Acute care Flashcards
What investigations will you perform?
I would investigate with bedside tests, blood tests and imaging.
At the bedside I would check the obs, perform an ECG, take a urine sample for dipstick, check the BG (urine bHCG, PEFR, sputum/stool sample)
I would take a full set of baseline bloods - FBC, U&E, CRP, LFTs, clotting (as well as BC, amylase, G&S/X-match, TFTs, d-dimer, troponin, para/salicylate levels) and a VBG/ABG
In the first instance I would request a CXR/AXR and would discuss with a senior the need for further imaging such as USS, CT
(I’d also consider an LP at this point)
What would be your management plan?
I will call for help and manage the patient with a systematic A to E approach.
Airway - if the airway was compromised I would perform jaw thrust and consider airway adjuncts
Once airway is secure I would ask nurse to help me assess the obs including pulse, RR, BP, temp, sats
Breathing - as the patient is unwell I would give high flow O2 at 15L/min through a non-rebreathe mask.
To support circulation I would ask the nurse raise the patients legs while securing venous access with 2 wide bore cannulae, and give a bolus of 500ml 0.9% saline over 15 mins. At this point I would reassess the obs.
DEFG
Disability - GCS, pupils
Exposure - rashes, abdo exam, lines
To manage the acute presentation I will take a stepwise approach and follow the trust protocol for x.
What you do in this case of suspected anaphylaxis?
Alongside my A to E management I would take a stepwise approach and follow the trust protocol for anaphylaxis.
Adrenaline 0.5ml 1:1000 500micrograms IM
Hydrocortisone 200mg IV
Chlorphenamine 10mg IV
If a wheeze was present I would treat as acute asthma with nebulised salb 5mg.
How would you manage this case of suspected sepsis?
Alongside my A to E management I would take a stepwise approach take a stepwise approach and follow the sepsis 6 protocol, ideally with senior support.
This includes administering fluids, high flow oxygen and broad-spectrum Abx according to local guidelines.
I would take a VBG for lactate, take blood cultures and consider catheterising the patient to measure UO.
If the source of infection was unclear I would continue to Ix the patient.
How would you manage this patient with suspected pulmonary oedema?
Alongside my A to E management I would take a stepwise approach and follow the trust protocol for acute heart failure.
I would ensure the patient was sat up and had high flow oxygen, and administer a bolus of IV furosemide 40mg, I would also consider s/l GTN and diamorphine especially if the patient is distressed. I would then reassess the patient. If the patient was hypotensive I would request immediate critical care input for vasopressors.
If the patient was not responding to this management I would escalate to my senior for consideration of NIV and consider alternative Dx.
How would you manage this patient with suspected ACS?
Alongside my A to E management (12 lead ECG, IV access, obs, cardiac monitor, bloods inc trop, INR, glucose, lipids) I would take a stepwise approach and follow the trust protocol for ACS, will input from cardiology.
I will give the patient analgesia, IV morphine with IV metoclopramide and administer aspirin 300mg and ticagrelor 180mg. I would consider GTN & give O2 if sats are <90%. Once ACS is confirmed I would arrange for transfer to a PCI unit, or if not possible within 2 hours, refer to cardiology for thrombolysis. The patient will need UFH prior to PCI.
The patient would be discharged on DABS
- Dual antiplatelets
- ACEi
- Beta blocker
- Statin high dose
Complications - FAM
How would you manage this acute asthma exacerbation?
Alongside my A to E management I would take a stepwise approach and follow the trust protocol for acute asthma. This would include assessing the severity of the attack. An ABG would be part of this to look for PO2 and a rising PCO2.
I will give the patient 5mg salbutamol via an O2-driven nebuliser, with ipratropium bromide 0.5 mg
4–6 hourly. I would also prescribe oral prednisolone 50mg or IV hydrocortisone 100mg.
I would reassess the patient and repeat salb neb every 15 minutes if needed.
If the patient was not responding to this management I would escalate to my senior for consideration of IV Mg sulphate or aminophylline. If the patient was deteriorating or their CO2 was rising, I would seek immediate help from an anaesthetist/ICU specialist.
How would you manage this patient with a bowel obstruction?
Alongside my A to E management I would take a stepwise approach and follow the trust protocol.
After gaining IV access, I would ensure the patient was NBM, give analgesia, fluids and anti-emetic if appropriate.
I would “drip and suck” using a wide bore NG tube for decompression of the stomach and administering IV fluids. The patient may also require a catheter. I’d also refer to general surgeons, as resection may be necessary particularly in the case of perforation.
eCXR - perforation
CT AP - localise site/cause
What are your differentials for chest pain?
