Acute care

Question 1

Aspirin OD management dose

Answer 1

<125mg/kg: discharge (return if Sx esp. vomiting, tinnitus, sweating)
>125 mg/kg or unknown: 50g activated charcoal. Protect airway
>500mg/kg if <1hr: gastric lavage, >1hr 50g charcoal

Question 2

Aspirin OD severe features

Answer 2

coma, convulsion, aki, pulmonary oedema

Haemodialysis + NaHCO3 infusion

Question 3

Aspirin OD no severe features

Answer 3

rehydrate
take salicylate level, FBC, U+E, INR
ABG (if met. acidosis give NaHCO3 if pH <7.3, haemodialysis if <7.2)

Question 4

Aspirin OD severity by salicylate level

Answer 4

mild (300-600mg/L): rehydrate with fluids, repeat levels until pek
Mod (600-800)L urinary alkalinisation
sev (800+) haemodialysis

Question 5

aspirin OD Cx

Answer 5

severe features (coma, convulsion, AKI, pulmonary oedema)
All Mx by haemodialysis +/- NaHCO3

Question 6

Aspirin OD prognosis

Answer 6

Depends on severity
With Mx mild-mod can expect full recovery
Severe at risk of morbidity from coma/convulsion or AKI

Question 7

Burns rule of 9s

Answer 7

Torso (front): 18%
Back: 18%
Leg: 18% (9% front, 9% back)
Arm: 9% (4.5% front 4.5% back)
Head 9% (4.5% front 4.5% back)
Genitals 1%
Hand 1%

Question 8

Burns degrees

Answer 8

First deg:
Erythema
Pain
ABSENCE of blister
Sunburn

Second deg (partial)
Red/Mottled
Flash burns
Blister
Hot liquids

Third deg (full thickness)
Dark and leathery
DRY
Fire Elecricity, Prolonged exposure to hot liquids/objects

Question 9

Burns req. hospitalisation

Answer 9

• > 15% In adult, 10% in child
• Any burn in very young, elderly ot infirm
• Any FULL THICKNESS
• Burns to face, hands, feet, perineum
• Circumferential full thickness burn
• Inhalation injury
  Ass. Trauma or significant preburn morbidity

Question 10

Burns wound care first aid

Answer 10

Cool water continuously for 30m

If burn area large apply clean wraps and keep patient warm

Question 11

burns would care initial Mx

Answer 11

1. Tetanus prophylaxis
   
   2. Debride bullae, excise necrotic tissuse initially and during first 7d
   3. After debridement cleanse with chlorhexidine, and apply thin layer of silver sulfadiazin
      Dress with petroleum gauze and dry gauze thick enough to prevent seepage

Question 12

burns daily mx

Answer 12

1. Change dressing twice daily if poss and remove loose tissue
   
   2. Inspect wound for signs of infection
   3. Adminster topical Abx daily
   4. Systemic Abx low threshold
      For burns on hands cover with silver sulfadiazine and place in loose glove. Elevate for 48hrs then begin hand rehab exercises. Clean and check daily`

Question 13

Burns healing phase

Answer 13

Apply split thickness skin grafts to full thickness burns after wound excision or appearance of granulation tissue

Question 14

Nutrition in burns

Answer 14

Up to 6000kcals/day may be required. Consider NG tube

Ensure patient not anemic or electrolyte imbalanced

Question 15

burns Cx

Answer 15

Scarring and contracture in childen - early surgical release of potentially problematic scars
Circumferential burns causing distal ischaemia - release of eschar to enable blood flow
Loss of function in fingers/toes - early debridement and rehabiliton of hands
Fluid Loss - cover burns adequately and perform close fluid balance observation
Infection - examine site of burn for signs of infection, apply topical abx and consider systemic Abx at low threshold

Question 16

Burns prognosis

Answer 16

First degree: few days of pain, should resolve entirely with analgesia and topical emollient
Second degree: Expect full recovery, potential scarring. Heals in 2-3 weeks
Third degree: depends on extent and location: risks of complications high and scarring certain. Risk of death is considerable from fluid loss and infection if not closely monitored.
Consider long term psychiatric impact of serious burns

