Acute Medicine Flashcards
Headache Red Flags
Thunderclap = sudden onset, maximal within 5 minutes
New onset neurological deficit
New cognitive dysfunction/personality change
History of malignancy (especially if < 20)
Immunosuppression e.g. HIV
Impaired GCS
Recent head injury (< 3 months)
Triggered by cough/valsalva
Worse on waking/lying down
+ sudden LoV/painful eye (?GCA ?AACG)
Substantial change in usual headaches
Differentials for Thunderclap Headache
Subarachnoid haemorrhage
Internal Carotid Artery Dissection
ICH
Pituitary Apoplexy
CVST
Reversible Cerebral Vasoconstriction Syndrome
Acute hypertensive crisis
Posterior Reversible Leucoencephalopathy
Primary cough, sexual, and exertional headache
Causes/RFs for SAH
85% of non-traumatic SAH = due to aneurysms in the circle of Willis
5% = AVMs/Tumours/ Vasculitides/Arterial dissection
RFs
- FHx
- PKD
- CTD e.g. Ehler Danlos, Marfan’s, Pseudoxanthoma elasticum
- Vascular RFs = HTN, smoking
- Cocaine/meth use
- IE with mycotic aneurysms
Investigating SAH
CTH
- if <6 hours after onset and negative = excluded!
Lumbar Puncture
- >6 hours onset
CT Angiogram if xanthochromia/RBC positive LP but CTH negative
Management of SAH
ABCDE
Depends on cause
Refer to neurosurgical team - ?coil vs clip
BP control
Supportive Rx (?ICU/HDU)
Complications of SAH
Vasospasm (4-10days post)
Hydrocephalus (20%)
- Raised ICP = CN palsies, reduced GCS, Cushing’s Triad
Rebleeding (17%)
Seizuers
Arrhythmias
Hyponatraemia (SIADH vs Salt-wasting)
Death
When to perform a CT head prior to LP (for meningitis)?
Consider CTH prior to LP if:
- > 60
- Focal neurology deficit
- Reduced GCS
- Seizures
- Features of raised ICP e.g. papilloedema
- History of SoL/cancer/immunosuppression
Indications for Non Traumatic CT Head
Confusion/Reduced GCS and known ICH/cerebral infarct/SoL/CNS infection
New focal neurological deficit e.g. stroke
Thunderclap headache
New headache and features of raised ICP e.g. papilloedema
New/worsening headache and history of cancer/immunosuppresion/pregnancy or >50
1st Seizure or change in seizure pattern
Management of Migraines
CONSERVATIVE
- Avoid exacerbating factors/triggers e.g. cut out all caffeine
- Sleep hygiene
- Education/reassurance
MEDICAL
- Prophylatic Rx e.g. propanolol, candesartan, topiramate (avoid if trying to get pregnant!)
- Rescue Rx = simple analgesia, triptans (avoid if IHD)
- Do NOT give COCP
Management of Cluster Headache
Acute Attack = triptans (SC or nasal), ?high flow oxygen
Prophylaxis = verapamil or lithium
Definition of HTN
> 135/85 = Stage 1 Hypertension (confirmed with ambulatory/home BP monitoring)
> 150/95 = Stage 2 Hypertension
> 180/120 = Severe/Malignant HTN (depends if features of End Organ Damage present)
When would you treat stage 1 HTN?
1) If > 80
2) If <80 AND
- Evidence of end organ damage
- CVD
- Renal disease
- Diabetic
- Q Risk >10%
Outline the management of Stage 2 HTN
If < 55 or T2DM
- ACEI first line
If >55 / Afro-Caribbean ethnicity
- CCB first line
2nd line = ACEI + CCB / ACEI + diuretic
3rd line = ACEI + CCB + diuretic
4th line = refer to specialist ?spironolactone ?alpha blocker ?beta blocker
When should we consider Secondary HTN?
