Acute care Flashcards
Diarrhoea followed by widespread non blanching red rash and what to check
Vasculitis
Check renal function, proteinuria
Classification of post op haemorrhage e
Primary - continuous, starting during surgery, replace blood loss, treat shock, may return to theatre for haemostasis
Reactive - bleeding starts in response to blood pressure increase (anaesthetic wears off and stress reaction)
Secondary - infection 1-2w post op
Causes of sinus bradycardia
Drugs - b blockers, digoxin, amiodarone, verapamil Acute MI (inferior) Sick sinus syndrome Vasovagal Hypothyroid Hypothermia RICP Cholestasis
Manage bradycardia
Treat if under 40 or symptomatic
Atropine 0.6-1.2mg IV
Pacing - wire or external
Isoprenaline infusion
Red flags for headache
Thunderclap - SAH
Worse leaning forward, in morning and coughing - RICP, venous thrombus
Unilateral and eye pain - acute glaucoma, cluster headache
Scalp tenderness, over 50 - giant cell arteritis
Fever or neck stiffness - meningitis
Reduced consciousness
Pregnant - pre eclampsia
Travelling - malaria
3 signs elicited on exam for meningitis
Kernig’s sign - pain and resistance on extension of knee when hip flexed
Brudzinski sign - hip and knee flex when neck flexed
Tripod - stand up in tripod position to avoid bending neck
Immediate managements for coma
Hypoglycaemia - 50ml 50% dextrose iv stat
Wernicke’s encephalopathy - thiamine
Opiate OD - naloxone (0.4-2mg iv), IM or NGT
Benzo OD - flumazenil only if airway compromise
Septic - abx, acyclovir (herpes simples)
Causes of coma
V - stroke, subdural/subarachnoid hypertensive encephalopathy
I - meningitis, encephalitis (herpes simples, malaria
T - trauma
M - hypoglycaemia, dka, honk, hypoxia, co2 narcosis, hypothermia, addisonian crisis, myxoedema (hypothyroid), hepatic/uraemic encephalopathy
I - tricyclics, alcohol, carbon monoxide
N - tumour
C - epilepsy non-convulsive or post ictal state
GCS make up
Motor: 6 fully responsive 5 localised response to pain 4 withdraws from pain 3 flex to pain 2 extend to pain 1 no response Verbal: 5 orientated 4 confused conversation 3 inappropriate speech 2 incomprehensible speech 1 none Eye opening: 4 spontaneous 3 in response to speech 2 in response to pain 1 none
Grades of hypertensive retinopathy
Grade 1 - twisting of retinal arteries with silver wiring (reflective)
Grade 2 - with AV napping - arteries thickened over veins
Grade 3 - with flame shaped haemorrhages and cotton wool exudates (infarcts)
Grade 4 - with papilloedema
Bell’s palsy senses findings
Hyperacusis
Midriasis
Altered/metallic taste
Non forehead sparing
Types of shock
Pump failure: cardiogenic, or secondary to PE, tamponade, tension pneumothorax
Circulatory failure:
- anaphylaxis
- hypovolaemia including heat exhaustion, fluid (diarrhoea etc) and bleeding (incl third spacing)
- sepsis
- hypothyroid, addisons
- neurogenic - spinal surgery
- drugs - antihypertensives, anaesthetics
Doses of 2 abx for sepsis
Meropenem 1g/8h
Co amoxiclav 1.2g/8h
Manage heat exhaustion causing shock
Cooling
0.9% saline
Hydrocortisone
What is anaphylaxis
Type 1 IgE mediated hypersensitivity reaction
Causes: urticaria, capillary leak, wheeze, cyanosis, oedema due to histamine
Other sx: diarrhoea, vomiting, itchy, sweating
Management for anaphylaxis
Adrenaline IM 0.5mg of 1:1000 every 5m
Chlorphenamine 10mg iv
Hydrocortisone 200mg iv
ECG criteria for thrombolysis
ST elevation of 1mm or more in 2 or more limb leads
ST elevation of 2mm or more in 2 or more chest leads
New LBBB
Deep ST depression and tall R waves in V1-3
Contraindications to thrombolysis
Internal bleeding Suspected aortic dissection Oesophageal varices Recent haemorrhagic stroke Recent trauma or surgery within 2w Acute pancreatitis Severe liver disease Active lung disease with cavitation Cerebral neoplasm Severe hypertension
Possible ECG signs for NSTEMI
Normal
Inverted or flat t waves
St depression
Poor prognostic factors in NSTEMI
Over 70yo
Raised troponin
History of unstable angina
Comorbidities - previous mi, poor lv function, diabetes
Causes of cardiogenic shock
MI Arrhythmia PE Tamponade Tension pneumothorax Myocarditis Aortic dissection Endocarditis
Manage cardiogenic shock
