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Finals > Acute Care > Flashcards

Acute Care Flashcards

1
Q

Outline what you’d do under ‘A’ of the primary survey?

A

Protect C spine
Assess: signs of obstruction, patency
Manage: establish patent airway

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2
Q

Outline what you’d do under ‘B’ of the primary survey?

A

Assess: RR, chest movements, percuss, auscultate
Manage: if no resp effort treat as arrest, O2, results of assess

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3
Q

Outline what you’d do under ‘C’ of the primary survey?

A

Assess: pulse, BP, cap refill, haemorrhage, UO
Manage: if shocked, in no CO treat as arrest

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4
Q

Outline what you’d do under ‘D’ of the primary survey?

A

Assess: level of consciousness (AVPU), pupils, cap glucose

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5
Q

Outline what you’d do under ‘E’ of the primary survey?

A

Undress pt, but cover to avoid hypothermia

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6
Q

What would you do after the A-E assessment?

A

Quick Hx from pt and family
PMH - diabetes, asthma, COPD, alcohol, opiate or rec drugs, epilepsy, recent head injury, recent travel
Meds
Allergies

Once ventilation and circulation are adequate, proceed to carry out Hx, exam, investigations and management

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7
Q

Outline the red flag symptoms of headaches. What could be the cause?

A
  • First and worst -> SAH
  • Thunderclap -> SAH
  • Unilateral and eye pain -> cluster, acute glaucoma
  • Unilateral and ipsilateral symptoms -> migraine, tumour, vascular
  • Cough-initiated -> inc ICP, venous thrombosis
  • Persisting ± scalp tenderness in over 50s -> GCA
  • Headache with fever/neck stiffness -> meningitis
  • Change in the pattern of usual headaches
  • Dec level of consciousness
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8
Q

Two key questions to ask about headaches?

A

Travel Hx -> malaria

Pregnancy -> pre-eclampsia

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9
Q

Causes of a headache that would show no signs on exam

A 
Tension
Migraine
Cluster
Post-trauma
Drugs - nitrates, CCB
CO poisoning
SAH
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10
Q

Causes of a headache with signs of meningism

A

Meningitis

SAH

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11
Q

Causes of a headache with dec conscious level or localising signs?

A 
Stroke
Encephalitis/meningitis
Cerebral abscess
SAH
Venous sinus occlusion
Tumour
Subdural haematoma
TB meningitis
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12
Q

Causes of papilloedema

A

Tumour
Venous sinus occlusion
Malignant HTN
Any CNS infection, if prolonged

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13
Q

Causes of acute breathlessness with wheezing?

A

Asthma
COPD
Heart failure
Anaphylaxis

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14
Q

Causes of acute breathlessness with stridor?

A

Foreign body aspiration or tumour
Acute epiglottitis
Anaphylaxis
Trauma

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15
Q

Causes of acute breathlessness with crepitations?

A

Heart failure
Pneumonia
Bronchiectasis
Fibrosis

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16
Q

Causes of acute breathlessness with a clear chest?

A 
PE
Hyperventilation
Metabolic acidosis
Anaemia
Drugs
Shock
CNS causes
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17
Q

Key investigations in acute breathlessness?

A

Bedside - O2, pulse, temp, peak flow, ABG, ECG
Bloods - glucose, FBC, U+E, drug screen
Imaging - CXR

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18
Q

Life threatening causes of chest pain

A 
Acute MI
Angina/acute coronary syndrome
Aortic dissection
Tension pneumothorax
PE
Oesophageal rupture
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19
Q

Non-life threatening causes of chest pain

A 
Pneumonia
Chest wall pain - muscular, fractures, bony mets, costochondritis
GORD
Pleurisy
Empyema
Pericarditis
Oesophageal spasm
Herpes zoster
Cervical spondylosis
Intra-abdo (chole, ulcerations, panc)
Sickle cell crisis
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20
Q

Key investigations in acute chest pain

A

Bedside - ECG
Bloods - FBC, U+E, troponin
Imaging - CXR

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21
Q

Define a coma

A

Unrousable unresponsiveness

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22
Q

Give some metabolic causes of coma

A 
Drugs
Poisoning - CO, alcohol, tricyclics
Hypoglycaemia, hyperglycaemia (ketoacidotic)
Hypoxia, COPD
Septicaemia
Hypothermia
Myxoedema, Addisonian crisis
Hepatic/uraemic encephalopathy
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23
Q

Give some neurological causes of coma

A

Trauma
Infection - meningitis, encephalitis, malaria, typhoid, typhus, rabies
Tumour - 1’ or 2’
Vascular - stroke, subdural, subarachnoid, hypertensive encephalopathy
Epilepsy

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24
Q

At what GCS would you consider intubation?

