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Acute care Flashcards

1
Q

Acute Exacerbation of COPD Mx

A
  • 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)
  • Intubation
    - If still severely acidotic/hypercapnic with NIV
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2
Q

COPD Exacerbations 3 most common organisms

A

Haemophilus Influenzae
Streptococcus Pneumoniae
Moraxella Catarrhalis

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3
Q

Acute exacerbation of COPD Ix

A

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

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4
Q

Types of pneumothorax

A

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

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5
Q

Causes/risk factors for pneumothorax

A

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

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6
Q

Pneumothorax Ix

A

*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)
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7
Q

Pneumothorax Mx

A

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

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8
Q

Pneumonia most common organisms

A

Typical
Strep Pneumoniae
Haem Influenzae
Moraxella Catarrhalis

Atypical (no cell wall)
Mycoplasma Pneumoniae
Chlamydia pneumophila
Legionella pneumophilia

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9
Q

Pneumonia Ix

A

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
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10
Q

Pneumonia Mx

A
  • 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

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11
Q

PE risk factors

A
  • Immobilisation (long haul flights, surgery etc.)
  • Hypercoagulability (Factor V leiden, APLS, Cancer)
  • Pregnancy
  • Prev. DVT
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12
Q

PE Ix

A

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

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13
Q

PE Mx

A

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
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14
Q

Meningitis Causative Organisms

A 
Bacteria
Neisseria Meningitidis
Haemophilus Influenzae
Strep Pneumoniae
Listeria Monocytogenes (in elderly)

Viral (more common)
HSV
VZV
Enteroviruses

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15
Q

Meningitis Ix

A

Circulation

  • Bloods (FBC, U&Es, CRP, Glucose (if drowsy), blood cultures)
  • Basic obs (fluid resus as necessary)
  • LP
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16
Q

Meningitis Mx

A

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)

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17
Q

Encephalitis differentials

A

Encephalopathy (without infectious prodrome):

  • Hypoglycaemia
  • Hepatic encephalopathy
  • DKA
  • Drugs
  • Hypoxic Brain injury
  • Uraemic encephalopathy
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18
Q

Encephalitis Ix

A

Bloods: FBC, Blood cultures, viral PCR
Contrast CT: Focal temporal lobe enhancement = HSV encephalitis (MRI if contrast allergic)
LP: After CT

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19
Q

Encephalitis Mx

A

IV acyclovir

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20
Q

Cerebral Abscess Ix

A

Bloods: FBC, U&Es, CRP, blood cultures
Imaging: CT head (ring enhancing lesion)

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21
Q

Cerebral abscess Mx

A

Control ICP

Urgent neurosurgical referral

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22
Q

Status epilepticus/prolonged seizure causes

A

Infection
- Meningitis/encephalitis

Malignancy
- SOL

Metabolic

  • Hypoglycaemia
  • Electrolyte abnormalities (check Ca)
  • Overdose/drug toxicity
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23
Q

Status Epilepticus Mx

A

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)

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24
Q

Head Injury Mx

A

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
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25
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
26
Indications for CT head <8h in head injury
Loss of consciousness or amnesia AND: - >65yo - Coagulopathy - Dangerous mechanism - Retrograde amnesia >30mins
27
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
28
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
29
Cushing's triad of raised ICP
Hypertension Bradycardia Fluctuating RR
30
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
31
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
32
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
33
HHS vs DKA
Longer Hx marked dehydration Glucose normally >30mmol, osmolality >320 No ketones
34
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
35
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
36
General investigation pairings
Resp: CXR + ABG Metabolic: Glucose + tox screen Surgical: G+S + X-match + clotting
37
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 ```
38
Anaphylaxis Precipitants
Must suspect if rapid onset airway/breathing/circulatory compromise Drugs e.g. penicillin, contrast Allergens e.g. peanuts, eggs
39
Drowsiness/reduced GCS differentials
Stroke Encephalitis Trauma (EDH/SDH,SAH) SOL Hypoglycaemia Encephalopathy
40
Dyspnoea differentials
``` Pneumothorax Pneumonia PE Asthma COPD Pulmonary Oedema ```
41
Abdo pain differentials
Surgical Acute abdomen Bowel obstruction ``` Medical Basal pneumonia MI DKA Gastroenteritis ```
42
Chest pain differentials
Stable angina Unstable angina MI Aortic dissection
43
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
44
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
45
Haemorrhagic stroke Mx
Stop causative meds Reverse anticoagulation (PCC + Vit.K if on warfarin) Control BP Call neurosurgery
46
TIA Mx
Aspirin 300mg OD Secondary CV prevention Refer to specialist TIA clinic - MRI, carotid doppler
47
Anticoagulant vs antiplatelet rule
Arterial thrombosis = antiplatelet Venous thrombosis (e.g. DVT) = Anticoagulant
48
Signs of HHS/differences from DKA
``` Glucose >30 Osmolality >320 pH >7.3 Ketones <3 Hx is longer (>1 week) ```
49
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
50
DKA Ix
Breathing - CXR - ABG (if hypoxic) Circulation - Bloods (FBC, U&E, LFT, CRP, Blood cultures, VBG, capillary glucose) - ECG Urine dipstick and MSU
51
DKA presentation
``` Drowsiness Vomiting Abdo pain Polyuria Polydipsia ```
52
DKA triggers
``` Infection MI Pancreatitis New medication Non-compliance/wrong insulin dose ```
53
Differentials for refractory acidosis
``` Aspirin overdose DKA Lactic acidosis (especially in diabetics) ```
54
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 ```
55
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
56
AF Ix
Rule out secondary causes ECG Bloods (FBC, U&E, CRP, TFTs, clotting, troponin) ECHO - check for valvular heart disease
57
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%
58
Mx of different kinds of shock
Septic shock: Sepsis 6 Haemorrhagic shock: Replace lost volume Neurogenic shock: Vasopressors Anaphylactic shock: IM adrenaline
59
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
60
What is in a confusion screen?
Septic screen (look for source of infection anywhere) Metabolic (haematinics, U&Es, glucose, TFTs, Blood gas) Toxicology
61
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)
62
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
63
When to do an endoscopy in UGI bleed
Straight after resus if unstable Urgently if: - Suspicion of continuing UGI bleed - Blatchford score >6
64
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
65
Contraindications for NSAIDS (BARS)
Bleeding Asthma Renal failure Stomach (peptic ulcer/gastritis)

Acute Care (1 decks)

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