Pulmonary capillary wedge pressure low = plasma expander
High = inotropic support dobutamine
Dopamine
Severe asthma and life threatening asthma features
Severe: rr>25, pulse >110, PEFR <50%, unable to complete sentences
Life threatening: silent chest, cyanosis, bradycardia, hypotension, PEFR <33%, exhaustion, normal/high pCO2, pOw <8, low pH
Manage life threatening asthma
Salbutamol 5mg and ipratropium 0.5mg nebs
Hydrocortisone/prednisolone
Magnesium sulphate 1.2-2g iv
Aminophylline
Causes of pneumothorax
Pneumonia, TB, abscess Trauma CT disorders Cystic fibrosis, asthma, copd, fibrosis Carcinoma Iatrogenic
Complications of pneumonia
Abscess Pleural effusion Empyema Resp failure Septicaemia Pericarditis Myocarditis Cholestatic jaundice Renal failure
Examination findings for PE
Gallop rhythm Loud P2 Pleural rub AF Raised JVP RV heave Cyanosis, tachypnoea, hypotension
Initial antibiotics for meningitis and other drug for meningitic
Benzylpenicillin 1.2g iv/im then cefotaxime 2g (trust guidelines)
Dexamethasone
Normal LP opening pressure
18-20cm
CSF in pyogenic meningitis, TB and viral
Pyogenic - Turbid, polymorphs, high cell count, low glucose, high protein
TB - fibrin web, mononuclear, medium cell count, low glucose medium protein
Viral - clear, mononuclear, medium cell count, high glucose, low protein
Causes of encephalitis
Viral - HSV, CMV, arbovirus, EBV, VZV, measles, mumps
Non-viral - bacterial meningitis, TB, listeria, malaria
Bloods and LP and treatment for encephalitis
Blood cultures
Blood film for malaria parasites
PCR of serum, throat swab and MSU
Toxoplasma IgM titre
LP - moderate protein and lymphocytes, low glucose
Acyclovir 10mg/kg/8h within 1h for HSV empirical
Causes of cerebral abscess
Infection - ear, sinus, dental, periodontal Skull fracture Congenital heart disease Endocarditis Bronchiectasis
Manage status epilepticus
Lorazepam IV 2-4mg over 30 seconds Rectal diazepam Buccal midazolam Phenytoin infusion Diazepam infusion Dexamethasone if cerebral oedema/vasculitis
CI to phenytoin in status epilepticus
Bradycardia or heart block
Indications for CT head after head injury
Vomiting Reduced GCS Focal neuro deficit Suspected skull fracture Seizure post trauma Loss of consciousness and over 65yo, coagulopathy, anterograde amnesia or high impact injury
Long term complications of head injury
Subdural haematoma Seizures Parkinsonism Diabetes insipidus Dementia
Bad prognostic factors in head injury
Old age Decerebrate rigidity Extensor spasms Increased blood pressure Low pO2 Temperature high
Normal ICP and pathophysiology of RICP
0-10mmHg
Vasogenic - increased cap permeability from infection, trauma, ischaemia, tumour
Cytotoxic - cell death from hypoxia
Interstitial - obstructive hydrocephalus
What is Cushing’s response in RICP
Falling hr and increasing bp
Management of ventilation in RICP
Cause hyperventilation to decrease pCO2 and cause vasoconstriction
Management of RICP
Hyperventilate
Mannitol but cautious of rebound increase in ICP
Dexamethasone if cerebral oedema around tumour
Fluid restriction to under 1.5l /d
Triggers for DKA
Surgery Infection MI Pancreatitis Chemotherapy Antipsychotics
Electrolyte abnormality in DKA
Hyponatraemia due to osmolar compensation for hyperglycaemia
Normal or high sodium = severe water loss
Manage DKA
Soluble insulin IV novorapid 4-8u, change to sc when ketones under 1 and eating
5% dextrose when glucose under 10
Fluids and potassium replacement
DKA complications
Cerebral oedema
Aspiration pneumonia
VTE
Low electrolytes - phosphate, magnesium, potassium
Manage hypoglycaemia
200-300ml of 10% dextrose
Or glucagon 1mg IM
Diabetic emergencies
DKA
Hypoglycaemia
HONK - hyperglycaemic hyperosmolar non-ketotic
Hyperlactataemia - with metformin or sepsis
What is HONK and how to treat and cause
Dehydration and high BM for a week with hyperosmolarity and no ketone production, from drugs, MI or bowel infarct
Give saline and K once urine flowing, may need insulin but wait for 1h to check
Myxoedema coma features
Hypothyroid, hypothermia, hypoglycaemia, hyporeflexia, bradycardia, seizures, coma
Exam - goitre, cyanosis, low BP, HF, signs of precipitants
Treat myxoedema coma
