Acute Medicine Flashcards
CA territories in MI?
Inferior = right CA
Anterior/septal = LAD
Lateral = circumflex
What is D dimer good for and not good for?
Good for ruling out (95% sensitivity)
Bad for ruling in (50% specificity)
Management of PE?
ABCDE - CALL FOR HELP!
15L O2 NRBM Anticoagulation (enox 1.5 mg/kg/24h SC) CTPA Pain relief Fluids if hypotensive
Oral anticoagulation (warfarin) for 3 months after at least
Interpretation of CURB65 score?
0-1 = low severity 2 = moderate severity 3-5 = high severity
Causes of CAP?
Step pneumoniae Haemophilus influenza A&B Staph aureus Maroxella catarrhalis. Mycoplasma pneumoniae, Chlamydia pneumoniae Legionella pneuomphilia
Viruses 15%.
Causes of HAP?
Gram -ve enterobacteria
Pseudomonas Klebsiella E.coli S.Pneumoniae S.Aureus (+ MRSA).
Cultures in pneumonia?
Blood Cultures – if CURB-65 >2
Sputum Cultures – if CURB-65 >3
Antibiotics in CAP?
Mild/Moderate CAP =
Amoxicillin (PO/IV), or doxycycline + clarithromycin if not improving or atypical suspected.
Severe CAP =
Co-amoxiclav + clarithromycin
OR
Cefotaxime/cefuroxime + clarithromycin
Antibioitcs in HAP?
Co-amoxiclav (if severe, Tazocin)
Cefotaxime + metronidazole
How to examine a DVT leg?
Warm, red, tender, swollen limb (leg >3cm compared to other calf measured 10cm below tibial tuberosity), pitting oedema.
Risk factors for DVT?
Age >60 yrs, obesity, recent surgery/immobility/long distance travel, oestrogen (pregnancy, HRT, OCP), PMH or FH of PE/DVT, malignancy, thrombophilia, medical comorbidity (CCF, IBD, active inflammation)
Treatment dose LMWH?
Enoxaparin 1.5mg/kg OD SC
Tinzaparin 175 units/kg OD
Causes of cellulitis?
Staph Aureus (may be MRSA), group A streptococci.
More common if immunosuppressed (diabetes, steroids)
Management of cellulitis?
No systemic symptoms = Oral abx (flucloxacillin 1g/6h PO; if MRSA, 200mg doxycycline STAT then 100mg/24h PO)
Systemic symptoms/Spreading infection = Admit for short course IV abx (flucloxacillin 1g QDS IV; if MRSA, vancomycin 1g/12h IV).
Diagnostic criteria for DKA?
Hyperglycaemia (>11mmol/L)
Acidosis (venous pH <7.3 or bicarb <15mmol/L)
Blood ketones >3mmol/L or ketonuria (>++)
Fluids in DKA?
0.9% saline 1L over 1 hour
1L over 2 hours 1L over 2 hours 1L over 4 hours 1L over 4 hours 1L over 6 hours
Add potassium to 2nd bag - no greater than 10mmol per hour
REASSESS AT 12 HOURS
When BM <14, start 10% glucose at 125 ml/hr alongside saline
What to do if shocked in DKA?
0.9% saline 500ml over 15 minutes - recheck
Keep giving until resuscitated and call ICU/critical care
Potassium in DKA?
Still give if K+ normal - only withhold K+ if >5.5.
If < 3.5, get help, they need a central line
What to keep checking in DKA?
BP, HR, UO, GCS, VBG, K+ and ketones hourly
Insulin in DKA
Fixed rate IV infusion 0.1 unit/kg/hr IV
(50 units actrapid in 50ml 0.9% saline)
Continue until ketones <0.3 mmol/L and pH >7.3 –> convert to SC insulin if eating and drinking normally.
Do you continue long acting insulin in DKA?
YES
Prevents rebound hypo when IV stopped.
Definition of hypoglycaemia?
<3mmol/L
What is a normal blood glucose level?
Between 3.9 and 5.5
Causes of hypoglycaemia?
Too much insulin, too much exercise, too little carbohydrates or combination. • Alcohol • Sulphonylureas • Adrenal failure • Liver failure • Hypopituitarism • Infection • Patients with DM secondary to total pancreatectomy more susceptible
Features of hypoglycaemia?
