Acute medicine Flashcards by H Jalisi

ABCDE protocol

Airway
- assess: patency, secretions/vomit, obstruction
- manage: airway manoeuvres, suction, airway adjunct
Breathing
- assess: RR, O2 sats, palpation/percussion/auscultations, later CXR
- manage: O2
Circulation
- asses: HR + BP, cap refill/perfusion, cyanosis, auscultation
- manage: fluids, bloods/ABG
Disability
- asses: AVPU/GCS, glucose, PEARL
Exposure
- assess: whole body inspection

*Use SBAR for handover: situation, background, assessment, recommendation

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Why does alcohol withdrawal occur?

Alcohol is a depressant (GABA agonist) so chronic use leads to upregulation of glutamate receptors

When alcohol is removed, the upregulation of glutamate receptors means there is an increase in CNS stimulation thus there is a gradula increase in CNS overactivity

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Timeline of alcohol withdrawal

Minor 6hrs
- anxiety, tremor, palpitations, GI upset
Hallucinations 12hrs
Seizures 32 hrs
- short, generalised tonic-clonic seizures
Delirium tremens 48hrs
- delirium, severe tremor, fever, FATAL

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Ddx of delirium tremens

Acute liver failure
- ammonia (encephalopathy), albumin (ascites + peripheral oedema), bilirubin (jaundice), blood factors (bruising)
Wernicke’s encephalopathy
- Confusion, Ataxia, Nystagmus

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Hx and O/E of alcohol withdrawal

CAGE question./longer AUDTI question.
Signs of alcohol abuse (smell, hygiene etc.)
Chronic liver disease signs

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Mx of alcohol withdrawal

1) Benzodiazepines (chlordianzepoxide, diazepam)
2) Pabrinex (B1 to prevent Wernicke’s)
3) Glucose (if hypo + needed with pabrinex)
4) Manage alcohol dependence (Drug+Alcohol Liaison specialist, therapy)

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What scale is used to assess severity of alcohol withdrawal?

CIWA-Ar scale

Nausea/vomiting
Tremor
Paroxysmal sweats
Anxiety
Agitation
Tactile disturbances
Auditory disturbances
Visual disturbances
Headache/fullness in head
Orientation/clouding of sensorium
dw don’t need to memorise

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What should you also consider if you suspect alcohol withdrawal?

Hypoglycaemia
Electrolyte distubrances
Hepatic encephalopathy

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Anaphylaxis presentation

Airway = throat/tongue swelling, stridor
Breathing = SOB, increased HR, decreased O2
Circulation = SHOCK; decreased BP, increased HR, low consciousness
Shin/mucosal = uritcaria + angioedema, flushing
Sense of impeding doom

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What causes anaphlyaxis?

Life-threatening, systemic, hypersensitivity reaction

mast-cell/basophil degranulation
increased capillary permeability, bronchospasm, decreased vascular tone

3 common triggers

1) Food (child) - nuts
2) Drugs/chemicals (adults) - penicillin
3) Toxins - bee/wasp stings
* RF = Hx of atopy

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Mx of anaphylaxis

I. HELP
II. Remove trigger
III. Lie flat and raise legs
IV. IM adrenaline 0.5mg 1:1000
V. Airway, breathing, circulation
VI. IV chlorpheniramine + IV hydrocortisone

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What further ix could confirm anaphylaxis?

Increased serum tryptase and plasma histamine on blood tests

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What should follow up involve after an anaphylaxis reaction?

