Acute Care Flashcards
Red flags for headaches
FINE JVPP • F - Focal neurological deficit • I - Injury • N - Neck stiffness • E - Early morning headache • J - Jaw claudication • V - Vomiting or Visual disturbance • P - Photophobia or Pregnancy
Thunderclap headache
Subarach
Unilateral headache + eye pain
cluster
Worse in morning and bending forward
raised icp
headahce + scalp tenderness in over 50s
Giant cell arteritis
Ix of headaches
BOXES - Bloods: • FBC, CRP, U&E • ESR • Blood culture if pyrexia • Meningococcal PCR
Special test:
• LP
CT head
S&S of temporal arteritis
• Headache • Rapid onset <1 mth • Jaw claudication • Visual disturbances • Tender palpable temporal artery Systemic symptoms
Ix of temporal arteritis and tx
Ix:
• ESR - >50mm/hr
• Temporal artery biopsy - skip lesions
Tx:
• Prednisolone 250-1000mg IV if visual sx
• Urgent opthalmology review if visual symptoms
Differentials of SOB
- PE
- Pneumothorax
- Asthma/COPD
- Pneumonia
- Acute HF
- ACS
Ix for SOB
BOXES
Bloods: • FBC, U&E, CRP • D-Dimer to rule out PE • Blood culture if pyrexic • ABG
Orifice tests:
• Sputum
X-rays:
• CXR
ECG
Special:
• CTPA for PE
asthma emergency tx
O - Oxygen high flow non rebreath 15L
S - Salbutamol nebs 5mg
H - Hydrocortisone 100mg IV
I - Ipratropium 500mcg Neb
T - Theophylline: aminophylline infusion 1g in 1L saline 0.5ml/kg/h
M - Magnesium sulphate 2g IV over 20 mins
E - Escalate care with intubation and ventilation
COPD emergency tx
O - Oxygen 24-28% venturi mask S - salbutamol nebs 5mg H - Hydrocortisone 100mg IV I - Ipratropium 500mcg nebs T - Theophylline: aminophylline infusion 1g in 1L saline 0.5ml/kg/h
ABG
Decompensated HF tx
Management:
1. Sit pt upright 2. 100% oxygen non rebreath mask 3. IV access and ECG. Treat arrhythmias 4. Investigations whilst continuing treatment 5. Diamorphine IV 1.25-5mg 6. Furosemide 40-80mg IV 7. GTN spray 2 puffs. DON’T GIVE IF HEMOCOMPROMISED 8. If systolic >100mmHg, nitrate infusion eg isosorbide dinitrate 9. If pt worsening, consider CPAP
Consider discontinuation of beta blockers in short term.
Anaphylaxis tx
Tx: • IM adrenaline 0.5mg repeat every 5 mins up to 3 times • 15L oxygen • 5mg salb nebs • IV fluid challenge • Hydrocortisone 200mg IV • Chlorphenamine 10mg IV
Choking adult tx
Tx:
1. Ask pt to cough - if they can, encourage to cough and monitor 2. If they cant - 5 back blows and then 5 abdo thrusts. Keep going until pt becomes unconscious 3. Unconscious pt: a. Begin CPR - even if carotid pulse present b. Call for help and ambulance
IHD RFs
IHD RFs - HOPEFULS: H - HTN O - Obesity P - PVD E - Elevated LDL F - FHx U - Up glucose (DM) L - Low HDLL S - Smoking, Sex (male), Sedentary
Chest pain differentials acute
3Ps, 2As
1. ACS 2. PE 3. Aortic dissection 4. Pnuemothorax 5. Pneumonia
Chest pain ix
BOXES - Bloods - trop, FBC, WBC, CRP
CXR
ECG
CTPA (PE), CT angio (aortic dissection)
Give wells score criteria. When do you anticoagulate?