Autonomic: sweating, palpitations, shaking, hunger, anxiety, tachycardia.
Neuroglycopenic: confusion, drowsiness, odd behavious, speech difficulty, incoordination, FND
General: malaise, headache, nausea.
Investigations in hypo?
CBG
U&Es (check for nephropathy
C-peptide – low C-peptide = exogenous insulin, high C-peptide = endogenous insulin
Hypoglycaemia management - conscious?
15-20g quick acting carbohydrate e.g. 4-5 glucotabs or glucogel/hypostop gel, lucozade, fruit juice
Repeat blood glucose after 10-15 mins
If glucose <4mmol/L repeat glucotabs up to x3.
If no improvement after 3 times, consider IM glucagon or IV 10% glucose
Hypoglycaemia management - unconscious?
ABCDE assessment
75-100ml 20% glucose or 150-200ml 10% glucose IV over 15 mins or 1mg IM glucagon
Repeat blood glucose after 10-15 mins
Further management post-hypo?
- Continuous infusion of 10% glucose for 8hrs if caused by long-acting insulin/sulphonylurea
- Regular CBG monitoring
- Treat cause
- Give thiamine before glucose if chronic alcohol use)
- Once CBG >4 encourage long acting carbohydrate food – biscuits/toast/normal meal
- Do not omit normal insulin doses
- DO NOT drive for 45 mins
management PCM overdose?
<4hrs post-OD
Wait for 4 hours to elapse – can’t read off graph yet, not accurate before this time.
4-8hrs post-OD
Take paracetamol level. If over level on nomogram, treat. Then psychiatric assessment.
Parvolex = 98% effective before 8 hours.
8-15hrs post-OD
Treat before level comes back.
Stop treatment if below treatment line.
> 15hrs post-OD
TREAT
Same if overdose is staggered.
PCM overdose amount and outcome?
<75mg/kg = rarely toxic
75-150mg/kg = unlikely toxicity
> 150 mg/kg = SERIOUS
Doses of parvalex?
x mg/kg IV in xml 5% glucose or 0.9% saline
150 in 200 over 1 hour
50 in 500 over 4 hours
100 in 1000 over 16 hours
When to discontinue parvalex?
Discontinue treatment if plasma concentration is later reported to be below treatment line and patient is asymptomatic with normal LFTs, creatinine and PT.
Side effects of parvalex?
20% have pseudoallergic reaction (anaphylactoid) – flushing, rash, pruritus, urticaria, nausea, vomiting –> stop infusion and give chlorphenamine.
Most severe reactions (↓HR ↑BP + bronchospasm) manage as anaphylaxis with infusion slowed or stopped.
Features of PCM overdose?
Initial
No specific symptoms, or mild N+V
After 24h
RUQ pain +/- evidence of liver failure (↑PT, ↑ALT, ↑AST)
PT/INR is best marker of synthetic function.
After 3-5 days
Recovery may begin, or fulminant hepatic failure will develop with coagulopathy, ↓blood glucose, encephalopathy and AKI (hepatorenal syndrome)
Features of alcohol withdrawal?
12-36h post-alcohol;
Uncomplicated = anxiety, tremor, sweating, vomiting, fever, irritability, ataxia
Can have hallucinations (mostly visual) and alcohol-related seizures.
3-4d post-alcohol; delirium tremens
Medical emergency
Coarse tremor, confusion, delusions, hallucinations, agitation, HR >100, fever, labile mood (untreated mortality 15%)
Scoring system for alcohol withdrawal?
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)
1-7 each for nausea & vomiting, tactile disturbances, tremor, auditory disturbances, paroxysmal sweats, visual disturbances, anxiety , headache, agitation & orientation
<10 = mild alcohol withdrawal 10-20 = moderate alcohol withdrawal >20 = severe withdrawal
Management of alcohol withdrawal?
Reducing dose chlordiazepoxide PO– over days
If cannot tolerate oral - IV/rectal diazepam solution
Correct electrolyte abnormalities – IV phosphates if low
Wernicke’s prevention
How to prevent Wernicke’s
Thiamine 25mg/24h PO and vitamin B
High-risk = IV Pabrinex 2 pairs/8h IV for 5 days – a high-potency combination of B and C vitamins – may sometimes cause anaphylaxis).
