Acute Medicine Flashcards
Explain the management process for anaphylaxis?
- ABCDE approach
- A = maintain patency, if GCS < 8 –> intubate
- B = 100% O2 on 15 L, Salbutamol if bronchospasm (indicated by wheeze)
- C = IV access (14-18gauge cannula), Fluids if hypo (500ml of warm crystalloid or 0.9% saline),
- IM Adrenaline 0.5-1mg (repeat until HR and BP stabilise)
- Alternatives: Prochloperazine (anti-histamine 10mg IV) or dexamethasone (steroid 200mg IV)
- Mast Cell Tryptase (MCT) measure at time of incident, 4hrs after and 24hrs after
- Monitor NP, HR, RR, O2 sats, temperature
Explain the management of paracetamol overdose?
- ABCDE assessment
- Assess risk of toxicity, if < 75mg/kg then unlikely, if >150mg/kg then significant risk
3a. if <1hr –> Activated charcoal
4. 4hrs later measure PPC also FBC, INR, U+Es. LFTs
- if still at risk (assess using PPC)? –> then N-acetylcysteine
3b. if > 8hrs –> N-acetylcysteine then measure PPC (assess risk)
3c. if > 24hrs - measure PPC (assess risk), other test results (late): raised bilirubin + creatinine; low albumin; hypoglycaemia; acidosis;
Why do patients get paracetamol toxicity?
OD causes stores of glutathione to run out –> inability to metabolise excessive amount of paracetamol
What is the treatment of paracetamol toxicity post 8hrs? Explain the dosing regimen?
N-Acetylcysteine
- 150mg over 1 hr
- 500mg over 4hr
- 100mg over 16hrs
What are the key investigations for paracetamol toxicity?
- Plasma paracetamol concentration - determine level in relation to weight to determine risk
- INR (NAC) affects levels
- U+E and LFTs
What is the key investigation for anaphylaxis?
Mast cell tryptase
What are the symptoms of paracetamol toxicity (sequelae)?
- Early = N+V
- 24-72 hrs = RUQ pain and tenderness
- 3-5 days = jaundice, coagulaopthy (bruising), hypoglycaemia
What are the effects of amphetamines?
Increased energy, talkativeness; decreased need for food; hallucinations; dilated pupils
What are the OD effects of amphetamines?
- Lack of energy
- Psychosis (hallucinations, delusions, paranoid thoughts, agitation)
- Others: increased RR, HR, hyper-reflexia, tremor etc
- Severe: cardiogenic shock, AKI, fever
What is the general treatment for amphetamines (think immediate treatment and 6 complications, be logical and keep it brief)
- <1hr Activated charcoal
- Metabolic acidosis - IV bicarb
- HTN - IV GTN
- Hypotension - Vasopressor and IV glucagon
- Agitation or Seizure - IV loraz, midaz, benzo
- Hyperthermia - cooling measures e.g. tepid sponge, cold saline, dantrolene
What are the mild and severe effects of opioid toxicity
Mild - pin point pupils, nausea and vomiting, sweating, agitation, euphoria, drowsy, confused
Severe - Hallucinations, respiratory depression, decreased HR, RR, GCS, myoclonic jerks
What is the management for opioid toxicity (no excuse for not getting this)
- Naloxone - 0.4mg injection - repeat in 60 s with 0.8mg if no improvement (max dose 2mg)
What are the toxic effect of TCAs and at what doses are its effects worrying? What is the main worrying complications?
> 10mg is significant toxicity
30mg is high chance of seizures and coma
- Mild - blurred vision, urinary retention, dry mouth, agitation, confusion, hallucinations
- Severe - hypoxia, resp depression, metabolic acidosis, seizures and coma
- Oesophageal burns
What are the ECG findings of TCA overdose?
- Prolonged QTC - if >100mms then significant risk of seizure and coma
- Dominant R wave in AVR
- Sinus tachycardia
What is the treatment for TCA overdose.