T3 slow infusion then levothyroxine
Hydrocortisone, especially if pituitary hypothyroidism
Saline, abx, oxygen, warm etc
Features of hyperthyroid (thyrotoxic storm)
Agitated, confusion, coma
D&V
Goitre, bruit, Raised temperature, AF, tachycardia
Acute abdo, heart failure, CVS collapse
Causes of thyrotoxic storm
Thyroid surgery Radioiodine MI Infection Trauma
Confirm diagnosis of thyrotoxic storm
Technetium uptake
Manage thyrotoxic storm
Stabilise: Saline, NGT if vomiting, Sedate if necessary with chlorpromazine
Peripheral effects: Propranolol if cardiac output OK, High dose digoxin to slow heart
Suppress thyroid: carbimazole PO or NGT
Hydrocortisone or dexamethasone
Treat infection, cool incl paracetemol
Presentation of addisonian crisis
Shock - high pulse, vasoconstriction, postural hypotension, oliguria, weak, confused, coma
Hypoglycaemia
History of addisons with infection but no increase in steroids, or forgotten to take steroids
What investigaions and treatment for addisonian crisis
Cortisol and ACTH with heparin and straight to lab
Monitor for low BM
Find infection
Hydrocortisone 100mg IV stat then change to oral after 72h
Antibiotics
May need glucose
Saline
Presentation of hypopituitary coma
Hypothermia, refractory hypotension, septic signs without fever = chronic hypophyseal failure
Short stature, loss of axillary hair, gonadal atrophy
Headache, meningism, opthalmoplegia, reduced consciousness, hypoglycaemia
Investigate and treat hypopituitary coma
Cortisol T4, TSH ACTH Glucose Pituitary fossa CT/MRI
Treat: hydrocortisone 100mg IV, T3, surgery if apoplexy
Features and causes of hypertensive crisis in phaeochromocytoma
Pallor, feel about to die, pulsating headache
Raised temperature, LVF, cardiogenic shock, VT, ST elevation
Caused by stress, GA, parturition, abdo palpation
Treat phaeochromocytoma emergency
Phentolamine to maintain safe BP
Phenoxybenzamine
= alpha blockers
Indications for urgent dialysis
Persistently high potassium over 7 Pulmonary oedema and no diuresis Highly catabolic state with rapidly progressing renal failure Acidosis with pH under 7.2 Pericarditis
ECG changes of high potassium
Tall tented t waves Flat p waves Increasing PR interval Wide qrs VF/VT
Drug Management of hyperkalaemia
Calcium gluconate 10ml of 10% IV over 2mins, repeat as necessary
Novorapid insulin and glucose IV
Nebulised salbutamol
Calcium resonium orally or enema
Drugs that can cause metabolic acidosis
Alcohol
Antifreeze ethylene glycol
Paracetamol
Carbon monoxide
Symptoms of digoxin toxicity and treatment
Cognition decreased Nausea, anorexia Arrhythmia Yellow/green halos Correct hypokalaemia, give digoxin-specific antibody fragments
Opiate overdose treatment and it’s side effects
Naloxone 0.4-2mg every 2 mins until breathing adequate, max 10mg
Can cause diarrhoea and cramps
Features of aspirin toxicity and pH change
Vomiting, dehydration, hyperventilation, sweating
Tinnitus, vertigo
Lethargy and coma, seizures
Reduced bp, heart block, pulmonary oedema, hyperthermia
Initially respiratory alkalosis due to resp centre stimulation, then metabolic acidosis
Manage metabolic acidosis in aspirin toxicity
Bicarbonate
Bicarbonate and KCl to alkalinise urine, monitor for hypokalaemia
Dose of paracetamol that is toxic and treatment, and ADR
150mg/kg or 12g in adults, less if malnourished
Give N-Ac if over treatment line, or over 8h and suspect high dose, at 150mg/kg in 5% dextrose 200ml in 15mins
Can cause rash - treat with chlorphenamine
When is paracetamol treatment graph not accurate
Long acting paracetamol
HIV positive as hepatic glutathione is reduced
Pre-existing liver disease or enzyme induction
Things to monitor in paracetamol overdose
Encephalopathy or RICP (oedema) - high BP, bradycardia, decerebrate, extensor spasms
INR (peaks at 48-72h)
Renal impairment - creatinine and urine flow
pH
Severe hypotension (<80)
Causes of lactic acidosis in paracetamol OD
1) metabolite of paracetamol inhibits aerobic respiration
2) liver failure causes lactate build up and shock which causes tissue hypoperfusion
Complications of hypothermia
Arrhythmia Pneumonia Pancreatitis Acute renal failure Intravascular coagulation