SIRS? Sepsis? Severe Sepsis? Septic shock?
2 of... Temp >38 or <36 RR >20 WCC >14 or <4 HR >90
Sepsis = SIRS + infection
Severe sepsis = sepsis + end organ damage
Septic shock = severe sepsis and hypotension
Causes of sepsis?
Skin/soft tissues - cellulitis/gangrene Intra-abdominal perforation; biliary tract Chest pnuemonia Urinary tract UTI; pyelonephritis Heart endocarditis Post-op wound infection; bowel leak
Causes of hypovolaemic shock?
Haemorrhage = Trauma (external/internal bleeding), ruptured AAA, GI bleed
Salt + water loss = Diarrhoea, vomiting, burns, polyuria (DI and DM)
3rd space loss = Acute pancreatitis, ascites
Class of haemorrhagic shock?
I = <750ml II = 750-1500 ml III = 1500 - 2000 ml IV = >2000 ml
Management of severe haemorrhage?
ABCDE
don’t push BP >100
Consider urgent blood transfusion
AKI stages?
1 = 1.5-1.9x or <0.5ml/kg/hr for 6-12 hours
2 = 2.0-2.9x or <0.5ml/kg/hr for >12 hours
3 = 3x or <0.3ml/kg/hr for >12 hours or anuria for 12 hours
Definition of AKI?
Rise in serum creatinine >26µmol/L within 48hrs or rise in serum creatinine 1.5 x baseline value within 1wk or urine output <0.5ml/kg/hr for 6hrs.
Management of AKI?
ABCDE assessment – IV access and bloods
Treat underlying cause
Aim for euvolaemia Stop nephrotoxic drugs Treat underlying cause Manage complications Optimise BP (fluids, no antihypertensives, consider vasopressors)
Complications (and management of AKI)?
OSHO
Obstructed – catheter will relieve uretheral obstruction; ureteric obstruction may require nephrostomy or stenting.
Shocked – fluid resuscitate +/- inotropes
Overloaded – O2, furosemide, nitrates
Hyperkalaemia – insulin, glucose, calcium gluconate and salbutamol
Indications for RRT?
Really really really unhappy dialysis (patients)
Refractory hyperkalaemia Refractory fluid overload Refractory metabolic acidosis Uraemia Drug intoxication
Features of delirium?
CA2MS –
changeable course
acute onset + attention poor
muddled thinking
shifting consciousness.
Can be hyper- or hypoactive.
Causes of delirium?
DELIRIUM
Drugs (withdrawal/toxicity, anticholinergics)/Dehydration
Electrolyte imbalance/Environmental factors
Level of pain
Infection/Inflammation (post surgery)
Respiratory failure (hypoxia, hypercapnia)
Impaction of faeces
Urine retention
Metabolic disorder (liver/renal failure, hypoglycaemia)/Myocardial infarction
Management of delirium?
Calming environment
Rationalise medication
Hydrate (oral better than IV)
Monitor bowels/treat constipation
Frequently reorientate and reassure
Optimise sensory impairment (glasses, hearing aid)
Look for and treat infection
Don’t argue or confront, move ward/bay, use restrains routinely or do unnecessary procedures.
Indications for sedation in delirium?
Carry out essential investigations
Prevent danger to self or others
Relieve patient distress
Sedation drugs in delirium?
Haloperidol 0.5mg PO, 1-2 hourly PRN – daily max = 5mg – avoid atypicals in elderly.
Can add lorazepam but try to avoid as tolerance and dependence may occurs.
Initial management anaphylaxis?
CALL FOR HELP - ABCDE
Airway, O2, IV access, bloods, raise legs
Adrenaline 1:1000 0.5mg (0.5ml) IM STAT
IV saline/hartmann’s 500ml STAT
Subsequent anaphylaxis management?
Hydrocortisone 200mg IV or IM
Chlorphenamine 10mg IV or IM
Salbutamol neb (if wheeze a feature) 5mg
Anaphylaxis doses for kids?
ADRENALINE = Over 12 = 0.5 mg, 6-12 = 0.3 mg, < 6 = 0.15 mg
CHLORPHENAMINE = over 12 = 10 mg, 6-12 = 5 mg, 6m - 6y = 2.5 mg, < 6 months = 250 mcg/kg
HYDROCORTISONE = Over 12 = 200 mg, 6-12 = 100mg, 6m - 6 years = 50mg, <6 months = 25 mg
What is mast cell tryptase?