A

<8

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25
Q

Investigations for coma

A

Bedside - normal obs
Bloods - routine biochem, haem, thick films, blood cultures, blood ethanol, drug screen
Imaging - CT head, if normal (and no CI) do an LP

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26
Q

Outline the motor part of the GCS

A 
6 - obeys commands
5 - localising to pain
4 - withdrawing to pain
3 - flexor response to pain
2 - extensor response to pain
1 - no response to pain
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27
Q

Outline the verbal part of the GCS

A 
5 - orientated (time, place, person)
4 - confused conversation
3 - inappropriate speech
2 - incomprehensible sounds
1 - none
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28
Q

Outline the eye opening part of the GCS

A

4 - spontaneous
3 - in response to speech
2 - in response to pain
1 - none

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29
Q

Describe a decorticate posture and the causes of it

A

Flexion - arms bent inwards on chest, thumbs tucked in a clenched fist, legs extended
Implies damage above the level of the red nucleus in the midbrain

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30
Q

Describe a decerebrate posture and the causes of it

A

Extension - adduction and int rotation of shoulder, pronation of forearm
Indicates midbrain damage below the level of the red nucleus

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31
Q

Define sepsis

A

Life-threatening organ dysfunction caused by a dysregulated host response to infection

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32
Q

Define septic shock

A

Sepsis in combination with either:

  • lactate >2mmol/L despite adequate fluid resus, OR
  • the pt is requiring vasopressors to maintain MAP >65
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33
Q

List some moderate-risk criteria for sepsis

A 
Reports of altered mental state
RR 21-24
SBP 91-100
HR 91-130
UO - nil for 12-18h
Local signs of infection
Rigors, or temp <36
Impaired immunity
Recent surgery/trauma/invasive procedure
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34
Q

List some high-risk criteria for sepsis

A 
Altered mental state
RR >24 or new need for O2 to maintain sats >92%
SBP <90 or >40 less than baseline
HR >130
UO nil for 18h
Mottled, ashen, or cyanotic skin
Non-blanching rash
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35
Q

Define low-risk sepsis

A

No moderate or high-risk criteria

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36
Q

Define moderate-risk sepsis

A

At least one moderate criterion

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37
Q

Define high-risk sepsis

A

At least one high-risk criterion OR at least 2 moderate risk criteria, with AKI or lactate >2

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38
Q

Acute management of sepsis

A 
A-E assessment
Determine risk
Bedside invest - ABGs
Bloods - cultures, U+E, CRP, FBC, LFT, clotting
Micro - sputum and urine, wound swabs
Imaging - CXR, consider CT/USS/MRI/echo
Treatment - ABx, fluids, O2
Review
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39
Q

Signs and symptoms of anaphylactic shock

A

Itching, sweating, diarrhoea and vomiting, erythema, urticaria, oedema
Wheeze, laryngeal obstruction, cyanosis
Tachycardia, hypotension

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40
Q

Acute management of anaphylaxis

A 
Secure airway - give O2
Remove cause
Adrenaline IM 0.5mg (0.5ml of 1:1000), repeat every 5min
Secure IV access
Chlorphenamine 10mg IV, and hydrocortisone 200mg IV
IV fluids
If wheeze - treat for asthma
Still hypotensive - contact ICU
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41
Q

What is meant by acute coronary syndrome?

A

Incl unstable angina, STEMI, and NSTEMI

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42
Q

Management of acute coronary syndrome

A

Brief Hx, quick exam and ECG
Bloods - U+Es, troponin, glucose, cholesterol, FBC
Imaging - CXR

Treatment =

  • Aspirin 300mg PO + ticagrelor 180mg
  • Morphine 5-10mg IV
  • GTN
  • O2 if sats <95%
  • Restore coronary perfusion (if <12h since onset)
  • Anticoagulation (bivalirudin)
  • B-blocker (bisoprolol)
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43
Q

How would you decide between PCI or fibrinolysis in an acute STEMI?

A

PCI if STEMI on ECG and PCI available within 120mins.

Otherwise fibrinolysis

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44
Q

Contraindications to thrombolysis

A 
Previous IC haemorrhage
Ischaemic stroke <6m ago
Cerebral malignancy or AVM
Recent major trauma/surgery/head injury (<3wk)
GI bleed (<1m)
Known bleeding disorder
Aortic dissection
Non-compressible punctures (liver biposy, LP)
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45
Q

Relative CIs to thrombolysis

A 
TIA <6m
Anticoagulant therapy
Pregnancy/<1wk post-partum
Refractory HTN
Advanced liver disease
Infective endocarditis
Active peptic ulcer
Prolonged/traumatic resus
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46
Q

Assessment and management of ACS without STE?

A

Brief Hx, quick exam, ECG
Bloods - FBC, U+Es, troponin, glucose, cholesterol
Imaging - CXR

Treatment =

  • Oral antiplatement (aspirin 300mg + ticagrelor 180mg)
  • Anticoagulation (fondaparinux 2.5mg, or enoxaparin 1mg/kg/12h)
  • B-blockers (unless on verapamil)
  • Nitrates
  • ACE-i
  • Lipid management
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47
Q

Causes of severe pulmonary oedema

A

Cardiovasular - LV failure, valve disease, arrhythmias
ARDS from any cause
Fluid O/L
Neurogenic

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48
Q

Differentials for severe pulmonary oedema

A

Asthma/COPD, pneumonia and pul oedema are often hard to distinguish
Therefore, consider treating all three (salbutamol nebs, furosemide, diamorphine and amoxicillin)

