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Acute Care & Trauma Flashcards

1
Q

What is acute kidney injury?

A

A syndrome of decreased renal function, measured by serum creatinine or urine output, occurring over hours-days

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2
Q

Summarise the epidemiology of acute kidney injury

A

Common - occurs in up to 18% of hospital patients

50% of ICU patients

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3
Q

What are the risk factors for AKI?

A 
Hospital stay
Pre-existing CKD
Increasing age
Male
Comorbidity - CVD, malignancy, chronic liver disease, complex surgery
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4
Q

What are the commonest causes of AKI?

A 
Sepsis
Major surgery
Cardiogenic shock
Other hypovolaemia
Drugs - NSAIDs, ACEis, diuretics
Hepatorenal syndrome
Obstruction
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5
Q

How can the causes of AKI be categorised?

A

Pre-renal: decreased kidney perfusion
Renal: intrinsic renal disease
Post-renal: obstruction to urine

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6
Q

What are the presenting signs + symptoms of AKI?

A 
May be asymptomatic at first
Decreased urine output
N + V
Dehydration
Confusion
Hypertension
Abdo + back pain
Oedema
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7
Q

How is AKI investigated?

A

URINE DIPSTICK: proteinuria/haematuria –> intrinsic renal disease

USS: small kidneys –> CKD; asymmetry –> renal vascular disease

LFTs: check renal function - hepatorenal

Platelets: if low, need blood film to check for haemolysis (HUS/TTP)

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8
Q

How is AKI diagnosed?

A
  • Rise in creatinine > 26umol/L within 48h
  • Rise in creatinine > 1/5 x baseline (ie before AKI) within 7 days
  • Urine output <0.5mL/kg/h for >6 consecutive hours
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9
Q

How is AKI managed?

A

Pre-renal: correct volume depletion and/or increase renal perfusion via circulatory/cardiac support, treat any underlying sepsis

Renal: refer for likely biopsy and specialist treatment of intrinsic renal disease

Post-renal: catheter, nephrostomy, or urological intervention

ALL: manage fluid balance, acidosis, hyperkalaemia, and timely recognition of those who may require renal replacement (dialysis)

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10
Q

What are the complications of AKI?

A
  1. Hyperkalaemia - IV CaCl, insulin, salbutamol
  2. Pulmonary oedema - O2, diamorphine, furosemide, GTN, isosorbide dinitrate
  3. Metabolic acidosis
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11
Q

What is ARDS?

A

A non-cardiogenic pulmonary oedema and diffuse lung inflammation syndrome that often complicates critical illness

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12
Q

What are the criteria for a diagnosis of ARDS?

A

Need all 3:

  1. Acute onset (within 1 week)
  2. Bilateral opacities on chest x-ray
  3. PaO₂/FiO₂ (arterial to inspired oxygen) ratio of ≤300 on positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) ≥5 cm H₂O
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13
Q

What are the causes of ARDS?

A

Most common cause = sepsis (septic shock), usually w pulmonary origin (e.g., pneumonia)

Pulmonary: pneumonia, gastric aspiration, inhalation, injury, vasculitis, contusion

Also: acute pancreatitis, trauma, burns, fat embolism, DIC, drugs/toxins - aspirin, heroin, paraquat, acute liver failure

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14
Q

What are the risk factors for ARDS?

A 
Sepsis
Aspiration
Pneumonia
Severe trauma
Blood transfusions
Lung transplant
Pancreatitis
EtOH misuse
Burns + smoke inhalation
Drowning
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15
Q

Summarise the epidemiology of ARDS

A

Incidence = 64/100,000
10-15% ITU patients
Increasing incidence among mechanically ventilated patients

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16
Q

What are the presenting signs of ARDS?

A 
Cyanosis
Tachypnoea
Tachycardia
Peripheral vasodilation
Bilateral fine inspiratory crackles
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17
Q

How is ARDS investigated?

A

CXR: bilateral infiltrates consistent w pulmonary oedema and not fully explained by atelectasis or pulmonary effusions

ABG: PaO2/FiO2 < 300 on PEEP/CPAP > 5cm H20 - low partial oxygen pressure

Sputum/blood/urine culture: +ve if underlying infection (sepsis)

Amylase and lipase: 3x upper limit –> acute pancreatitis

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18
Q

What is alcohol withdrawal?

A

Occurs in patients with alcohol dependence when their daily alcohol consumption is decreased or stopped

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19
Q

What causes alcohol withdrawal?

A

Abstinence from alcohol in a person with alcohol dependence

Chronic alcohol use results in upregulation of post-synaptic NMDA Rs and down-regulation of post-synaptic GABA Rs

The decrease in blood [ethanol] due to abrupt cessation in alcohol consumption –> imbalance between stimulatory (NMDA) and inhibitory (GABA) systems in CNS

Excessive stimulatory effect –> clinical signs and symptoms

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20
Q

How is alcohol withdrawal investigated?

