Acute Medicine Flashcards
What is the initial assessment and management of ACS?
300mg PO aspirin 300mg PO clopidogrel Diamorphine 2.5-10mg Metoclopramide 10mg IV GTN spray two puffs High flow oxygen Secure IV access 12 lead ECG FBC, glucose, troponin, lipids CXR to asses cardiac size and pulmonary oedema General examination
What conditions mimic pain in ACS?
Pericarditis Aortic dissection Pulmonary embolism Oesophageal reflux, spasm, rupture Biliary tract disease Perforated peptic ulcer Pancreatitis
What ECG changes are indicative of STEMI?
ST elevation
Pathological q waves (deep q waves) - indicate abnormal electrical conduction
ST depression is seen in leads reciprocal to the ST elevated leads
PR segment elevation/depression
When do serum Troponin levels rise and fall in STEMI?
Rise within 3-12 hours
Peak within 24-48 hours
Return to baseline over 5-14 days
Measure at presentation and at 10-12 hours after presentation
What are the indications for thrombolysis?
Cardiac pain within 12 hours and ST elevation in two contiguous ECG leads
Cardiac pain with new LBBB on ECG
Between what interval from the onset of chest pain should thrombolysis be administered?
Greatest benefit within four hours
Between 12-24 hours- thrombolysis if persisting symptoms and st elevation
What are common thrombolysis agents?
Streptokinase
Alteplase (rtPA) - use IV heparin as well
Reteplase
Tenecteplase
What are the complications and contraindications of thrombolysis?
Complications: Bleeding Hypotension Allergic reactions Intracranial haemorrhage
Contraindications: Internal bleeding Suspected aortic dissection Recent head trauma Previous haemorrhage stroke Trauma/surgery in last two weeks
What is the role of beta blockers and ACEI in STEMI?
Beta blockers:
Unless contraindicated
Use short acting agent IV eg metoprolol
Particularly of benefit in patients with tach arrhythmia, ongoing pain, hypertension
ACEI:
After aspirin, beta blockers and reperfusion, all patients with STEMI should receive ACEI in 24 hours
What is the gold standard for coronary reperfusion in STEMI?
PCI
Within 2 hours, 90 mins
What are the indications for PCI?
All patients with chest pain and st elevation or new LBBB
What is the difference between NSTEMI and unstable angina?
NSTEMI has evidence of myocardial damage, whereas unstable angina does not
How does NSTEMI/UA present?
Rest angina
New onset severe angina
Previously diagnosed angina which has become more frequent, longer in duration, or lower in threshold
How can NSTEMI/UA be diagnosed?
ECG changes:
ST depression
T wave inversion
Occasionally q waves or LBBB
Markers of cardiac injury:
A positive biochemical marker (CK, CKMB, troponin) with the aforementioned ECG changes is diagnostic of NSTEMI. If no changes in cardiac markers over 24-72 hours, UA is diagnosed
What agents are used to treat symptoms and for their anti-ischaemic effects in NSTEMI/UA?
Analgesia-Diamorphine 2.5-5mg IV- reduces pain and blood pressure
Nitrates - GTN infusion
B-blockers - start on presentation, shift acting metoprolol
Calcium antagonists- diltiazem/ verapamil to reduce hr and BP
Statins - atorvastatin - 80mg od
What anti platelet therapy is used in NSTEMI/UA?
Aspirin - 300mg administered indefinitely in emergency department - continue indefinitely
Clopidogrel - 300mg - continue on 75 mg for 12 months
What anti thrombotic therapy is used in NSTEMI/UA?
LMWH -
dalteparin/enoxaparin
Continue for 2-5 days after last episode of pain/ ECG changes?
Fondaparinux?
What are signs of severe haemodynamic compromise in bradyarrythmias?
And how should these be treated
Impending cardiac arrest
Severe pulmonary oedema
Blood pressure below 90
Depressed consciousness
Tachy - unsynchronised external defib
Brady - temporary pacing
How does atrial fibrillation typically present?
Palpitations Chest pain Breathlessness Collapse Hypotension Embolus - stroke, peripheral Asymptomatic Occur in 10-15% patients post MI
What is the curb 65 scoring system for pneumonia, and what actions should be taken for the different scores?
Confusion - amts less than/equal to 8 Urea - >7mmol Respiratory rate - greater than 30 BP - less than 90/60 Age - greater than 65
> 3- admit to hospital
2- increased risk of mortality- short inpatient stay
0-1- low risk, may be suitable for home treatment
What is the initial management and investigations for pneumonia
ABCDE Venous access, arrange for CXR Bloods- RBC, u+es, LFT, CRP ABG- give 02 if necessary Culture blood and sputum Pain relief- paracetamol and NSAID
More investigations if necessary Urine for legionella antigen Pleural fluid aspiration Mycoplasma cold agglutinins Bronchoscope and lab age if fail to respond
What is the empirical management of mild, moderate, severe CAP?
