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Acute Care Flashcards

1
Q

Define acute respiratory distress syndrome + give the diagnostic criteria

A

Definition: Non-cardiogenic pulmonary oedema + diffuse lung inflammation, often complication of critical illness.

Criteria (need all 3): Acute onset (<1w) Bilateral opacities on CXR PaO2:FiO2 <=300 on PEEP (or CPAP >=5cm H20) (BMJ)

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2
Q

Recognise the signs of acute respiratory distress syndrome on physical examination

A

Tachypnoea

Cyanosis

Bilateral fine creps

SIRS

(AS Medicine)

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3
Q

Identify appropriate investigations for acute respiratory distress syndrome

A

Bloods: FBC, UE, LFTs, lipase (or amylase), CRP, cultures, ABG, clotting

Cultures: blood, sputum, urine

Imaging: CXR

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4
Q

Recognise the presenting symptoms of acute respiratory distress syndrome

A

Most common presenting sx are dyspnoea and hypoxaemia, which progress to acute respiratory failure

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5
Q

Explain the aetiology / risk factors of acute respiratory distress syndrome

A

Most common cause: sepsis from pulmonary source. 2nd: sepsis from other source

Other pulmonary causes: aspiration, inhalation injury, pulmonary contusion, TRALI

Other systemic causes: acute pancreatitis, trauma, burns, DIC, drug overdose (opiates, aspirin)

RFs: smoking, ETOH, chronic disease

(BMJ)

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6
Q

Summarise the epidemiology of acute respiratory distress syndrome

A

Incidence 64: 100 000 /year

10% admitted to ITU

(BMJ)

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7
Q

Summarise the prognosis for patients with acute respiratory distress syndrome

A

Mortality: 30-50% (depending on severity)

Morbidity: weakness, neuropathies, chronic pain, join disorders in survivors

(BMJ)

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8
Q

Identify the possible complications of acute respiratory distress syndrome

A

Immediate: multiple-organ failure, pneumothorax

Mid term: ventilator-associated pneumonia

Long-term: pulmonary fibrosis –> prolonged respiratory failure

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9
Q

Generate a management plan for acute respiratory distress syndrome

A

Medical mx (ABCDE)

Consult senior, admit ITU

Treat hypoxaemia:

  • maintain O2 >88%, usually requires intubation + mechanical ventilation (occasionally NIV). Low tidal volume (6cc/kg) to prevent ventilator-assoc lung injury. This can –> resp acidosis, so if pH<7.15 consider bicarbonate infusions.
  • Fluid balance: slightly negative, aim CVP<4.
  • Supportive: haemodynamic support to maintain MAP>60 mmHg, control BM, DVT prophylaxis

Treat cause:

-sepsis six

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10
Q

Define sepsis syndromes

A

SIRS = A multi-system inflammatory response that can result from infectious or non-infectious (eg. burns, pancreatitis) causes, featuring 2 or more of:

  • temp >38.3 or <36.0
  • tachycardia >90
  • tachypnoea >20
  • PaCO2 <4,3
  • glucose >7.7 (no T2DM)
  • acutely altered mental state
  • WCC >12 or <4, or with >10% immature forms

Sepsis = SIRS + source of infection

Septic shock = sepsis with profound circulatory, cellular and metabolic abnormalities, associated with greater risk of mortality

(BMJ)

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11
Q

Explain the aetiology / risk factors of sepsis syndromes

A

Sepsis: 90% bacterial cause (E.coli, S. aureus most common). 75% community-acquired. 60% respiratory source. (BMJ)

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12
Q

Summarise the epidemiology of sepsis syndromes

A

Depends on definitions.

Incidence approx 176-380 / 100 000 /y

More common in the >65

(BMJ)

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13
Q

Identify appropriate investigations for sepsis syndromes

A

Sepsis Six:

  • take 3 things: blood cultures, blood lactate, urine hourly (consider catheter to measure UO)
  • give 3 things: empirical IV abx, IV fluids, high flow O2 (if PaO2<94%)
    plus. ..