Tells you whether reaction is anaphylaxis or anaphylactoid
Take when having reaction and afterwards
Define anaphylaxis?
Type I hypersensitivity reaction via IgE. Mast cell and basophil degranulation –> increased vascular permeability, bronchial smooth muscle contraction and myocardial dysfunction.
Causes of unconscious patient/low GCS?
COMA
Cerebral - haemorrhage, infarction, tumour, infection, trauma
OVERDOSE
METABOLIC = endocrine (hypo/hypergly), environmental (hypo/hypertherm), organ failure, electrolytes, acid-base, vitamin deficiencies, sepsis
A = arrhythmias, asphyxia, anaemia, AMI/PE, any cause of shock
Investigations in unconscious patient/low GCS?
ECG FBC U/E creatinine LFT Glucose Blood cultures ABG CXR C-spine CT head
Reversible causes of cardiac arrest
Hypoxia
Hypovolaemia
Hypo/hyperkalaemia
Hypothermia
Thrombosis - coronary or pulmonary
Tension pneumothorax
Tamponade - cardiac
Toxins
During CPR?
Ensure high quality compressions
Minimise interruptions to compressions
Use waveform capnography
Vascular access (IV or IO)
Shockable rhythms
VF
Pulseless VT
Non-shockable rhythms?
PEA
Asystole
Drugs in cardiac arrest?
Adrenaline IV 1mg 1:10,000 - after third shock and repeat in alternate cycles. If non-shockable, ASAP.
Amiodarone IV 300mg - after third shock, flushd with 20ml 0.9% NaCl or 5% dextrose
What to do when you get the ROSC?
ABCDE approach Aim for SpO2 94-98% Aim for normal PaCO2 12-lead ECG Treat precipitating cause Targeted temperature management
Management of COPD exacerbation
NEBS
Salbutamol 5mg 4 hourly
Ipratropium 500mcg 6 hourly
drive by air
STEROIDS
Prednisolone 30mg PO (or hydrocortisone 200mg IV)
ANTIBIOTICS
Amoxicillin 500mg TDS PO or Co-amoxiclav 625 mg TDS PO for 5 days
or
Doxycycline 200mg OD 5 days
How to guide further management in COPD exacerbation?
ABG
Normal (for them) – continue current O2 and give regular nebs
Worsening hypoxaemia - ↑FiO2, repeat ABG <30 min, watch for confusion which should prompt a repeat ABG sooner; consider NIV.
↑CO2 retention or ↓GCS – request senior help urgently – consider ICU input, aminophylline 5mg/kg IV bolus over 20 mins, NIV.
Criteria for NIV in COPD exacerbation?
Respiratory acidosis pH 7.25-7.35
Consider intubation and ventilation if impaired consciousness or severe hypoxaemia
Mneomonic for COPD management?
SIPA –> NIV
Salbutamol Ipratropium Prednisolone Amoxicillin NIV
Investigations in SAH?
CT head - urgent
LP - 12 hours after osnet - looking for xanthochromia (yellow CSF)
Management of SAH?
Lie patient flat and advise not to get up or eat.
Analgesia (codeine 30mg PO or 5mg morphine IV) and anti-emetic (metoclopramide 10mg IV/IM).
Refer urgently to neurosurgeon for endovascular coiling or neurosurgical clipping and consider transfer to ICU if ↓GCS.
Reassess often and request neuro obs.
Nimodipine (60mg/4h PO) prevents vasospasm.
Keep systolic <130mmHg, using IV β-blockers, unless lethargic (suggests vasospasm; may require permissive hypertension).
When does venous sinus thrombosis happen?
Pregnancy
Cancer
Causes of transient loss of consciousness?
HEAD
Hypoxia/Hypoglycaemia
Epilepsy
Affective
Dysfunction of brainstem (vertebrobasilar stroke, TIA or migraine)
Causes of transient loss of consciousness?
HEART
Heart (IHD) Emobli Aortic Obstruction (stenosis/HOCM) Rhythm disorders (CHB) Tachyarrhythmias (VT, SVT, long QT)
Causes of transient loss of consciousness?