Causes of chest pain can be cardiovascular, pulmonary, GI or chest-wall related. A common cardiac cause would be ACS, however it is important to also consider dissection and tamponade. For pulmonary causes you would consider PE and pneumothorax. GI causes include GORD and more rarely oesophageal rupture. Chest wall musculoskeletal pain is a common differential.
In this case the xyz is pointing me towards a cardiac cause however I would like to keep a broad differential as I begin to investigate.
What are your differentials for this patient with abdominal pain?
My differential in this case is guided by the location of the pain.
Common causes of RLQ pain include appendicitis, ectopic pregnancy, ovarian torsion, terminal ileitis.
Common causes of RUQ pain includes cholecystitis, cholangitis, hepatitis, liver abscess. I would also consider extra-GI pathology such as basal pneumonia.
Common causes of LLQ pain include diverticulitis, UC, ectopic pregnancy, ovarian torsion.
Common causes of LUQ/epigastric pain include peptic ulcer disease, GORD, pancreatitis, I would also consider extra-GI pathology such as ACS and basal pneumonia.
In this case the xyz is pointing me towards an appendicitis however I would like to keep a broad differential as I begin to investigate.
How would you manage this patient’s PE?
Predisposing factors - patient (age, obesity), condition (pregnant, cancer, trauma, acute illness, prev DVT, thrombophilia), circumstance (immobile, long haul flight, post-surgery, HRT/COCP)
Alongside my A to E management I would take a stepwise approach and follow the trust protocol for suspected pulmonary embolism. This would include assessing for haemodynamic instability and calculating the Well’s score to guide next steps.
If PE is likely and the patient is relatively stable I would request a CTPA to confirm the PE and administer a high dose oral DOAC such as apixaban 10 mg twice daily.
If the patient is in shock due to a massive PE the patient will likely require thrombolysis with alteplase. The patient will also be given anticoagulation i.e. fondaparinux.
If the patient was not responding to this management I would escalate to my seniors.
How would you manage this acute COPD exacerbation?
As this patient has COPD I will give O2 via 28% Venturi mask at 4 l/min aiming for sats of 88-92% (adjust target range to 94-98% if the pCO2 is normal)
Alongside my A to E management I would take a stepwise approach and follow the trust protocol for COPD exacerbation. Repeated ABGs would be part of this to look for PO2 and a rising PCO2.
I will give the patient 5mg salbutamol via an air-driven nebuliser, adding in ipratropium bromide 0.5 mg
if there is a poor response. I would also prescribe oral prednisolone 50mg. If there were indications of infection, I would prescribe antibiotics according to local sensitivities (amox)
If the patient was not responding to this management I would escalate to my senior for consideration of IV theophylline or NIV (BiPAP). Further deterioration would warrant careful consideration of intubation and ventilation, which can carry a poor prognosis in COPD patients.
How would you manage this case of suspected bacterial meningitis?
Signs of meningism - headache, neck stiffness, photophobia +/- N&V
Alongside my A to E management I would take a stepwise approach following the hospital protocol for meningitis, ideally with senior support.
My A to E would include a VBG for lactate, take blood cultures and consider catheterising the patient to measure UO.
If the patient had signs of sepsis or raised intracranial pressure I would delay the LP and give immediate broad spectrum Abx according to trust guidelines. Otherwise I would do an immediate LP to confirm Dx and guide treatment, however this should not delay empirical Abx therapy.
CIs: seizures, focal neurology, septic, coagulopathy, local abscess
Patients with complication i.e. sepsis, raised ICP, seizure, give broad-spectrum IV Abx according to local guidelines (cef +/- amox) along with IV dexamethasone.
How would you manage this case of suspected variceal bleed?
Alongside my A to E management I would take a stepwise approach and follow the trust protocol for suspected variceal bleed.
This would include correcting clotting (FFP/vit K), giving terlipressin + prophylactic Abx.
I would then refer the patient for an urgent endoscopic band ligation. The patient may need further intervention if these measures fail i.e. TIPSS procedure.
How would you manage this seizure?
Alongside my A to E management (bloods incl. electrolytes, bHCG, drug levels, DEFG) I would take a stepwise approach and follow the trust protocol for status epilepticus.
The first step for someone with IV access would be IV lorazepam 4mg bolus, otherwise buccal midazolam or rectal diazepam. The IV lorazepam can be repeated after 10 mins if the patient is still fitting. I would discuss with senior colleagues to need for IV phenytoin or levetiracetam.If the patient was not responding to this management I would escalate to anaesthetics or ICU.