- Long QTC - IV bicarbonate
- Seizures - IV lorezepam/diazepam
- Resistant hypo - IV glucagon or vasopressor e.g. noradrenaline
- Arrhythmia - IV Magnesium
What are the features of alcohol withdrawal?
- Nausea, vomiting, shaking, fever, pale, tonic-clonic, raised HR/RR
- peaks at 12-24hrs, usually relieves within 48hrs - Severe i.e. DT
- temperature,
- Delusions + Hallucinations (lilliputian or wenicke-korsakoff)
- coarse tremor, acutely confused
- CV collapse
What is the treatment of alcohol withdrawal?
- IV pabrinex (thiamine)
- Chlodizepoxide reducing regimen
- 20mg/6hrly
- Then reduce over 1 week - Vitamin supplements
- IV vitamin B/C - Fluid resuscitation
- can require around 10L
- do not give saline if known chronic liver disease, give dextrose 5% as often hypoglycaemic
What is the major complications of alcohol withdrawal
- Delirium tremens
2. Wernicke-Korsakoff syndrome
What are the symptoms of DVT?
Moderate leg pain and swelling (>65%)
Distended superficial veins
Erythema
Hot
Homan’s sign - pain in calf on dorsiflexion of foot
Acute breathless and chest pain (if PE has developed)
what are the key investigations for DVT?
- Two level Well’s score (if ≥ 2 DVT likely –> USS, if < 2 DVT unlikely = D-dimer)
- Venous compression USS of leg vein (if +ve = anticoagulate; if -ve do D-Dimer)
- Also abdo and rectal/pelvic exam
- Bloods - FBC, INR, clotting, U+Es, APTT
What are the key symptoms of PE?
Sudden onset chest pain and dyspnoea Haemoptysis Acute desaturation (low O2%), increased HR, RR, JVP Dizzy and Syncope DVT signs Mild fever
What are the investigative findings/ladder for PE?
- Bloods - FBC, U+Es, Clotting, INR, APTT
- ABG - hypoxia
- ECG - Sinus tachycardia, S1Q3T3, RBBB. RAD (latter two suggest massive emboli)
- Two level Well’s score (≥5 PE likely –> CTPA, < 5 PE unlikely –> D-Dimer)
- CTPA (+ve –> anticoagulate; -ve –> D-dimer)
5b. V/Q mismatch
5c. Pulmonary angiography
What is the treatment pathway for PE?
- Oxygen - 15L/min via NRBM
- LMWH, Fondaparinoux or UFH (if severely renal impaired) give for at least 5d
- PO NSAIDs for pain (opiate will likely exacerbate respiratory depression)
- Warfarin - have overlap, continue LMWH until INR 2-4, then stop LMWH, continue warfarin for 4-6 weeks mod, 3-6 months for all others
- Thrombolysis if haemodynamic unstable
- Alteplase or Streptokinase - Embelectomy if massive
- IVC filter
What is the treatment pathway for DVT?
- LMWH, Fondaparinoux or UFH (if severely renal impaired) give for at least 5d
- Warfarin - have overlap, continue LMWH until INR 2-4, then stop LMWH, continue warfarin for 3 months
- Thrombolysis if patient has symptomatic iliofemoral DVT, good fun status, survival > 1 year and low bleed risk
- Alteplase or Streptokinase - IVC filter
What investigative pathway must you put a patient with unprovoked DVT or PE?
Cancer screening pathway
What are the symptoms of cellulitis
Obvious skin break or point of infection Swollen leg Erythematous Hot Painful Spreads rapidly Shiny thin skin U/L (unusual if B/L) Fever, rigors, malaise, lethargy Blisters and bullae may develop Crepitus if anaerobic
What are the causative organisms of cellulitis
Strep (66%) and staph (33%)
What is the treatment of cellulitis?
Flucloxacillin (staph)
Benzylpenicillin or Phenoxy-methyl-penicillin (if strep confirmed)
Clindamycin, clarithromycin or vancomycin (if pen allergic)
What is a sign of anaerobic cellulitis?
crepitus