If <40 and lack risk factors for HTN (e.g. CKD) or their HTN is resistant to treatment
Causes of Secondary HTN
ENDOCRINE
- Primary hyperaldosteronism (Conn’s)
= Most common cause
- Cushing’s syndrome
- Phaeochromocytoma
- Acromegaly
- Thyrotoxicosis
- Congenital Adrenal Hyperplasia
RENAL
- Glomerulonephritis
- Adult PKD
- Renal artery stenosis
Carcinoid syndrome
How would you investigate someone for Secondary HTN?
Bedside
- ECG
- Fundoscopy
- Urine dip
Bloods
- Routine FBC, U&Es, glucose, lipids
Renal USS
Further Ix tailored by underlying suspicion of cause
- Renin:Aldosterone ratio
- Dexamethasone Suppression Test
- TFTs
- OGTT & IGF1
- ?Renal angiogram
Define Acute Severe Hypertension.
How would you manage a patient with Acute Severe HTN?
BP > 180/120
No evidence of acute end organ damage/grade III or IV retinopathy
Rx =
1) 24 hour ambulatory/home BP monitoring
2) Arrange follow up within 7 days
3) If confirmed persistent HTN = start treatment
Define Malignant HTN
How would you manage a patient with Malignant HTN?
A.k.a Accelerated HTN
BP >180/120 with signs of retinal haemorrhage +/- papilloedema
No other signs of Acute End Organ damage
Rx
1) Start treatment e.g. amlodipine
2) Shared decision making with patient - most can be discharged home with follow up e.g on ambulatory care with home BP monitoring
Outline features which would make you concerned for a Hypertensive Emergency
Chest pain (?ACS)
(?Hypertensive encephalopathy/ICH/Stroke/SAH)
- Confusion
- Seizures
- Reduced GCS
Proteinuria
New AKI/deterioration in renal function
HTN in Pregnancy
= Systolic >140 or diastolic > 90
(or increased by >30 (s) / >15 (d) since booking BP)
PRE-EXISTING HTN
- History of HTN before 20 weeks
GESTATIONAL HTN
- HTN occurring after 20 weeks
- Usually resolves after birth
PRE-ECLAMPSIA
- HTN & proteinuria > 20 weeks
- High risk pts given Aspiring 75mg OD from 12 weeks
Features of Pre-eclampsia
Hypertension
Proteinuria
Headache
Visual disturbance, papilloedema
RUQ pain
Brisk reflexes
Seizures = ECLAMPSIA
Treatment of Pre-Eclampsia
PO labetalol/nifedipine if BP >160/110
Optimum timing of delivery
If develop eclampsia = IV magnesium 4g
Well’s Score - DVT
0 - DVT unlikely
1-2 = Do d-dimer
>3 = DVT likely, request USS
Active cancer (1)
Bedridden > 3 days/Major surgery <12 weeks ago (1)
Previous DVT (1)
Paralysis/plaster cast of that leg (1)
Calf swelling > 3cm (1)
Collateral (non varicose) superficial veins (1)
Entire leg swollen (1)
Tender along deep venous system (1)
Pitting oedema (1)
If alternative diagnosis as/more likely = - 2 points
Wells Score - PE
<4 = PE unlikely, do d-dimer
>5 = PE likely, do CTPA
Previous DVT/PE = 1.5 points
Immobilisation >3 days/surgery in last 4 weeks = 1.5 points
Malignancy (received treatment in last 6 months/palliative) = 1
Clinical signs of DVT = 3
HR > 100 = 1.5
Haemoptysis = 1
If PE is number 1/equally likely diagnosis = +3
CHA2DS2S Vasc Score
Determines risk of stroke with AF
C - CHF
H - HTN
A - Age: 65-74 = (1), >75 = (2)
D - Diabetes
S2 - Stroke/TIA = (2)
S - Sex: M = (0), F = (1)
Vasc = Vasculopathy e.g. IHD, PVD
M F Low Risk 0 1 Moderate Risk 1 2 High Risk 2 3
What is the ORBIT score?
Score used to assess bleeding risk for patients on anticoagulation for AF
5 components
1) Hb - if < than normal range = 2 pts
2) Age > 74 = 1 pt
3) Bleeding history = 2 pts
4) eGFR < 60 = 1 pt
5) Already on antiplatelets = 1 pt
Max 7 points
How would you assess a patient in whom you suspect TIA?