Question 17

CO aetiology/RF

Answer 17

Binds to Hb with 220% greater affinity thatn O2. Reduces oxygen carrying capacity and leads to cellular hypoxia
COHb causes greater affinity of unbound Hb for O2 so causes left shift of Hd diss curve (greater % Ohb at same PO2)
CO also binds heme moeity of cytochrome C and inhibits mt. respiration

Risk factors: Exposure = fire, water heaters, gas stoves, vehicles
Patient = unborn baby (HbF), children, elderly

Question 18

CO epi

Answer 18

60 deaths annually from accidental poisoning in England and Wales
200 non fatal hosp. admissions
Relatively common cause of fatal poisoning

Question 19

History in CO poisoning

Answer 19

Headache 90%, N+V 50%, Vertigo 30%, altered LOC 30%

Often seen in clusters of patients all exposed at same source

Question 20

Examination in CO poisoning

Answer 20

?tachycardic and tachypnoeic
Mental state changes (confusion or reduced LOC)
On eye examination: retinal haemorrhage, congestion, papilledema
Kidneys risk ichaemic injury (reduced urine output, increased creatinine, Reduced GFR)

Question 21

Investigations in CO poisoning

Answer 21

A-E approach
ABG with CO-oximetry
FBC, U+E, baseline trop
ECG
CXR (looking for pulmonary oedema)

Question 22

Management of CO poisoning

Answer 22

Supplemental O2 is cornerstone. Initiate immediately and continue throughout

Severe poisoning (indicated by alteration to LOC, cardiac ischaemia, tachycardia +/- hypotension):
Emergent hyperbaric O2

Question 23

Complication of CO poisoning

Answer 23

CO poisoning has predilection for globus pallidus:
Amnesia, Dementia
Irritability
Psychosis - antipsychotic
Loss of executive function
Depression - therapy/drugs
Cortical blindness
Parkinsonism

Renal ischaemia and AKI (fluids and oxygen)

Schedule neuropsychiatric r/v at d/c and at 1-2m to identify any deficit and plan management accordingly. Up to 40% of pts develop chronic impairment.

Question 24

CO toxicity prognosis

Answer 24

Varies with severity, comorbidity

Documented abnormal brain imaging and persistent defecit have poorest prognosis (long term impairment)

Question 25

DIC Management principles

Answer 25

Cornerstone is treating underlying condition (ABO reaction, cancer (leukaemia), pancreatitis, sepsis, Cx of pregnancy (abruption, eclampsia, amniotic fluid embolus)

Question 26

DIC when patient is bleeding Mx

Answer 26

Those with DIC and bleeding OR at high risk of bleeding (eg invasive operation) and a platelet count <50. Consider platelet transfusion
- If unable to infuse plasma bc of fluid balance use factor concentrates (prothrombin complex conc.)
Consider need for vitamin K if risk of deficiency

Question 27

DIC with prominent thrombosis Mx

Answer 27

In DIC with predominant thrombosis (arterial or DVT, or purpura fulminans) consider heparin therapeutic dose.

Question 28

Critically ill DIC patients Mx

Answer 28

In critically ill patientes with no bleeding VTE proph. With prophylactic doses of heparin or LMWH.
- If septic + DIC consider recombinant human activated protein C
- If at high risk of bleeding do not give protein C
If invasive procedure needed stop protein C shortly before

Question 29

Complications of DIC

Answer 29

1. Thrombus: therapeutic dose of heparin
   
   2. Bleeding: Platelets and FFP, Vit K if needed. ?factor concentrates
   3. AKI
   4. Tamponade: pericardiocentesis (needle inserted through anterior chest wall into pericardial sac and blood is drained)
   5. Haemothorax:?exploratory surgery to stop at source. insert chest drain
   6. Intracerebral haematoma: may require neurosurgical intervention for decompression. Check need for plateletes and FFP
      Shock: transfuse blood, try to correct platelets and FFP

Question 30

Prognosis of DIC

Answer 30

20-50% mortality
DIC from sepsis carries worst prognosis
Depends on underlying condition and the ability to manage it, as well as patient specifics such as age and extent of systemic disease.