A
  1. Serum urea + creatinine: elevated or nomal - dehydration leads to renal impairment
  2. LFTs - high or normal
  3. Toxicology screen - +ve for ethanol
  4. Electrolyte panel - metabolic acidosis, hypokalaemia
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21
Q

Summarise the epidemiology of alcohol withdrawal

A

50% of alcohol-dependent patients experience symptoms of AWS upon reduced alcohol intake

8% of hospital patients at risk of AWS

16-31% of ITU patients at risk

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22
Q

What are the presenting symptoms of alcohol withdrawal?

A

Tremor
N+V

Seizures
Hallucinations
Delusions
Fast heartbeat
Hyperthermia
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23
Q

What are the presenting signs of alcohol withdrawal?

A

Tremor
Hypertension
Memory disturbance - disoriented
Waxing + waning in level of consciousness

Seizures
Hallucinations
Delusions
Tachycardia
Hyperthermia
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24
Q

How is alcohol withdrawal managed?

A
  1. BZD - chlordiazepoxide
  2. Supportive care
  3. Phenobarbital - sedative
  4. Pabrinex
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25
What are the possible complications of alcohol withdrawal?
1. Over-sedation 2. DT 3. Alcohol withdrawal seizures 4. Status epilepticus 5. Mortality
26
What is the prognosis for alcohol withdrawal?
Persistent insomnia + autonomic symptoms for a few months after acute withdrawal phase Usually last for 6 months 50% patients remain abstinent for a year Relapse prevention w counselling, self-help groups, pharmacotherapy
27
What are the risk factors for alcohol withdrawal syndrome?
Hx of AWS and DT | Abrupt withdrawal of alcohol
28
What is anaphylaxis?
An acute, severe, life-threatening allergic reaction in pre-sensitised individuals, leading to a systemic response caused by the release of immune and inflammatory mediators from basophils and mast cells. At least 2 organ systems involved
29
What are the causes of anaphylaxis?
Exposure to allergen in pre-sensitised individuals Common allergens = drugs, foods, insect stings, exercise
30
What are the risk factors for anaphylaxis?
<30 yo: food-associated, exercise-induced Atopy/asthma Hx of anaphylaxis Exposure to common sensitiser
31
Summarise the epidemiology of anaphylaxis
Under-reported Prevalence = 1-17% Adults - drug- and vaccine-induced reactions - pencillin, NSAIDs Kids - food
32
What are the presenting symptoms of anaphylaxis?
``` Itching Sweating Diarrhoea Vomiting Difficulty breathing ```
33
What are the presenting signs of anaphylaxis?
``` Hyperhidrosis Erythema Urticaria Oedema Wheeze Laryngeal obstruction Cyanosis Tachycardia Hypotension ```
34
How is anaphylaxis investigated?
Serum tryptase: elevated In vitro IgE: >0.35 = atopy Skin test: >3mm diameter Challenge test: objective symptoms of allergy response
35
How is anaphylaxis managed?
1. Cardiorespiratory assessment + supportive measures 2. IM adrenaline 3. Assess + secure airway 4. IV normal saline If hypotensive + glucagon If persistent resp symps + inhaled SABA - salbutamol Hives + rhinorrhoea - H1+2 antagonist (diphenhydramine) Post-emergency stabilisation: Prednisolone Ongoing: immunotherapy
36
What are the possible complications of anaphylaxis?
1. MI 2. Death - following CV shock or cardiac arrest if delay in IM adrenaline administration 3. Recurrence
37
What is the prognosis for anaphylaxis?
Individuals w previous reactions are at higher risk of recurrence Outlook depends on success of immune therapy, allergen avoidance, and compliance with carrying epipen
38
What is ABG?
An arterial blood glass test measures the pH and levels of oxygen and carbon dioxide in the blood from an artery
39
What is an ABG used for?
To check how well the lungs are able to move oxygen into and remove carbon dioxide from the blood
40
What are the indications for an ABG?
- Any unexpected deterioration in ill patient - Acute exacerbation of chronic chest condition - Impaired consciousness or respiratory effort - Signs of CO2 retention - Cyanosis, confusion, visual hallucinations (signs of low PaO2) - To validate measurements from transcutaneous pulse oximetry
41
What are the signs of CO2 retention?
Bounding pulse Drowsy Tremor (flapping) Headache
42
What are the possible complications of an ABG?
``` Local haematoma Arterial vasosapsm Arterial occlusion Air or thrombus embolism Local anaesthetic anaphylactic reaction Infection Needle stick injury ```
43
What is aspirin overdose?
Salicylate poisoning The result of ingestion of, or topical exposure to, chemicals metabolised to salicylate
44
What are the risk factors for aspirin overdose?
- Ingestion of 150mg/kg or more, or 6.5g or more, of aspirin or aspirin-equivalent - Children < 3yo - Adults < 70yo - Hx of self-harm or suicide attempt
45
What causes aspirin overdose?
