Acute care and conditions Flashcards
Acute care and conditions
What are the features of alcohol withdrawal syndrome?
Autonomic hyperactivity Tremulousness Restlessness Hallucinations Seizures Delirium tremens
What is the cause of AWS?
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
What is delirium tremens?
Rapid onset of confusion and AWS features 2-3 days post-withdrawal
What are the investigations for AWS?
U+E
LFTs, INR
Glucose
Toxicology screen
What is the management for an alcohol-dependant Pt who can be managed at home?
Advice to slowly reduce alcohol
Provide information on local alcohol support services
What is the management of AWS?
- Benzodiazepines (chlordiazepoxide, diazepam)
- Pabrinex (B vitamins) to prevent Wernicke’s
- Glucose (if hypoglycaemic)
- Manage alcohol dependence
What is the CIWA-Ar?
10 item assessment tool used to quantify severity of AWS
What is the medical treatment for AWS?
1st line- benzodiazepines (chlordiazepoxide)/clomethiazole
- oral: mild
- IV: moderate/severe
Seizure- lorazepam
What are the features of anaphylaxis?
Wheeze
Hives
Facial swelling
Nausea/vomiting
What is the immediate management of anaphylaxis?
Call for help Remove trigger Position Pt with raised legs ABC IM adrenaline 0.5mg 1:1000 100% oxygen
What is the post-resusitation management of anaphylaxis?
Slow chlorphenamine/diphenhydramine and ranitidine (antihistamine)
Slow IV hydrocortisone
Neb salbutamol/ipratropium if wheezy
What is the post-resusitation investigation of anaphylaxis?
Serum tryptase + plasma histamine:
- at time of stabilisation
- 1/2 hours later
Don’t need to do if diagnosis of anaphylaxis is definite
What are the features of paracetamol overdose?
Asymptomatic for 24hrs
Nausea, vomiting abdo pain 2-3 days after ingestion
What are the investigations for paracetamol overdose?
Serum paracetamol level ASAP
Serum AST/ALT
Arterial pH/lactate
U+E
What are the causes of opiate overdose?
Substance abuse/recent abstinence
Self harm
Iatrogenic
What are the features of opiate overdose?
Miosis Bradypnoea Altered mental status Needle marks Decreased GI motility Dramatic response to naloxone
What are the investigations for opiate overdose
Therapeutic trial of naloxone
ECG- MI/QRS prolongation
What are the indications for placing a catheter?
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
What are the complications of placing a catheter?
Recurrent UTIs Trauma Accidental removal Renal complications- kidney stones, hydronephrosis, scarring Pain Recurrent blockage
What are the indications for epidural injections?
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
What are the complications of epidural injections?
Failure to achieve analgesia or anaesthesia Accidental dural puncture with headache Bloody tap Catheter placement into vein Misplacement in subarachnoid space Neurological injury Abscess
What are the indications of ABGs?
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
What are the complications of ABGs?
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
How do you take a blood transfusion specimen?
2 G+S pink vials
Label at the bedside handwritten
How do you monitor a blood transfusion?
Assess baseline observations
Monitor Pt vital signs
Document everything
Halt transfusion immediately if adverse reaction occurs
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
C. Opiate overdose
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. IV Lorazepam
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
C. Admit and give oral Lorazepam
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. Single dose equivalent of >150mg/kg or >6.5 g
What are the first signs of paracetamol overdose?
A. Nausea and vomiting B. Stomach cramps C. RUQ pain D. Asymptomatic E. Hallucinations
D. Asymptomatic
What is the daily maximum recommended dose of paracetamol?
A. 1000 mg B. 1500mg C. 4g D. 5g E. 10g
C. 4g
what do you assess/manage for A of A-E?
AIRWAY
- Assess: patency, secretions/vomit, obstruction
- Manage: airway manovres, suction, airway adjuncts
what do you assess/manage for B of A-E?
BREATHING
- Assess: RR, O2 sats, palpation/percussion/auscultation, later CXR
- Manage: oxygen
what do you assess/manage for C of A-E?
CIRCULATION
- Assess: HR and BP, cap refill/perfusion, cyanosis, auscultation
- Manage: fluids, bloods/ABG
what do you assess for D of A-E?
DISABILITY
Assess: AVPU/GCS, glucose, PEARL
what do you assess/manage for D of A-E?
EXPOSURE
assess whole body
manage: remove clothing
What framework do you use for handover?
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
What are the 2 problems associated with alcohol use disorder?
Harmful drinking –> physical health problems
Alcohol dependence –> cravings, tolerance
Define AWS
Physical and psychological symptoms associated with sudden decrease in alcohol consumption
Which 2 receptors are implemented in AWS?
