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Medicine Y6 > Acute Care > Flashcards

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
Q

Recognise the presenting symptoms of anaphylaxis

A

Acute onset

Key: urticaria, angio-oedema, dyspnoea, wheeze, rhinitis

Other: pruritus, conjunctivitis, N/V. abdo pain, inspiratory stridor, dizziness, tachycardia

(BMJ)

26
Q

Identify appropriate investigations for anaphylaxis

A

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
Q

Generate a management plan for anaphylaxis

A

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
Q

ABG: indications

A

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
Q

Define arterial blood gas

A

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.

(UpToDate)

30
Q

Define aspirin overdose

A

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
Q

Recognise the presenting signs and symptoms of aspirin overdose

A

Early: tinnitus, vertigo, N/V, D&V, hyperpnoea (tachypnoea + deep resp effort)

Subsequent: altered mental state, pyrexia, non-cardiac pulmonary oedema, arrythmias

(UpToDate)

32
Q

Identify appropriate investigations for aspirin overdose

A

Bloods: serum salicylate (2 hourly), ABG (2 hourly), UEs (hourly, K+ important), toxicology screen, serum ketones, FBC, LFTs, clotting, glucose

Imaging: ECG, CXR

33
Q

Aspirin overdose: Indications for an A&E referral from community for an acute ingestion

A
  • 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
Q

Generate a management plan for aspirin overdose

A

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
Q

Aspirin overdose: criteria mild/moderate/severe

A

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
Q

Identify the possible complications of aspirin overdose

A

Immediate: ARDS, cardiac arrest, seizures (in severe toxicity), drug-induced hepatitis

37
Q

Summarise the prognosis for patients with aspirin overdose

A

Morbidity: non-fatal salicylate poisoning associated with full recovery

Mortality: more likely at higher doses and longer times to presentation

38
Q

Summarise how aspirin overdose triggers acid-base imbalance

A

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
Q

Define multi-organ dysfunction syndrome

A

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
Q

Generate a management plan for multi-organ dysfunction syndrome

A

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
Q

Summarise the prognosis for patients with multi-organ dysfunction syndrome

A

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
Q

Identify appropriate investigations for multi-organ dysfunction syndrome

A

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
Q

Define paracetamol overdose

A

Overdose = any ingestion of >4g/24h or >75mg/kg/24h

Single acute overdose = any ingestion of >4g (or >75mg/kg) in 1h

(BMJ)

44
Q

Generate a management plan for paracetamol overdose

A
  • 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
Q

What are the indications for liver transplant in severe paracetamol overdose?

A

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
Q

Recognise the presenting symptoms of paracetamol overdose

A

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
Q

Identify risk factors for paracetamol overdose

A

RFs:

hx of self-harm

hx of frequent analgaesic use

Use of CP450 inhibitors (SICKFACES.COM)

Glutathione deficiency

48
Q

Identify appropriate investigations for paracetamol overdose

A

Bloods: serum paracetamol level, LFTS (for AST, ALT), ABG (for pH, lactate). UEs, PTT/INR

Urine: drug screen (consider)

(BMJ)

49
Q

Identify the possible complications of paracetamol overdose

A

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
Q

Summarise the prognosis for patients with paracetamol overdose

A

Mortality: 1-2% (hepatic failure)

Morbidity: Hepatotoxicity (<10%) recovers over 1-3 wks

(BMJ)

51
Q

Mx of K+>6.5

A

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
Q

What are the Sepsis Trust ‘red flags’ for sepsis? What do they indicate?

A

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
Q

GP: when do you refer burns to secondary care?

A

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
Q

What is the classification of burns?

A

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
Q

How do you assess the % of total body area affected in a burn?

A

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
Q

Outline the management of superficial burns

A
  • 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

(passmedicine)

57
Q

What are the indications of CT head w/i 1h in head injury?

A

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
Q

Generate a management plan for head injury

A
  • 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
Q

What is the normal rate for IV fluid maintenance therapy?

A

30ml /kg / 24h 0.9% saline

(+ 100g glucose / 24h)

(+1mmol/kg/24h K+)

  • adjust down if obese / frail / renal failure / malnourished
  • (NICE, passmedicine)*
60
Q

What are the main drugs used in beta blocker overdose?

A
  • Medical (ABCDE)
    • 1st line: atropine (if bradycardic)
    • 2nd line: glucagon

(passmedicine)

Medicine Y6 (14 decks)

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