Bedside: urine dip

Bloods: VBG, FBC (with differential), UEs, LFTs, glucose, coagulation (may need central line), CRP

Cultures: urine, blood, wound, sputum

Imaging: CXR

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14
Q

Generate a management plan for sepsis and systemic inflammatory response syndrome (SIRS)

A

Medical Mx (ABCDE):

Sepsis Six (within 1h):

  • take 3 things: blood cultures, serial blood lactate, urine hourly (consider catheter to measure UO)
  • give 3 things: empirical IV abx, IV fluids, high flow O2 (if PaO2<94%)
  • Fluid resus: normal saline (30ml/kg, can be given in 500ml boluses over 30mins each if hypovolaemic, aim CVP 8-12 mmHg)
  • Antibiotics: according to local guidelines, adjust according to source and organism
  • Glycaemic control: aim glucose 7.8-10.0 mmol/L. Insulin infusion protocol to bring it down.
  • consult senior on whether they need invasive monitoring (central venous catheter) or organ support (vasopressors, inotropes) or escalation to HDU/ITU
  • (BMJ)*
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15
Q

Identify the possible complications of sepsis and systemic inflammatory response syndrome (SIRS)

A

Short-term: ARDS, hypotension, DIC, multiple organ system failure, acute kidney dysfunction (oliguria), myocardial dysfunction/failure

Long-term: neurological sequelae

(BMJ)

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16
Q

Summarise the prognosis for patients with sepsis and systemic inflammatory response syndrome (SIRS)

A

Mortality: sepsis = 31% (according to Surviving Sepsis Campaign), septic shock = 50-70%

(BMJ)

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17
Q

Define alcohol withdrawal

A

A condition in alcohol abusers where decreased alcohol intake leads to blood alcohol levels below that to which they are habituated, leading to withdrawal sx starting 4-12h from last drink

(BMJ)

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18
Q

Recognise the presenting symptoms of alcohol withdrawal

A

Key: alcohol use, change in mental status, seizures, hallucinations, delusions

Other: N/V, HTN, tachycardia, tremor, fever

(BMJ)

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19
Q

Identify appropriate investigations for alcohol withdrawal

A

Bloods: UE, LFTs, toxicology screen, ABG (in case lactic acidosis), thiamine levels, folate levels

Imaging: CT head (rule out other cause of confusion)

(BMJ)

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20
Q

Generate a management plan for alcohol withdrawal

A

Medical mx (ABCDE):

1st line: chlordiazepoxide PO/IV/IM, every 4-6h, wean down dose. (Alternatives: diazepam, lorazepam, clomethiazole). SE: beware resp depression!

+ admit if in acute alcohol withdrawal, high risk of seizure/DT, <16, vulnerable (some frail, homeless, <18). With continuous cardiac monitoring and pulse oximetry

+ thiamine PO/IV/IM OD +/- folic acid PO OD +/- MgSO4 IV (+ monitor for hypermagnesaemia)

Conservative mx:

Counselling, follow-up

(BMJ)

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21
Q

Identify the possible complications of alcohol withdrawal

A

Short-term: delirium tremens (5%), seizures, status epilepticus, over-sedation

(BMJ)

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22
Q

Summarise the prognosis for patients with alcohol withdrawal

A

Morbidity: persistent insomnia, autonomic sx (usually last 6m), relapse (50% within 1y)

(BMJ)

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23
Q

Define anaphylaxis

A

Definition:

Acute, severe, life-threatening allergic reaction in pre-sensitized individuals, leading to a systemic response caused by the release of immune and inflammatory mediators from basophils and mast cells. 2+ organs involved. (BMJ)

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24
Q

Summarise the epidemiology of anaphylaxis

A

Incidence unknown as no consensus criteria, but thought to be increasing. (BMJ)

Lifetime prevalence ~1-2% population (MedScape)

