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Acute care and conditions Flashcards

Acute care and conditions

1
Q

What are the features of alcohol withdrawal syndrome?

A

Autonomic hyperactivity
Tremulousness
Restlessness
Hallucinations
Seizures
Delirium tremens

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2
Q

What is the cause of AWS?

A

Body has increased levels of glutamate to balance the GABA/alcohol to glutamate ratio
Sudden withdrawal of alcohol means there is an imbalance of GABA to glutamate
high glutamate –> excitatory symptoms

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3
Q

What is delirium tremens?

A

Rapid onset of confusion and AWS features 2-3 days post-withdrawal

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4
Q

What are the investigations for AWS?

A

U+E
LFTs, INR
Glucose
Toxicology screen

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5
Q

What is the management for an alcohol-dependant Pt who can be managed at home?

A

Advice to slowly reduce alcohol
Provide information on local alcohol support services

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6
Q

What is the management of AWS?

A
  1. Benzodiazepines (chlordiazepoxide, diazepam)
  2. Pabrinex (B vitamins) to prevent Wernicke’s
  3. Glucose (if hypoglycaemic)
  4. Manage alcohol dependence
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7
Q

What is the CIWA-Ar?

A

10 item assessment tool used to quantify severity of AWS

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8
Q

What is the medical treatment for AWS?

A

1st line- benzodiazepines (chlordiazepoxide)/clomethiazole
-oral: mild
-IV: moderate/severe

Seizure- lorazepam

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9
Q

What are the features of anaphylaxis?

A

Wheeze
Hives
Facial swelling
Nausea/vomiting

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10
Q

What is the immediate management of anaphylaxis?

A

Call for help
Remove trigger
Position Pt with raised legs
ABC
IM adrenaline 0.5mg 1:1000
100% oxygen

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11
Q

What is the post-resusitation management of anaphylaxis?

A

Slow chlorphenamine/diphenhydramine and ranitidine (antihistamine)
Slow IV hydrocortisone
Neb salbutamol/ipratropium if wheezy

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12
Q

What is the post-resusitation investigation of anaphylaxis?

A

Serum tryptase + plasma histamine:
- at time of stabilisation
- 1/2 hours later
Don’t need to do if diagnosis of anaphylaxis is definite

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13
Q

What are the features of paracetamol overdose?

A

Asymptomatic for 24hrs
Nausea, vomiting abdo pain 2-3 days after ingestion

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14
Q

What are the investigations for paracetamol overdose?

A

Serum paracetamol level ASAP
Serum AST/ALT
Arterial pH/lactate
U+E

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15
Q

What are the causes of opiate overdose?

A

Substance abuse/recent abstinence
Self harm
Iatrogenic

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16
Q

What are the features of opiate overdose?

A

Miosis
Bradypnoea
Altered mental status
Needle marks
Decreased GI motility
Dramatic response to naloxone

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17
Q

What are the investigations for opiate overdose

A

Therapeutic trial of naloxone
ECG- MI/QRS prolongation

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18
Q

What are the indications for placing a catheter?

A

Obstruction (BPH)
Bladder weakness or nerve damage
Childbirth with epidural
Before, during and after surgery
Delivery of medication directly to bladder (chemo for bladder cancer)
Urinary incontinence

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19
Q

What are the complications of placing a catheter?

A

Recurrent UTIs
Trauma
Accidental removal
Renal complications- kidney stones, hydronephrosis, scarring
Pain
Recurrent blockage

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20
Q

What are the indications for epidural injections?

A

Analgesia
-single injection for pain relief
-post operative

Anaesthesia
-slower onset than spinal analgesia – gradual decrease in BP
-adjunct to general anaesthesia
sole anaesthetic technique: Cesarean sections

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21
Q

What are the complications of epidural injections?

A

Failure to achieve analgesia or anaesthesia
Accidental dural puncture with headache
Bloody tap
Catheter placement into vein
Misplacement in subarachnoid space
Neurological injury
Abscess

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22
Q

What are the indications of ABGs?

A

Respiratory failure- acute or chronic
Cardiac failure
Liver failure
Renal failure
Hyperglycaemic states- DM
Multiorgan failure
Sepsis
Burns
Poisons/toxins
Ventilated patients
Severely unwell patients

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23
Q

What are the complications of ABGs?

A

Local haematoma
Arterial vasospasm
Arterial occlusion
Air or thrombus embolism
Local anaesthetic anaphylactic reaction
Infection at puncture site
Vessel laceration
Needlestick injury to health care professional

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24
Q

How do you take a blood transfusion specimen?

A

2 G+S pink vials
Label at the bedside handwritten

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25
Q

How do you monitor a blood transfusion?

A

Assess baseline observations
Monitor Pt vital signs
Document everything
Halt transfusion immediately if adverse reaction occurs

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26
Q

A 21 yo M is brought in to A&E by his friends because he is unresponsive. On examination you find miosis and a respiratory rate of 8 bpm. The patient is deeply unresponsive to pain.
What is the most likely explanation for this presentation?