GABA- downregulated in chronic alcohol use
Glutamate- upregulated in chronic alcohol use
Describe the progression of AWS
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
4 signs of acute liver failure (ABBA)
Ammonia –> encephalopathy
Bilirubin –> jaundice
Blood factors –> bruising
Albumin –> ascites and peripheral oedema
3 features of wernicke’s encephalopathy (CAN)
Confusion
Ataxia
Nystagmus
Scale used for severity of AWS
CIWA-Ar scale (Clinical Institute Withdrawal Assessment from Alcohol Revised scale)
Ddx for AWS
Hypoglycaemia
Electrolyte abnormalities
Hepatic encephalopathy
rely on history
Define anaphylaxis
A life-threatening, systemic, hypersensitivity reaction
Characterised by airway +/- breathing +/- circulation problems
Usually associated with skin/mucosal changes
3 common triggers for anaphylaxis
- Food (children) –> nuts
- Drugs/chemicals (adults) –> penicillin, NSAIDs, latex, contrast agent
- Toxins –> bee/wasp sting, venom
Pathophysiology of anaphylaxis
Mast-cell/basophil degranulation:
- Increased capillary permeability
- Bronchospasm
- Reduced vascular tone
A-E presentation of anaphylaxis
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
Epidemiology/Risk factors for poisoning
Accidental poisoning in children <10yrs
Deliberate poisoning >10yrs, usually 15-35yrs, often associated with alcohol use
Investigations for suspected poisoning
ABCDE assessment ECG FBC, U&E, LFT, INR, glucose Paracetamol and Salicylate levels ABG
What general management would you consider for poisoning within a timeframe of <4 hours?
ACTIVATED CHARCOAL if <4h
Reduces absorption of drug
What constitutes an aspirin overdose?
Usually 300mg tablets
OD >150mg/kg
Severe if >500mg/kg
Early presentation of aspirin overdose
Tinnitus, deafness, dizziness (aspiringing)
Hyperpnoea (rasp-irin)
N&V, diarrhoea (most poisonings)
Hyperthermia, sweating (per-spirin-g)
Late/severe presentation of aspirin overdose
Low BP and heart block
Pulmonary oedema
Low GCS + seizures
Laboratory findings in aspirin overdose
Early: respiratory alkalosis
Late: high anion gap metabolic acidosis
Management of aspirin overdose
Urine alkalinisation with IV sodium bicarbonate
Dialysis
What constitutes a paracetamol overdose?
Usually 500mg tablets
OD> 150mg/kg, 12g can be fatal
Pathophysiology of paracetamol overdose
XS paracetamol metabolised by CYP450 in liver to NAPQI, which is conjugated with glutathione and excreted
glutathione depleted, toxic NAPQI accumulates, hepatocyte necrosis
Presentation paracetamol overdose
<24 hrs: mild N&V, lethargy
24-72 hrs: RUQ pain, vomiting, hepatomegaly
>72hrs: acute liver failure
Management paracetamol overdose
IV N-acetyl cysteine if below treatment line
Liver transplant
Presentation opiate overdose
CNS depression (PNS effects):
- Respiratory depression
- Bradycardia, Hypotension
- Pinpoint pupils
- Late/severe: low GCS/coma
3 types of catheter + indications
Foley catheter
3-way catheter
Indications: recurrent clots/haematuria
Extra lumen for irrigation
Suprapubic catheter
Indications: long-term use, urethral damage (trauma, surgery, stricture)
What can commonly cause catheter blockage? How is it managed?
Can be due to biofilm formation (infection with Proteus mirabilis commonly)
1st step: bladder wash out 2nd step: replace catheter
What test do you need to do before performing an ABG?
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
Indications for ABG
Accurate measurement of PaO2 required
Otherwise can use VBG (venous blood gas) for same results
G+S vs X match
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
When are packed red cells indicated?
if Hb <70g/l or >30% loss of blood volume
1 unit increases Hb by 10-15g/l
When are platelets indicated?
If platelets <20*109/L
When is FFP indicated?
To correct clotting defects e.g DIC
Early complications of blood transfusions
- Anaphylaxis
- Acute haemolytic reaction
- Bacterial infection
- Febrile non-haemolytic reaction
- Transfusion associated circulatory overload (TACO) or transfusion associated lung injury (TRALI)
Late complications of blood transfusions
- Delayed haemolytic reaction
- Infection
- Transfusion associated graft vs host disease
- Iron overload
List the layers that are crossed during epidural
Skin subcutaneous fat muscle supraspinous ligament interspinous ligament ligamentum flavum epidural space
Indications for epidural
lower extremity surgery (sensory and nerve block), particularly obstetrics