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49
Q

Symptoms and signs of severe pulmonary oedema

A

Symptoms - dyspnoea, orthopnoea, pink frothy sputum
Signs - distressed, pale, sweaty, tachycardic, tachypnoea, pulsus alternans, raised JVP, fine lung crackles, gallop rhythm, wheeze, usually sitting up and leaning forward

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50
Q

Investigations in severe pulmonary oedema

A

Bedside - ECG
Bloods - U+E, troponin, ABG, BNP
Imaging - CXR, echo

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51
Q

Management of severe pulmonary oedema

A 
Sit pt upright
High-flow O2 if low sats
IV access + monitor ECG
Investigations
Diamorphine 1.25mg IV slowly
GTN spray
If SBP >100, start nitrate infusion
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52
Q

Define cardiogenic shock

A

State of inadequate tissue perfusion primarily due to cardiac dysfunction. It may occur suddenly, or after progressive worsening heart failure

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53
Q

Causes of cardiogenic shock

A 
MI
Arrhythmias
PE
Tension pneumothorax
Cardiac tamponade
Myocarditis
Valve destruction
Aortic dissection
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54
Q

Management of cardiogenic shock

A

If the cause is MI - reperfusion
Manage in coronary care unit, or ICU

Investigations =
Bedside - ECG, ABG, UO, cardiac monitoring
Bloods - U+E, troponin
Imaging - CXR, CT if indicated

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55
Q

Outline the pathophysiology on cardiac tamponade

A

Pericardial fluid collects
Intrapericardial pressure rises
Heart cannot fill
Pumping stops

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56
Q

Causes of cardiac tamponade

A 
Trauma
Lung/breast cancer
Pericarditis
MI
Bacteria

Rare - inc urea, radiation, myxoedema, dissecting aorta, SLE

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57
Q

Signs of cardiac tamponade

A

Beck’s triad - Low BP, raised JVP, with muffled HS

Kussmaul’s sign - inc JVP on inspiration

Echo may be diagnostic
CXR - globular heart
ECG - electrical alternans

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58
Q

Define broad complex tachycardia

A

ECG rate >100bpm with QRS complexes >120ms

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59
Q

Differentials for broad complex tachycardia

A

VT
SVT with aberrant conduction
Pre-excited tachy with underlying WPW

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60
Q

Management of regular broad complex tachy

A
  • if VT or uncertain rhythm give amiodarone 300mg IV

- if known Hx of SVT and BBB treat as narrow complex tachy (adenosine)

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61
Q

Management of irregular broad complex tachy

A
  • seek expert help

- usually AF with BBB, pre-excited AF (give amiodarone), or polymorphic VT

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62
Q

Management of VT

A

Amiodarone

Shock if unstable

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63
Q

What is Torsade de pointes

A

Form of VT, with a constantly varying axis, often in the setting of long QT syndromes

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64
Q

Causes of Torsade de pointes

A

Congenital or from drugs (antidysrhythmics, tricyclics, antipsychotics)

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65
Q

Management of Torsade de pointes

A

If congenital long-QT give B-blockers

If acquired long-QT correct hypokalaemia, and give magnesium sulphate

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66
Q

Define narrow complex tachycardia

A

ECG rate >100bpm and QRS complex duration <120ms

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67
Q

Differentials for narrow complex tachycardia

A

Sinus tachy
Atrial tachyarrhythmias
Junctional tachycardia

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68
Q

Define sinus tachy

A

Normal P waves followed by normal QRS - not an arrhythmia, but if necessary rate control with B-blockers

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69
Q

Define atrial tachyarrhythmias and give some examples

A

Rhythm arises in atira, AVN is bystander

  • AF
  • atrial flutter (sawtooth baseline, 2:1 block)
  • atrial tachy
  • multifocal atrial tachy
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70
Q

Define junctional tachy and give some examples

A

AVN is part of the pathway, P wave is either buried in QRS complex, or occurring after QRS

  • AV nodal re-entry tachy
  • AV re-entry tachy (incl an accessory pathway e.g. WPW)
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71
Q

Management of narrow complex tachy

A

1) O2 if sats <90, IV access, ECG

2) Regular?
Irregular - AF
Regular - continuous ECG, vagal manoeuvres. If unsuccessful, give adenosine

3) Sinus rhythm acheived?
Yes - Paroxysmal re-entrant SVT
No - possible atrial flutter (control rate with B-block)

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72
Q

How does adenosine work in SVT?

A

Causes transient AV block

Distinguishes between re-entrant SVT and atrial flutter

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73
Q

Management of SVT

A

Adenosine

If fails, use verapamil

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74
Q

Management of AF or atrial flutter

A

Manage rate control

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75
Q

Management of junctional tachy

A

Try vagal manoeuvres
Adenosine will usually cardiovert to sinus rhythm
If it fails, use B-blockers or verapamil

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76
Q

Describe WPW syndrome

A

Caused by a congenital accessory conduction pathway between the atria and ventricles.
Resting ECG shows short PR interval and wide QRS due to delta wave
Present with SVT which may be due to AVRT, pre-excited AF, or pre-excited atrial flutter

