Acute medicine Flashcards
1
Q
what is a FAST scan
A
Focused assessment with sonography in trauma
2
Q
when is FAST scan used
A
when triaging and managing major incident scenarios or if a CT isnt going to be immediate
- doesnt offer additional info to that obtained with CT and shouldnt be performed if it delays transfer to CT
3
Q
when is plain film used in trauma
A
when looking at Ap chest, pelvis and c spine series
4
Q
when might a chest xray be used in trauma scenarios
A
to evaluate serious injury such as flail chest, massive pneumothorax, haemothorax, ET tube placement and widened mediastinum
5
Q
what is flail chest
A
when two or more contiguous ribs are fractured in two or more places
6
Q
what is a flail chest commonly associated with
A
pulmonary contusion/laceration
pneumothorax
haemothorax
7
Q
what is a widened mediastinum
A
A mediastinum is considered widened if it is more than 8 cm wide on a posteroanterior view of a chest X-ray
8
Q
what can a widened mediastinum indicate
A
haemopericardium
bleeding from the great vessels
9
Q
what types of haemorrhage can be caused by a pelvic fracture
A
pelvic, thigh and/or retroperitoneal haemorrhage
9
Q
what is a AP compression pelvic fracture
A
An anteroposterior (AP) compression pelvic fracture - crush injury which results in the disruption of the pubic symphysis and the pelvis opens like a book
10
Q
what are the different types of AP compression fracture
A
APC-I: A slight widening of the pubic symphysis and/or anterior SI joint. This is generally considered a stable injury, but unstable forms can be rare and difficult to diagnose.
APC-II: A widened anterior SI joint, with disruption of the anterior SI, sacrotuberous, and sacrospinous ligaments.
APC-III: A complete disruption of the SI joint, with lateral displacement.
11
Q
what is a vertical shear pelvic injury
A
it is an injury which results in vertical, unilateral fractures of the pubic rami and vertical fracture of the sacral foramina on the same side
12
Q
what is lateral compression pelvic injury
A
lateral force causes sacral fracture with separation of the pubis symphysis
resulting in oblique fractures of the pubic rami bilaterally, impacted fractures of the sacral foramina ipsilateral to the force, with infolding of the hemipelvis
13
Q
what imaging modality is used for traumatic c spine injury investigations
A
CT
14
Q
what is a jefferson fracture
A
a C1 fracture
- the space between the peg of C2 and the lateral masses of C1 are widened on both sides
- the lateral masses are both laterally displaced and no longer align with the lateral masses of c2
15
Q
what causes a C1 fracture
A
verticle force loaded through the occiput - i.e drivers vs windscreen with neck extended
16
Q
what is a hangman fracture
A
it is a C2 fracture which may involve with odontoid peg, vertebral body or the posterior elements
17
Q
what causes a hangman fracture
A
high force hyperextension injury
18
Q
what is a flexion teardrop fracture
A
it is fracture of the cervical spine caused by the sudden pull of the longitudinal ligament on the anterior, inferior aspect of the vertebral body following extreme hyperextension of the neck
19
Q
what is a burst fracture
A
it results from axial loading most often due to motor vehicle accidents and falls
- usually produces a comminuted, vertical fracture through the vertebral body
20
Q
when is a body CT performed in a trauma situation
A
to look for occult injuries which are not clinically detectable (unconscious patient, distracting injury)
21
Q
when do you CT in trauma
A
if the patient is haemodynamically stable
if they have more than one body system injured/rtc with fatalities
when there is findings on plain film/FAST scan is inconclusive or suggestive of injury
obvious severe injury
22
Q
what is silver trauma
A
it is trauma in an older patient - 60/65
23
Q
what are respiratory physiological differences in the elderly
A
increased chronic respiratory illnesses
lower chest wall compliance making ventilation more difficult
higher rates of kyphosis which reduces the space for lung expansion thus reducing ventilation
24
