Acute Care and Trauma Conditions Flashcards
What is Alcohol withdrawal?
AWS or ‘the shakes’ occurs in patients with alcohol dependence when their daily ETOH consumption is decreased or stopped
What causes Alcohol withdrawal?
Removal of ETOH in diet
Chronic alcohol causes up-regulation of NMDA and down-regulation of GABA (inhibitory)
ETOH removal causes imbalance of stimulation and inhibition
What are the symptoms felt while withdrawing on alcohol?
Minor symptoms (insomnia, fatigue, tremor, mild anxiety, mild restlessness, nausea and vomiting, headache, excess sweating, palpitations, anorexia, depression, craving)
Alcohol hallucinations: Visual, audible + tactile hallucinations
Withdrawal seizures
Delirium tremens - lasts 3-4 days
What is the time frame for symptoms in alcohol withdrawal?
Minor symptoms (6-12hrs) Alcohol hallucinations (12-24hrs) Withdrawal seizures (24-48hrs) Delirious tremens (48-72hrs)
How do you manage alcohol withdrawal symptoms?
Decide whether they need hospital admission (previous DT or AW seizures)
What medications are used for acute alcohol withdrawal?
Benzodiazepines (Chlordiazepoxide) Thiamine Others: - Clomethiazole - Carbamezapine - Antipsychotic drugs
What is Delirium tremens?
Medical emergency, a hyperadrenergic state
How does someone with delirium tremens present?
Tachycardia Hyperthermia and excessive sweating Hypertension Tachypnoea Tremor Mydriasis Ataxia Altered mental status Cardiovascular collapse
What are the Risk factors for Delirium tremens?
Previous history Co-existing infection Recent higher than normal ETOH intake Older age Abnormal LFTs
What is the management for DT?
Admit to ICU
Treat hypoglycaemia
Sedate with Benzodiazepines
Add barbituates in those refractory to benzodiazepines
For Wernicke’s encephalopathy - 2 pairs of ampoules pabrinex (IV 3x daily for 3 days)
Magnesium to protect from seizures and arrhythmias
What is anaphylaxis?
Severe, life threatening, generalised or systemic hypersensitivity reaction
What are the 2 criteria needed for anaphylaxis?
- Sudden onset and rapid progression of symptoms
- Life threatening airway and/or breathing /circulation problems
What are the exogenous causes of anaphylaxis?
Food (Peanuts, beans, tree nuts, fish, shellfish, eggs, milk, sesame)
Venom (Bee stings, wasp stings)
Drugs (ABx, Opioids, NSAIDs, IV contrast media, muscle relaxants, other anaesthetic drugs)
What is the cellular function behind anaphylaxis?
Allergen reacts with specific IgE Abs on mast cells and basophils
Causes capillary leakage, mucosal oedema and ultimarely shock and asphyxia
Rarely symptoms can be delayed by a few hours
Some are idiopathic
What are the symptoms of anaphylaxis?
History of sensitivity of allergens, recent history of exposure to new drug/allergen Skin symptoms (Pruritis, urticaria, erythema, rhinits, conjunctivitis, angio-oedema)
What are the signs of anaphylaxis?
Itching of palate or ears Dyspnoea Laryngeal oedema (stridor) Wheezing (Bronchospasm) General symptoms (palpitation and tachycardia, nausea, vomiting and abdo pain)
What are the investigations for Anaphylaxis?
Serum mast cell tryptase ASAP
Obeserve patients
How do you generally manage anaphylaxis?
ABCDE A - Airway (clear and remove allergen) B - Breathing (look for and treat bronchospasm) C - Circulation (colour, pulse, BP) D - Disability E - Exposure
High-flow O2 Lay them flat Adrenaline IV fluids Chlorphenamine Hydrocortisone
What strength adrenaline, chlorphenamine and hydrocotsione do you give?
Adrenaline (IM):
>12 - 500 micrograms
12-6 - 300 micrograms
<6 - 150 micrograms
Clorphenamine (IM or IV slowly): >12 - 10milligrams 6-12 - 5milligrams 6 - 6 months - 2.5milligrams <6 months - 25 micrograms
Hydrocortisone (IM or IV slowly): >12 - 200milligrams 12-6 - 100milligrams 6 - 6 months - 50 milligrams <6 months - 25 milligrams
What is salicylate poisoning?
Result of indigestion of or exposure to checmials metabolised by salicylate e.g. Aspirin
What causes salicylate poisonsing?
150mg/kg or 6.5g (whichever is less)
What are the risk factors of salicylate poisoning?
Ingesting aspirin, oil of wintergreen, bismuth subsalicylate
Hx of self-harm / suicide
<3 or 70
What are the symptoms of Salicylate poisoning?
Nausea Vomiting Haematemesis Epigastric pain Tachypnoea Tinnitus/Deafness Fever Sweating
What are the signs of Salicylate poisoning?
Abnormal behaviour Kussmaul breathing Hypovolaemia Stupor Dizziness Rales + LowO2 saturation Rash
What investigations are done for Salicylate poisoning ?
ABG (Originally resp. alkalosis, then develop metabolic acidosis)
Serum electrolyte panel - Hypokalaemia, hypocalcaemia, hypomagnaemia
CXR - Pulmonary Oedema
Blood glucose - High or low
Serum Ketones - Positive in kids
LFT - AST and ALT raised
ECG - Tachy, prolonged QT, monomorphic ventricular tachy, torsade de point may be present
How do you treat Salicylate poisoning?