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77
Q

Risk of WPW

A

Degeneration to VF and sudden death

78
Q

Management of WPW

A

Felcainide
Propafenone
Sotalol
Amiodarone

79
Q

Management of irregular narrow complex tachy

A

Assume AF
Rate control - metoprolol, verapamil (or digoxin in HF), amiodarone
Anticoagulation with warfarin or NOAC
If onset <48h consider cardioversion

80
Q

Define bradycardia

A

<60bpm - may be normal and asymptomatic in the very fit and young

81
Q

Symptoms of bradycardia

A 
Often asymptomatic
Fatigue
Nausea
Dizziness
Presence of syncope, chest pain, or breathlessness is concerning
82
Q

Causes of bradycardia

A

Physiological
Cardiac - degenerative changes causing fibrosis of conduction pathways, post-MI, sick sinus syndrome, iatrogenic, aortic valve disease, myocarditis, cardiomyopathy
Non-cardiac - vasovagal, endocrine (hypothyroid, adrenal insufficiency), metabolic (hyperkal, hypoxia), hypothermia, raised ICP
Drug-induced - B-blockers, amiodarone, verapamil, diltiazem, digoxin

83
Q

Management of bradycardia

A

O2 if hypoxic, BP, ECG, IV access

Atropine
Adrenaline

84
Q

Give some symptoms and signs of anaphylaxis

A

Symptoms - pruritis, urticaria, rhinitis, palpitations, N+V, abdo pain, feeling faint, SOBSigns - dyspnoea, stridor, wheeze, tachycardia, cyanosis, hypotension

85
Q

Give some differential diagnoses of anaphylaxis

A

Life-threatening asthmaSeptic shockPanic attack

86
Q

Describe the ‘A’ part of ABCDE for anaphylaxis

A

Airway - check for obstruction, maintain airway

87
Q

Describe the ‘B’ part of ABCDE for anaphylaxis

A

RR + accessory musclesChest expansionO2 sats -> give 85% O2 >10L/min via bag maskAuscultate -> wheeze * IM ADRENALINE 0.5MG IM + SALBUTAMOL NEBS*

88
Q

Describe the ‘C’ part of ABCDE for anaphylaxis

A

Cyanosis?
Pulse + cap refill
BP + JVP => hypotensive? give 500ml fluid challenge
2x wide-bore cannulae (take FBC, U&Es, LFTs, CRP)
ECG
Temp

89
Q

Management of STEMI

A

Morphine - 5-10mg IV (give metoclopramide 10mg IV)
O2 - if sats <95% or pt SOB
Nitrates
Aspirin 300mg + Ticagrelor 180mg
Restore coronary perfusion - PCI (if available in 3h), or fibrinolysis

90
Q

Why might you see an inc ALT on sepsis? Why are the other LFTs normal?

A

Sepsis causes dec perfusion to liver, leading to hepatocellular hypoxia
The other LFTs are deranged in cholestasis, which doesn’t occur in sepsis

91
Q

Causes of a raised lactate (>10)

A

Acute abdomen
Seizures
Sepsis

92
Q

Causes of neutropenic sepsis

A 
Chemotherapy
Carbimazole
Clozipine
Sepsis
Haematological malignancies
93
Q

Differentials for acute severe asthma

A 
Acute infective exacerbation of COPD
Pulmonary oedema
Upper resp tract obstruction
PE
Anaphylaxis
94
Q

Investigations for acute severe asthma

A

Bedside - PEF, ABG (if sats <92)
Bloods - FBC, U+E
Imaging - CXR

95
Q

Outline the parameters for severe asthma

A
  1. Unable to complete sentences
  2. RR >25
  3. HR >110
  4. PEF 33-50%
96
Q

Outline the parameters for life-threatening asthma

A
  1. PEF <33%
  2. Silent chest, cyanosis, feeble resp effort
  3. Arrhythmia or hypotension
  4. Exhaustion, confusion, coma
  5. ABG - normal/high CO2, O2 <8
97
Q

Management of an acute asthma attack

A

Assess severity, warn ICU if severe or life-threatening

  • Salbutamol 5mg neb with O2
  • if sev/LT add ipratropium 0.5mg/6h to neb
  • Hydrocortisone 100mg IV (or pred 40-50mg PO)
Reassess every 15min.
If PEF <75:
- Repeat salb neb every 15-30mins
- add ipratropium if not already
- Monitor ECG
- Consider MgSO4
98
Q

What would you do if a pt with acute asthma wasn’t improving after a5-30mins?

A

Refer to ICU for consideration of ventilatory support and intensive medical therapy (e.g. aminophyliine, IV salb)

99
Q

What would you do if a pt with acute asthma was improving after 15-30mins?

A
  • Cont neb salb every 4-6h (+ipratropium if started)
  • pred 40-50mg PO for 5-7d
  • monitor PEF and sats
  • if PEF >75% after 1h, consider discharge
100
Q

Outline when you’d discharge after an episode of acute severe asthma

A

Pts with PEF >75% within 1h of initial treatment.