what are cardiac physiological differences in the elderly
hypertension and orthostatic blood pressure changes are common
reduced cardiac output
increased vascular resistance due to stiff vessels or atherosclerosis
heart failure
25
what are neurological physiological differences in the elderly
dementia
more space between brain and skull increasing the space for bleeding without mass effect
conditions like parkinsons are more common
26
what in the elderly can increase frailty
skin is more fragile
bones are more brittle - osteoporosis
more prone to infection
polypharmacy
difficulty getting up leading to rhabdomyolysis, pressure damage and hypothermia
27
what is the initial management for someone presenting with traumatic injury
CABCDE
- control catastrophic haemorrhage
- airway with c-spine protection
- breathing with ventilation
- circulation with haemorrhagic control
- disability: neurological status
- exposure and environment
28
what are different mechanisms of injury it regards to trauma
blunt force - road traffic collision, falls, assault
penetrating injuries - knife, gun shot
sporting injuries
blast injury - primary to quintenary
29
what are the priorities in a trauma situation
stop the bleeding
prevent hypoxia and acidaemia
prevent traumatic cardiac arrest
30
what is the ATMIST handover in a trauma situation
Age
Time
Mechanism
Injury
Specifics
Treatment given
31
what needs to be done to control catastrophic haemorrhage
clear any clots obscuring bleeding source
direct pressure
indirect pressure
torniquet
haemostatic agents
32
how quickly does the airway need to be secured in a major trauma situation
in 45 minutes
33
what are absolute indications for intubation
- inability to maintain and protect own airway regardless of consciousness level
- inability to maintain adequate oxygenation with less invasive maneuvers
- inability to maintain normocapnia
- deteriorating conscious level
- significant facial injuries
- seizures
34
what are causes of breathing issues in traumatic injury
airway obstruction/disruption
tension pneumothorax
open pneumothorax
massive haemorrhage
flail chest
cardiac tamponade
35
what are symptoms of a tension pneumothorax
consistent history
air hunger
hypoxia
hypotension
36
what is a massive haemothorax
when there is over 1500ml blood in the thoracic cavity
37
what is an open pneumothorax
a wound to the chest wall which communicates with the pleural cavity
the wound will be over 2/3 size of the trachea
air moves down the pressure gradient and becomes trapped in the chest
38
what are symptoms of cardiac tamponade
Becks triad
Hypotension with a narrowed pulse pressure.
Jugular venous distention (JVD)
Muffled heart sounds.
39
what are symptoms of a bleeding patient
sweaty
anxious and confused
pallor
peripherally cool
tachycardia
tachypnoea
increased CRT
narrow pulse pressure
hypotension
bradycardia
arrest
40
where are the most common sites of major haemorrhage
external haemorrhage
chest
abdomen
pelvis
long bones
41
what are the clinically important long bones in major haemorrhage
femur
humorous
tibia
42
what is used when there is suspicion of a pelvic fracture
use a binder - put at the level of the greater trochanter
43
why do you aim for permissive hypotension in trauma
because if you increase fluid in someone bleeding it can increase mean arterial pressure, therefore increasing the bleeding rate
it also dilutes the blood, can impair coagulopathy and cause acidosis
44
what do you give a patient with major haemorrhge
tranexamic acid
blood products
clotting factors - two red cells to one clotting factors
45
what are indications for blood product administration in trauma situations
systolic BP under 90
heart rate over 150
low GCS
obvious massive blood loss
46
what is assessed in disability during CABCDE
neuro issues
- use AVPU over GCS
- motor score of GCS is the most predictive outcome
47
what are the two types of head injury
the primary injury = the incident
the secondary injury = hypoxic injury, hypoperfusion, hypoglycaemia
48
how do you calculate cerebral perfusion pressure
mean arterial pressure - intercranial pressure
49