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25
Recognise the presenting symptoms of anaphylaxis
Acute onset Key: urticaria, angio-oedema, dyspnoea, wheeze, rhinitis Other: pruritus, conjunctivitis, N/V. abdo pain, inspiratory stridor, dizziness, tachycardia *(BMJ)*
26
Identify appropriate investigations for anaphylaxis
**Manage first, investigations after** Confirm dx: serum tryptase (raised). Not necessary when dx definite Confirm atopy: in vitro IgE testing Identify allergen: skin test, challenge test
27
Generate a management plan for anaphylaxis
**Medical mx (ABCDE)**: Secure airway (intubate if necessary), give 100% O2 (nonrebreather, 15L), feet up IM adrenaline 0.5mg (adult, 0.5ml of 1:1000) every 5 mins IV access + IV chlorphenamine 100mg + IV hydrocortisone 200mg + IV fluids (normal saline, 1-2L at rate 5-10ml/kg in first 5mins then at 125 ml/h. Up to 7L may be required) If wheeze, nebulized salbutamol (5mg) Monitor: cardiac monitor, regular obs If still hypotensive, admit to ITU as may need ventilation, IV adrenaline, aminophylline *(BMJ)*
28
ABG: indications
Monitor acid-base balance Monitor PaO2, PaCO2 Assess response to therapeutic interventions Detect abnomal haemoglobins (eg in CO poisoning) Emergency blood sample where venous sampling not feasible *(UpToDate)*
29
# Define arterial blood gas
An arterial blood gas (ABG) is a test that measures the oxygen tension (PaO2), carbon dioxide tension (PaCO2), acidity (pH), oxyhemoglobin saturation (SaO2), and bicarbonate (HCO3) concentration in arterial blood. ## Footnote *(UpToDate)*
30
# Define aspirin overdose
Acute or chronic salicylate exposure causing toxic effects. Acute: \>6.5g or \>150mg/kg Chronic: \>150mg/kg/day Fatal dose: 10-30g (adults), as little as 3g in some children *(BMJ)*
31
Recognise the presenting signs and symptoms of aspirin overdose
Early: tinnitus, vertigo, N/V, D&V, hyperpnoea (tachypnoea + deep resp effort) Subsequent: altered mental state, pyrexia, non-cardiac pulmonary oedema, arrythmias *(UpToDate)*
32
Identify appropriate investigations for aspirin overdose
**Bloods:** _serum salicylate_ (2 hourly), ABG (2 hourly), UEs (hourly, K+ important), toxicology screen, serum ketones, FBC, LFTs, clotting, glucose **Imaging:** ECG, CXR
33
Aspirin overdose: Indications for an A&E referral from community for an acute ingestion
- pt symptomatic - \<12h from exposure and total amount ingested can not be estimated - amount ingested \>6.5g or \>150mg/kg - intentional self-harm or malicious administration by another - home situation is of some concern (if not referred, follow-up at 12h if non-enteric coated or 24h if enteric coated preparations)
34
Generate a management plan for aspirin overdose
**Medical Mx (ABCDE):** - _GI tract decontamination_: activated charcoal (single-dose PO, 1g/kg, \<=50g) given if pt presents within 2h *(NICE)* of ingestion or used enteric-coated aspirin. - _serum/urine alkalinisation_: sodium bicarbonate infusion if clinically moderate/severe toxicity or while salicylate levels \>40mg/dL. Initial IV bolus 1-2mmol/kg, then infusion of 100-150mmol in 5% dextrose in 1L sterile water with rate titrated to target serum pH \<=7.5 and urine pH 7.5-8. Alkalaemia is NOT a CI. Stop when levels decreasing, most recent level \<40mg/dL and asymptomatic. - _haemodialysis_: if clinically severe (AKI, pH\<7.2, fluid overload, resp distress, salicylate levels \>90mg/dL( Support - intubation + ventilation avoided unless there is hypoventilation. Otherwise the pt's hyperapnoea --\> resp alkalosis --\> (in blood HSal --\> H+ and Sal -) --\> less HSal to enter CNS - _K+ balance_: required for alkalinisation. Correct hypoK with enteral or parenteral K+, monitor levels hourly - _IV fluids_: rehydrate and maintain UO. Normal saline 10-15ml/kg/h for 2h, then titrate to UO of 1-2ml/kg/h - _supplement glucose_ to maintain high normal levels * (UpToDate)*
35
Aspirin overdose: criteria mild/moderate/severe
Classification: **Mild**: levels _40-60_mg/dL (\<45mg/dL in children/elderly). Tinnitus, N/V, malaise, dizziness **Moderate**: levels _60-80_mg/dL (47-70mg/dL in children/elderly). Tachypnoea, hyperpyrexia, diaphoresis, loss of co-ordination, restlessness **Severe**: levels _\>80_mg/dL (\>70mg/dL in children/elderly). Hypotension, metabolic acidosis persists after rehydration, oliguria, renal insufficiency, neurological tox (BMJ)
