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Year 3 - Diseases > Acute medicine > Flashcards

Acute medicine Flashcards

1
Q

Define diabetic ketoacidosis

A

An acute metabolic complication of diabetes that is potentially fatal and requires prompt medical attention for successful treatment. It is characterised by absolute insulin deficiency and is the most common acute hyperglycaemic complication of type 1 diabetes mellitus

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2
Q

Describe epidemiology of diabetic ketoacidosis

A
  • Data from the UK National Diabetes Audit show a crude one-year incidence of 3.6% among people with type 1 diabetes.
  • In the UK nearly 4% of people with type 1 diabetes experience DKA each year.
  • About 6% of cases of DKA occur in adults newly presenting with type 1 diabetes.
  • About 8% of episodes occur in hospital patients who did not primarily present with DKA
  • Can occur in T2DM, more likely in older, overweight, non-white people with type 2 diabetes
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3
Q

Describe aetiology/ risk factors of diabetic ketoacidosis

A
  • Most common precipitating events are infection and discontinuation of, or inadequate, insulin therapy.
  • Underlying medical conditions, such as myocardial infarction or pancreatitis, that provoke the release of counter-regulatory hormones are also likely to result in DKA in patients with diabetes.
  • Drugs that affect carbohydrate metabolism, such as corticosteroids, thiazides, sympathomimetic agents (e.g., dobutamine and terbutaline), second-generation antipsychotics, immune checkpoint inhibitors, cocaine, and cannabis may contribute to the development of DKA.
  • The use of sodium-glucose co-transporter 2 (SGLT2) inhibitors
  • High acetone
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4
Q

List symptoms of diabetic ketoacidosis

A
  • Gradual drowsiness
  • Vomiting
  • Dehydration
  • Abdo pain
  • Polyuria, polydipsia
  • Lethargy
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5
Q

List signs of diabetic ketoacidosis

A
  • Coma
  • Kussmal hyperventilation
  • Ketotic breath
  • Dehydration (dry mucous membranes)
  • Sucussion splash on auscultation (sloshing sound on sudden movement - suggests gastric stasis and dilatation)
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6
Q

Describe investigations for diabetic ketoacidosis

A
  • Venous blood gas (acidaemia, pH low or HCO3 low)
  • Blood ketones (over 3mmol)
  • Blood glucose, capillary, lab (high)
  • Urea and electrolytes
  • Full blood count
  • Urinalysis
  • ECG
  • Pregnancy test
  • Amylase and lipase
  • Cardiac enzymes
  • Creatinine kinase
  • Chest x-ray
  • Liver function tests
  • Blood, urine, and sputum cultures
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7
Q

List criteria for severe DKA

A

One or more of:

  • Blood ketones over 6mmol/l
  • Venous bicarb <5
  • Venous pH<7
  • k<3.5 on admission
  • GCS<12
  • O2 sats less than 92
  • SBP <90
  • Pulse over 100 or under 60
  • Anion gap above 16

Admit to ICU

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8
Q

List complications of diabetic ketoacidosis

A
  • Cerebral oedema
  • Aspiration pneumonia
  • Hypokalamia
  • Hypomagnesaemia
  • Hypophosphataemia
  • Thromboembolism
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9
Q

Describe prognosis of diabetic ketoacidosis

A
  • Mortality rates have fallen significantly in the last 20 years from 7.96% to 0.67%
  • Death is rarely caused by the metabolic complications of hyperglycaemia or ketoacidosis but rather relates to the underlying illness.
  • The prognosis is substantially worsened at the extremes of age and in the presence of coma and hypotension.
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10
Q

Describe management of DKA

A
  • Start fluid 1L of saline over 1 hour, or if systolic less than 90 500ml over 15 mins then assess (FIRST STEP)
  • Give 50 units of insulin with 50ml 0.9 saline, infuse at 0.1 unit/kg/h. (fixed rate insulin) COntinue regular insulin doses at usual times. Aim to reduce ketones by 0.5mmol/l/H or raise of bicarb by 3. Increase insulin infusion until achieved
  • Continue fluids, assess need for K+ (give if potassium under 5.5)
  • Consider catheter if urine not passed by 1 hour. NG if vomiting or drowsy.
  • LMWH for hospital stay
  • When glucose <14mmol/L sart 10% glucose at 125ml/H alongside saline, prevent hypoglycaemia
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11
Q