Refer to immunology/allergy clinic
- RAST specific IgE testing to determine allergies
Provide EpiPen and education re anaphylaxis
Get a medic alert bracelet

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Poisoning summary card

Administration of XS pharmaceutical agent
- accidental in <10yo, deliberate >10yo (typically alcohol in 15-35 yo)

Ix
- ABCDE, ABG, ECG, FBC, U&E, LFT, INR, glucose, paracetamol + salicylate levels

TOXBASE, National Poisons Information Service
consider activated charcoal if = 4hrs to reduce absorption of drug
consider gastric lavage (rare)

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Compare early and late presentations of aspirin overdose

Early

N&V, diarrhoea
‘per-spirin-g’ = hyperthermia, sweating
‘raspi-irin’ = hyperpnoea (stimulates respiratory centre in medula)
‘aspirin-ging’ = tinnitus, deafness, dizziness

Late/severe

pulmonary oedema
decreased BP and heart block
seizures + decreased GCS

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What counts as an aspirin overdose and what would lab results show?

> 150mg/kg, severe if >500mg/kg

Lab results:
Early => early respiratory alkalosis
Late => high anion gap metabolic acidosis

Mx of aspirin OD

Urine alkalinsation with IV sodium bicarbonate

Dialysis

Timeline of paracetamol sx

Often asymptomatic presentation

Timeline:
<24hr = mild N&V, lethargy
24-72hr = RUQ pain, vomiting, hepatosplenomegaly
>72 hr = acute liver failure

How does a paracetamol OD lead to liver failure?

XS paracetamol is metabolised by CYP450 in the liver to NAPQ1, which is then conjugated to glutathione and excreted
XS means glutathione is depleted and toxic NAPQ1 accumulates, causing hepatocyte necrosis :(

What dose is a paracetamol OD and how is it managed?

> 150mg/kg, 12g can be fatal

Mx:

IV N-acetyl-lysteine if below treatment line (graph used to determine)
liver transplant

What does opiate OD result in and how is it treated?

CNS depression

respiratory depression
bradycardia, hypotension
pinpoint pupils
late/severe: low GCS/coma

IV naloxone (muscarinic receptor antagonist)

When is a catheter indicated?

Urinary retention and to monitor urine output

Types of blood transfusions

X-match for:
Packed red cells
- indicated if Hb <7g/l or 30% loss of blood volume
- 1 unit increases Hb by 10-15g/l
Platelets
- when plts <20x10[unit]
FFP
- correct clotting factors => DIC

Complications of blood transfusions

EARLY (<24hrs)
Febrile non-haemolytic reaction
Anaphylaxis
Acute haemolytic reaction
Bacterial infection
Transfusion associated circulatory overload or transfusion associated lung injury

LATE (>24hrs)
Iron overload
Transfusion associated graft vs host disease
Infection
Delayed haemolytic reaction

What layers does an epidural go through?

at L3/4, indwelling catheter inserted through: | skin => subcutaenous fat => muscle => supraspinous ligament => interspinal ligament => ligamentum flavum

When is an epidural indicated and what are its possible complications?

Lower extremity surgery (sensory and nerve block), particularly in obstetrics Complications - dural puncture (headache = lie flat, oral fluids, caffeine to help) - vessel puncture (treat w/ ABC) - hypoventilation (due to motor block of intercostals) - epidural haematama or abscess

A 21 yo M is brought in to A&E by his friends because he is unresponsive. On examination you find miosis, a respiratory rate of 8 bpm. The patient is deeply unresponsive to pain. What is the most likely explanation for this presentation? ``` A. Aspirin overdose B. Anaphylactic shock C. Opiate overdose D. Paracetamol overdose E. The patient is sleeping ```

C. Opiate overdose

A 40 yo M is brought in to A&E by his friends because he is unresponsive. His friends tell you that he has just had a seizure before coming to A&E. They reluctantly tell you that he is now abstinent from alcohol for 1 week. What is the best immediate management for this patient? ``` A. IV Lorazepam B. Send to ITU C. Watch and wait D. Start 0.9% saline infusion E. Give oxygen 100% ```