36
Identify the possible complications of aspirin overdose
Immediate: ARDS, cardiac arrest, seizures (in severe toxicity), drug-induced hepatitis
37
Summarise the prognosis for patients with aspirin overdose
Morbidity: non-fatal salicylate poisoning associated with full recovery Mortality: more likely at higher doses and longer times to presentation
38
Summarise how aspirin overdose triggers acid-base imbalance
Mixed respiratory alkalosis - metabolic acidosis (most common) - aspirin increases respiratory drive, blowing off CO2 --\> respiratory alkalosis. This happen first. - aspirin uncouples oxidative phosphorylation, leading to a build up of lactic acid and ketoacids --\> metabolic acidosis. This is slower. Remember: H+ and Sal- \<----\> HSal HSal can easily cross cell membranes and BBB (so have toxic effects and be reabsorbed), whereas Sal- can not. Alkalosis drives this equation to the left so is useful. Hence mx includes serum/urine alkalinisation (sodium bicarbonate) and permissive resp alkalosis (ie only intubate if hypoventilating)
39
# Define multi-organ dysfunction syndrome
Progressive organ dysfunction in an acute ill patient, such that haemostasis can not be maintained without intervention. It can be either primary or secondary. **Primary** - as a result of a well-defined insult in which organ dysfunction occurs early and can be directly attributed to the insult (eg renal failure due to rhabdomyolysis) **Secondary** - organ failure that is not a direct result of the insult itself, but is a consequence of the host's response (eg ARDS in pancreatitis) (UpToDate)
40
Generate a management plan for multi-organ dysfunction syndrome
**Medical mx (ABCDE):** - treat cause (eg Sepsis Six) - supportive: reverse hypotension, anaemia, coagulopathy, bleeding, shock - ITU care: may include dialysis, ventilatory support, sedation * (BMJ)*
41
Summarise the prognosis for patients with multi-organ dysfunction syndrome
40-75% in sepsis *(Medscape)* Each additional organ failure increases risk of death by 15-20% *(BMJ)* In general, the greater the number of organ failures, the higher the mortality, with the greatest risk being associated with respiratory failure requiring mechanical ventilation. *(UpToDate)*
42
Identify appropriate investigations for multi-organ dysfunction syndrome
Regular obs Bloods: FBC, UEs, ABG, LFTs + ix related to underlying cause Based on... There are no universally accepted criteria for individual organ dysfunction in MODS. However, progressive abnormalities of the following organ-specific parameters are commonly used to diagnose MODS and are also used in scoring systems (eg, SOFA or LODS) to predict ICU mortality. ●Respiratory – PaO2:FiO2 ratio ●Hematology – Platelet count ●Liver – Serum bilirubin ●Renal – Serum creatinine (or urine output) ●Brain – Glasgow coma score ●Cardiovascular – Hypotension and vasopressor requirement *(UpToDate)*
43
# Define paracetamol overdose
Overdose = any ingestion of \>4g/24h or \>75mg/kg/24h Single acute overdose = any ingestion of \>4g (or \>75mg/kg) in 1h *(BMJ)*
44
Generate a management plan for paracetamol overdose
* Medical (ABCDE): * 1st line: acetylcysteine (over 1h IV) * indicated if 1) doubtful / staggered overdose time or 2) plasma paracetamol concentration above tx line * most effective within 8h from overdose * + antiemetic (ondansetron IV) * + activated charcoal if presents 1h after ingestion) * Surgical: * Liver transplant: if liver failure indicated by King's College Criteria *(Passmedicine, BMJ)*
45
What are the indications for liver transplant in severe paracetamol overdose?
**King's College Hospital criteria for liver transplantation (paracetamol liver failure)** * Arterial pH \< 7.3, 24 hours after ingestion * or all of the following: * prothrombin time \> 100 seconds * creatinine \> 300 µmol/l * grade III or IV encephalopathy *(Passmedicine)*
46
Recognise the presenting symptoms of paracetamol overdose
Varies in stages after ingestion Stage 1 (0-24h): N/V, abdo pain, sweating, malaise Stage 2 (24-72h): Hepatic - RUQ pain, hepatomegaly. Renal - oliguria. Stage 3 (72-96h): Hepatic - Jaundice, confusion (hyperammonaemia), bleeding, lactic acidosis. *(UpToDate)*
47
Identify risk factors for paracetamol overdose
