Acute Care Flashcards
What scores are the GCS components out of?
Eyes 4
Verbal 5
Motor 6
What are the GCS values for Eyes
Eyes
- Spontaneously
- Speech
- Pain
- None
What is the GCS for verbal response
5 Orientation to time, person and place
4 Confused
3 Inappropriate words
2 Incomprehensible
1 None
What is the GCS for motor
6 Obeys command
5 Moves to localised pain
4 Withdraws from pain
3 Abnormal flexion
2 Abnormal extension
1 None
What posture is this and what is the
a) Signifiance
b) Potential progression
Decorticate: Abnormal flexion due to significant head trauma
Can progress to decererbate, indicating brain herniation (uncal)
Who gets a 1hour CT following a head injury?
GCS <13 on initial assessment
GCS <15 after 2 hours
Suspected skull or basilar skull fracture
Post-traumatic seizure
Focal neuro deficit
>1 episode of vomiting
Who gets an 8 hour CT following head injury
>65 years
Bleeding/clotting disorders
High velocity/height (>1m or 5 stairs)
>30 mins retrograde amnesia of events prior to injury
What criteria indicates immediate CT for children?
GCS < 14, <15 if under 1 year
LOC or amnesia >5 mins
>3 vomiting episodes
Sign of skull, basilar fracture
Dangerous mechanism (fall >3m, high velocity)
SUSPICION OF NAI
How do you manage a GCS of
<8
3-8
<8 means intubate
ICP monitoring (must do if CT abnormal)
How do toxidromes affect pupil responses
Dilate: Anticholinergics, sympathomimetic
Pinpoint: Cholinergics, opioids
No change: Sedative hypnotic
How do you distinguish between overdoses of
anticholinergics (atropine, antihistamine, tricyclics, olazapine, quetiapine)
sympathomimetic (Caffeine, cocaine, (meth)amphetamines, ritalin, LSD, theophylline, MDMA)
Anticholinergics: no RR change, bowel sounds or sweating
Sympathomimetics: Raised RR, bowel sounds present and sweating
Both have dilated pupils, raised HR and warm skin
How do you tell the difference between
cholinergics (mushrooms, pilocarpine, -cholines)
opioids (morphine, codeine, tramadol, heroin, fentanyl)
sedative-hypnotics (benzodiazepines, muscle relaxants, antiepileptics, anti-anxiety meds
Both cholinergics and opioids have pinpoint pupils
Cholinergics: Bowel sounds + sweaty; no changes to numbers (HR,RR, temp)
Opioids: No bowel sounds, dry skin. Reduced HR, RR and skin temp
Sedative-hypnotics: As per opioids but no pupil changes
Toxin Treatments
Paracetamol
N-acetylcysteine (+activated charcoal if <1hr)
Toxin treatments
Aspirin/salicylates
IV bircarbonate
+/- haemodialysis
Toxin treatments
Opioids/opiates
Naloxone
Toxin Treatments
Benzodiazepines
Flumazenil
The majority of overdoses are managed with supportive care only due to the risk of seizures with flumazenil. It is generally only used with severe or iatrogenic overdoses.
Toxin treatments
Tricyclic antidepressants
Prevent arrythmias: IV bicarbonate
Manage arrhythmias
lignocaine (NOT quinidine, flecainide)
Toxin treatments
Lithium
mild-moderate: fluid resuscitation
Severe: haemodialysis
Toxin treatments
Warfarin
Vitamin K, prothrombin complex
Toxin treatments
Heparin
Protamine sulphate
Toxin treatments
Beta-blockers
bradycardic then atropine
Glucagon if resistant
Ethylene glycol
fomepizole 1st line
Haemodialysis if refractory
Toxin treatments
Methanol poisoning
fomepizole or ethanol
haemodialysis
Toxin treatments
Organophosphate insecticides
atropine
Toxin treatments
Digoxin
Digoxin-specific antibody fragments
Toxin treatments
Iron
Desferrioxamine
Toxin treatments
Lead
Dimercaprol
calcium edetate
Toxin treatments
Carbon monoxide
100% oxygen
hyperbaric oxygen
Toxin treatments
Cyanide
Hydroxocobalamin
Also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate
When are the 5 doses of tetanus vaccine given?
2,3,4 months
3-5 years
13-18 years
For tetanus, what is considered a clean wound?
<6 hours old
non-penetrating with negligible damage
For tetanus, what is a prone wound?
