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Finals > Acute care > Flashcards

Acute care Flashcards

1
Q

Diarrhoea followed by widespread non blanching red rash and what to check

A

Vasculitis

Check renal function, proteinuria

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2
Q

Classification of post op haemorrhage e

A

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

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3
Q

Causes of sinus bradycardia

A 
Drugs - b blockers, digoxin, amiodarone, verapamil
Acute MI (inferior)
Sick sinus syndrome
Vasovagal
Hypothyroid
Hypothermia
RICP
Cholestasis
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4
Q

Manage bradycardia

A

Treat if under 40 or symptomatic
Atropine 0.6-1.2mg IV
Pacing - wire or external
Isoprenaline infusion

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5
Q

Red flags for headache

A

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

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6
Q

3 signs elicited on exam for meningitis

A

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

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7
Q

Immediate managements for coma

A

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)

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8
Q

Causes of coma

A

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

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9
Q

GCS make up

A 
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
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10
Q

Grades of hypertensive retinopathy

A

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

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11
Q

Bell’s palsy senses findings

A

Hyperacusis
Midriasis
Altered/metallic taste
Non forehead sparing

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12
Q

Types of shock

A

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

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13
Q

Doses of 2 abx for sepsis

A

Meropenem 1g/8h

Co amoxiclav 1.2g/8h

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14
Q

Manage heat exhaustion causing shock

A

Cooling
0.9% saline
Hydrocortisone

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15
Q

What is anaphylaxis

A

Type 1 IgE mediated hypersensitivity reaction
Causes: urticaria, capillary leak, wheeze, cyanosis, oedema due to histamine
Other sx: diarrhoea, vomiting, itchy, sweating

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16
Q

Management for anaphylaxis

A

Adrenaline IM 0.5mg of 1:1000 every 5m
Chlorphenamine 10mg iv
Hydrocortisone 200mg iv

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17
Q

ECG criteria for thrombolysis

A

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

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18
Q

Contraindications to thrombolysis

A 
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
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19
Q

Possible ECG signs for NSTEMI

A

Normal
Inverted or flat t waves
St depression

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20
Q

Poor prognostic factors in NSTEMI

A

Over 70yo
Raised troponin
History of unstable angina
Comorbidities - previous mi, poor lv function, diabetes

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21
Q

Causes of cardiogenic shock

A 
MI
Arrhythmia
PE
Tamponade
Tension pneumothorax 
Myocarditis
Aortic dissection
Endocarditis
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22
Q

Manage cardiogenic shock

A

Pulmonary capillary wedge pressure low = plasma expander
High = inotropic support dobutamine
Dopamine

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23
Q

Severe asthma and life threatening asthma features

A

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

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24
Q

Manage life threatening asthma

A

Salbutamol 5mg and ipratropium 0.5mg nebs
Hydrocortisone/prednisolone
Magnesium sulphate 1.2-2g iv
Aminophylline

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25
Q

Causes of pneumothorax

A 
Pneumonia, TB, abscess
Trauma
CT disorders
Cystic fibrosis, asthma, copd, fibrosis
Carcinoma
Iatrogenic
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26
Q

Complications of pneumonia

A 
Abscess
Pleural effusion
Empyema
Resp failure
Septicaemia
Pericarditis
Myocarditis
Cholestatic jaundice
Renal failure
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27
Q

Examination findings for PE

A 
Gallop rhythm
Loud P2
Pleural rub
AF
Raised JVP
RV heave
Cyanosis, tachypnoea, hypotension
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28
Q

Initial antibiotics for meningitis and other drug for meningitic

A

Benzylpenicillin 1.2g iv/im then cefotaxime 2g (trust guidelines)
Dexamethasone

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29
Q

Normal LP opening pressure

A

18-20cm

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30
Q

CSF in pyogenic meningitis, TB and viral

A

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

31
Q

Causes of encephalitis

A

Viral - HSV, CMV, arbovirus, EBV, VZV, measles, mumps

Non-viral - bacterial meningitis, TB, listeria, malaria

32
Q

Bloods and LP and treatment for encephalitis

A

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

33
Q

Causes of cerebral abscess

A 
Infection - ear, sinus, dental, periodontal
Skull fracture
Congenital heart disease
Endocarditis 
Bronchiectasis
34
Q

Manage status epilepticus

A 
Lorazepam IV 2-4mg over 30 seconds
Rectal diazepam
Buccal midazolam
Phenytoin infusion
Diazepam infusion
Dexamethasone if cerebral oedema/vasculitis
35
Q

CI to phenytoin in status epilepticus

A

Bradycardia or heart block

36
Q

Indications for CT head after head injury

A 
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
37
Q

Long term complications of head injury

A 
Subdural haematoma
Seizures
Parkinsonism
Diabetes insipidus
Dementia
38
Q

Bad prognostic factors in head injury

A 
Old age
Decerebrate rigidity
Extensor spasms
Increased blood pressure
Low pO2
Temperature high
39
Q

Normal ICP and pathophysiology of RICP

A

0-10mmHg
Vasogenic - increased cap permeability from infection, trauma, ischaemia, tumour
Cytotoxic - cell death from hypoxia
Interstitial - obstructive hydrocephalus

