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OSCE FINAL > Acute Management Recap > Flashcards

Acute Management Recap Flashcards

1
Q

Acute asthma attack adult criteria

Mod (4)

Severe (4)

Life Threatening (5)

Near -fatal (1)

A

Mod
- PEFR 50- 75%
- Speech normal
- RR < 25
- HR < 110

Severe
- PEFR 33-50%
- Can’t complete sentence
- RR > 25
- HR > 110

Life Threatening
- *O2 < 92%
- PEFR < 33%
- CO2 ‘normal’ 4 - 6kPa
- Decrease GCS
- *Bradycardia, hypotension, shock signs

Near fatal
- hypercapnnaia ( >6 kPa)

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2
Q

Acute asthma attack management adult

  1. First…

B - how much?
I - how much?
C (2) - how much?

Now….

M
A
S

Final step/ last resort?

Investigations you NEED to cover in A-E
1.
2.
3. only if…
4. 3 indications for this…

A
  1. Oxygen 15 L non-rebreath

B- B2 agonist (Neb SABA) Salbutamol 5mg every 20-30 mins or Terbutaline

I- Ipratropium (Musc. Antagonist) back 2 back 500 micrograms every 2-4 hours

C- Corticosteroid
IV hydrocortisone - 100mg IV 6 hourly
Oral pred - 40-50mg daily for 5 days

Now escalate!

M- MgSO4 IV
A- Aminophylline IV (bronchodilator by relaxing smooth muscles, competitively antagonises adenosine receptors)
S- Salbutamol IV
+/- intubation + ventilation or ECMO

Investigations you NEED to cover in A-E
1. full obs
2. PEFR
3. ABG if O2 <92%
4. CXR ***if life threatening, PTX or doesn’t respond to treatment

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3
Q

Acute asthma

Criteria for discharge

Acute asthma attack adult

A
  1. been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours
  2. inhaler technique checked and recorded
  3. PEF >75% of best or predicted
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4
Q

most common pathogens for infective COPD: (3 bacteria)

(1 viral)

A
  1. Haemophilus influenzae (most common cause)
  2. Streptococcus pneumoniae
  3. Moraxella catarrhalis
  4. human rhinovirus is the most important pathogen
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5
Q

COPD acute

Indications for admission (6)

A
  1. *severe breathlessness
  2. *acute confusion or impaired consciousness
  3. *cyanosis
  4. *oxygen saturation less than 90% on pulse oximetry.
  5. social reasons e.g. inability to cope at home (or living alone)
  6. significant comorbidity (such as cardiac disease or insulin-dependent diabetes)
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6
Q

COPD acute

Management of acute exacerbation of COPD

  1. first things first…
    - if <92%
    - Mask?
  2. drug - dose and administered?
  3. drug - dose and administered?
  4. drug - dose and administered?
    - severe =
    - mod =

Escalate!

  1. If treatment resistant try…
  2. If T2 Resp failure then…
A
  1. first things first… O2
    - If <92% give 15L non-rebreathe
    - When stable start with 28% 4L Venturi mask BLUE
    - aim for 88-92%
  2. B- B2 agonist (Neb SABA) Salbutamol 5mg every 20-30 mins or Terbutaline
  3. I- Ipratropium (Musc. Antagonist) back 2 back 500 micrograms every 2-4 hours
  4. C- Corticosteroid
    IV hydrocortisone - 100mg IV 6 hourly
    Oral pred - 30mg daily for 5 days

Now escalate!

  1. IV iminophylline
  2. If T2 Resp failure then…NIV (BiPAP)
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7
Q

COPD acute

Indications for BiPAP in COPD (4)

A
  1. pH 7.25- 7.35
  2. Type 2 resp failure due to chest wall deformity
  3. Neuromuscular disease
  4. cardiogenic pul oedema unresponsive to CPAP
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8
Q

Infective exacerbation of COPD: first-line antibiotics are (3)

Only give abx of hx of: (3)

A

amoxicillin or clarithromycin or doxycycline

Only give abx of hx of:
- Purulent sputum
- fever, raised inflam markers
- CXR showing consolitdation

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9
Q

COPD acute

the venturi masks
- colour
- %
- L/min

1
2
3
4
5
6

A
  1. BLUE 28% 4L/min
  2. White 28% 4L/min
  3. Orange 32% 6L/min
  4. Yellow 35% 8L/min
  5. Red 40% 8L/min
  6. Green 60% 12L/min
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10
Q

PTX

what is a:
primary pneumothorax
secondary pneumothorax
tension pneumothorax

symptoms:
2

signs:

6
2 tension

A

primary - air in pleural space with no underlying lung condition
secondary - air in pleural space with underlying lung condition
Tension - Both PTX can lead to tension where a sudden rise in intrathoracic pressure due to air entering but not able to escape (one way valve) leading to venous return being blocked and can cause obstructive shock and cardiac arrest

symptoms:
- sudden onset SOB
- pleuritic chest pain
-

signs:
- paradoxical breathing
- tachypnoea
- hypoxia
- reduced chest expansion
- hyperresonant to purcuss
- reduced breath sounds
- TENSION - trachea deviates to contralateral side (AWAY)
- TENSION - raised JVP

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11
Q

Acute pneumothorax management

management of primary PTX

1.