Puncture typee injuries in contaminated envirnoment
Wounds containing foreign bodies
Compound fractures
Wound/burns with systemic sepsis
Animal bites + scratches
What is a high-risk tetanus wound?
Soil, manure contaiminated wounds
Wounds with excessive devitalised tissue
Wounds requiring surgical intervention
Shot or not?
Full dose with final < 10 years ago
Full course with final >10 years ago
Unknown/incomplete vaccination status
No shot or Ig needed
Reinforce if tetanus prone, +IgG if high risk
Reinforce regardless, + Ig if high risk
What is a common complication of N-acetylcysteine and how do you manage this?
AnaphylacticOID reaction (non-IgE mediated)
Stop drug, give neb salbutamol and recommence at slower rate
What from the following would predispose someone to hepatotoxcity following paracetamol overdose?
Alcohol intake
Epilepsy treatment
Smoking
Depression treatmetn
Epilepsy treatment
Carbamazepine is an enzyme inducer
What class of drug leads to a mixed resp alkalosis and metabolic acidosis?
Aspirin/salicylate
resp alkalosis then later acidosis
How would you diferrentiate between sertraline and amitriptyline?
Both produce dilated pupils
TCAs produce dry skin, sertraline does not
TCAs cause QTc prolongation, SSRIs bar citalopram do not
What is the most important monitor for paracetamol overdose?
pH as <7.3 after 24 hours ingestion is bad
What are the King’s College Hospital criteria for liver transplantation?
Arterial pH <7.3 after 24 hours
or all 3 of:
- PT >100s
- Creatinine >300umol/l
grade III/IV encephalopathy
Where is dialysis useful in tricyclic overdoses?
Its not
What is the impact of alcohol on paracetamol overdose toxicity?
Not much and may be protective
What do ALTs and ASTs in the 10,000s indicative of?
Paracetamol overdose
What causes hyponatraemia?
Depletion of sodium
Excess of water
Outline the complication of hyponatraemia when
untreated
Overtreated
Untreated
Cerebral oedema –> uncal herniation (ipsilateral dilated pupil, contralateral paralysis)
Overtreated
Osmotic demyelination syndrome (paralysis, mouth problems, coma, locked in syndrome)
How do the causes of hyponatraemia differ if the urinary sodium is…
>20mmol/L
<20mmol/L
>20mmol/L
Low BP (renal loss): Diuretics, Addison’s, renal failure
Normal BP: SIADH (osmolality >500mmol/kg), hyothyroidism
<20mmol/L
Low BP (extra-renal): diarrhoea, vomiting, burns, sweating
High BP (water excess): hyperaldosteronism, nephrotic syndrome, IV dextrose, psychogenic polydipsia
How do you do you treat
Chronic, severely symptomatic hyponatraemia?
Acute, severly symptomatic hyponatraemia?
Chronic
hypovolaemic: isotonic saline
Eu/hypervolaemic: Fluid restrict to 500-1000ml/day
Acute
Close monitoring with hypertonic saline (3%) to correct faster
What is the rate of sodium correction in hyponatraemia?
4-6mmol/L in 24hrs
How do you manage a haemothorax post ABCDE
36F wide bore chest drain
Thoracotomy if >1.5L loss initially or ongoing loss of 200ml/hour for >2 hours
How to treat anaphylaxis initially (with doses)
IM adrenaline to anterolateral middle third of thigh
<6m: 100-150ug
<6yrs: 150ug
<=12yrs: 300ug
>12yrs: 500ug
Repeat dose every 5 mins
What is a common pitfall for adrenaline anaphylaxis dosing?
Anaphylaxis: 1:1000 IM
Cardiac arrest: 1:10,000 IV (100mcg in 1ml)
ANAPHYLAXIS USES 10X THE STRENGTH
What is a normal anion gap in metabolic acidosis?
What conditions have a raised anion gap?
(Na+ + K+) - (HCO3- + Cl-) = 8-14
Raised anion gap (introduction of acid into the body)
Lactate (shock, hypoxia)
Ketoacidosis (diabetic, alcoholic)
Uric acid (renal failure)
Acid poisoning (salicylates, methanol)
What things tend to cause metabolic alkalosis?
GI or renal upset
What things cause a respiratory acidosis?
When you can’t blow off enough CO2
- COPD
- Decompensation
- Sedatives
Respiratory alkalosis tends to be caused by what?
Where you’re hyperventilating so not getting enough CO2
Anxiety
Pulmonary embolism
Salicylate poisoning
CNS disorders
Altitude
Pregnancy