VESSELS
Vasvoagal
ENT (BPPV, labrynthitis, Meniere’s disease)
Situational (micturation syncope, cough syncope)
Sensitive carotid sinus
Ectopic pregnancy
Low vascular tone
Subclavian steal
Causes of transient loss of consciousness?
DRUGS
Antihypertensives
Beta blockers
Street drugs
What is the San Francisco Syncope rule
CHESS
CCF Haematocrit >30 ECG abnormalities Systolic < 90 SoB
Management of hyperkalaemia?
ABCDE – 15L O2 NRBM, monitor ECG on defib, BP, sats, venous access + bloods, ABG
Calcium gluconate 10% 10ml IV over 2 min, repeat ever 15 min p to 50ml until K+ corrected – protects heart.
Actrapid (insulin – 10 units) in 50ml of 50% glucose over 10min - drives K+ into cells (short-term)
Salbutamol 5mg nebuliser – drives K+ into cells (short-term)
Furosemide (with IV fluids if necessary) or Calcium Resonium (takes 24h) enhance K+ excretion.
If refractory or acidotic, dialysis may be necessary.
Stop any causative or nephrotoxic medication.
Causes of hyperkalaemia?
Haemolysed samples Renal failure K+ sparing diuretics ACEi Trauma Burns Excess K+ Large blood transfusions Addison’s disease
Causes of hypokalaemia?
Vomiting, diarrhoea, most diuretics, steroids and Cushing’s, inadequate replacement in fluids, alkalosis, Conn’s syndrome
Features of hypokalaemia?
Weakness, cramps, tetany, palpitations, nausea, paraesthesia
Muscle weakness, hypotonia, arrhythmias, hyporeflexia
Management of hypokalaemia?
ECG
Add 20-40mmol KCl to IV fluids or give Sando-K tablets (2 tablets/8h PO)
No greater than 10mmol/hr outside of HDU
Monitor U+E
ECG changes in hypokalaemia?
Prolonged PR interval T wave flattening or inversion U waves ST depression Atrial arrhythmia
Causes of hypernatraemia?
Fluid loss (diarrhoea, burns, fever, glycosuria e.g. DM, diabetes insipidus)
Inadequate intake (impaired thirst response in elderly or hypothalamic disease)
More rarely excess Na+ (iatrogenic, Conn’s syndrome)
Features of hypernatraemia?
Anorexia, nausea, weakness, hyperreflexia, confusion, ↓GCS
Assess fluid balance, volume status, neurological deficit
Management of hypernatraemia?
If extracellular Na+ rapidly corrected, osmotic forces will drive fluid into cells, causing lysis resulting in neurological damage and death.
Aim for slow correction of Na+ - 10mmol/L/24h at very most. Treatment guided by volume status.
If hypovolaemic…
0.9% saline 1L/6h (prevents sudden Na+ shifts) until normovolaemic
If normovolaemic…
Encourage oral fluids or 5% glucose 1l/6h. Monitor fluid balance and plasma Na+; consider urinary catheter.
Causes of hyponatraemia?
HYPOVOLAEMIC
Renal losses
Non-renal losses
HYPERVOLAEMIC
Excess fluids/SIADH
Heart/renal/liver failure
Causes of SIADH?
Malignancy (lung, pancreas, lymphoma) Lung infections CNS infections or vascular events Drugs (SSRIs, tricyclics, carbamezapine, antipsychotics) Idiopathic.
Features of hyponatraemia?
Diarrhoea vomiting Abdo pain tiredness urine frequency quantity and colour thirst constipation SoB, cough chest pain weakness
Management of hyponatraemia?
Should be corrected slowly to prevent fluid overload or osmotic demyelination. Rise of no more than 10mmol/L/24h.
HYPOVOLAEMIC
Replace lost fluid with 0.9% saline according to degree of dehydration; severe hypoV should be corrected and takes precedence over hyponatraemia. Try to establish cause of fluid loss and treat accordingly. Stop diuretics.
NORMOVOLAEMIC
slow 0.9% saline IV e.g. 1L/8-10h. Na+ should rise over a few days.
ODEMATOUS
identify and treat underlying cause
Risk factors for aortic disection?
Male Smoker HTN Obesity DM Previous IHD FH
Features of aortic dissection?
