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.
