Acute medicine Flashcards
Thermal burns initial first aid
ABCDE Within 20mins irrigate the burn Prevent hypothermia Lay cling film over the burn Elevate the area to prevent oedema Give pain relief
Chemical burns initial first aid
ABCDE
Remove affected clothing
Brush off agent if dry
Irrigate for an hour
Superficial epidermal burns advice
Cool bath / shower
Topical emollients
Cold compress
Simple analgesics
When should people with superficial burns seek further help
Blister formation - may indicate further dermal injury
What prophylaxis is important with burns
tetatnus
Investigations to order in those with burns
FBC
U and Es
Carboxyhaem
ABG
CT head/ spine
Wound biopsy culture / histology
outpatient management of cutaneous burns
wound cleaning (topical)
topical AB prophylaxis
Tetanus prophylaxis
Opioid analgesic
inpatient care of cutaneous burns
burn centre assessment
fluid resuscitation
supportive care
tetatnus immunicsation
Surgery?
Suspected wound infection in a burn, treatment?
AB and surgical debridement
4 cardiac rhythmic disturbances leading to cardiac arrest
VF
Pulseless VT
Pulseless electrical activity
Asystole
Bed side tests in a cardiac arrest
ABG Lactate FBC Toxicology Troponin Electrolytes and glucose
ECG
CXR
First line management in unwitnessed cardiac arrest
CPR
Shockable rhythms
pulseless VT and VF
1st line in shockable rhythms
CRP + defib + adrenaline 1mg every 3-5 mins
If IV access is not available in a shockable arrest how do you give the adrenaline
2mg diluted through an endotracheal tube
1st line in non shockable rhythms
CRP + adrenaline 1mg every 3-5 mins
Which anti arrhythmic can be considered in cardiac arrest
amiodarone
Return of spontaneous circulation management
ABCDE
Aim for SpO2 94-98%
12 lead ECG
treat precipitating cause
How often do you assess the rhythm in a cardiac arrest?
every 2 minutes
1st line in hypoglycaemic episode
Oral glucose - if alert
2nd line management of hypoglycaemic episode
IV glucose 20% in saline - if IV access and drowsy
IM glucagon - no IV access
Causes of hypoglycaemia
Insulin
Alcohol
Liver disease
Addisons
Ddx for meningitis
Encephalitis
Septicaemia
Subarachnoid
Kernigs sign
Pain on passive knee extension when the hip is flexed
1st line investigations in meningits
Blood culture FBC CRP UandE Calcium Magnesium Glucose Coag profile CT head LP
1st line antibiotic in meningitis
Cefotaxime / ceftriaxone
+ Vanc
> 50 give ampicillin too
Septicaemia means what should NOT be done (in the context of a meningitis hx)
LP
2nd line medical management of meningitis
Dex
predominant cell type in an LP from a pt with
1) bacterial meningitis
2) viral
polymorphs
mononuclear
glucose levels in an LP from a pt with
1) bacterial meningitis
2) viral
1) < 1/2 plasma
2) > 1/2 plasma
protein levels in an LP from a pt with
1) bacterial meningitis
2) viral
1) >1.5
2) <1
when to suspect encephalitis
abnormal behaviour
reduced consciousness
focal neurological signs
PRECEEDED BY INFECTIOUS ILLNESS
Investigations in encephalitis
Urine dip
Blood cultures
CT -
LP - send for PCR
Blood tests in suspected poisoning
Glucose UandEs FBC LFT INR ABG Paracetamol and salicylate levels Toxicology
Monitoring in suspected poisoning
Vital signs
ECG
Urine output
1st line in patients presenting <4hrs after OD on paracetamol
Activated charcoal
When should blood paracetamol level be taken
4hr post ingestion
If patient levels above the treatment line and stable and OD <10-12hrs ago give what?
n-acetylcysteine - IV with dextrose after level
Day after paracetamol OD check
INR
UandE
LFTs
If unsure when taken paracetamol OD / staggered OD
Give n-acetylcysteine without waiting for levels
septic shock definition
subset of sepsis, coexistance of persistent hypotension. requiring vasopressors to maintain MAP
sepsis definition
life threatening organ dysfunction due to dysregulated host response to infection
Differentials for sepsis
SIRS
MI
Acute pancreatitis
PE
Maintenance fluid calculation
30ml/kg/24hrs
then work out how many ml per hour
simple fluid maintenance prescribing
1 saline
2 dextrose
each with 20mmol of potassium
NSTEMI risk stratification tool
GRACE
Blood to take in a suspected overdose
Paracetamol Salicyltate levels Clotting screen LFTs FBC UandEs
Side effects of NAC
Hypoglycaemia
Bronchospasm
Shock
Vomiting
What to look for in a patient when assessing airway?
Full sentences
Added sounds
Using accessory muscles
How much oxygen should be given to patients in an acute situation?
15L through non rebreath mask
How much should adrenaline be given to an adult in suspected anaphylaxis?
1:1000 5ml 500 micrograms
How much naloxone should be given to a pt with opioid overdose?
400 micrograms IV
Criteria for CT scan in head injury?