Sudden onset severe chest pain, anterior or interscapular, tearing in nature, dizziness, breathlessness, sweating, neurological deficits.
Unequal radial pulses, tachycardia, hypotension/hypertension, difference in brachial pressures >15 mmHg, aortic regurgitation, pleural effusion (L>R), neurological deficits from carotid artery dissection,
Investigations in aortic dissection
CXR – classically widened mediastinum >8cm (rarely seen), irregularity of aortic knuckle and small left pleural effusion can develop from blood tracking down.
Echo – May show aortic root leak, aortic valve regurgitation or pericardial effusion. Also consider MRI/CT/conventional angiography.
Management of aortic dissection?
ABCDE - CALL FOR HELP
Hypotensive - treat as shock – O2 15 L/min, two large bore cannulae, X-match 6 units, analgesia (IV opioids).
Hypertensive - aim to keep systolic BP <100 mmHg – oral therapy with ACEi or CCB.
Further treatment = surgery (type A – ascending aorta) or conservative management (type B – only descending aorta)
Features of pericarditis?
Chest pain –> central, sharp, retrosternal, relieved by sitting forward, SOB, pleuritic, worse on exercise
Fever/cough/arthralgia/rash
Pericardial friction rub –> intermittent, positional, louder during inspirartion
Pericardial effusion may develop – rise in venous pressure
Causes of pericarditis?
MI
Infective - Viral (coxsackie, mumps, EBV, CMV, HIV, rubella, parvo), Bacterial (pneumococcus, meningococcus, chlamydia, gonorrhoea), TB
Locally invasive carcinoma
Rheumatic fever
Uraemia
Post cardiac surgery
Collagen vascular disease (SLE, polyarteritis nodosa)
What is Dressler’s syndrome?
autoimmune pericarditis +/- effusion 2-14 weeks post MI
Management of pericarditis?
Analgesia – NSAIDS – ibuprofen increases coronary flow + PPI (Opioid may be needed)
Steroids (especially if autoimmune cause) – prednisolone 60mg PO OD for 2 weeks
Colchicine analgesia 1mg/day
Pericardiocentesis for pericardial effusion
Stop anticoagulants in case of haemopericardium
Classification of pneumothorax?
Large = 50% of lung volume lost – lung margin >2cm from chest margin on CXR
Small = lung margin <2cm from chest wall on CXR
Management of simple pnuemothorax?
If bilateral or haemodynamically unstable, proceed straight to chest drain
PRIMARY
Small - discharge + safety net + follow up
Large/symptomatic - aspiration with 16-18G cannula –> chest drain/discharge
SECONDARY
Small - aspiration with 16-18G cannula, admit and observe for 24 hours
Large - chest drain
Where do you put a chest drain? What are the boundaires?
Triangle of safety
Base of axilla
Lateral edge of pec major
Lateral edge of lat dorsi
5th intercostal space (mid axilla) - above rib to avoid VAN
Features of opitate overdose?
Drowsiness, N+V, hypoventilation
(Miosis) pinpoint pupils, ↓RR, ↓GCS
Management of opiate overdose?
ABCDE
Activated charcoal if airway protected & substantial amount in last 2hours.
Naloxone 0.4-2mg IV
If paient has impaired consciousness ± respiratory depression.
Every 2 mins until breathing is adequate – has a short half-life so may need to be given often or IM; max 10mg)
Naloxone may precipitate features of opiate withdrawal (diarrhoea and cramps) – normally responds to diphenoxylate and atropine –> Sedate as needed.
Features of TCA overdose?
CNS - sedation, coma, convulsions, delirium
CV - sinus tachy + hypertension, broad complex tachydysrhytmia –> broad complex bradycardia
Anticholinergic - agitation, restlessness, delirium, myadriasis, dry warm flushed skin, urinary retetnion, tachycardia, ileus, myoclonic jerks
Examination in TCA overdose?
Dilated pupils, blurred vision, seizures, ↓GCS, dysrhythmia, tachycardia
Management of TCA overdose?