Define opioid overdose

A
  • An opioid is any synthetic or natural agent that stimulates opioid receptors and produces opium-like effects.
  • Opiates are opioids naturally derived from the opium poppy, Papaver somniferum, and include morphine and codeine.
  • Opioids are used in the treatment of pain but are often sold illicitly and abused for their euphoric effects.
  • An overdose occurs when larger quantities than physically tolerated are taken, resulting in central nervous system and respiratory depression, miosis, and apnoea, which can be fatal if not treated rapidly.
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12
Q

Describe epidemiology of opioid overdose

A
  • In US number of opioid related deaths quadrupled from 1991-2015
  • More than 5 million drug related ED visits 1/2 due to abuse
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13
Q

Describe aetiology of opioid overdose

A
  • Complications of substance abuse in regular users/abusers of illicit or prescription opioids
  • Unintentional overdose in patients prescribed opioids for pain by taking larger amounts than tolerated
  • Intentional overdose and intent of self-harm (suicidality)
  • Therapeutic drug error; iatrogenic overdose by a practitioner unfamiliar with opioid prescribing, or an adverse drug reaction
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14
Q

List risk factors for opioid overdose

A
  • Opioid abuse and dependence
  • Recent abstinence in chronic users
  • Chronic pain
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15
Q

List symptoms and signs of opioid overdose

A
  • Mioisis (constricted pupils)
  • Bradypnoea, bradycardia, hypotension
  • Altered mental status
  • Decreased GI motility
  • Old track marks on arms and legs
  • Pulmonary rales
  • Frothy pink sputum
  • Seizures
  • Dysrhythmias
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16
Q

List investigations for opioid overdose

A
  • Therapeutic trial of naloxone
  • ECG (QRS prolongation, signs of myocardial ischaemia)
  • CXR for ARDS/ abdo for drugs
  • Opiod urine screen
  • Gas chromatography/ mass spectrometry
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17
Q

Define aspirin overdose

A
  • Salicylate poisoning is the result of ingestion of, or (rarely) topical exposure to, chemicals metabolised to salicylate.
  • The most common source of salicylate poisoning is aspirin itself (acetylsalicylic acid), which is rapidly hydrolysed to salicylate in the gastrointestinal tract, liver, and bloodstream.
  • Acute toxicity may occur in adults and children after ingestion of ≥125 mg/kg salicylate.
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18
Q

Describe epidemiology of aspirin poisoning

A
  • UK deaths reduced by 22% following 1998 reduced pack size of analgesics
  • Non-fatal also reduced
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19
Q

Describe aetiology/risks of aspirin poisoning

A
  • Directly stimulates respiratory centre causing hyperventilation and respiratory alkalosis, also uncouples oxidative phosphorylation increasing glucose metbaolism causing ketosis
  • Accidental ingestion >125 mg/kg
  • History of self harm/suicide attempt
  • Incorrect dosing
  • Children under 3 and adults over 70 particularly t risk
  • Cutaneous absorption
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20
Q

List Signs and symptoms of aspirin poisoning

A

Early

  • Tinnitus, deafness, dizziness
  • Hyperpnoea
  • N&V, diarrhoea
  • Hyperthermia
  • Sweaiting

Late/Severe

  • Low BP
  • Heart block
  • Pulmonary oedema
  • Low GCS and seizures
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21
Q

Describe investigations for aspirin OD

A
  • ABG (early respiratory alkalosis, late high anion gap metabolic acidosis)
  • Plasma salicylate
  • Serum electrolyte panel, urea and creatinine
  • PT, aPTT, INR (thrombocytopenia, raised INR)
  • FBC
  • CBG
  • ECG
22
Q

Define paracetamol overdose

A
  • Max dose in 24 hours 4g
  • Acute overdose: excessive amounts of paracetamol ingested over a period of less than 1 hour; usually in the context of self-harm.
  • Staggered overdose: excessive amounts of paracetamol ingested over longer than 1 hour; usually in the context of self-harm.