RFs: hx of self-harm hx of frequent analgaesic use Use of CP450 inhibitors (SICKFACES.COM) Glutathione deficiency
48
Identify appropriate investigations for paracetamol overdose
Bloods: serum paracetamol level, LFTS (for AST, ALT), ABG (for pH, lactate). UEs, PTT/INR Urine: drug screen (consider) *(BMJ)*
49
Identify the possible complications of paracetamol overdose
Short term: acute liver failure, acute kidney injury (hepatorenal syndrome), multi-organ dysfunction syndrome Tx-reactions: oral acetylcysteine-related N/V, IV acetylcysteine-related anaphylactoid reaction or coagulopathy *(BMJ)*
50
Summarise the prognosis for patients with paracetamol overdose
Mortality: 1-2% (hepatic failure) Morbidity: Hepatotoxicity (\<10%) recovers over 1-3 wks *(BMJ)*
51
Mx of K+\>6.5
The British National Formulary (BNF) management of hyperkalaemia is as follows: If K+ \> 6.5 mmol/l or if there are ECG changes: * Administer calcium gluconate 10% 10-20ml by slow IV injection titrated to ECG response * Give 10 U Actrapid in 50 ml of 50% glucose over 10-15 ml IV * Consider use of nebulised salbutamol * Consider correcting acidosis with sodium bicarbonate infusion Monitor ECG, K+, glucose *(Passmedicine, BNF, Path)*
52
What are the Sepsis Trust 'red flags' for sepsis? What do they indicate?
Red flag signs: * systolic blood pressure \< 90mmHg or \> 40mmHg fall from baseline * mean arterial pressure \< 65mmHg * heart rate \> 131 per minute * respiratory rate \> 25 per minute * AVPU = V, P or U Indicate: sepsis six (if any present)
53
GP: when do you refer burns to secondary care?
Referral to secondary care from community: * All partial thickness (deep dermal) and full thickness burns * Superficial burns if * \>3% total body surface area (2% children) * Face, neck, perinuem, genitalia, flexures, hands, feet, circumferential * ?Non-accidental injury * Inhalation injury * Electrical or chemical burn *(passmedicine)*
54
What is the classification of burns?
Classification: * Superficial epidermal - red, painful * Partial thickness (superficial dermal) - red, painful, blistered * Partial thickness (deep dermal) - white +/- patches of non-blanching erythema + loss of sensation * Full thickness - white / brown / black, no blisters, no pain *(passmedicine)*
55
How do you assess the % of total body area affected in a burn?
Assessing the extent of the 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% Lund and Browder chart: the most accurate method *(passmedicine)*
56
Outline the management of superficial burns
* Medical (ABCDE) * Heat burn * W/i 20m of burn: irrigate with tepid (17C) water for 10-30 mins * Cover burn with layered clingfilm (not compressing) * Superficial epidermal: emollients, analgaesia * Partial thickness (superficial dermal): cleanse wound, leave blister intact, non-adherent dressing, avoid topical creams, review in 24 hours ## Footnote *(passmedicine)*
57
What are the indications of CT head w/i 1h in head injury?
Immediate CT head (within 1h) if: * GCS \< 13 on admission * GCS \< 15 2h after admission * Suspected open or depressed skull fracture * Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear) * Focal neurology * Vomiting \> 1 episode * Post traumatic seizure * Coagulopathy *(passmedicine, NICE)*
58
Generate a management plan for head injury
* Assess w/i 15 minutes on arrival to A&E * ABCDE * If GCS \<8 or = to 8, consider stabilising the airway (document all 3 components of GCS) * Treat pain with low dose IV opiates (if safe) * Full spine immobilisation until assessment if: * - GCS \< 15 * - neck pain/tenderness * - paraesthesia extremities * - focal neurological deficit * - suspected c-spine injury * Observations half-hourly until GCS 15 * Neurosurgical r/v if: * Persistent GCS \<=8 (or drops after admission) * Unexplained confusion \> 4h * Progressive neurological signs * Incomplete recovery post seizure * Penetrating injury * Cerebrospinal leak *(passmedicine, NICE)*
59
What is the normal rate for IV fluid maintenance therapy?
30ml /kg / 24h 0.9% saline (+ 100g glucose / 24h) (+1mmol/kg/24h K+) - adjust down if obese / frail / renal failure / malnourished * (NICE, passmedicine)*
60
What are the main drugs used in beta blocker overdose?
* Medical (ABCDE) * 1st line: atropine (if bradycardic) * 2nd line: glucagon ## Footnote *(passmedicine)*

Medicine Y6 (14 decks)

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