2.

what class as a fail? (2)

A

Mx of primary PTX

  1. Not SOB and PTX <2cm
    - supportive
    - discharge and review in clinic 2-4 weeks
  2. SOB or PTX >2cm
    - aspirate and 16-18G cannula
    - If fails chest drain

what class as a fail?
- SOB or CXR still >2cm

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12
Q

Acute pneumothorax management

management of secondary PTX

  • when go straight for the chest drain? (2)

Aspirate if… (1)

failure = … cm
then chest drain

If PTX is …. then admit and monitor for 24hours

Name some secondary causes of PTX (6)

A

when go straight for the chest drain? (2)
- if >50yo and
- SOB or >2cm

Aspirate if 1-2cm

failure = >1cm
then chest drain

If PTX is < 1cm then admit and monitor for 24hours

  1. COPD or asthma
  2. Erlos danlos
  3. marfans
  4. Cystic fibrosis or ILD
  5. empyema or infection or TB or pneumonia
  6. carcinoma
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13
Q

Discharge advice for PTX (3)

A
  1. cant scuba dive
  2. no flying for atleast 2 weeks after successful drainage or 1 week post CXR
  3. smoking cessation
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14
Q

Management of tension pneumothorax

  1. first….
    - colour and gauge
    - where?
  2. followed by…
    - borders of the safe triangle
A
  1. decompress pleural space by inserting a cannula (14 G ORANGE) into the second intercostal space in the midclavicular line on the affected side
  2. followed by the placement of a chest drain (tube thoracostomy) in the safe triangle of the chest to allow continuous drainage of air.

safe triangle:
- pec major
- lat dorsi
- line drawn hoizontal from nipple
- apex of axilla

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15
Q

Upper GI bleed

3 most common causes

Clinical features in general
1. All
2. All
3. All (lab)
Normal range =
4. cause 1
5. cause 2 (Name 5/7)
6. cause 3

A
  1. Peptic ulcer
  2. Oesophageal varices
  3. Mallory Weiss tear
  4. haematemesis (can be fresh blood or coffee ground vomit)
  5. Melina (black, tarry, offensive smelling)
  6. RAISED UREA
    (Normal 2.9-7.1 mmol/L)
  7. Peptic ulcer - epigastric abdo pain
  8. Oesophageal varices - chronic liver disease stigamta. often haem unstable (ascites, spider neavai, gnaecomastia, caput medusa, jaundice, muscle wasting, hepato-splenomegaly)
  9. Mallory-weiss - vomit bout no blood then blood
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16
Q

Management of Upper GI Bleed

  1. A
  2. B
  3. C
    Bloods? (5)
  4. D
  5. E

Once we figure out it’s an upper GI bleed what are we giving for RESUS?
1. first -
2.
3. If platelts less than… give…
4. If fibrinogen less than …. OR INR…. give…
5. If on warfarin give ….

  1. Oesophageal varices - drug, MOA?
  2. Oesophageal varices - drug, dose, how long for?
  3. Non-variceal bleeds CONSIDER - BUT…

-

when must this take place in severe bleeding?

A
  1. A - airway patent? need suction
  2. B - O2 sats, RR, *trachea, *chest expansion, percuss, ausc. (crackles if aspirated?) - CXR, ABG, O2?
  3. C - CRT (>2s), HR (tachy), BP (hypo - only if > 1.5L if 2L lost), ECG, access with 2 large bore cannulas, VBG, *CATHETER?! (want > 30ml/hr)
    - Cross-match and G&S
    - FBC (Hb)
    - Coag
    - LFT, U+E
  4. D
    - AVPU
    - pupils
    - BM
    - Temp
    - Palpate abdo (pain? ascites?) and calves
  5. E
    - site of bleed

Once we figure out it’s an upper GI bleed what are we giving?
1. 500ml STAT 0.9% NaCl (repeat up to 4 times, twice if risk of overload HF)
2. Major haemorrhage protocol and blood transfusion if needed
3. If platelets < 50 x 10^9/litre give platelet transfusion and if actively bleeding
4. Give FFP if fibrinogen < 1.5g/litre or if INR > x1.5 normal
- can offer cryoprecipitate (rich in factor VIII, Von Willebrand factor and fibrinogen - different from FFP because it’s frozen and thawed to get more cencetrated clotting factors)
5. If taking wafarin - prothrombin complex
6 . Oesophageal varices - terlipressin (its a vasoconstrictor of splancnic vessels [splenic A.], dec. blood flow in portal system and thus dec. blood loss)
7. Oesophageal varices - Ciprofloxacin 1g OD, for 7 days
8. Non-variceal bleeds CONSIDER - PPI but NOT BEFORE OGD!