Therapeutic excess:

  • Excessive paracetamol taken with intent to treat pain or fever and without self-harm intent.
  • Paracetamol ingested at a dose greater than the licensed daily dose AND more than or equal to 75 mg/kg/24 hours.
  • Can involve use of excessive doses of the same paracetamol product or inadvertent use of more than one paracetamol-containing product at the same time.
23
Q

Describe epidemiology of paracetamol overdose

A
  • Most common deliberate overdose

- Most commonly 500mg tablets, >150mg/kg is an overdose while 12g can be fatal

24
Q

Describe aetiology of paracetamol overdose

A
  • Self harm attempt or therapeutic error
  • CYP450 breaks down paracetamol to NAPQI, which is conjugated with gutathione and excreted
  • Depleted glutathione leads to NAPQI buildup
25
Q

List risks for paracetamol OD

A
  • History of self harm
  • History of freuqent meds for pain release
  • Glutathione deficiency (malnurishment, eating disorders, psychiatric disorders, chronic illness, cachexia, alcohol use disorder)
  • Use of P450 inducers (eg. carbamezepine, st.johns wort, phenytoin)
26
Q

List signs and symptoms of paracetamol overdose

A

Often asymptomatic

Less than 24 hrs

  • Mild Nausea and vomiting
  • Lethargy

24-48 hours

  • RUQ pain
  • Vomiting
  • Hepatomegaly

Over 72 hours
- Acute liver failure (jaundice, asterixis, altered consciousness)

27
Q

List investigations for paracetamol overdose

A
  • Serum paracetamol
  • LFT
  • PT and INR
  • Blood glucose
  • U and E
  • FBC
  • ABG or VBG (lactic acidosis)
  • Salicyclate/urinalysis/urine drug screen
28
Q

List indications for a catheter

A
  • Urinary retention

- Monitoring urinary output in unwell patients

29
Q

List types of catheter

A
  • Foley catheter
  • 3-way catheter (indications: recurrent clots/haematuria, extra lumen for irrigation)
  • Suprapubic catheter (indications: long-term use, urethral damage by trauma, surgery, or stricture)
30
Q

List complications of catheter insertion and how to treat them

A
  1. UTI
    - Bacteria in urine with catheter, only treated if symptomatic
    - 1st replace catheter, 2nd antibiotics
  2. Catheter blockage
    - Due to biofilm formation (infection with proteus mirabilis)
    - Bladder wash out 1at, 2nd replace catheter
31
Q

Define catheterisation

A

Insertion of a flexible tube into the bladder to collect urine in a drainage bag

32
Q

Define arterial blood gas

A

A sample of blood taken from an artery and analysed to identify pH, O2, CO2, HCO3- and therefore determine acidosis vs alkalosis. Also measures lactate and electrolytes

33
Q

Describe the process of collecting an ABG

A

Allen test:

  • Apply pressure over radial and ulnar arteries with hand elevated for 30 seconds until blanching of the palm
  • Release the ulnar artery – colour should return <8 seconds, indicates sufficient collateral circulation
  • Clean site (radial artery), apply local anaesthetic if possible, hold needle like a pen at 45 degrees and fill syringe, maintain pressure with gauze for 2 minutes afterwards
34
Q

List indications for ABG

A
  • Accurate measure of PaO2
  • Can use VBG otherwise for the same results
  • Useful in emergency setting
35
Q

List complications of ABG

A
  • Haematoma
  • Thrombus
  • Infection
36
Q

Define blood product transfusion including types

A
  • RBC transfusion
  • Platelet transfusion (eg. leukaemia patients)
  • Plasma transfusions (liquid part of blood- fresh frozen plasma is stored at -35 degrees)
  • Cryporecipitate is repeatedly thawed to produce concentrated clotting factors, eg. factor VIII, VWF and fibrinogen
  • Prothrombin complex concentrate (factor II)
37
Q

List indications for blood transfusion

A
  1. Packed red cells:
    Indicated if Hb <70g/l or >30% loss of blood volume
    1 unit increases Hb by 10-15g/l
  2. Platelets
    If platelets <20*109/L
  3. FFP
    To correct clotting defects e.g DIC
38
Q

List complications of blood transfusion

A

Early complications (<24 hours):

  • Anaphylaxis
  • Acute haemolytic reaction
  • Bacterial infection
  • Febrile non-haemolytic reaction
  • Transfusion associated circulatory overload (TACO) or transfusion associated lung injury (TRALI)

