
Urgently if:
- Suspicion of continuing UGI bleed
- Blatchford score >6
When might a person presenting with an UGI bleed require a CT CAP
If the patient has had previous aortic surgery, to rule out aorto-enteric fistula
Contraindications for NSAIDS (BARS)
Bleeding
Asthma
Renal failure
Stomach (peptic ulcer/gastritis)