Once stable…. Refer to gastro with Glasgow-Blatchford score for OGD
- *Rectal exam for melina?

OGD < 24 hours in severe bleeding

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17
Q

What is the Glasgow Blatchford Score?

Use MedCalc but what parameters do we look at?

Parameters:
1.
2.
3.
4. Other markers (5)
-
-
-
-
-

What is the Rockhall Score used for?

A

A quantitative way of measure indication for OGD and whether the bleed can be managed as inpatient or outpatient

Parameters:
1. Hb
2. Urea
3. Systolic BP
4. Other markers
- Pulse > 100 (1)
- Evidence of liver disease (2)
- syncope (2)
- melena (1)
- cardiac failure (2)

Rockhall Score
After endoscopy % risk of mortality and re-bleeding (age, co-morbities, shock, cause of bleed etc.)

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18
Q

Management of Upper GI Bleed

Oesophageal varices (consultant lead)
1. What do they do in OGD?
2. LAST LAST resort?

Prophylaxis of further variceal bleeding?
1. medication
2. Surgical (2)
-med given as well
3. Surgical procedure later on

A
  1. What do they do in OGD?
    - band ligaion
  2. LAST LAST resort?
    - Sengstaken-Blakemore tube

Prophylaxis of further variceal bleeding?
1. Propranolol
2. endoscopic sclerotherapy or further band ligation
- give PPI for this too
3. TIPSS - hepatic vein to the portal vein

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19
Q

What is considered a major haemorrhage and to start protocol? (2 definitions)

  1. Restore circulating volume, how? (3)
  2. GET HELP! contact….
  3. stop bleeding contact….
  4. Send off blood samples (3)
  5. ## Blood products given-
    - if assoc. with trauma/ obstetrics give…
    - on warfarin ….
    - on DOAC….
A
  • > 50% lost in 3 hours (70kg male >2500ml)
  • > 150ml/min rate
  1. Restore circulating volume, how?
    - 2 wide bore cannulas, 500ml 0.9% saline warmed, O2 and try to maintain BP)
  2. GET HELP! (gastro, med reg, haem, ITU, anaesthetics)
  3. stop bleeding (surgery, gynae, radiology)
  4. Send off blood samples
    - cross-match - Need 2 samples! - 6 units of blood made available
    - FBC
    - Clotting screen

If 2 samples not given then O- blood be issued

  1. Blood products given
    - 6 units of blood made available
    - If 2 samples not given then O- blood be issued
    - if haemorrhage assoc. with trauma or obstetrics then high risk of DIC then 4 units of FFP should be thawed
    - Warfarin - prothrombin complex given
    - DOACs - contactin Haem for reversal
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20
Q

DKA Management

Criteria for DKA
1.
2.
3.
4.

pathophysiology brief

presentation (7 - one includes triggers)

A

Criteria for DKA
1. glucose > 11
2. pH < 7.3
2. blood ketones > 3mmol/L or ++ urine ketones
3. Barcarb < 15 mmol/L

pathophysiology brief - uncontrolled lipolysis causing excess of free fatty acids that are ultimately converted to ketone bodies

presentation
1. Abdo pain
2. vomiting
3. Kaussmaul breathing
4. trigger? recent infection, surgery, trauma
5. acetone breathe
6. polyuria and polydipsia

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21
Q

DKA Management

  1. A
  2. B
  3. C
  4. D
  5. E

Once we have figured its a DKA give
1.
- what in first hour?
- what in subsequent hours?

    • adult
    • paeds
    • what to do with long and short acting?

3.
- Drops below… give…

4.
- how much?
- rate more than… need….

5.
6.
7. check 3 things

A
  1. A - airway patent? need suction
  2. B - O2 sats, RR, trachea, chest expansion, percuss, ausc. (crackles if infection?) - CXR, ABG, O2 - 15L non-rebreathe
  3. C - CRT (>2s), HR (tachy), BP (hypo - GIVE FLUID!), ECG, access with 2 large bore cannulas, VBG, *CATHETER?! (want > 30ml/hr)
    - Blood ketones
    - FBC (Hb)
    - LFT
    - U+E
  4. D
    - AVPU
    - pupils
    - BM!!!!
    - Temp
    - Palpate abdo (pain?) and calves
  5. ## E