A. Aspirin overdose
B. Anaphylactic shock
C. Opiate overdose
D. Paracetamol overdose
E. The patient is sleeping

A

C. Opiate overdose

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27
Q

A 40 yo M is brought in to A&E by his friends because he is unresponsive. His friends tell you that he has just had a seizure before coming to A&E. They reluctantly tell you that he is now abstinent from alcohol for 1 week.
What is the best immediate management for this patient?

A. IV Lorazepam
B. Send to ITU
C. Watch and wait
D. Start 0.9% saline infusion
E. Give oxygen 100%

A

A. IV Lorazepam

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28
Q

A 50 yo M known alcoholic presents to A&E with restlessness and tremors. He is anxious, pacing in the hallway. His observations show a HR of 121 bpm, BP of 169/104 mmHg. On further questioning he states he is nauseous and you can see he is visibly shaking. He says his symptoms started to develop 5 hours after his last drink.
What is the best management for this patient?

A. Admit and give IV Lorazepam
B. Send him home with some information on contacting local alcohol support service
C. Admit and give oral Lorazepam
D. Send him home with no treatment
E. Watch and wait

A

C. Admit and give oral Lorazepam

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29
Q

What is the definition of acute aspirin overdose?

A. Single dose equivalent of >150mg/kg or >6.5 g
B. Single dose equivalent of >100mg/kg or >4.5 g
C. Repeated exposure to high dose aspirin or equivalent
D. Taking more than a box of Boots aspirin in one sitting

A

A. Single dose equivalent of >150mg/kg or >6.5 g

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30
Q

What are the first signs of paracetamol overdose?

A. Nausea and vomiting
B. Stomach cramps
C. RUQ pain
D. Asymptomatic
E. Hallucinations

A

D. Asymptomatic

31
Q

What is the daily maximum recommended dose of paracetamol?

A. 1000 mg
B. 1500mg
C. 4g
D. 5g
E. 10g

A

C. 4g

32
Q

what do you assess/manage for A of A-E?

A

AIRWAY
- Assess: patency, secretions/vomit, obstruction
- Manage: airway manovres, suction, airway adjuncts

33
Q

what do you assess/manage for B of A-E?

A

BREATHING
- Assess: RR, O2 sats, palpation/percussion/auscultation, later CXR
- Manage: oxygen

34
Q

what do you assess/manage for C of A-E?

A

CIRCULATION
- Assess: HR and BP, cap refill/perfusion, cyanosis, auscultation
- Manage: fluids, bloods/ABG

35
Q

what do you assess for D of A-E?

A

DISABILITY
Assess: AVPU/GCS, glucose, PEARL

36
Q

what do you assess/manage for D of A-E?

A

EXPOSURE
assess whole body
manage: remove clothing

37
Q

What framework do you use for handover?

A

SBAR framework for handing over. Example:

Situation – 80F (on X ward in Y hospital).

Background – Admitted with diagnosis of X, medication Y

Assessment - Worried about X Vital signs are: XYZ and examination revealed: XYZ. We are giving fluids and Abx

Recommendation – patient is deteriorating, please review urgently

38
Q

What are the 2 problems associated with alcohol use disorder?

A

Harmful drinking –> physical health problems
Alcohol dependence –> cravings, tolerance

39
Q

Define AWS

A

Physical and psychological symptoms associated with sudden decrease in alcohol consumption

40
Q

Which 2 receptors are implemented in AWS?

A

GABA- downregulated in chronic alcohol use
Glutamate- upregulated in chronic alcohol use

41
Q

Describe the progression of AWS

A

6 HOURS
- Anxiety/agitation
- Palpitations
- GI upset
- Sweating + tremor

12 HOURS
- Visual/tactile hallucinations
- Normal mental status

36 HOURS
- Short, generalised tonic-clonic seizures

48-72 HOURS
- FATAL
- Delirium
- Severe tremor
- Fever
- High BP + HR

42
Q

4 signs of acute liver failure (ABBA)

A

Ammonia –> encephalopathy
Bilirubin –> jaundice
Blood factors –> bruising
Albumin –> ascites and peripheral oedema

43
Q

3 features of wernicke’s encephalopathy (CAN)

A

Confusion
Ataxia
Nystagmus

44
Q

Scale used for severity of AWS

A

CIWA-Ar scale (Clinical Institute Withdrawal Assessment from Alcohol Revised scale)

45
Q

Ddx for AWS

A

Hypoglycaemia
Electrolyte abnormalities
Hepatic encephalopathy

rely on history

46
Q

Define anaphylaxis

A

A life-threatening, systemic, hypersensitivity reaction

Characterised by airway +/- breathing +/- circulation problems

Usually associated with skin/mucosal changes

47
Q

3 common triggers for anaphylaxis

A
  • Food (children) –> nuts
  • Drugs/chemicals (adults) –> penicillin, NSAIDs, latex, contrast agent
  • Toxins –> bee/wasp sting, venom
48
Q