Don’t Die, Tell The Team To Calculate Criteria: D - DVT D - Diagnosis most likely PE T - Tachycardia TT - Three days immobility T - Thromboembolism in past C - Coughing up blood C - Cancer
2 or more anticoagulate
Acute STEMI tx
STEMI Management:
1. Use ECG monitor 2. Bloods for FBC, U&E, glucose, lipids, cardiac enzymes 3. Assess PCI or fibrinolysis contraindications 4. Aspirin 300mg PO + prasugrel (if no contra) + LMWH 5. Morphine 5-10mg IV + metoclopramide 10mg IV 6. Is PCI available within 120 mins? a. Yes - pci b. No- Fibrinolysis (tPA) with rescue PCI if not successful
Acute Treatment (MONA):
• M - Morphine + metoclopramide
• O - Oxygen (if O2 <94%)
• N - Nitrates (if hemocompromised DO NOT USE)
• A - Antiplatelets (aspirin + prasugrel)
Post MI prevention and depression tx
Post MI prevention: • Lifelong therapy of: ○ Aspirin ○ Antiplatelet eg clopidogrel ○ Beta blocker ○ ACEi ○ Statin • Lifestyle advice: ○ Mediterranean diet ○ Exercise - until slight breathlessness ○ Sex 4 weeks post uncomplicated MI. • Depression: ○ Treat with sertraline
Contraindications to PCI for MI
Contraindications to PCI: • Due to antiplatelets • High risk of bleeding • Allergy • Uncontrolled HT • Stroke • Bleeding disorders
PE tx - how long treatment?
Anticoagulant:
• Enoxaparin used until the diagnosis confirmed
• Then switch to warfarin after INR in target range. There will be drug overlap.
Length of anticoag:
• If PE precipitated by known event - 3 to 6 months
• If due to unknown event - 6 months minimum.
• If due to malignancy - 6 month anticoag
S&S of tension pneumo. tx
Examination:
• Pt looks ill
• Mediastinal shift
• Haemodynamic instability as tension compresses mediastinum
ABCDE + immediate large bore cannula 2nd ICS MCL
S&S of aortic dissection
S&S: • Tearing pain, sudden onset • Radiates into back • Hypertension • Blood pressure difference between arms greater than 20 mmHg • Neurological deficits
Ix for aortic dissection
Investigations:
• CXR - widened mediastinum, abnormal aortic knob, tracheal and oesophageal deviation
• CT angiography of thoracic aorta
• MRI angiography
RFs for aortic dissection
RFs: • Hypertension • Trauma • Collagen deficiency - marfans, ehlers danlos • Turners and noonans syndrome • Pregnancy
Severity scoring of pneumonia and what score means?
Severity assessed with CURB-65:
• Confusion = 1
• Urea > 7 = 1
• Respiratory rate > 30 breaths per minute= 1
• Systolic blood pressure < 90 mmHg / Diastolic < 60 mmHg = 1
• Age > 65 = 1
Score >2 admit to hospital.
Score >4 (30% mortality) consider ICU.
Define HAP
onset of sx 48 hrs post admission
Organisms causing community acquired pneumonia
1) strep pneumoniae
2) H influenzae
3) staph aureus
Tx of pneumonia, HAP and CAP
Management:
• Low/moderate severity - oral amoxicillin. Add macrolide if admitted to hospital
• high severity CAP: intravenous co-amoxiclav + clarithromycin OR cefuroxime + clarithromycin
• HAP - Gentomycin IV and cephalosporin
PT follow up with pneumococcal vaccine and flu vaccine with CXR 6 weeks later
HAP organisms
Staph aureus, gram neg enterobacteria, pseudomonas aeruginosa
Abdo pain differential generalised
Generalised:
1. Peritonitis 2. AAA 3. Ischemic bowel 4. Medical causes (DKA, pneumonia, MI, Addisonian crisis)
RUQ abdo pain differentials
Hepatitis, cholecystitis
LUQ abdo pain differentials
LUQ:
1. Peptic ulcer 2. Pancreatitis
abdo pain ix
BOXES
Bloods: • FBC, CRP, U&E • LFTs, amylase • INR • Glucose • VBG (lactate)
Orifice tests:
• Urine dip
• Urine beta HCG
Xrays:
• Erect CXR
• AXR if SBO
ECG
Special test:
• FAST scan for AAA
• USS/CT abdo
AAA ruptured S&S
syncope, shock, abdo and back pain, vomiting, pulsatile mass in abdo
Tx of ruptured AAA
A-E
Management:
• High flow O2, IV access
• Bloods - FBC, U&E, clotting, cross match
• Fluids and O- Blood. Keep systolic below 100mmHg (permissive hypotension)
• Unstable pt - immediate open surgical repair
• Stable pt - CT angiogram to see if EV repair is possible