For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:
GCS less than 13 on initial assessment in the emergency department.
GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
Suspected open or depressed skull fracture.
Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
Post-traumatic seizure.
Focal neurological deficit.
More than 1 episode of vomiting.
Mneumonic for a quick hx in an emergency situation
AMPLE
allergies medication PMH Lead up to PC Eat and drank last?
Medications in anaphylaxis
Adrenaline - 0.5ml of 1:1000 or 0.5mg IM
Chlorphenamine - 10mg
Hydrocortisone - 200mg
Blood to take in an acute situation
FBC UandE LFTs CRP Group and save (consider cross match) VBG - glucose and lactate Clotting Glucose
consider ABG
Initial management of a GI bleed
Protect airway NBM Two large bore cannulae in AQF Blood including coag, G&S and cross match Catheterise - urine output Obs every 15mins o
GI bleed fluid management
Normal saline fast until blood arrives
Consider FFP for low platelets
Correct coagulopathy
Immediate investigation in upper GI bleed
OGD
If variceal bleed identified on OGD give what
Broad spectrum AB and talopressin
Impratropium dose in acute asthma
500 micrograms
Bloods in meninigits
FBC UandE LFT Coag Group and save CRP PCR serology blood cultures EBV HIV HSV
1st seziure presentation what is likely
structural brain abnormality >50%
Investigations in status epilepticus
bedside - urine dip and culture, observations, ECG
bloods - FBC, U&E, LFT, glucose, lactate, VBG, CRP, Ca2+
Consider - toxicology screen
- CT
- EEG
Initial management of SE
ABCDE
Slow IV bolus of lorazepam 2-4mg
Can give another dose if no response in 10 mins
OR rectal diazepam
If no response to lorazepam what could be given next in SE?
If due to ?alcohol - thiamine
blood glucose low - start with 50ml of 20% glucose
Treat acidosis
Treat hypotension
IV infusion of phenytoin
Definitive management of SE
General anaesthetic
shock definition
circulatory failure resulting in inadequate organ perfusion
MAP =
CO X SVR
CO =
HR X Stroke volume
Causes of inadequate CO
Hypovolaemia - bleeding / fluid loss
Pump failure - arrythmia, ACS, valve failure
Causes of loss of SVR
Sepsis
Anaphylsxis
Neurogenic
Endocrine disorder - e.g. addisons
Presentation of ecstasy poisoning (MDMA)
Agitation, anxiety, confusion and ataxia
CV - tachycardia, hypertension
Hyponatraemia
Hyperthermia
Rhabdomyloysis
Treatment of hyperthermia in ecstasy poisoning if supportive therapy doesn’t work?
Dantrolene
MOA of cocaine
Blocks uptake of dopamine, noradrenaline and serotonin
CV effects of cocaine
MI Tachy and bradycardia Hypertension QRS widening and QT prolongation Aortic dissection
Neurological effects of cocaine
Seizures
Mydraisis
Hypertonia
Hyperreflexia
In patients who have taken cocaine and have abdo pain, consider?
Ischaemic colitis
Systemic SE of cocaine
Hyperthermia
Metabolic acidosis
Rhabdomyolysis
1st line in cocaine toxicity
Benzodiazipines
Features of opioid misuse
Pinpoint pupils Drowsiness Rhinorrhoea Watering eyes Yawrning Needle track marks
Complications of opioid misuse
Viral infection
Infective endocarditis
VTE
Overdose - resp depression and death
Emergency management of opioid overdose
IV or IM naloxone
meaning of organ contusion
brusing
Extradural haematoma is
Bleeding between dura and the skull - arterial
Majority of extradural haematomas caused by?
skull fractures to the temporal bone causing rupture of the middle meningeal artery
Presentation of extradural haematoma
Quicker onset than subdural
features of raised ICP
May have a lucid interval
What is subdural haematoma?
bleeding of the outermost layer of the meninges - venous
risk factors for a subdural haematoma?
Old age
Alcoholism
Anticoagulation
presentation of subdural haematoma
a little while after a fall, become drowsy etc
slow onset of symptoms
Medications to reduce ICP
Mannitol and furosemide
Minimum of cerebral perfusion pressure in adults
70 mmHg
Unilateral dilation of one pupil and sluggish light response / fixed indicates?
3rd nerve palsy due to tentorial herniation
Bilateral dilated pupils + sluggish or fixed pupils indicates?
Poor CNS perfusion
or bilateral 3rd nerve palsy
Causes of bilaterally constricted pupils?
Opiates
Pontine lesions
Metabolic encephalopathy
Causes of unilateral constricted pupil?
sympathetic pathway disruptiob
Acute stroke management
Exclude haemorrhagic stroke
Then give 300mg Aspirin and then altepase within 4.5hrs
Management of ketoacidosis
P A N I C S
Potassium - measure hourly
Acidosis - check venous pH and ketone levels
Normal saline - bolus if BP <90 or 1L in 1st hr
Insulin infusion - 0.1 units/kg/hr
Catheter and culture - urine and bloods
Stomach aspiration if drowsy
