Acute Care and Trauma Flashcards

Question

What are the signs on physical examination of acute kidney injury?

Answer 1

Hypotension Signs of dehydration: Dry mucous membranes, postural hypotension Tachycardia Distended bladder if due to post-renal obstruction Fluid overload (HF, cirrhosis, nephrotic): raised JVP, pulmonary/peripheral oedema Pallor, rash, bruising (vascular disease)

Answer 2

Depends on cause ``` Bloods: FBC - anaemia, leukocytosis, thrombocytopenia U&Es - check for hyperkalaemia Blood culture if suspecting sepsis Creatinine - measure eGFR - high PSA - elevated if BPH, prostatic cancer ABG - metabolic acidosis ``` Abdo USS if suspect obstruction CXR - pulmonary oedema AXR - renal stones Urinalysis - urine dip and microscopy: Blood - nephritic cause Leucocyte esterase and nitrites - UTI Glucose, protein and urine osmolality Immunology: Serum immunoglobulins and protein electrophoresis: for multiple myeloma and Bence-Jones proteins in the urine ANA and anti-dsDNA: associated with SLE Complement levels: low in active lupus Anti-GBM antibodies: Goodpasture's syndrome Antistreptolysin-O antibodies: high after Streptococcal infection Virology: check for hepatitis and HIV

Answer 3

1. Avoid nephrotoxic agents - Remove drugs such as antibiotics, NSAIDs, ACEi - No radiocontrast procedures 2. Manage fluid levels - If signs of dehydration - IV fluids eg saline, vasopressors eg noradrenaline - If signs of fluid overload - fluid restriction, furosemide 3. Protect from hyperkalaemia - Give IV calcium gluconate - protect heart - Give IV insulin and glucose 4. Dialysis if AKI refractory to treatment Indications: Refractory hyperkalaemia, Refractory pulmonary oedema, metabolic acidosis, uraemic complications eg pericarditis, uraemic encephalopathy Monitor serum creatinine, sodium, potassium, calcium, phosphate and glucose Identify and treat infection Urgent relief of urinary tract obstruction Refer to nephrology if intrinsic renal disease is suspected

Answer 4

``` Metabolic acidosis Hyperkalaemia Uraemic complications - pericarditis, uraemic encephalopathy Fluid overload CKD End stage renal disease Pulmonary oedema ```

Answer 5

Inpatient mortality varies depending on cause and comorbidities Indicators of poor prognosis: Age, multiple organ failure, oliguria, hypotension, CKD Patients who develop AKI are at increased risk of developing CKD Irreversible in 5-7% of adults

Answer 6

Burns are very common injuries, predominantly to the skin and superficial tissues, caused by heat from hot liquids, flame, or contact with heated objects, electrical current, or chemical. Severity is assessed by burn size (% total body surface area) and depth (first to fourth degree).

Answer 7

Thermal burns: heat from hot liquids, flame, or contact with heated objects Young children - 70% of burns caused by scalding from hot liquids Older children and young working adults, flame injuries are more likely Older adults, scalds and cooking accidents are most common Electrical burns Chemical burns: exposure to industrial or household chemical products Non-accidental burns: Approximately 20% of burns in younger children involve abuse or neglect Radiation burns

Answer 8

Difficult to determine as many people do not seek medical help 250,000 people suffer burn injuries in the UK

Answer 9

1st degree burns - dry, red, painful, blanching skin affected 2nd degree - red, clear blisters, wet, weepy, blanching, painful 2nd degree deep partial thickness - colour variation (white, red, yellow), blisters, may not blanch 3rd degree - dry, waxy white, leathery grey, no blanching, stiff, inelastic, pain due to deep pressure 4th degree - charred black, dry, patches of dead skin Blistering sloughing skin Underlying wet, tender erythema Flame injury can present with leathery burns

Answer 10

``` Mainly clinical diagnosis FBC: Low haematocrit Hypovolaemia Neutropenia Thrombocytopenia ``` Metabolic panel: High urea, creatinine, glucose Hyponatraemia Hypokalaemia Carboxyhaemoglobin high if inhalational injury ABG - metabolic acidosis if inhalational injury Wound biopsy and histology if suggestions of infection

Answer 11

Excessive ingestion of aspirin causing toxicity >150mg/kg/day ``` Severity is dose-dependent >150mg/kg: mild >250mg/kg: moderate >500mg/kg: severe >700mg/kg: potentially fatal ```

Answer 12

Accidental ingestion Self-harm Attempted suicide Incorrect dosage in children or older adults Salicylate activates respiratory centre - causes respiratory alkalosis Compensatory urinary excretion of bicarbonate and potassium - METABOLIC ACIDOSIS

Answer 13

One of the most common drug overdoses Accidental overdose in children and overdose for attempted suicide decreased following introduction of maximum number of aspirin you could purchase