Otherwise:

  • stable on d/c meds for 24h
  • inhaler technique check
  • PEF >75%
  • steroids + bronchodilator therapy
  • written mng plan
  • GP apt in 2d
  • resp clinic apt in 4wk
101
Q

SEs of salbutamol

A

Tachycarida
Arrhythmias
Tremor
Hypokalaemia

102
Q

SEs of aminophylline

A

Tachycardia
Arrhythmias
Nausea
Seizures

103
Q

Investigations in acute exacerbations of COPD

A

Bedside - ABG, ECG
Bloods - FBC, U+E, CRP, cultures (if pyrexial)
Imaging - CXR
Others - sputum culture

104
Q

Management of acute exacerbation of COPD

A
  • Neb salbutamol 5mg/4h + ipratropium 500mcg/6h

If sats <88:
- O2 24-28% (aim ABG O2 >8, CO2 <15)

  • IV hydro 200mg + oral pred 30mg OD (7-14d)

If infection:
- amoxicillin 500mg/8h PO

  • physiotherapy
105
Q

What would you do if a pt with acute COPD isn’t improving with initial treatment?

A
  • Consider IV aminophylline

- consider NIPPV if RR >30, or pH <7.35, or CO2 rising

106
Q

Causes of pneumothorax

A
  1. Spontaneous - rupture of a subpleural bulla
  2. CLD - asthma, COPD, CF, lung fibrosis, sarcoidosis
  3. Infection - TB, pneumonia, abscess
  4. Trauma - iatrogenic (pleural aspiration)
  5. Carcinoma
  6. CT disorders - Marfan’s, Ehlers-Danloa
107
Q

Symptoms and signs of pneumotherax

A

Symptoms - may be asym, or sudden SOB and/or pleuritic chest pain. Sudden deterioration of asthma/COPD

Signs - dec expansion, hyper-resonance, dec BS.
In tension, trachea is deviated away

108
Q

Investigations for pneumothorax

A

Bedside - ABG (in dyspnoeic/hypoxic pts, and in CLD)
Bloods - N/A
Imaging - CXR (unless tension)

109
Q

Management of a primary pneumothorax

A

SOB and/or >2cm rim of aim?

  • n -> d/c + outpt review
  • y -> attempt aspiration

Aspiration successful?

  • y -> d/c + outpt review
  • n -> chest drain
110
Q

Management of a secondary pneumothorax

A

SOB or >2cm rim of air?
- y -> chest drain

1-2cm rim of air:

  • n (<1) -> admit for 24h ob and O2
  • y -> aspiration

Aspiration successful?

  • y -> admit for 24h ob + O2
  • n -> chest drain
111
Q

When would you request surgical input with a pneumothorax?

A 
Bilateral
Lung fails to expand within 48hr of drain
Persistant air leak
2 or more prev on same side
Hx of pneumothorax on opp side
112
Q

Signs of a tension pneumothorax

A 
Resp distress
Tachycardia
Hypotension
Distended neck veins
Trachea deviated away from pneumothorax
Inc percussion note
Dec air entry
113
Q

Management of tension pneumothorax

A

BEFORE requesting CXR!

Large-bore (14-16G) needle with syringe (partially filled with saline) into 2nd IC space MC line. Remove plunger and allow air to bubble through syringe (saline acts as water seal)

Alt, insert large-bore cannula

114
Q

Common causative organisms of pneumonia

A 
Strep pneumoniae (commonest)
H influenzae
Mycoplasma pneumonia
Staph a (in ICU pts)
Legionella + Chlamydia psittaci
Gram -ve bacilli e.g. pseudomonas (in HAP or immunocomp)
115
Q

Symptoms and signs of pneumonia

A

Symptoms - fever, rigors, malaise, anorexia, SOB, cough, purulent sputum, haemoptysis, pleuritic chest pain

Signs - fever, cyanosis, herpes labialis, confusion, tachypnoea, tachycardia, hypotension, dec expansion, dull percussion, inc vocal resonance, bronchial breathing, pleural rub

116
Q

Management of pneumonia in acute setting

A

A-E assessment - O2 if hypoxic, fluids if hypotensive etc

Analgesia for chest pain (paracetamol 1g, NSAID)

If no improvement, consider CPAP, NIV if hypercapnic

117
Q

Investigations for pneumonia

A

Bedside - sats, ABG if <92
Biochem - FBC, U+E, LFT, CRP
Micro - blood cultures, sputum cultures, viral throat swab, pleural fluid asp + culture
Imaging - CXR

118
Q

Outline the CURB score, and how it relates to management

A 
C onfusion (AMT <8)
U rea >7
RR >30
BP <90/60
A ge >65
0-1 = home Mx
>2 = hospital
>3 = severe, consider ICU referral
119
Q

Mx of pneumococcal pneumonia

A

Amoxicillin (or
Benzylpenicillin or
Cephalosporin

120
Q

Mx of staphlococcal pneumonia

A

Flucloxacillin ± rifampicin

121
Q

Complications of pneumonia

A 
Pleural effusion
Empyema
Lung abscess
Resp failure
Septicaemia
Pericarditis
Myocarditis
122
Q

Risk factors for PE

A 
Malignancy
Surgery - esp pelvic and LL
Immobility, active inflam
Pregnancy, COCP, HRT
Prev TE, inherited thrombophilia
123
Q