Mild moderate- amoxicillin plus clarithromycin or doxycycline
Severe - coamoxiclav IV plus clarithromycin IV
Or
Cefuroxime/cefotaxime IV plus clarithromycin IV
What is the empirical treatment of hospital acquired pneumonia
Cefotaxime IV with or without metronidazole IV
What is the empirical management of aspiration pneumonia?
Cefuroxime and metronidazole
Or Benzylpenicillin and gentamicin and metronidazole
What is the initial management of acute severe asthma attack?
Monitor PEFR and ABG
Sit patient up in bed
PEF is 33-50% predicted
(PEF <33% is life threatening)
High percentage O2 via reservoir mask
Nebulisers bronchodilators- 5mg salbutamol, repeat every 15-3ins if required
Add ipratropium bromide 0.5mg 4-6 hourly if initial response to salbutamol is poor
IV access
Steroids 200mg hydrocortisone IV
Antibiotics if evidence of chest infection
Adequate hydration
Consider IV magnesium, aminophylline, salbutamol infusion
What are the features of a mild- moderate asthma attack and how is it managed?
No severe features, pef 51-75% of predicted
Administer nebulised salbutamol 5mg and oral prednisolone 30-60mg
Reassess after 30 mins, if worse, treat as per severe asthma, if no better, repeat nebs
Discharge on oral prednisolone 30-40mg is for 7 days
Inhaled corticosteroid, inhaled beta agonist
What investigations should be ordered for acute exacerbation of COPD?
U+Es - dehydration, RF
FBC- leucocytosis, anaemia, secondary polycythaemia
ABG and pulsox
Sputum and blood culture
Peak flow- compare to what is normal for patient
CXR
ECG- check for mi or arrhythmia causing breathlessness
What is the management of acute exacerbation if COPD
Venturi mask O2 - 24-28% O2
ABG
If type 2 resp failure, consider NiV - CPAP or BIPAP, especially if failure to respond to bronchodilator therapy
Nebulised salbutamol 5mg
Consider IV salbutamol or aminophylline
Nebulised ipratropium bromide 500mcg 6 hourly
Steroids - 200mg hydrocortisone IV or 30-40mg prednisolone PO
Physio may help to clear bronchial secretions
What is the role if mechanical ventilation in acute exacerbation of COPD?
Ventilation should be considered where respiratory failure is present (paO2 less than 7.3) regardless of CO2 levels, and in those who fail to respond to first line treatment including bronchodilator therapy
Check with ITU staff!
Good outcome if young, good exercise tolerance, acute resp failure
Poor outcome if old, comirbidities, on O2 therapy at home
What is adult respiratory distress syndrome?
A common clinical disorder in which damage to the alveolar epithelial and endothelial barriers of the lung, acute inflammation, and protein rich pulmonary oedema leads to acute respiratory failure.
Often occurs in the setting of multiple organ failure
What are the diagnostic criteria for ARDS?
Acute onset of respiratory failure with one or more of the risk factors
Hypoxaemia- ALI- paO2:fiO2 ratio <19mmHG with normal colloid oncotic pressure
What investigations are appropriate in ARDS?
CXR ABG Blood, urine, sputum culture ECG Pulmonary artery catheter to measure pulmonary capillary wedge pressure, cardiac output
Which disorders are most associated with ARDS? Direct and indirect lung injury
Direct lung injury Aspiration Inhalation of smoke/noxious gases Pneumonia Pulmonary contusions Drug OD- O2, opiates, bleomycin, salicytes
Indirect lung injury Shock Septicaemia Pancreatitis Burns/ trauma Head injury and increased ICP Liver failure
How and where is ARDS most appropriately managed?
Usually HDU/ICU
Identify and treat underlying cause
Respiratory support to improve gas exchange and correct hypoxia- High O2 conc or mechanical ventilation
Cardiovascular support- arterial line, inotropes, fluid resus
What are causes of pneumothorax?
Primary/spontaneous- tall young men who smoke- rupture if apical subpleural blend
Secondary/spontaneous- pleural rupture due to underlying lung disease: emphysema, fibrosis etc
Infection- cavitating pneumonia
Trauma- chest trauma in RTA
Iatrogenic- mechanical ventilation, pleural biopsy, subclavian vein cannulation
What are signs of tension pneumothorax?
Distressed patient
Tachypnoeic with cyanosis
Profuse sweating
Marked tachycardia and hypotension
How may acute upper GI bleed present?