Acetylsalicylic acid (aspirin) is rapidly hydrolysed to salicylate in the GIT and bloodstream
46
What are the signs of aspirin overdose?
``` Unexplained delirium Fever Diaphoresis Tachypnoea Hyperpnoea Kussmaul's breathing Movement disorders, asterixis, stupor Confusion and/or delirium Coma and/or papilloedema Volume depletion ```
47
How is aspirin overdose investigated?
1. ABG 2. Serum electrolyte panel 3. Serum salicylate level 4. Serum urea + creatinine
48
What are the possible acute complications of a blood product transfusion?
Acute haemolytic reaction Allergic reaction Anaphylactic reaction Coagulation problems in massive transfusion Febrile non-haemolytic reaction Metabolic derangements Mistransfusion (incorrect product) Septic/bacterial contamination Transfusion-associated circulatory overload Transfusion-related acute lung injury (TRALI) Urticarial reaction
49
What are the indications for a cryoprecipitate transfusion?
Is high in factor VIII and fibrinogen tf used in hypofibrinogenaemia 1. Haemorrhage after cardiac surgery 2. Massive haemorrhage or transfusion 3. Surgical bleeding
50
What are the indications for a platelet transfusion?
Haemorrhage prophylaxis in patients with thrombocytopaenia or platelet function defects
51
What are the possible delayed complications of a blood product transfusion?
``` Delayed haemolytic reaction Iron overload Microchimerism Overtransfusion/undertransfusion Post-transfusion purpura Transfusion-associated graft-versus-host disease Transfusion-related immunomodulation ```
52
What are the possible infectious complications of a blood product transfusion?
``` Hep B Hep C Human T-lymphotrophic virus 1 or 2 HIV Creutzfeldt-Jakob disease Human herpesvirus 8 Malaria + babesiosis Pandemic influenza West Nile virus ```
53
What is fresh frozen plasma?
A blood product made from the liquid portion of whole blood
54
What is cryoprecipitate?
Frozen blood product prepared from blood plasma High in factor 8 + fibrinogen FFP thawed at 1-6oC Centrifuged Precipitate collected Precipitate resuspended in small amount of residual plasma and then re-frozen for storage
55
What is prothrombin complex concentrate?
AKA factor IX complex | = factors 2, (7,) 9, 10
56
What are the indications for prothrombin complex concentrate?
1. Prevents bleeding in haemophilia B if pure factor 9 unavailable 2. Reverses warfarin (+ other vitamin K antagonists) 3. Factor 2/7/9/10 deficiency
57
What is burns injury?
Injury to the skin and superficial tissues, caused by heat from hot liquids, flames, or contact with heated objects, electrical current or chemicals
58
What are the risk factors for burns injury?
- Young childrne - Age > 60 - Male sex
59
Summarise the epidemiology of burns injury
- Common - Death rates have been decreasing in developed countries - Rate of child deaths from burns is over 7x higher in developing than in developed countries - 250,000 per year in UK - Approx 175,000 to A and E - 13,000 admitted to hospital
60
What are the causes of a burns injury?
1. Thermal burns - heat, hot liquids, flame, contact w heated objects 2. Electrical burns - caused by low-, intermediate-, and high voltage exposures 3. Chemical burns - exposure to industrial or household chemical products 4. Non-accidental burns - abuse or neglect in children
61
How are burns classified?
``` Superficial (1st) - epidermis Superficial partial thickness (2nd) - extends into superficial (papillary) dermis Deep partial thickness (2nd) - extends into deep (reticular) dermis Full thickness (3rd) - extends through entire dermis 4th degree - extends through entire skin and into underlying fat, muscle and bone ```
62
How is a burns injury investigated?
FBC - low haematocrit, hypovolaemia, neutropneia + thrombocytopenia (last 2 -sepsis) Metabolic panel - high urea, cr, glu, hypoNa, hypoK Carboxyhaemoglobin - high (-inhalation injury) ABG - metabolic acidosis (-inhalation injury) Fluorescein staining - damaged corneal epithelial cells in corneal burns CT head spine - brain injury/fracture in cases of head or spine trauma Wound biopsy culture/histology - sepsis?
63
What are the features of a superficial burn?
Epidermis Red wo blisters Dry Painful
64
What are the features of a superficial partial thickness burn?
``` Epidermis + superficial (papillary dermis) Redness w clear blister Blanches w pressure Moist Very painful ```
65
What are the features of a deep partial thickness burn?
``` Epidermis + deep (reticular) dermis Yellow or white Less blanching than superficial partial thickness May blister Fairly dry Pressure and discomfort ```
66
What are the features of a full thickness burn?
``` Epidermis + entire dermis Stiff and white/brown No blanching Leathery Painless ```
67
What are the features of a 4th degree burn?
``` Entire skin and into underlying fat, muscle and bone Black Charred with eschar Dry Painless ```

Y3 (20 decks)

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