Symptoms and signs of PE

A

Symptoms - acute SOB, pleuritic chest pain, haemoptysis, syncope

Signs - hypotension, tachycardia, gallop rhythm, inc JVP, RV heave, tachypnoea, cyanosis, AF

124
Q

Investigations for PE

A

Calulate Wells score

  • > 4 CTPA
  • <4 D-dimer (if +ve CTPA)

Bedside - ECG, ABG
Biochem - FEB, U+E, clotting, D-dimer (if low pre-test probability)
Imaging - CXR, CTPA

125
Q

Management of PE

A

O2 if hypoxic
Morphine 5-10mg IV (with antiemetic) if pain

IV access, start LMWH
Fluids if hypotensive

If haemo unstable - thrombolysis

Initiate LT anticoag -> DOAC or warfarin (3m if remedial cause, otherwise 3-6m)

126
Q

Causes of acute upper GI bleeding

A 
Peptic ulcer disease
Gastroduodenal erosions
Oesophagitis
Mallory-Weiss tear
Varices
Others - malignancy, vascular malformations, swallowed blood (facial trauma, nose bleeds)
127
Q

Symptoms and signs of upper GI bleeding

A

Symptoms - haematemesis or melaena, dizziness ± fainting, abdo pain

Signs - tachycardia, dec JVP, dec UO, cool and clammy, signs of CLD

128
Q

Immediate management of acute upper GI bleed with shock

A

1) Protect airway, NBM, 2 large-bore cannulae
2) Urgent bloods - FBC, U+E, LFT, gluc, clotting, X-match 4-6units
3) Rapid IV fluids
4) If grade III or IV shock give blood
5) Correct clotting abnormalities
6) If known CLD or alcohol excess give terlipressin + broad-spec Abx
7) Notify surgeons ± ICU referral

129
Q

Signs of shock

A

Peripherally cool/clammy, cap refill >2s, UO <0.5mg/kg/h
Dec GCS
Tachycardic
SBP <100

130
Q

Immediate management of upper GI bleed w/o shock

A

1) A-E
2) 2 Large bore cannulae, take bloods + give fluids (blood if Hb drop <70)
3) CXR, ECG, ABG
4) Urinary catheter
5) Correct clotting abnormalities
6) If CLD or alc excess give terlipressin + broad spec Abx
7) Urgent endoscopy

131
Q

As a GP, what would you do if you suspected a pt had meningitis?

A

Arrange urgent transfer to secondary care.

If non-blanching rash is present, give benzylpenicillin 1.2g IM/IV before admitting

132
Q

Common causative organisms of meningitis

A

Meningococcus
Pneumococcus
(Less common - H influenzae, listeria, HSV, VZV)

133
Q

Differentials for meningitis

A 
Malaria
Encephalitis
Septicaemia
SAH
Dengue
Tetanus
134
Q

Early and late features of meningitis

A

Early - headache, fever, leg pains, cold hands and feet, abnormal skin colour

Late - meningism (neck stiff, photophobia, Kernig’s sign), dec GCS, seizures, petechial rash, shock

135
Q

What is Kernig’s sign?

A

Pain and resistance on passive knee extension with ip fully flexed

Sign of meningism

136
Q

Management of meningitis

A

1) If raised ICP get ICU
2) Early Abx (ceftriaxone ± amox) - cultures first, LP first (if no shock, rash or raised ICP)
3) If features of meningism give dex 10mg/6h IV

137
Q

Describe the differences between CSF in bacterial and viral meningitis

A

Bacterial - looks turbid, polymorphic cells, cell count 90-1000 or more, gluc <1/2 plasma, >1.5 protein

Viral - clear, mononuclear cells, cell count 50-1000, gluc >1/2 plasma, proteins <1

138
Q

What would make you suspect encephalitis?

A

Any pt with odd behaviour, dec consciousness, focal neurology or seizures

139
Q

Symptoms and signs of encephalitis

A

Symptoms - bizarre behaviour, confusion, fever, headache, seizures, Hx travel/animal bite

Signs - behaviour, dec GCS, coma, fever, focal neuro signs

140
Q

Causes of encephalitis

A

Viral - HSV 1+2, arboviruses, CMV, EBV, VZV, HIV, measles,mumps

Non-viral - any bact meningitis, TB, malaria, listeria, Lyme disease

141
Q

Investigations for encephalitis

A

Bedside - normal obs
Biochem - routine
Micro - blood cultures, throat swab, malaria film, LP
Imaging - EEG, contrast CT

142
Q

Management of encephalitis

A

Start aciclovir within 30min of arrival (10mg/kg/8h IV over 1h) for 14d

Supportive therapy + symptomatic treatment

143
Q

When would you suspect cerebral abscess?