Once we have figured its a DKA give
1. F - Fluid - 1L in first hour 0.9% NaCl, 1L every 2 hours following
2. I - Insulin - fixed rate 0.1 Units/kg/hr Actrapid
Paeds give 0.05 - 0.1 Units/kg/hr Actrapid
- keep long acting!! stop short acting
3. G - Glucose - if drops < 14mmol/L then add in 125ml/hour of 10% glucose
4. P - Potassium - add K+ to second bag - 20mmol per 500ml of fluid.
If rate > 20mmol/hr then need cardiac monitoring
5. I - Infection - fevers? blood cultures? Abx?
6. C - fluid chart - input and output CATHETER!
7. K - Ketones - monitor pH, Ketones an bicarb

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22
Q

Potassium level checks in the first 24 hours and what to do

  1. > … No K+ needed
  2. ….-…… Give …..
  3. < …… Senior review
A
  1. > 5.5 mmol/L - No K+ needed
  2. 3.5 - 5.5 - Give 40mmol per 1L of fluid
  3. < 3.5 - Senior review
23
Q

DKA resolution is defined as: (3)

when does a consultant endocrinologist need to be called?

Complications (6 and one key one for PAEDS!)

A

pH >7.3 and
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L

  • If both the ketonaemia and acidosis have NOT been resolved within 24 hours.

Complications
1. gastric stasis
2. thromboembolism
3. arrhythmias secondary to hyperkalaemia/iatrogenic hypokalaemia
4. iatrogenic due to incorrect fluid therapy: cerebral oedema*, hypokalaemia, hypoglycaemia
5. acute respiratory distress syndrome
6. acute kidney injury

24
Q

Management Hyperosmolar hyperglycaemic state

what is it?

who stereotypically gets it?

Precipitating factors (3)

Presentation:
how long does it take to come on?
- key collection of symptoms (3)
- systemic (2)
- Neuro (2)
- a key compliction

A

what is it?
Hyperglycaemia results in osmotic diuresis, severe dehydration, and electrolyte deficiencies.
hyperglycaemia → ↑ serum osmolality → osmotic diuresis → severe volume depletion

who steriotypically gets it?
Presents in the elderly with type 2 diabetes mellitus

Precipitating factors
intercurrent illness
dementia
sedative drugs

Presentation:
Takes days compared to DKA which is hours

consequences of volume loss:
- clinical signs of dehydration
- polyuria
- polydipsia

systemic:
- lethargy
- nausea and vomiting

neurological:
- altered level of consciousness
-focal neurological deficits

haematological:
- hyperviscosity! (may result in myocardial infarctions, stroke and peripheral arterial thrombosis)

25
Q

Management Hyperosmolar hyperglycaemic state

diagnostic criteria (not set in stone)
1.
2.
3…… work out by how?
4. negative -
5. negative -

A
  1. hypovolaemia
  2. marked hyperglycaemia (>30 mmol/L)
  3. significantly raised serum osmolarity (> 320 mosmol/kg)
    can be calculated by: 2 * Na+ + glucose + urea
  4. no significant hyperketonaemia (<3 mmol/L)
  5. no significant acidosis (bicarbonate > 15 mmol/l or pH > 7.3 - acidosis can occur due to lactic acidosis or renal impairment)
26
Q

Management Hyperosmolar hyperglycaemic state

  1. first things first… estimated at?
  3. controversial
  4. prevent …
A

Management

  1. fluid replacement
    fluid losses in HHS are estimated to be between 100 - 220 ml/kg
    IV 0.9% sodium chloride solution
    typically given at 0.5 - 1 L/hour depending on clinical assessment
  2. potassium levels should be monitored and added to fluids depending on the level
  3. insulin - should not be given unless blood glucose stops falling while giving IV fluids
  4. venous thromboembolism prophylaxis
    patients are at risk of thrombosis due to hyperviscosity
27
Q

Features of Hypoglycaemia

what is a normal blood glucose level?
definition of hypo =

Symptoms when B.M < … (4) and why?!

Symptoms when B.M < … (4) and why?!

Rare and severe (2)

A

what is a normal blood glucose level?
fasting 4.0-5.8 mmol/L

definition of hypo = <3.0mmol/l. In hospitalised patients, a blood glucose ≤4.0 mmol/L should be treated if the patient is symptomatic

<3.3 mmol/L cause autonomic symptoms - release adrenaline and glucagon
sweating, shaking, nausea, anxiety

<2.8 mmol/L - neuroglycopenic symptoms due to inadequate glucose supply to the brain:
Weakness, Vision changes, Confusion, Dizziness

Rare and severe
seizure and then coma

28
Q

Risk factors of Hypoglycaemia (8)

A
  1. Insulin-dependent diabetes
  2. Previous history of hypoglycaemic episodes or reduced hypoglycaemia awareness
  3. **Alcohol misuse!!!
  4. Impaired renal function
  5. Cognitive dysfunction/dementia
  6. Profound starvation
  7. Increased exercise
  8. Food malabsorption issues (e.g. coeliac disease, bariatric surgery, gastroenteritis)
29
Q

Management of Hypoglycaemia

In the community:
Conscious
1.
- can repeat how many times?
- ensure what after resolved?
Unconscious
1.