Small bowel obstruction abdo pain causes
Hernia, adhesions
S&S of small bowel obstruction abdo pain
S&S:
• Colicky abdo pain - True waxing and waning
• Vomiting - Gastric contents –> bile –> feces
• Abdo distension
• Absolute constipation - no flatus or feces
• Tinkling or absent bowel sounds
• Tympanic (hollow) sound on percussion
• FOCAL TENDERNESS = ISCHEMIA
Ix for SBO
Investigations: • ABG - serum lactate • Routine bloods - high urea and hypokalaemia may be present • AXR: ○ Dilated bowel >3cm ○ Visible valvulae conniventes ○ Erect xray for free gas • CT abdo - find cause of obstruction
Ischemic red flags of SBO
ISCHEMIC RED FLAGS:
• FOCAL TENDERNESS
• PAIN WAS COLICKY NOW CONSTANT
Tx of SBO
Tx: • Conservative - first line if no ischemia: ○ NBM ○ IV fluids + catheter ○ Analgesia + metoclopromide • Laparotomy indicated for: ○ Ischemia ○ SBO in virgin abdomen ○ No improvement in 48 hrs
Causes of abdo distension
Abdo distension Causes - 6Fs: • Fluid • Fat • Flatus • Feces • Fetus • Fucking big tumour
Precipitating factors of a DKA
Precipitating factors:
• Infection
• Missed insulin doses
• MI
Ix of DKA
Ix: • Glucose >11 • pH <7.3 • Bicarb <15mmol • Ketones >3mmol or urine ketones ++
S&S of DKA
S&S: • Abdo pain • Polyuria, polydipsia, dehydration • Deep hyperventilation - Kussmaul resp • Pear drop smelling breath
Tx of DKA
Tx: • VBG, BM, U&E • Saline fluids • Insulin IV infusion - 0.1u/kg/h • Correct hypokalaemia (due to insulin)
Addisonian crisis occurs in what pts?
Occurs in pts on LT steroids that suddenly stop or not increased during illness
Tx of addisonian crisis
Tx: • Bloods for cortisol and ACTH. U&Es (high K and low Na) • Hydrocortisone 100mg IV stat • Support BP • Monitor BMs.
Tx of cholecystitis
Management:
• Antibiotics - IV coamox and metronidazole
• Fluid resus pathway if signs of sepsis evident
• NG tube if pt vomiting
• Cholecystectomy necessary
Tx of pancreatitis
Management: • High flow O2 • IV fluids - 500ml/hr of crystalloid • Nasogastric tube if pt vomiting • Catheterisation to monitor urine output • Opioid analgesia
Ix of pancreatitis
Investigations:
• Serum amylase - 3x upper limit of normal
• LFTs - gallstones can cause pancreatitis
• Serum lipase
• Imaging - USS AP and CT scan
Red flag sx of sepsis?
Red flag symptom + suspected infection: • Systolic BP <90mm or >40mmhg fall from baseline • UO <0.5ml/kg/h • HR >130 bpm • RR >25 per min • AVPU = V, P, or U
Signs of TCA OD?
Severe poisoning features: • Arrhythmia • Seizures • Metabolic acidosis • Coma
Tx of TCA OD
Management:
• IV bicarb
• IV lipid emulsion
S&S of amphetamine OD and TX?
S&S: • Dilated pupils • HTN • Tachycardia • Skin pallor • Hyperexcitable • Paranoia
Tx:
• Sedate with BZD if agitated
• Cool if necessary
• Monitor HTN
S&S of BZD OD
S&S: • Drowsiness • Slurred speech • Hypotension • Resp depression
Tx of BZD OD
Tx:
• Gastric lavage if recent ingestion
• Flumazenil
antidote to digoxin posioning
Antidote - Digoxin immune fab
Tx of status epilepticus
Tx:
• 1st line - IV lorazepam
• 2nd line - BZD ineffective within 10 mins –> IV phenytoin, sodium valproate, or levetiracetam
• 3rd line - 30 mins of SE –> general anasthesia
Ix of hypoglycaemia
Ix:
• BM <2.5mmol
Tx of hypoglycaemia
Tx:
1. Conscious - 250ml of lucozade, 3 glucose tablets, glucogel 2. IV glucose 200 ml of 10% solution in 50 ml aliquots 3. Repeat glucose testing every 10 mins until stable 4. Review reasons for hypoglyc
S&S of hyperosmolar hyperglycaemia state
S&S: • Focal CNS signs - tremors, motor or sensory impaired • Decreased GCS • Reduced BP • DIC • Leg ischemia
Ix of HHS
Ix: • Low BP - dehydration • Osmolality >320mOsmol/kg • >30mmol BM • pH >7.3 • Bicarb >15mmol
Tx of HHS
Tx: • LMWH • Saline fluids • Replace potassium • ONLY USE INSULIN IF BM NOT FALLING WITH ABOVE
Tx of bites?
Tx:
1. Clean with soap and water 2. Check tetanus status 3. Ppx against infection eg co-amox 4. Consider risk of HIV or hep B if human bite