A

Any pt with raised ICP, esp if fever or inc WCC

May follow ear, sinus, dental or peridontal infection, skull fracture, congenital HD, endocarditis, bronchiectasis

144
Q

Signs of cerebral abscess

A 
Seizures
Fever
Localising signs
Signs of inc ICP
Coma
Sepsis signs
145
Q

Investigations for cerebral abscess

A

Bedside
Biochem - FBC, ESR
Micro - biopsy
Imaging - CT/MRI

146
Q

Management of cerebral abscess

A

Urgent neurosurgical referral
Treat raised ICP - e.g. mannitol (dex if oedema)
Discuss with micro re. likely cause

147
Q

Define status epilepticus

A

Seizures lasting >30min, or repeated seizures without intervening consciousness.
Usually occurs in pts with known epilepsy

148
Q

Investigations in status epilepticus

A

Bedside - cap glucose, ABG, ECG, pulse ox
Biochem - FBC, U+E, Ca, gluc, tox screen
Micro - LP, culture blood + urine
Imaging - EEG, CT

149
Q

Management of status epilepticus

A

Basic life support

  1. Lorazepam 0.1mg/kg (usually 4mg) as a slow bolus. If no response in 10-20min, give 2nd. Consider rectal route.

If fits continue:

  1. Phenytoin infusion 10-18mg/kg IVI
  2. ICU help
  3. Dexamethasone if vasculitis/cerebral oedema possible
150
Q

Initial management of head injury

A

ABC
Treat seizures with lorazepam ± phenytoin

Assess consciousness:
If GCS <8 -> call ICU to manage airway

Check for CSF leak
Palpate neck posteriorly - if tenderness, deformity immobilise neck + XR/CT

Involve neurosurgeons early if dec GCS or inc ICP

Assess for anterograde or retrograde amnesia

151
Q

Indications for CT head within 1h

A
  • GCS <13 initially, or <15 2h after injury
  • Focal neuro deficit
  • suspected open or depressed skull fracture, signs of basal skull fracture, CSF leak
  • Post-traumatic seizures
  • Vomiting more than once
152
Q

Indications for CT head within 8h

A

Any LOC or amnesia AND any of:

  • age >65
  • coagulopathy
  • high-impact injury
  • retrograde amnesia >30min
153
Q

Indications for CT spine within 1h

A
  • GCS <13 on initial assess
  • pt has been intubated
  • definitive diagnosis of C-spine injury needed urgently
  • pt having other areas scanned
  • clinical suspicion AND any of: age >65, high-impact, focal neuro deficit, paraesthesia in UL or LL
154
Q

When would you admit a pt after head injury?

A

1) If there are new, clinically signif abnormalities on CT
2) GCS <15 after CT
3) When CT indications met but CT unavailable
4) Other concerns - drugs, alcohol, other injuries, CSF lead, shock, meningism

155
Q

Early and late complications of head injury

A 
Early = extradural/subdural haemorrhage, seizures
Late = subdural, seizures, diabetes insipidus, parkinsonism, dementia
156
Q

Causes of raised intracranial pressure

A 
Primary tumour or mets
Head injury
Haemorrhage
Infection
Hydrocephalus
Cerebral oedema
Status epilepticus
157
Q

Signs and symptoms of raised ICP

A

Headache - worse on coughing or leaning forward
Vomiting
Altered GCS - drowsy, irritable
Bradycardia and HTN (Cushing’s response)
Pupil changes (constriction first, then dilatation)
Dec visual acuity, peripheral fields loss
Papilloedema (unreliable sign)

158
Q

Investigations for raised ICP

A

Bedside - N/A
Lab - FBC, UE, LFT, gluc, clotting, osmolality
Micro - blood culture, LP
Imaging - CXR, CT head

159
Q

Management of raised ICP

A
  • Correct hypotension, treat seizure
  • Elevate head of bed to 30’
  • If intubated, hypervent to dec CO2 (3.5-4), maintain O2 >12
  • IV mannitol 20%
  • If oedema, give IV dexa
  • Fluid restrict (<1.5L/d)
160
Q

Describe the mechanism of DKA

A

Excessive glucose but lack of insulin.

Body enters starvation state where ketoacidosis is only method of energy production

161
Q

Typical presentation of DKA

A 
Drowsiness
Vomiting
Dehydration
Abdo pain
Polydipsia
Polyuria
Lethargy
Anorexia
Coma
162
Q

Triggers of DKA

A 
Infection
Surgery
MI
Pancreatitis
Chemotherapy
Antipsychotics
Non-compliance with insulin
163
Q

How would you diagnose DKA?

A
  1. Acidaemia (pH <7.3 or HCO3 <15)
  2. Hyperglycaemia (>11), or known DM
  3. Ketonaemia (>3) or signif ketonuria (>2+)
164
Q

Investigations in DKA

A

Bedside - urine dip, ECG, cap gluc, VBG
Lab - glucose, ketones, UE, osmolality, FBC
Micro - blood cultures
Imaging - CXR

165
Q

Outline the criteria for severe DKA

A 
Blood ketones >6
Venous bicarb <5
pH <7
K <3.5 on admission
GCS <12
Sats <92% on air
SBP <90
Pulse >100 or <60
Anion gap >16
166
Q

Management of DKA

A

1) Fluids - 1L saline 1hr, or fluid challenge if hypotensive
2) Insulin - add 50units soluble insulin to 50ml saline. Infuse at 0.1unit/kg/h. Cont their normal long-acting insulin as normal
3) When gluc <14, start 10% glucose at 125ml/h alongside saline
4) Cont fixed-rate insulin until ketones <0.6, bicarb >15, pH >7.3
5) Find and treat causes

167
Q

What blood changes do you monitor in DKA? What rate are you aiming for?