Answer 14

``` Initially asymptomatic Fever, sweating, flushing Nausea, vomiting, dehydration, epigastric pain Tinnitus, deafness, vertigo Shortness of breath ``` ``` Late stages: Lethargy Confusion Convulsions Coma Respiratory distress Drowsiness ``` Rare: non-cardiogenic pulmonary oedema

Answer 15

Tachypnoea Tachycardia Fever Epigastric tenderness

Answer 16

Serum salicylates - elevated Serum ketones - elevated ABG - respiratory alkalosis followed by metabolic acidosis Electrolytes - hypokalaemia, hypocalcaemia, hypomagnesaemia LFTs - elevated AST and ALT if hepatotoxicity Clotting - elevated PT Toxicology CXR - pulmonary oedema ECG - hypokalaemia - small T waves, U waves

Answer 17

Ingestion of a larger quantity of opioids that can be physically tolerated, resulting in dangerous CNS and respiratory depression, miosis and apnoea

Answer 18

Substance abuse in regular users of illict or prescription opioids Unintentional overdose for pain relief Intentional overdose - self-harm, suicide Iatrogenic Recent abstinence in chronic users leading to decreased tolerance ``` Increased toxicity at lower dose due to: Hypothyroidism Hypotension Asthma Renal or hepatic impairment ``` ``` Risk Factors: Mental health conditions Alcoholics Opioid abuse and dependence Recent abstinence in chronic users Morphine toxicity at a lower dose ```

Answer 19

The elderly are at greater risk because they are more likely to be on opiates Heroin and morphine are responsible for most drug-related deaths Most common cause of death of former inmates after leaving prison due to loss of tolerance

Answer 20

``` Constipation (decreased GI motility if chronic) Altered mental status Coma Pink frothy sputum if causes ARDS Seizures Nausea and vomiting Loss of appetite Sedation Craving the next dose Drowsiness (if acute overdose) ```

Answer 21

``` Miosis/pinpoint pupils Bradypnoea (reduced RR) Needle or track marks Pulmonary rales if causes ARDS Respiratory depression Hypotension and tachycardia ```

Answer 22

Toxicology screen Therapeutic trial with IV naloxone (opioid antagonist) - shows reversal of overdose symptoms ECG - check for myocardial ischaemia CXR - may show ARDS

Answer 23

Excessive ingestion of paracetamol causing toxicity | Acute overdose is ingestion >4g or >75mg/kg in <1 hour

Answer 24

Intentional overdose - self-harm or suicide Therapeutic error - consistently taking small amounts over appropriate dosage Incorrect dosing The maximum recommended dose is 2 x 500 mg tablets (allows 4 times in 24 hours) Intake > 12 g can cause hepatic necrosis ``` Risk Factors: Chronic alcohol abusers History of self-harm History of frequent or repeated use of medications for pain relief Patients on enzyme-inducing drugs (e.g. anticonvulsants) Malnourished Anorexia nervosa Pre-existing liver disease Acute or chronic starvation ```

Answer 25

Paracetamol is the most common drug used in overdose in the UK - 48% of poisoning admissions to hospital Causes 100 deaths per year in the UK

Answer 26

First 24 hours: Asymptomatic Mild GI disturbance - nausea, vomiting, anorexia, abdominal pain, lethargy, malaise 24-72 hours: RUQ pain Vomiting ``` 72+ hours: Increased confusion (encephalopathy) Jaundice Decreased consciousness level Asterixis ```

Answer 27

Less than 24 hours: no signs 24-72 hours: hepatomegaly, RUQ tenderness 72+ hours: jaundice, coagulopathy, hypoglycaemia, renal angle tenderness, asterixis

Answer 28

Serum paracetamol - peak levels 4hrs after ingestion AST and ALT - elevated Arterial pH and lactate - acidaemia and elevated lactate U+Es - renal impairment PT - prolonged INR - increased

Answer 29

An autosomal recessive disorder caused by defective globin chain synthesis, due to reduced or absent alpha or beta chains.

Answer 30

Alpha: Autosomal recessive mutation in one of the 4 alpha genes on chromosome 16 1 abnormal gene = asymptomatic silent carrier 2 abnormal genes = alpha thalassemia minor, mild microcytic anaemia 3 abnormal genes = HbH disease/alpha thalassemia major, microcytic anaemia and hepatosplenomegaly 4 abnormal genes = Hb Bart's hydrops fetalis - incompatible with life Beta: Autosomal recessive mutation in one of the beta genes on chromosome 11 1 gene with reduced or absent synthesis - beta thalassemia minor 2 genes with reduced synthesis = beta thalassemia intermedia 2 genes with absent synthesis = beta thalassemia major

Answer 31

More common in Africa, Mediterranean and South-East Asia

Answer 32

Alpha thalassemia minor and HbH disease: Pallor Shortness of breath Fatigue ``` Beta thalassemia major: Pallor Shortness of breath Fatigue Jaundice Ascites Growth retardation Symptoms of haemochromatosis Failure to thrive Prone to infection ``` Alpha and beta trait: May be asymptomatic Detected in routine bloods or due to family history

Answer 33

``` Beta thalassemia major: Ascites Hepatosplenomegaly Jaundice Enlarged head and cheeks - chipmunk facies Pallor Frontal bossing ```

Answer 34

FBC - microcytic anaemia, decreased MCH Peripheral blood smear: microcytic hypochromic RBCs, target cells, golf ball-like cells in alpha thalassemia, high reticulocyte count Hb electrophoresis: Alpha - HbH band in HbH disease Beta - decreased HbA, increased HbF and HbA2 Genetic testing ``` Beta thalassemia major: Unconjugated bilirubin - elevated LDH - elevated Serum iron, ferritin and transferrin - increased Abdo USS - hepatosplenomegaly Skull X-Ray - hair on end sign ``` Bone Marrow biopsy - Hypercellular, erythroid hyperplasia