A. IV Lorazepam

When should you consider to admit a pt with alcohol withdrawal?

``` Pts at high risk of developing withdrawal seizures or delirium tremens <16 yo in acute alcohol withdrawal Vulnerable people (frail, cognitively imparied, multiple comobidities, lack of social support, learning difficulties, 16-18yos) ```

A 50 yo M known alcoholic presents to A&E with restlessness and tremors. He is anxious, pacing in the hallway. His observations show a HR of 121 bpm, BP of 169/104 mmHg. On further questioning he states he is nauseous and you can see he is visibly shaking. He says his symptoms started to develop 5 hours after his last drink. What is the best management for this patient? ``` A. Admit and give IV Lorazepam B. Send him home with some information on contacting local alcohol support service C. Admit and give oral Lorazepam D. Send him home with no treatment E. Watch and wait ```

C. Admit and give oral Lorazepam

In anaphylaxis, what is the emergency management? ``` A. IV Adrenaline B. IM Amiodarone C. IM Glucagon D. Sublingual Adrenaline E. IM Adrenaline ```

E. IM Adrenaline

What is the definition of acute aspirin overdose? A. Single dose equivalent of >150mg/kg or >6.5 g B. Single dose equivalent of >100mg/kg or >4.5 g C. Repeated exposure to high dose aspirin or equivalent D. Taking more than a box of Boots aspirin in one sitting

A. Single dose equivalent of >150mg/kg or >6.5g *C is chronic aspirin overdose

What are the first signs of paracetamol overdose? ``` A. Nausea and vomiting B. Stomach cramps C. RUQ pain D. Asymptomatic E. Hallucinations ```

A. Asymptomatic

What is the daily maximum recommended dose of paracetamol? ``` A. 1000 mg B. 1500mg C. 4g D. 5g E. 10g ```

C. 4g

A 65 year old man with a history of self-harm presents to A&E with severe nausea and vomiting. He tells you that he took ‘some tablets’ but he didn’t bother to look at what they were. He suffers from stable angina but his PMHx is otherwise unremarkable. His observations are as follows: ``` HR 110 BP: 110/85 RR: 30 O2 sats: 100% Temp: 39.0 ``` ``` What is the most likely diagnosis? A. SSRI toxicity B. Paracetamol overdose C. Myocardial infarction D. Aspirin overdose E. Panic attack ```

D. Aspirin overdose

An 18 year old girl is brought to A&E with difficulty in breathing. On examination, you note swelling of the lips and tongue and an erythematous rash over her face and trunk. Her observations are as follows: ``` HR 160 BP: 70/50 RR: 40 O2 sats: 92% Temp: 37.2 ``` ``` What is the next best step in management of this patient? A. IV adrenaline 0.5mg B. IM adrenaline 0.5mg C. IV adrenaline 0.25mg D. IM adrenaline 0.25mg E. Start high-flow oxygen ```

B. IM adrenaline 0.5mg

A 35 year old man presents to A&E in respiratory depression with needle track marks on his arms. He has pinpoint pupils on examination. His observations are as follows: ``` HR 40 BP: 60/30 RR: 8 O2 sats: 90% Temp: 37.2 ``` ``` What is the next best step in management of this patient? A. IV naltrexone B. IV naloxone C. IV saline 0.9% 1L bolus D. IV flumazenil E. IV atropine ```

B. IV naloxone

``` A 62yr old gentleman is brought to A&E by his wife who suspects that her husband has been drinking. It is clear that the gentleman is disoriented, and he has a particularly unsteady gate. On examination, you note: spider naevi, gynaecomastia, nystagmus on lateral gaze and mild peripheral neuropathy. His blood results are as follows: FBC: Hb: 12.5g/dL (13.5-17.5g/dL) MCV: 105fL (80-96) HCT: 0.35 (0.4-0.5) Platelet: 200*10^9/L (150-400*10^9) WBC: 8,000/mL (4,000-10,000) U&E: Normal CRP: Normal INR: 0.7 (<1.1) ``` ``` What is the most likely diagnosis? A. Hepatic Encephalopathy B. Wernicke’s Encephalopathy C. Encephalitis D. Normal Pressure Hydrocepahlus E. Delirium tremens ```

B. Wernicke's Encephalopathyy