In the hospital:
Conscious
1.
Unconscious or can;t swallow
1. how much?
2. how much?

  • in mean time
A

In the community:
Conscious
1. oral glucose 20g
- Repeat B.M after 10-15 mins and if the patient is still hypoglycaemic, can repeat glucose gel a further 2-3 times.
- When the patient is fully alert, give longer-acting carb for the patient to eat (e.g. toast).

Unconscious
1. IM or s/c glucagon rescue pack

In the hospital:
Conscious
1. oral glucose 10-20g liquid, gel or tablet
Unconscious or can’t swallow
1. Have IV access - 10% glucose 150ml STAT
2. Don’t have IV access - IM 1mg glucagon rescue pack

GCS < 8 - get senior! and anaesthetics and maintain airway in mean time

30
Q

Acute Management Status Epileptics

definition? (2)

A

definition:
seizure > 5 mins or
>= 2 seizures in within a 5-min period without the person returning to normal between them

31
Q

Acute Management Status Epileptics

REMEMBER…
1. A
- bigger than you think for this one
2. B
3. C
Bloods (6)
4. D
5. E

Steps as to what medications to terminate:

  1. Time =
    Hospital - dose
    Community - dose (2)
  2. Time =
  3. Time =
    (3 options and doses)
  4. Time =
A

REMEMBER… GET THE TIMER GOING

  1. A - airway patent? Give them a head tild chin lift and ask someone to bag and mask them.
    Get an airway adjunct in
    - If can open mouth - Guedel (oropharyngeal)
    - If can’t because jaw clenched - NP
  2. B - O2 sats, RR, *trachea, *chest expansion, percuss, ausc. (crackles if aspirated?) - CXR, ABG, O2?
  3. C - CRT (>2s), HR (tachy), BP, ECG, access with 2 large bore cannulas, VBG, *CATHETER?! (want > 30ml/hr)
    Bloods
    - FBC
    - U+E (hyponatraemia can cause seizure)
    - Lactate (rasied in tonic-clonic)
    - *Toxicology screen
    - Have epilepsy and already on anticonvulstants? Check therapeutic/ serum levels
    - Signs of Infection - blood culture, CRP
  4. D
    - AVPU
    - pupils
    - *BM - Hypoglycaemia < 2.8 causes neuro signs
    - Temp
    - Palpate abdo and calves
  5. E

Steps as to what medications to terminate:
1. At 5 minutes:
IV Lorazepam 4 mg bolus in adults
Community (no IV access) - Buccal Medazolam 10mg or PR diazepam

  1. At 10 minutes:
    Repeat dose
  2. At 15 minutes:
    - IV levatricitam 60mg/kg max 4500mg
    - IV valproate 40mg/kg
    - IV phenytoin - 20mg/kg NEEDS CARDIAC MONITORING
  3. At 30 minutes:
    General anaesthesia
32
Q

Acute management of Stroke A-E

A

A - secure airway (if GCS < 8 then need help with airway)

B - O2 sats (give 15L non -rebreathe if needed), check trachea, chest expansion, percuss, ausc. chest

C- CRT, feel temp peripherally, pulse (AF?), BP (don’t need to treat if high unless hypertensive enceph), ECG, (AF?), palp apex, ausc. HS, get IV access and take bloods (FBC, clotting screen, VBG,

D- pupillary reflex, AVPU or GCS, tympanic temp, BM (*hypo can mimic), palpate abdomen, palpate calves

Once established potential stroke
1. CT non-contrast to rule out haemorrhagic
2. Then aspirin 300mg
3. <4.5 hrs and no CI? Alteplase (thrombolysis)
4. Thrombectomy?
5. Clopidpgrel 75mg lifelong

Keep stable
1. Temp
2. BM
3. Hydration
4. O2

33
Q

Talk through GCS

eyes - 4

mouth - 5

motor - 6

A

eyes - 4
4 = alert
3 = open to voice
2 = open to pain
1 = unresponsive

mouth - 5
5 = orientated to time, place, person
4 = confused
3 = inappropriate sounds
2 = just noises, incomprehensible
1 = unresponsive

motor - 6
6 = can follow command (squeeze my finger)
5 = localises pain
4 = moves away from pain
3 = flex to pain
2 = extend
1 = unresponsive

34
Q

Acute management of Stroke A-E

Contra-indications fro Thombolysis (9)

A
  1. Previous intracranial bleed
  2. Preg?
  3. Malignant/ uncontrolled HTN
  4. Ischaemic stroke last 3 months
  5. LP last 7 days
  6. Seizure before stroke
  7. active inter-cranial carcinoma or aneurysm
  8. Head injury last 3 months
  9. clotting disorder
35
Q

Acute management of Stroke A-E

Inter-cranial Bleeding

types:
1. Intercerebral - characteristics
2. Subarachnoid - characteristics

Management (4 steps)

If they have had a fall make (arguably more extra or subdural) but make sure to do a…

A

Management
1. NO ASPIRIN!!
2. Anticoagulant reversal: discuss with haematology if required
3. Blood pressure lowering: aim for BP < 140 mmHg systolic (if <6 hours of onset) or < 180 mmHg systolic (if >6 hours of onset). Use labetalol 10mg IV, then consider GTN infusion.
4. Referral: consider referral to neurosurgery for advice regarding potential surgical intervention.