Pathophysiology of anaphylaxis

A

Mast-cell/basophil degranulation:

  • Increased capillary permeability
  • Bronchospasm
  • Reduced vascular tone
49
Q

A-E presentation of anaphylaxis

A

Airway
Throat/tongue swelling, stridor

Breathing
SOB, increased RR, decreased O2

Circulation
SHOCK –> low BP, high HR, decreased consciousness

Skin/Mucosal
Urticaria and angioedema
Flushing

SENSE OF IMPENDING DOOM

50
Q

Epidemiology/Risk factors for poisoning

A

Accidental poisoning in children <10yrs

Deliberate poisoning >10yrs, usually 15-35yrs, often associated with alcohol use

51
Q

Investigations for suspected poisoning

A

ABCDE assessment
ECG
FBC, U&E, LFT, INR, glucose
Paracetamol and Salicylate levels
ABG

52
Q

What general management would you consider for poisoning within a timeframe of <4 hours?

A

ACTIVATED CHARCOAL if <4h
Reduces absorption of drug

53
Q

What constitutes an aspirin overdose?

A

Usually 300mg tablets
OD >150mg/kg
Severe if >500mg/kg

54
Q

Early presentation of aspirin overdose

A

Tinnitus, deafness, dizziness (aspiringing)
Hyperpnoea (rasp-irin)
N&V, diarrhoea (most poisonings)
Hyperthermia, sweating (per-spirin-g)

55
Q

Late/severe presentation of aspirin overdose

A

Low BP and heart block
Pulmonary oedema
Low GCS + seizures

56
Q

Laboratory findings in aspirin overdose

A

Early: respiratory alkalosis
Late: high anion gap metabolic acidosis

57
Q

Management of aspirin overdose

A

Urine alkalinisation with IV sodium bicarbonate
Dialysis

58
Q

What constitutes a paracetamol overdose?

A

Usually 500mg tablets
OD> 150mg/kg, 12g can be fatal

59
Q

Pathophysiology of paracetamol overdose

A

XS paracetamol metabolised by CYP450 in liver to NAPQI, which is conjugated with glutathione and excreted
glutathione depleted, toxic NAPQI accumulates, hepatocyte necrosis

60
Q

Presentation paracetamol overdose

A

<24 hrs: mild N&V, lethargy
24-72 hrs: RUQ pain, vomiting, hepatomegaly
>72hrs: acute liver failure

61
Q

Management paracetamol overdose

A

IV N-acetyl cysteine if below treatment line
Liver transplant

62
Q

Presentation opiate overdose

A

CNS depression (PNS effects):
- Respiratory depression
- Bradycardia, Hypotension
- Pinpoint pupils
- Late/severe: low GCS/coma

63
Q

3 types of catheter + indications

A

Foley catheter

3-way catheter
Indications: recurrent clots/haematuria
Extra lumen for irrigation

Suprapubic catheter
Indications: long-term use, urethral damage (trauma, surgery, stricture)

64
Q

What can commonly cause catheter blockage? How is it managed?

A

Can be due to biofilm formation (infection with Proteus mirabilis commonly)

1st step: bladder wash out 2nd step: replace catheter

65
Q

What test do you need to do before performing an ABG?

A

Allen test:
- Apply pressure over radial and ulnar arteries with hand elevated for 30 seconds until blanching of the palm
- Release the ulnar artery – colour should return <8 seconds, indicates sufficient collateral circulation

66
Q

Indications for ABG

A

Accurate measurement of PaO2 required
Otherwise can use VBG (venous blood gas) for same results

67
Q

G+S vs X match

A

G&S: only valid for 72 hours, identifies blood type and presence of antibodies

X-match: tests patient blood with donor blood to check compatibility

68
Q

When are packed red cells indicated?

A

if Hb <70g/l or >30% loss of blood volume
1 unit increases Hb by 10-15g/l

69
Q

When are platelets indicated?

A

If platelets <20*109/L

70
Q

When is FFP indicated?

A

To correct clotting defects e.g DIC

71
Q

Early complications of blood transfusions

A
  • Anaphylaxis
  • Acute haemolytic reaction
  • Bacterial infection
  • Febrile non-haemolytic reaction
  • Transfusion associated circulatory overload (TACO) or transfusion associated lung injury (TRALI)
72
Q

Late complications of blood transfusions

A
  • Delayed haemolytic reaction
  • Infection
  • Transfusion associated graft vs host disease
  • Iron overload
73
Q

List the layers that are crossed during epidural

A

Skin
subcutaneous fat
muscle
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space

74
Q

Indications for epidural

A

lower extremity surgery (sensory and nerve block), particularly obstetrics

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