why do you aim for a higher mean arterial pressure in a patient with a head injury and haemorrhage compared to a patient with a major haemorrhage only
because with a head injury MAP needs to be higher to maintain cerebral perfusion pressure - maintain brain oxygenation
50
what can cause a traumatic cardiac arrest
haemorrhage
lack of oxygenation
tension
tamponade
51
what causes shock
circulatory failure and tissue hypoperfusion
52
what are fluid causes of shock
hypovolaemic shock
haemorrhagic shock
53
what are pump causes of shock
cardiogenic
obstructive (tension pneumothorax, PE and tamponade)
54
what are pipe causes of shock (vessel causes)
distributive (noradrenaline and endocrine)
septic
anaphylactic
55
how do you treat hypovolaemic shock
give fluids
56
how do you treat haemorrhagic shock
red cells
fresh frozen plasma
platelets
cryoprecipitate
57
how do you treat septic/anaphylactic shock
fluids
vasopressors
58
how do you treat cardiogenic shock
inotropes +/- fluids
59
what are the 5 Rs of fluid prescribing
resuscitation
routine maintenance
replacement
redistribution
reassessment
60
what are different types of prescribed fluid
crystalloids (salt): 0.9% saline, hartmans
colloids
61
what are the principles of fluid prescription
calculate the deficit
assess losses and requirement (maintenance)
62
what are the two types of fluid loss
sensible - measurable
insensible - difficult to measure
63
what are the signs of some dehydration in the WHO dehydration classification
two or more of the following:
restlessness
irritability
sunken eyes
thirsty
reduced skin turgor
64
what are the signs of severe dehydration in the WHO dehydration classification
two or more of the following:
lethargy
unconsciousness
sunken eyes
unable to drink/drink poorly
very reduced skin turgor
65
what are causes of respiratory failure
alveolar collapse - pneumonia, anaesthesia, lying down
fluids - oedema
bronchoconstriction - asthma, COPD
66
what is the PaO2 which indicates respiratory failure
less than 8
67
what does high CO2 indicate
poor ventilation
68
what external ventilation is used for O2 issues
EPAP - Expiratory Positive Airway Pressure
69
what external ventilation is used for CO2 issues
IPAP - Inspiratory positive airway pressure
70
when is EPAP used
in type 1 respiratory failure
71
when is BiPAP used (EPAP+IPAP)
in type 2 respiratory failure
72
when is non invasive ventilation used
COVID
post anaesthetic
COPD
oedema
(pneumonia)
73
what happens when non invasive ventilation fails
intubation and ventilation
74
what is AKI stage 1
1.5X creatine
<0.5 ml/kg/hr for >6hrs urine output
75
what is AKI stage 2
2X creatine
<0.5 ml/kg/hr for >12 hours urine output
76
what is AKI stage 3
3X creatine
<0.3 ml/kg/hr for >24 hours
anuria > 12 hours
RRT (dialysis)
77
what causes acute interstitial nephritis
NSAIDs
78
what causes direct tubular toxicity
contrast
gentamicin
79
what is breakthrough pain
a sudden increase in pain which may occur in patients who already have chronic pain
- transitory flare of pain
80
what is the method of action of paracetamol
in inhibits CNS prostaglandins
81
what is the method of action of NSAIDS
inhibits COX enzymes
- ibuprofen is non selective
- celecoxib is selective
82
what should you check before starting paracetamol
liver impairment/liver damage
severe cachexia (less than 50kg weight)
83
what should be checked before prescribing NSAIDs
renal and platelet count
84
what are contraindications for NSAID use
GI bleeding
ulcer history
asthma
85
what concurrent medications should be checked for when prescribing NSAIDs
warfarin
digoxin
steroids
- increases bleeding risk
86
what are examples of weak opioids
codeine
dihydrocodeine
tramadol
87
what are considerations when prescribing opioids
route
timing
renal function
previous opioid use
allergies
acceptability or side effects
polypharmacy
previous addictions
safety of medication at home
patient concerns
driving
88
what are opioid side effects
common: constipation, nausea, sedation, dry mouth
less frequent: psychomimetic side effects, confusion, myoclonus
rare: allergy, respiratory depression, pruritis
89