A

Aim to dec ketones by 0.5mmmol/L/h, OR
rise in bicarb of 3mmol/L/h
Fall in gluc of 3mmol/L/h

168
Q

Complications of DKA

A 
Cerebral oedema
Aspiration pneumonia
Hypokalaemia
Hypomagnesaemia and hypophosphataemia
Thromboembolism
169
Q

Signs and symptoms of myxoedema coma

A 
Look hypothyroid
Hypothermia
Hyporeflexia
Hypoglycaemic
Bradycardic
Coma/seizures
Goitre
Cyanosis
Hypotensive
HF
170
Q

Management of myxoedema coma

A
  • > ICU!
    1) Bloods - T3, T4, TSH, FBC, UE, cultures, cortisol, glucose, ABG
    3) Correct any hypoglycaemia
    4) Give T3 IV slowly
    5) Give hydrocortisone IV
    5) Abx if infection
    6) Caution with fluids - rehydrate if needed
    7) Active warming if hypothermic
171
Q

Signs and symptoms of a hyperthyroid crisis

A 
Hyperthermic
Agitated, coma, confusion
Tachycardia, AF
D+V
Goitre
Acute abdo
HF
172
Q

Management of hyperthyroid crisis

A

1) Bloods - T3, T4, TSH, cultures
2) Fluids if dehydrated
3) If no C/I start propranolol (diltiazem if prop C/I)
4) Digoxin to slow heart
5) Antithyroid drugs - carbimazole, 4h later Lugol’s solution (aqueous iodine)
6) Hydrocortisone or dex to prevent peripheral T4->T3
7) Treat any infections

173
Q

Presentation of an Addisonian crisis

A

May present in shock (tachycardic, postoral hypotension, oliguria, weak, confused)
Usually already diagnosed with Addison’s who hasn’t doubled steroid dose

174
Q

Management of Addisonian crisis

A

1) Bloods - cortisol + ACTH, UE
2) Hydrocortisone IV stat (change to PO steroids after 72h)
3) IV fluid bolus
4) Monitor BM
5) Blood/urine/sputum culture
6) Abx if infection suspected

175
Q

BZD OD antidote

A

Flumazenil

176
Q

B-blocker OD antidote

A

If severe bradycardia or hypotension:
Atropine up to 3mg IV
Glucagon + 5% dex if atropine fails
Consider enoximone

177
Q

Management of CO poisoning

A

Remove source
100% O2 until COHb <10%
Give mannitol if cerebral oedema

178
Q

Symptoms of digoxin OD

A 
Dec cognition
Yellow-green visual halos
Arrhythmias
Nausea
Anorexia
179
Q

Management of digoxin OD

A

If serious arrhythmias present, correct hypokal and inactivate digoxin with Digi-Fab (specific antibody fragment)

180
Q

Management of INR 5-8 (no bleed)

A

Withold 1-2 doses

Restart warfarin at lower maintenance dose

181
Q

Management of INR 5-8, minor bleed

A

Stop warfarin and admit for urgent IV vit K

Restart warfarin when INR <5

182
Q

Management of INR >8, no bleed

A

Stop warfarin and seek haem advice

183
Q

Management of INR >8, minor bleed

A

Stop warfarin and admit for urgent IV vit K
Check INR daily
Restart warfarin at lower dose when INR <5

184
Q

Management of major bleed in patient on warfarin

A

Stop warfarin

Give prothrombin complex concentrate + vit K IV

185
Q

Signs and symptoms of paracetamol OD

A

None initially, may be vomiting ± RUQ pain

Later - jaundice and encephalopathy ± AKI

186
Q

Management of paracetamol OD

A

1) GI decontamination if <4h - activated charcoal 1g/kg (max 50g)
2) Bloods - gluc, UE, LFT, INR, ABG, FBC, bicarb, blood paracetamol levels at 4h post-ing
3)
- If <10-12h with no vomiting and para blood levels above line on graph -> start acetylcysteine
- If >8-24h + suspicion of large OD (>7.5g) - start acetylcysteine

187
Q

Causes of hypothermia

A
  • impaired homeostatic mechanisms (usually age-related)
  • low room temp
  • impaired thermoreg (pneumonia, MI, HF)
  • dec metabolism (immobility, hypothyroid, DM)
  • autonomic neuropathy (DM, Parkinson’s)
  • excess heat loss
  • dec cold awareness (dementia, confusion)
  • inc exposure to cold (falling outside)
  • drugs (major tranquilisers, antidep, diuretics, alcohol)
188
Q

How would you determine the severity of hypothermia

A

If they’re shivering then it’s mild

If they’re not shivering despite temp <35, then it’s severe

189
Q

Investigations in hypothermia

A

Urgent UE, gluc, amylase
TFTs, FBC, blood cultures
Consider ABG/VBG
ECG - may show J waves

190
Q

Test to establish whether an episode was due to anaphylaxis

A

Serum tryptase

191
Q

In the treatment of anaphylaxis, how often can adrenaline be given?

A

Every 5min

Finals (25 decks)

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