If fall: PRIMARY SURVEY IN E!!
1. Look across whole of head
2. Look for signs of basal skull fracture (behind ears etc.) and every boney prominance
3. palpate every joint (neck, soulders, elbow, wrist, pelvis, knee, ankle)

36
Q

Acute management of Stroke A-E
(Questions for end)

What long-term management would you take into account for someone who has had a stroke?

A

Conservative
- fluid assessment
- feeding and safe swallow assessment SALT
- Disability scale - functional status
- physiotherapy
- glycaemic control if NBM
- smoking cessation

Medical
- Antiplatelet (clopidogrel)
- Anti-coag if AF (usually after 14 days)
- BP control
- Lipid lowering (statin)

Surgery
- Carotid USS to check if vascular surgery is an option

37
Q

Adult Tachycardia Management (not full A-E)
LIFE THREATENING!

  1. A-E assessment make sure to include: (4)
  2. If Life Threatening Signs (4)
  3. If there is any of the above signs do what/ what will they do?

If unsuccessful?
1.
2.

A
  1. A-E assessment make sure to include: (4)
    - O2 if < 94% (non-rebreathe 15L)
    - Get IV access wide bore cannula
    - Monitor ECG, BM, Obs, BP
    - Identify and treat reversible causes causing sinus tachy eg. hypovolaemia, electrolyte abnormalities
  2. If Life Threatening Signs (4)
    - Shock - Systolic < 90mmHg
    - Syncope
    - MI
    - Severe Heart failure

** Call anaesthetics, sedation and will need Sync DC Cardioversion 3 attempts

  • if unsuccessful:
    1. Amioderone 300mg IV over 20-30 mins
    2. repeat shocks
38
Q

Adult Tachycardia Management (not full A-E)
NO life threatening signs - NARROW

  1. First …

Narrow Regular =
(4 management steps)

GIVE ME DOSAGES!

Narrow Irregular = probable…
1. try
2. consider (2)
3. MAKE SURE!

A
  1. First is the tachy narrow (< 0.12s 3 small sq) or broad?

Narrow Regular = SVT
1. Vagal manoeuvres (carotid massage or valsalva)
2. Adenosine rapid bolus 6mg then 12mg then 18mg
3. B-blocker (atenalol 2.5mg every 5 mins) or CCB rate limiting (Verapamil 5mg over 2mins or 3 if elderly)
4. DC sync cardioversion 3 attempts and sedate
—————————————————-

Narrow Irregular = probable AF
1. Try rate with B-blocker (atenalol 2.5mg every 5 mins)
2. Consider amioderone (5mg/kg) or digoxin if evidence of HF
3. Anticoagulate if >24hrs since onset

39
Q

Adult Tachycardia Management (not full A-E)
NO life threatening signs - BROAD!

  1. First …

Broad Regular
Option 1:
1.

Option 2:
1.

If either option failed then…

Broad Irregular =
Option 1:
1.

Option 2:
1.

A
  1. First is the tachy broad? (> 0.12s 3 small sq)

Broad Regular =
Option 1: If VT or unsure of rhythm
1. Give amioderone 300mg IV over 10-60mins

Option 2: If confirmed previous SVT with BBB/ aberrant conduction
1. Treat as narrow complex tachy (vagal mon etc.)

If either scenario and don’t work then:
DC sync cardioversion 3 attempts and sedate

Broad Irregular =
Option 1: Tosardes de Pointes
1. MgSO4 2g IV over 10 mins

Option 2: AF with BBB
1. Treat as irreg narrow complex (eg. Block, HF?, Anti-coag etc.