ABCD2 Score - high risk if >4
Age >60
BP > 140/90
Clinical features
Duration > 1hr vs 10-60 minutes
Diabetes
Bedside
- BP
- ECG (?AF) and 24 hour ECG monitoring
Bloods
- Routine FBC, U&Es, LFTs, coag
- HbA1c, glucose, lipid profile
- ?thrombophilia screen if young
Imaging
- Consider CT head/MRI head (esp if already on anticoag)
- Carotid Doppler USS
- Echocardiogram
Refer to TIA clinic, for assessment within 24 hours
Consider admitting if crescendo TIAs
How would you manage a patient with TIA?
CONSERVATIVE
- Stop smoking
- Reduce alcohol intake
- Lifestyle measures
MEDICAL
- ?Antihypertensive agents
- Statin
- Aspirin + clopidogrel
SURGICAL
- Refer for carotid endartectomy if carotid stenosis 70-99% on symptomatic side
DVLA Advice for Stroke/TIA
Group 1 Drivers =
- Stop driving for 1 month
- Review with doctor
Group 2 Drivers =
- Stop driving for 1 year
- Review with doctor
DVLA Advice for Seizures
Group 1 Drivers =
- Cannot drive until seizure free for 1 year
Group 2 Drivers =
- Cannot drive until seizure free for 5 years AND haven’t been on AEDs for 5 years
- If multiple seizures = must be seizure free for 10 years
Management of Atrial Fibrillation
What agents can be used for Rhythm Control?
When is rhythm control preferred?
Agents = Amiodarone, Flecainide (cannot use if HF or IHD)
Preferred if:
- < 65
- Symptomatic/paroxysmal
- 1st presentation
- AF secondary to precipitant e.g. infection
Management of Atrial Fibrillation
What agents can be used for Rate Control?
When is rate control preferred?
Agents = Beta blockers, CCBs, Digoxin
Preferred if:
- >65
- History of IHD
- Permanent AF
How would you investigate a patient with new AF?
ABCDE
History
Bedside
- BP
- ECG/telemetry
Bloods
- FBC, U&Es, LFTs
- Coag
- TFTs (REMEMBER thryoid!!!!)
- Extended electrolytes
- Glucose, lipids
Imaging
- Echocardiogram (exclude valvular disease)
How would you manage a patient with AF?
ABCDE - determine if haemodynamically stable or not
- haemodynamically unstable = cardioversion!
1) Rate vs rhythm control
2) Assess for precipitants/reversible causes
3) ?Anticoagulation (CHADSVasc)
4) ?Elective cardioversion (REFER TO CARDIOLOGY)
- if onset < 48 hours = heparinise and cardiovert as inpatient
- if onset > 48 hours = 3 weeks of anticoagulation prior to cardioversion
What is Sickle Cell Disease?
Autosomal recessive condition of abnormal Hb synthesis
Definitive Ix = haemoglobin electrophoresis, genetic testing
How might a patient with Sickle Cell Disease present?
1) Thrombotic “painful” crises
- Usually precipitated by infection/dehydration
- Thromboses in various organs e.g PEs, AVN of hip
- Rx = transfusions/transfusion exchange/analgesia
2) Sequestration = hypovolaemic shock
- Pooling of blood in spleen/lungs
3) Acute Chest = fever, SoB, tachycardic, hypoxia, chest pain
- May need transfusion exchange
4) Aplastic Crisis = pancytopaenia = anaemia, infection, thrombocytopaenia
5) Infection
- At increased risk of infection due to hypo/asplenism (esp encapsulated bacterium)
Outline the long term management of Sickle Cell disease
MDT approach - haematology, respiratory, geneticists
Antibiotics prophylaxis and immunisations (pneum, flu, mening)
Folic acid (reduces risk of BM aplasia)
Hydroxycarbamide
- Can reduce incidence of crises
- Indicated if >3 vaso-occlusive crises in 1 year OR stroke OR recurrent acute chest syndrome