40
Q

What is Cushing’s response in RICP

A

Falling hr and increasing bp

41
Q

Management of ventilation in RICP

A

Cause hyperventilation to decrease pCO2 and cause vasoconstriction

42
Q

Management of RICP

A

Hyperventilate
Mannitol but cautious of rebound increase in ICP
Dexamethasone if cerebral oedema around tumour
Fluid restriction to under 1.5l /d

43
Q

Triggers for DKA

A 
Surgery
Infection
MI
Pancreatitis
Chemotherapy
Antipsychotics
44
Q

Electrolyte abnormality in DKA

A

Hyponatraemia due to osmolar compensation for hyperglycaemia

Normal or high sodium = severe water loss

45
Q

Manage DKA

A

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

46
Q

DKA complications

A

Cerebral oedema
Aspiration pneumonia
VTE
Low electrolytes - phosphate, magnesium, potassium

47
Q

Manage hypoglycaemia

A

200-300ml of 10% dextrose

Or glucagon 1mg IM

48
Q

Diabetic emergencies

A

DKA
Hypoglycaemia
HONK - hyperglycaemic hyperosmolar non-ketotic
Hyperlactataemia - with metformin or sepsis

49
Q

What is HONK and how to treat and cause

A

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

50
Q

Myxoedema coma features

A

Hypothyroid, hypothermia, hypoglycaemia, hyporeflexia, bradycardia, seizures, coma
Exam - goitre, cyanosis, low BP, HF, signs of precipitants

51
Q

Treat myxoedema coma

A

T3 slow infusion then levothyroxine
Hydrocortisone, especially if pituitary hypothyroidism
Saline, abx, oxygen, warm etc

52
Q

Features of hyperthyroid (thyrotoxic storm)

A

Agitated, confusion, coma
D&V
Goitre, bruit, Raised temperature, AF, tachycardia
Acute abdo, heart failure, CVS collapse

53
Q

Causes of thyrotoxic storm

A 
Thyroid surgery
Radioiodine
MI
Infection
Trauma
54
Q

Confirm diagnosis of thyrotoxic storm

A

Technetium uptake

55
Q

Manage thyrotoxic storm

A

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

56
Q

Presentation of addisonian crisis

A

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

57
Q

What investigaions and treatment for addisonian crisis

A

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

58
Q

Presentation of hypopituitary coma

A

Hypothermia, refractory hypotension, septic signs without fever = chronic hypophyseal failure
Short stature, loss of axillary hair, gonadal atrophy
Headache, meningism, opthalmoplegia, reduced consciousness, hypoglycaemia

59
Q

Investigate and treat hypopituitary coma

A 
Cortisol
T4, TSH
ACTH
Glucose
Pituitary fossa CT/MRI

Treat: hydrocortisone 100mg IV, T3, surgery if apoplexy

60
Q

Features and causes of hypertensive crisis in phaeochromocytoma

A

Pallor, feel about to die, pulsating headache
Raised temperature, LVF, cardiogenic shock, VT, ST elevation
Caused by stress, GA, parturition, abdo palpation

61
Q

Treat phaeochromocytoma emergency

A

Phentolamine to maintain safe BP
Phenoxybenzamine
= alpha blockers

62
Q

Indications for urgent dialysis

A 
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
63
Q

ECG changes of high potassium

A 
Tall tented t waves
Flat p waves
Increasing PR interval
Wide qrs
VF/VT
64
Q

Drug Management of hyperkalaemia

A

Calcium gluconate 10ml of 10% IV over 2mins, repeat as necessary
Novorapid insulin and glucose IV
Nebulised salbutamol
Calcium resonium orally or enema

65
Q

Drugs that can cause metabolic acidosis

A

Alcohol
Antifreeze ethylene glycol
Paracetamol
Carbon monoxide

66
Q

Symptoms of digoxin toxicity and treatment

A 
Cognition decreased
Nausea, anorexia
Arrhythmia
Yellow/green halos
Correct hypokalaemia, give digoxin-specific antibody fragments
67
Q

Opiate overdose treatment and it’s side effects

A

Naloxone 0.4-2mg every 2 mins until breathing adequate, max 10mg
Can cause diarrhoea and cramps

68
Q

Features of aspirin toxicity and pH change

A

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

69
Q

Manage metabolic acidosis in aspirin toxicity

A

Bicarbonate

Bicarbonate and KCl to alkalinise urine, monitor for hypokalaemia

70
Q

Dose of paracetamol that is toxic and treatment, and ADR

A

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

71
Q

When is paracetamol treatment graph not accurate

A

Long acting paracetamol
HIV positive as hepatic glutathione is reduced
Pre-existing liver disease or enzyme induction

72
Q

Things to monitor in paracetamol overdose

A

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)

73
Q

Causes of lactic acidosis in paracetamol OD

A

1) metabolite of paracetamol inhibits aerobic respiration

2) liver failure causes lactate build up and shock which causes tissue hypoperfusion

74
Q

Complications of hypothermia

A 
Arrhythmia
Pneumonia
Pancreatitis
Acute renal failure
Intravascular coagulation

Finals (13 decks)

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