40
Q

Adult Bradycardia Management (not A-E)

A
41
Q

PE Presentation (5)

A
  1. Pleuritic chest pain
  2. haemoptysis
  3. syncope (due to right suded heart strain)
  4. cough
  5. SOB
42
Q

Acute Management - Pulmonary Embolism A-E

  1. A -
  2. B -
  3. ## C -
  4. D
  5. E

indications for V/Q (3)

PE management
1.
2. if shock

A
  1. A - airway patent? need suction
  2. B - O2 sats, RR, trachea, chest expansion, percuss, ausc. - CXR (good to rule out pneumonia), ABG if <92%, O2?
  3. C - CRT (>2s), HR (tachy), BP (hypo - if in shock) ECG, access with 2 large bore cannulas, VBG, *CATHETER?! (want > 30ml/hr)
    - FBC (Hb)
    - Coag
    - LFT, U+E
    - CRP
    - Trop to rule out
  4. D
    - AVPU
    - pupils
    - BM
    - Temp
    - Palpate abdo and calves*!
  5. E

Wells score results
<= 4 d-dimer first
> 4 straight to CTPA or V/Q

indications for V/Q
- preg
- ckd or allergic to contrast

PE management
1. DOAC (3 months if cler cause, 6 if no clear cause)
2. If in shock - Continuous unfractionated Heparin and then consider Thrombolysis (alteplase)

43
Q

ECG findings of PE

(5)

if repeated PEs then could have…

A
  1. sinus tachy
  2. S1Q3T3 - V1 S wave high amplitude, V3 Q high, T wave inversion
  3. RBBB
  4. Right axis deviation
  5. new onset AF

repeated - IVC filter

44
Q

Acute Management: Heart Failure/ Pul Oedema

A
B
C
D
E

CXR signs: A-F

Once you know its Pul Oedema:
1.
2.
3. Resp failure-
4. If in shock -

Avoid - (2)
stop - if….

Later: during admission
1.
2.
3.

A
  1. A - airway patent? need suction
  2. B - O2 sats, RR (tachy), trachea, chest expansion, percuss (dull if pleural eff) , ausc. (coarse crackles, dec. breath sounds) - CXR, ABG if <92%, O2?
    SIT PATIENT UP!
  3. C - CRT (>2s), HR (tachy), BP (hypo - if in shock) ECG, access with 2 large bore cannulas, VBG, *CATHETER?! (want > 30ml/hr), check oral mucosa if dry, elevated JVP
    - FBC (Hb)
    - LFT, U+E
    - CRP
    - Trop to rule out
    - Plasma BNP
  4. D
    - AVPU
    - pupils
    - BM
    - Temp
    - Palpate abdo and calves*!
  5. E

CXR -
A- alveolar opacification (batwing)
B- kerley B lines
C -caridomegaly (AP)
D - Diversion of upper lobes and diaphram blunting
E- Effusion pleural
F - fluid in horizontal fissure (R)

Once you know:
1. Furosamide - 40mg PO
2. If resistant 40-80mg IV
3, Resp failure- CPAP
4. If in shock - get senior - inotropic agents e.g. dobutamine

Avoid - GTN or opiates
Stop - B-blocker if HR < 50, Keep ACEi

Later:
1. Fluid restriction
2. Daily weights
3. Echo

45
Q

Acute Management: Opioid Overdose

Typical triad presentation:
1
2
3

Three groups of patient it can affect
1
2
3

A

Triad:
1. Pin point pupils (miosis)
2. Resp depression
3. Decreased GCS

Three groups of patient it can affect:
1. IVDU
2. prescribed for pain relief - inpatient elderly frail
3. Taken deliberate overdose

46
Q

Acute Management: Opioid Overdose

A

B

C

D

E

Once you know it opioid overdose:
1.
2. repeat –

A
  1. A - airway patent? need suction- put in Guedel if cant then NP etc.
  2. B - O2 sats, RR (severe Brady <12), trachea, chest expansion, percuss, ausc. (could’ve vom and aspirated) - CXR, ABG if <92% (can have T2 resp failure in overdose), O2?
  3. C - CRT, HR, BP, ECG, access with 2 large bore cannulas, VBG, *CATHETER?! (want > 30ml/hr)
    - FBC (Hb)
    - LFT, U+E
    - CRP
    - Toxicology screen
  4. D
    - AVPU
    - pupils!!
    - BM
    - Temp
    - review drug chart
    - Palpate abdo and calves!
  5. E
    - * EXPOSE - check fentanyl patch (upper arm, chest, back)

Once you know it opioid overdose:
1. Naloxone 400 micrograms IV
- can be repeated at 800 micrograms at 1 minute intervals

47
Q

Acute Management: Benzo Overdose

Clinical Features:

A
  1. Decreased GCS
  2. Resp depression
  3. Hypotension
  4. Bradycardia
  5. Rhabdomyolysis
  6. Hypothermia
48
Q

Acute Management: Benzo Overdose

Reversal agent for Benzo overdose:
1.

can only give if: (3)

A
  1. A - airway patent? need suction - put in Guedel if cant then NP etc.
  2. B - O2 sats, RR (brady), trachea, chest expansion, percuss, ausc. - CXR, ABG if <92%, O2?
  3. C - CRT, HR, BP (hypo) ECG (can get arrhythmias), access with 2 large bore cannulas, VBG, *CATHETER?! (want > 30ml/hr)
    - FBC (Hb)
    - LFT, U+E
    - CRP
    - Creatinine kinase
    - Toxicology screen
    - Lactate
  4. D
    - AVPU
    - pupils- DILATED!! (not pinpoint like opioid)
    - BM
    - Temp
    - Palpate abdo and calves*!
    - review drug chart
  5. E