Haematemesis- bright red, dark clots, coffee grounds
Malaena- from anywhere proximal to caecum
Weakness, sweating, palpitations
Postural dizziness, fainting
Collapse or shock
What are causes of acute upper GI bleeding?
Peptic ulcer Gastroduodenal erosions Oesophagitis Varices Malory Weiss tear Upper GI malignancy Vascular malformations
What factors indicate a high risk of death in acute upper GI bleed, and what scoring system incorporates these?
Rockall scoring system
Age greater than 60 Shock - SBP 100 Comorbidities- cardiac, renal, liver, malignancy Diagnosis of GI tract malignancy Blood in upper GI tract
What is the initial management of acute upper GI bleeding?
Position patient on side to protect the airway
Secure IV access
Take FBC and U+E, platelets and LFTs, clotting and crossmatch
Fluid resus
Monitor urine output
IV PPI - 80mg omeprazole bolus, followed by 8mg/hr infusion
Contact on call endoscopy team and surgeons
What general measures can be taken to stop bleeding in acute upper GI bleed?
Platelet count below 50,000/mm3 requires platelet support
If on anticoagulants, give FFP and vitamin k
Serum calcium may drop after blood units given, replace with calcium gluconate
Tranexamic acid may be helpful
How does biliary obstruction present?
Jaundice RUQ pain and tenderness Fever Itching Dark urine and pale stools Septic shock
What investigations are indicated in biliary obstruction, and what may they show?
Wcc- increased U+es- renal failure LFTs- increased bilirubin, alp, ggt, and amylase if concomitant pancreatitis Blood cultures CRP USS - dilates ducts and gallstones AXR- aerobilia may be due to gas forming organism ERCP- stones in CBD MRCP
What may cause biliary obstruction?
Gallstones Malignancy Postoperative stricture Primary sclerosing cholangitis Primary biliary cirrhosis
How is biliary obstruction managed?
Analgesia
Antibiotics if septic
If dilated ducts:
Indicates gallstones
ERCP to decompress biliary system
If not dilated ducts:
Autoantibodies- pANCA, AMA
When stable, consider ERCP, liver biopsy
What is a differential for ascites?
Ovarian cyst
Obesity
Pregnancy
Abdominal mass
What are causes of ascites?
Cirrhosis and portal hypertension Malignancy Congestive cardiac failure Pancreatic ascites Nephrotic syndrome Hypothyroidism Infection eg TB
What investigations are indicated in ascites?
U+es, glucose, FBC, pregnancy test, LFTs, blood cultures, amylase
Ascitic tap unless malignant cause!
USS, axr, ct scan?
Urine sodium, 24hr protein
After treating the cause, how is ascites treated?
Restrict salt intake to 90mmol a day
Paracentese- if tense or moderate. Replace albumin afterwards
Start spironolactone at 100mg a day
How can AKI be defined?
Abrupt (within 48 hours) reduction in kidney function
Absolute increase in serum creatinine of >/= 26mmol
Or
>50% relative increase inn serum creatinine
Or
Reduction in urine output - less than 0.5 ml/kg per hour for more than six hours
How does AKI present?
Asymptomatic Incidental finding on biochemical screening Oliguria Malaise, confusion, seizures, coma Nausea, anorexia, vomiting Haematuria Vasculitic rash Multi organ failure
What are pre renal causes of AKI?
Hypovolaemia Hypotension Renal artery emboli Renal artery stenosis and ACEI Hepatorenal syndrome
What are post renal causes of AKI
Renal vein thrombosis Increased intrabdominal pressure HIV drugs Ureteric stones Prostatic hyper trophy
What are renal causes of AKI?
Vasculitis eg SLE Glomerulonephritis Acute tubular necrosis- due to ischaemia, septicaemia, gentamicin, radio contrast, malaria Scleroderma crisis Calcium/urate oxalate overload
What investigations are indicated in AKI?
UandEs FBC- anaemia suggests chronic RF Coagulation- to detect DIC, SLE LFTs- hepatitis, paracetamol OD Blood cultures Immunology- antigens etc CRP - raised in Vasculitis Protein strip- for para proteins, BJ proteins Urine dipstick, Micro and culture Renal USS CXR to assess heart size, pulmonary oedema ECG - hyperkalaemia
How is AKI managed?
Treat hyperkalaemia- calcium gluconate, glucose and insulin, salbutamol nebs, dialysis?
Treat metabolic acidosis- 50-100ml of 8.4% bicarbonate via central line
Treat pulmonary oedema
Oxygen, CPAP?, IV GTN, IV furosemide, Diamorphine
Assess hydration and fluid balance- if depleted, fluid challenge with saline
Treat infection
Stop nephrotoxic drugs
Identify intrinsic renal disease
Relieve obstruction
