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Acute Care > Acute care > Flashcards

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
Q

Indications for CT head <1h in head injury

A
  • 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
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26
Q

Indications for CT head <8h in head injury

A

Loss of consciousness or amnesia AND:

  • > 65yo
  • Coagulopathy
  • Dangerous mechanism
  • Retrograde amnesia >30mins
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27
Q

Indications for CT Cervical Spine <1h in head injury

A
  • 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
Q

Indications for cervical spine X-ray <1h in head injury

A

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
Q

Cushing’s triad of raised ICP

A

Hypertension
Bradycardia
Fluctuating RR

30
Q

Raised ICP Mx

A 
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
Q

DKA Mx

A
  • 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
Q

Hypoglycaemia Mx

A

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
Q

HHS vs DKA

A

Longer Hx
marked dehydration
Glucose normally >30mmol, osmolality >320
No ketones

34
Q

Addisonian Crisis Mx

A 
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
Q

Acute poisoning Mx

A

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
Q

General investigation pairings

A

Resp: CXR + ABG
Metabolic: Glucose + tox screen
Surgical: G+S + X-match + clotting

37
Q

Anaphylaxis Mx

A

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
Q

Anaphylaxis Precipitants

A

Must suspect if rapid onset airway/breathing/circulatory compromise

Drugs e.g. penicillin, contrast
Allergens e.g. peanuts, eggs

39
Q

Drowsiness/reduced GCS differentials

A

Stroke

Encephalitis

Trauma (EDH/SDH,SAH)

SOL

Hypoglycaemia
Encephalopathy

40
Q

Dyspnoea differentials

A 
Pneumothorax
Pneumonia
PE
Asthma 
COPD
Pulmonary Oedema
41
Q

Abdo pain differentials

A

Surgical
Acute abdomen
Bowel obstruction

Medical
Basal pneumonia
MI
DKA
Gastroenteritis
42
Q

Chest pain differentials

A

Stable angina
Unstable angina
MI
Aortic dissection

43
Q

Stroke Hyperacute Mx

A

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
Q

Stroke acute Mx

A

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
Q

Haemorrhagic stroke Mx

A

Stop causative meds
Reverse anticoagulation (PCC + Vit.K if on warfarin)
Control BP
Call neurosurgery

46
Q

TIA Mx

A

Aspirin 300mg OD
Secondary CV prevention
Refer to specialist TIA clinic - MRI, carotid doppler

47
Q

Anticoagulant vs antiplatelet rule

A

Arterial thrombosis = antiplatelet

Venous thrombosis (e.g. DVT) = Anticoagulant

48
Q

Signs of HHS/differences from DKA

A 
Glucose >30
Osmolality >320
pH >7.3
Ketones <3
Hx is longer (>1 week)
49
Q

Mx of HHS

A

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
Q

DKA Ix

A

Breathing

  • CXR
  • ABG (if hypoxic)

Circulation

  • Bloods (FBC, U&E, LFT, CRP, Blood cultures, VBG, capillary glucose)
  • ECG

Urine dipstick and MSU

51
Q

DKA presentation

A 
Drowsiness
Vomiting
Abdo pain
Polyuria
Polydipsia
52
Q

DKA triggers

A 
Infection
MI
Pancreatitis
New medication
Non-compliance/wrong insulin dose
53
Q

Differentials for refractory acidosis

A 
Aspirin overdose
DKA
Lactic acidosis (especially in diabetics)
54
Q

Signs of severe DKA requiring early ITU input

A 
Blood ketones >6
pH <7
Sats <92
Systolic BP <90 after bolus
K <3.5 on admission
GCS <12
55
Q

In what conditions is secondary CV prevention indicated

A

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
Q

AF Ix

A

Rule out secondary causes

ECG
Bloods (FBC, U&E, CRP, TFTs, clotting, troponin)
ECHO - check for valvular heart disease

57
Q

How do you assess the area of a burn

A

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
Q

Mx of different kinds of shock

A

Septic shock: Sepsis 6
Haemorrhagic shock: Replace lost volume
Neurogenic shock: Vasopressors
Anaphylactic shock: IM adrenaline

59
Q

Mx of STEMI

A

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
Q

What is in a confusion screen?

A

Septic screen (look for source of infection anywhere)
Metabolic (haematinics, U&Es, glucose, TFTs, Blood gas)
Toxicology

61
Q

Confusion Mx

A

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
Q

Blatchford score vs Rockall score

A

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
Q

When to do an endoscopy in UGI bleed

A

Straight after resus if unstable
Urgently if:
- Suspicion of continuing UGI bleed
- Blatchford score >6

64
Q

When might a person presenting with an UGI bleed require a CT CAP

A

If the patient has had previous aortic surgery, to rule out aorto-enteric fistula

65
Q

Contraindications for NSAIDS (BARS)

A

Bleeding
Asthma
Renal failure
Stomach (peptic ulcer/gastritis)

Acute Care (1 decks)

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