Reversal agent for Benzo overdose:
1. Flumenzil IV (GABA anatgonist)

Should only be used when:
1. Benzo only drug (not mixed overdose)
2. No previous benzo dependancy
3. CNS depression so much that cant ventilate self

Use TOXBASE or BNF for dose

49
Q

ACS

Differentiating ACS with labs/ ECG
1. unstable angina (3)

  1. NSTEMI (3)
  2. STEMI(3)

Cardiac territories:
Inferior / RCA =
Lateral / Left circumflex =
Anterior =
Septal =
Apex =
Postero-lateral =

What’s seen in LBBB? (2)

A

Differentiating ACS with labs/ ECG
1. unstable angina
- happens at rest (unpredictable)
- CAN have ECG changes but might not
- NO increase in trop

  1. NSTEMI
    - happens at rest (unpredictable)
    - WILL have ECG changes but not elevation
    - Increase in trop
  2. STEMI
    - happens at rest (unpredictable)
    - WILL have persistent ST elevation ECG
    - Increase in trop

Cardiac territories:
Inferior / RCA = II, III AvF
Lateral = I , AvL, v5-v6
Anterior = V1 - V4 (LAD)
Septal = V1-V2
Apex = V5-V6
Postero-lateral = v7-v9 (60% = RCA // 20% = LCA or codominance)

What’s seen in LBBB? (2)
- Broad QRS
- Negative V1 (W) and Positive V6 (M)

50
Q

STEMI Diagnostic criteria

  • All -
    Men

all - other leads

A
  • All - new LBBB
    Men
  • < 40 = ST elevtion (2.5 small sq) v2-v3
  • > 40 = ST elevtion (2 small sq) v2-v3

Women
- 1.5 small sq in women v2-v3

  • 1 small sq in any other leads
50
Q
  1. A -
  2. B -
  3. C -
    6 bloods:
  4. D
  5. E

Once established ACS
1.
2.
3.
4. (2 options)
Signs of pul oedema -
Hypo -

STEMI -
NSTEMI -

Time frames for STEMI?

A
  1. A - airway patent? need suction- put in Guedel if cant then NP etc.
  2. B - O2 sats (<92% give O2 but if not then don’t), trachea, chest expansion, percuss, ausc. - CXR, ABG if <92%, O2?
  3. C - CRT, HR, BP, ECG, access with 2 large bore cannulas, VBG, *CATHETER?! (want > 30ml/hr)
    - Trop
    - FBC (Hb)
    - LFT, U+E
    - Serum glucose
    - Coag
  4. D
    - AVPU
    - pupils
    - BM
    - Temp
    - review drug chart
    - Palpate abdo and calves!
  5. E

Once established ACS
1. All get 300mg Aspirin
2. Morphine (if really bad!)
3. Nitrates - GTN (CI if hypotensive)
4. Tecagralor (low bleed risk)/ Clopidogrel 300mg (bleed risk)
Signs of Pul. Oedema? Furosamide
Hypotensive? IV fluid

STEMI - get PCI!
NSTEM- GRACE score then PCI

Time frames for STEMI?
- < 2hrs away go for PCI, < 12 hours of onset
- > 2 hrs could thrombolysis, needs to be within 12 hours of onset

51
Q

Hyperkalaemia

Normal range -

Severe

-
-
-

A

Normal range - 3.5-5.0mmol/L

Mild - 5.5 - 5.9
Mod - 6.0 - 6.4
Severe >6.5

ECG changes with measurements
- Tall tented T waves (slower repolarisation)
- PR prolongation and enlonaged T waves (atrial paralysis)
- Bradyarrythmias 7 - 9mmol/L (escape rhythm, slow AF)
- Asystole or VF > 9.0mmol/L

52
Q

Management of hyperkalaemia (6)

Indications for dialysis
- you know a way to remember this!

A
  1. A-E assessment
  2. K+ > 6.0 check the lab to see if haemolysed! (pseudo)
  3. Calcium gluconate - 10%, 30ml IV slow infusion
    - stablizes cardiac membrane
  4. Insulin with Dextrose - Actrapid 10 units in 50%, 50ml dextrose
    - pushes K+ intracellularly
  5. Caclium resonium or loop diuretic
    - K+ in the bowel/ urine and will excrete K+
  6. Dialysis if treatment resistant

Indications for dialysis
A - Acidosis < 7.2
E - Electrolyte (K+ treatment resistant)
I- Intoxication (lithium, aspirin and anti-freeze)
O - Oedmea (pulmonary)
U Ureamia
- Encephalopathy - flapping tremor and confusion
- Pericarditis - pericardial rub

OSCE FINAL (4 decks)

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