what are the indications of fentanyl/buprenorphine patch
intolerable side effects
oral route difficulties
renal impairment
90
how long does it take for a fentanyl/buprenorphine patch to reach analgesic concentrations
it takes three days - dont use in acute pain or unstable pain
91
what are long term harms of opioid use
falls
sensitivity reduction
changes in immune system and endocrine issues
fractures
dependence
hyperanalgesia
92
what are examples of palliative care emergencies
febrile neutropenia
superior vena cava obstruction
stridor
hypercalcaemia
spinal cord compression
opioid overdose
massive haemorrhage
93
what is neutropenic sepsis in palliative care
it is when neutrophils are severely reduced caused by chemotherapy/bone marrow infiltration
94
what neutrophil count is indicative of neutropenic sepsis
cell count of under 0.5
95
how do you treat neutropenic sepsis
IV access
broad spectrum antibiotics (tazocin)
close observations
fluid resuscitation
96
what causes superior vena cava obstruction
lung cancer/tumour obstruction
- obstruction in the upper body compressing the superior vena cava
97
what are symptoms of superior vena cava obstruction
facial swelling
redness
periorbital oedema
arm swelling
breathlessness
distended veins on the chest
98
how do you diagnose superior vena cava obstruction
CT chest
99
how do you treat superior vena cava obstruction
ABC
high dose steroids (dexamethasone 16mg)
consider anticoagulation
stenting
radiotherapy
chemotherapy
100
what should be considered when a patient on palliative care has stridor
head and neck tumour
lung and upper GI tumour
101
what are signs of stridor
noisy breathing on inspiration
harsh breathing sounds
breathless
102
how do you treat stridor
oxygen/heliox
high dose steroids
urgent ENT/oncology review
tracheostomy
stenting
radiotherapy
103
what causes malignant hypercalcaemia
cancer which has spread to the bone
- breast, lung, kidney, thyroid (prostate)
104
what are symptoms of acute hypercalcaemia
thirst
confusion
constipation
global deterioration
105
what are symptoms of chronic hypecalcaemia
depression
abdo pain
constipation
calculi
106
how do you diagnose malignant hypercalcaemia
corrected calcium over 2.6
- level over 2.8 will be symptomatic
107
how do you treat malignant hypertension
IV fluids
IV bisphosphonate
denosumab
108
what are signs of malignant spinal cord compression
paraesthesia
sensory loss
cauda equina
weakness or functional loss
back pain
difficulty walking
109
how do you diagnose malignant spinal cord compression
MRI spine (gold)
if there is no MRI then do CT
clinical signs
110
how do you treat malignant spinal cord compression
high dose steroids (dexamethasone)
radiotherapy
surgery
111
what can cause massive haemorrhage in palliative patients
head and neck tumours
lung tumours
GI tumours
previous bleeds
112
how do you treat major harmorrhage in palliative care
stop anticoagulation
dark towels, stay with the patient, midazolam
113
what might indicate opioid overdose in palliative care
change in condition including a sudden improvement of pain
114
how do you treat opioid overdose in palliative care
clinical assessment
naloxone (diluted in water) - give 20mcg every two minutes and review
dose reduction
115
what is the period 'end of life'
the last 12 months of life
116
what is important to plan in end of life care
advanced statements
advanced decisions
lasting power of attorney
advanced care planning - reSPECT plan
117
what are signs that someone is dying
reduced oral intake
increased dependence
not responding to treatment
change in consciousness
respiratory and cardiovascular change
fatigue and sleeping more
struggling with medication and swallowing
118
what needs to be considered in an individualised end of life care plan
ceiling of escalation - what interventions will and wont be done
pre-emptive prescribing
prepare the family
DNA CPR
where do they want to die
119
what medications will be pre-emptively prescribed in end of life care
pain - morphine
breathlessness - morphine
secretions - buscipan
agitation - midazolam
nausea - haloperidol
120