Sodium Bicarbonate
What is Diabetic ketoacidosis?
Medical emergency with a significant morbidity and mortality.
What characterises DKA?
Hyperglycaemia
Acidosis
Ketonaemia
Which conditions precipitate DKA?
Infection
Discontinuing insulin
Inadequate insulin
CVS disease
Drug treatments (Steroids, thiazide-like diuretics or SGLT2 inhibitors)
Menstruation
Phsyiological stress (pregnancy, trauma and/or stress)
What symptoms and signs are found in DKA?
Dehydration Kussmaul breathing Deteriorated mental state Screening in neurological exam Check surface for abscesses, boil or other rashes
What invsetigations are done for Diabetic ketoacidosis?
Capillary blood glucose Urine dipstick (glycosuria and ketonuria) Assay blood glucose (Ketonuria) Glucose (Raised) Urea and creatinine (Raised) Cardiac enzymes Amylase Blood cultures 12-lead ECG CXR Anion gap (>13) Plasma osmolality (>290)
How do you calculate the anion gap?
[Na+] - [Cl-] + [HCO3-]
How do you calculate the plasma osmolality?
2([Na+] + [K+]) + [Urea] + [Glucose]
How do you manage Diabetic ketoacidosis?
Assess severity Immediate resuscitation Large-bore IV LMWH and TED stocking IV insulin and glucose
How do you assess severity ?
Check for the following: - Blood ketones (>6) - Bicarbonate level (<5) Venous/arterial pH (<7) Hypokalaemia (<3.5) GCS (<12) O2 sats <92% SBP (<90) Tachycardia Anion gap >16
What is a head injury
When you have an injury to the head
What can be caused by a head injury?
Soon after: - Extradural/subdural haemorrhage - Seixures Late onset: - Subdural haemorrhage - Seizures - Diabetes insipidus - Parkinsonism - Dementia
What are the symptoms of a head injury?
Unconscious Headache Dizziness Blurred vision Confused and disorientated Nausea and vomiting Varies on severity
What are the signs of a head injury?
Low GCS
Blurred vision
Papilloedema
Varied pupil size
What investigations are done for a head injury?
ABG FBC Basic obs Pupils Anterograde amnesia U&E Glucose Blood alcohol/toxicology screen If indicated, CT head
What is Multi-organ dysfunction syndrome?
A hypometabolic, immunodepressed state with clinical and biochemical evidence of decreased functioning of the body’s organ systems (2 or more systems) that develops after an acute injury or illness
What causes Multi-organ dysfucntion syndrome?
Complex interplay of interdependent factors
- Genetics
- Comborbidities
- Medication, therapies and ICU supports
- Macrocirculatory changes
- Inflammation
- Coagulation cascade
- Neuro-endocrine factors
- Mitochondrial dysfunction
Which conditions causes MODS?
- Sepsis
- Major trauma
- Burns
- Pancreatitis
- Aspiration syndromes
- Extracorporeal circulation
- Multiple blood transfusion
- Ischaemia-reperfusion injury
- AI disease
- Eclampsia
- Poisoning
What are the symptoms of MODS?
Varies on organ affected
What are the signs of MODS?
Presence of a Systemic inflammatory response and dysfunction of atleast 2 organs
- AKI
- ARDS
- Cardiomyopathy
- Encephalopathy
- GI dysfunction
- Hepatic dysfunction
- Coagulopathy and bone marrow suppression
What are the investigations for MODS?
FBC with relevant added tests according to signs e.g. LFTs, amylase
Monitor closely
What is Opiate overdose?
Take more opiates than you should
What causes opiate overdose?
Opiates with widespread disease
- Codeine
- Diamorphine
- Dihydrocodeine
- Fentanyl
- Loperamide
- Methadone
- Morphine
What are the risk factors for opiate overdose?
Mental health condition Alcoholics Morphine toxicity at lower dose due to: - Hepatic impairment - Renal impairment - Hypotension - Hypothyroidism - Asthma
What are the symptoms of opiate overdose?
Constipation Nausea and vomiting Loss of appetite Sedation Craving next dose Drowsiness Urticarial like rash and itching
What are the signs of opiate overdose?
Respiratory depression
Hypotension
Tachycardia
Pinpoint pupils
What investigations are done for opiate overdose?
Toxicology screen
Paracetamol blood level
If in doubt, give a test dose of naloxone
How do you treat opiate overdose?
Naloxone
What is a paracetamol overdose?
Excessive ingestion of paracetamol causing toxicity
What causes a paracetamol overdose?
Intake of 150mg/kg or >12g in adults can cause hepatic necrosis
What are the risk factors for paracetamol overdose?
Chronic alcohol abusers Patients on enzyme-inducing drugs Malnourished Anorexia nervosa HIV Paracetamol overdose
What are the symptoms of paracetamol overdose?
0-24 hours: - Asymptomatic - Mild nausea/vomiting - Lethargy - Malaise 24-72 hours - RUQ pain - Vomiting 72+ hours - Increased confusion (encephalopathy) - Jaundice - AKI
What are the signs of paracetamol overdose?
0-24 hours - No signs 24-72 hours - Hepatomegaly and tenderness 72+ hours - Jaundice - coagulopathy - Hypoglycaemia - Renal angle tenderness
What investigations are done for paracetamol overdose?
Measure paracetamol levels
- Peaks at 4hrs after ingestion
Others: FBCs, U&Es, LFTs, Glucose, LFTs, Clotting screen, Lactate and ABG
How do you treat paracetamol overdose?
N-acteylcysteine