ABCDE - ICU and anaesthetist
- Gastric lavage + activated charcoal if <1hr
- ECG monitoriing
- Sodium bicarbonate - 50mmol IV 8.4% boluses – aim for pH 7.45-7.55
Seizures – benzos (diazepam 5-10mg IV), sodium bicarb, rapid sequence intubation and ventilation
Hypotension – IV crystalloid, vasopressors (ICU), sodium bicarb
CNS depression – prompt intubation at onset of CNS depression. Hyperventilate intubated patients to pH 7.5-7.55.
What supplies posterior and anterior circulation?
Posterior = verterbrobasilar (occipital, brainstem, cerebellum)
Anterior = internal carotid (rest of brain)
Bamford stroke classification
TACS
All of:
Motor/sensory deficit in 2 or more of face, arm or leg
Homonymous hemianopia
Higher cortical function
Bamford stroke classification
PACS
2 out of 3 of TACS criteria Or Higher cortical dysfunction alone Or Isolated motor deficit not meeting LACS criteria
Bamford stroke classification
LACS
PURE MOTOR/SENSORY
Motor and/or sensory deficit affecting 2 or more of face, arm, leg
No higher cortical dysfunction or hemianopia
Bamford stroke classification
POCS
Any of:
• Ipsilateral cranial nerve palsy + contralateral motor/sensory deficit
• Bilateral motor/sensory deficit
• Disordered conjugate eye movement
• Cerebellar dysfunction
• Isolated hemianopia or cortical blindness
Investigations in stroke?
Bloods – Acute - FBC, U+E, LFT, lipids, glucose, cardiac markers, clotting, G+S
ECG
CXR
CT head
Echo/carotid Doppler/24h ECG – if anterior circulation stroke.
Management of stroke?
ABCDE
O2 15L NRBM, obs, ECG
Venous access + bloods
NBM IV fluids
Examine patient - RS, CVS, abdo, neuro - EXACT NEURO DEFICITS
Urgent CT scan
Thrombolysis/aspirin after CT excludes haemorrhage
Who should be considered for thrombolysis?
Age <80 - <4.5 hours from start of symptoms
Age >80 - <3 hours from start of symptoms
Non-haemorrhagic stroke (excluded by CT)
Significant symptoms and not improving
Contraindications to thrombolysis?
Active bleeding CNS trauma neoplasms or arteriovenous malformations previous intracerebral haemorrhage ischaemic stroke in previous 6mths major trauma/surgery in past 3wk non-compressible punctures in past 24hrs (LP etc).
Management of ischaemic stroke?
aspirin 300mg/24h PO/PR for 14d (provided no haemorrhage on CT)
Then clopidogrel (or aspirin/dipyridamole) for secondary prevention
Management of haemorrhagic stroke?
FFP/prothrombin complex concentrate, vitamin K and surgical review.
Important thing to do with stroke patients?
Assess safety of swallow - NBM + IV fluids if concerns and SALT referral
Stroke ward for mobilisation with MDT
ABCD2 score?
Age >60 BP >140/90 Clinical features (unilateral weakness = 2, speech disturbance = 1) Duration (>60 mins = 2, 10-60mins = 1) Diabetes
>4 = high risk >5 = 8% risk of stroke in next 48h
Antiplatelet therapy started immediately and carotid doppler
Features of severe asthma attack?
Incomplete sentences, PEFR 33-50% of best
HR >110
RR >25
Features of life threatening asthma attack?
33 92 CHEST
PEFR <33% of best Sats <92%, Cyanosis Hypotension Exhaustion Silent chest Tachycardia
PaO2 <8kPa Normal PaCO2 Poor respiratory effort Altered GCS Arrhythmia
Near fatal asthma attack?
CO2 retention – CALL ICU
Management of acute asthma attack?
ABCDE
15 L NRBM
ABG
IV access + bloods
OSHITME
Salbutamol 5mg neb with O2
Ipratropium bromide 500mcg neb with O2
Hydrocortisone 200mg IV (or pred 40mg PO)
Senior help at this point…
Theophylline 5mg/kg IV bolus
Mag sulph
Management of seziures?
CONSERVAITVE
O2, recovery position, monitor, ?hypoglycaemia
BENZOS Buccal midazolam/PR diazepam 10mg IV lorazepam 4mg (slow bolus) ?pabrinex Repeat after 5 minutes if necessary
PHENYTOIN
20mg/kg IV or phenobarbital
need an anesthetist at this point for RSI with thiopentone