what is the next step if someone has had two doses of IM adrenaline (with fluids) and they are still hypotensive and breathing isnt improving
start IV adrenaline infusion
121
what are causes of transient non visible haematuria
UTI
menstruation
vigorous exercise
sexual intercourse
122
what are causes of persistent non visible haematuria
cancer
stones
BPH
prostatitis
urethritis e.g chlamydia
renal causes: IgA nephropathy
123
what are causes of red/orange urine where blood is not present on the dipstick
foods: beetroot, rhubarb
drugs: rifampicin, doxorubicin
124
how is haematuria tested for
urine dipstick is the test of choice for detecting haematuria
persistent non-visible haematuria is often defined as blood being present in 2 out of 3 samples tested 2-3 weeks apart
renal function, albumin:creatinine (ACR) or protein:creatinine ratio (PCR) and blood pressure should also be checked
urine microscopy may be used but time to analysis significantly affects the number of red blood cells detected
125
when do you urgently refer someone for haematuria
Aged >= 45 years AND:
unexplained visible haematuria without urinary tract infection, or
visible haematuria that persists or recurs after successful treatment of urinary tract infection
Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test
126
what is the triad of nephrotic syndrome
1. Proteinuria (> 3g/24hr) causing
2. Hypoalbuminaemia (< 30g/L) and
3. Oedema
127
what are causes of nephrotic syndrome
primary: minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy
secondary: diabetes, SLE, amyloidosis, infection (HIV, Hep B/C), drugs (NSAIDs)
128
what are the most common type of renal stones
calcium oxalate
129
what are the clinical features of UTI in adults
dysuria
urinary frequency
urinary urgency
cloudy/offensive smelling urine
lower abdominal pain
fever: typically low-grade in lower UTI
malaise
in elderly patients, acute confusion is a common feature
130
when should you send a urine culture in suspected UTI diagnosis
women aged > 65 years
recurrent UTI (2 episodes in 6 months or 3 in 12 months)
pregnant women
men
visible or non-visible haematuria
131
what are examples of neuropathic pain
diabetic neuropathy
post-herpetic neuralgia
trigeminal neuralgia
prolapsed intervertebral disc
132
what is the treatment of neuropathic pain
first line: amitriptyline, duloxetine, gabapentin or pregabalin (monotherapy)
tramadol can be used as rescue therapy
topical capsaicin for localised pain
133
what are causes of acute interstitial nephritis
drugs: the most common cause, particularly antibiotics
penicillin
rifampicin
NSAIDs
allopurinol
furosemide
systemic disease: SLE, sarcoidosis, and Sjogren's syndrome
infection: Hanta virus , staphylococci
134
what are the features of acute interstitial nephritis
fever, rash, arthralgia
eosinophilia
mild renal impairment
hypertension
135
what investigations are done for suspected acute interstitial nephritis
sterile pyuria
white cell casts
136
who is at an increased risk of developing AKI
chronic kidney disease
other organ failure/chronic disease e.g. heart failure, liver disease, diabetes mellitus
history of acute kidney injury
use of drugs with nephrotoxic potential (e.g. NSAIDs, aminoglycosides, ACE inhibitors, angiotensin II receptor antagonists [ARBs] and diuretics) within the past week
use of iodinated contrast agents within the past week
age 65 years or over
137
what are the two key ways AKI can be detected
a reduced urine output. This is termed oliguria and is defined as a urine output of less than 0.5 ml/kg/hour
fluid overload
a rise in molecules that the kidney normal excretes/maintains a careful balance of. Examples include potassium, urea and creatinine
138
what are symptoms and signs of AKI
reduced urine output
pulmonary and peripheral oedema
arrhythmias (secondary to changes in potassium and acid-base balance)
features of uraemia (for example, pericarditis or encephalopathy)
139
when is AKI diagnosed
- a rise in serum creatinine of 26 micromol/litre or greater within 48 hours
- a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
- a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than
140