Late complications (>24 hours):

  • Delayed haemolytic reaction
  • Infection
  • Transfusion associated graft vs host disease
  • Iron overload
39
Q

Define epidural

A
  • Indwelling catheter put in extradural space, usually put in L3/L4
  • Layers crossed: skin, subcutaneous fat, muscle, supraspinous ligament, interspinous ligament, ligamentum flavum
  • Used for anaesthetic
40
Q

List indications for an epidural

A
  • Lower extremity surgery (sensory and nerve block)

- Particular obstetrics

41
Q

List complications of epidural

A
  • Dural puncture (manifests with headache, give fluids, caffeine and blood patch - inject blood near the hole so it will clot)
  • Vessel puncture (ABC)
  • Hypoventilation (motor block of intercostals, may require ventilation)
  • Epidural haematoma or abscess
42
Q

Define head injury

A
  • Head injury is trauma to the head that may or may not be associated with soft tissue injury, skull fractures and TBI. Closed intact dura mater, open breach of dura mater
  • Traumatic brain injiry is disruption of the brian resulting from a head injury
  • Primary is a brain injury that occurs at the time of the trauma as an immediate consequence of head injury
  • Secondary brain injury is indirect from acute CNS insults and/or their treatment
43
Q

Describe epidemiology of head injury

A
  • 800/100000
  • Esp. children 1-4, teens, young adults 15-24 and adults over 65
  • More common in male
44
Q

Describe aetiology of head injury

A
  • Blunt head injury blunt force trauma (falls in kids and elderly most common, motor vehicle accidents 2nd most common, contact sports)
  • Penetrating head injury (less common - high-velocity missile injury, low velocity non-missile injury assult, accidental injury)
  • Blast injury caused by blast from explosion
45
Q

Describe signs and symptoms of head injury

A
  • LOC
  • Headache
  • Amnesia
  • Raised ICP - altered mood and behaviour, dizziness N and V, cushing triad, CN palsies, slurred or disorganised speech, impaired coordination
  • Abnormal posturing (decorticate (flexion of upper and extension of lower, proximal brainstem) or decerebrate (extension, distal brainstem or pons)
  • Haematoma
  • Liqorrhoea (leakage of CSF, halo sign)
  • CSF rinorrhoea, recoon eyes (anterior skull fracture)
  • Basilar skill fracture (CSF otorrhoea, haemotympanum, battle sign)
  • Facial deformaties
46
Q

List investigations for head injury

A
  • GCS
  • Head CT no contrast to identify need for surgical intervention (haemorrhage, mass effect, herniation, diffuse axonal injury, cerebral contusion cerebral oedema, bone fractures, pneumocephalus)
  • Image other possible sites of imaging
  • MRI head (if CT not showing anything abnormal, may show microhaemorrages, DAI, contusions)
  • CT spine/maxillofacial in suspected CSF leak
  • CT or MR angiography (suspected intracranial arterial injury, CTA spot sign)
  • Blood glucose, alcohol, urine toxicology, serum electrolyte, ABG analysis
  • Coagulation
  • Blood group and save
  • Pregnancy test
47
Q

Define multi organ dysfunction syndrome

A

A clinical syndrome of progressive failure of two or more organs in a critically ill patient.

48
Q

Describe epidemiology of multi organ dysfunction syndrome

A
  • 15% ICU patients, contributing to 50% deaths in ICU (commonest cause of death in ICU)
  • Sepsis most common trigger
49
Q

Describe aetiology of multi organ dysfunction syndrome

A
  • Illness, injury or infection that triggers SIRS resulting in tissue injury
  • Sepsis
  • Major truama
  • Major durgery
  • Burns
  • Pancreatitis
  • SHick
  • Aspiration syndromes
  • Blood transfusions
  • Autoimmune disease
  • Acute HF
  • Poisons
50
Q

List risk factors for multi organ dysfunction syndrome

A
  • Genetics
  • Premorbid organ dysfunction
  • Medication, therapies, ICU supports
  • Infection
51
Q

List symptoms and signs of multi organ dysfunction syndrome

A
  • AKI and uraemic acidosis (altered mental state, reduced urine output)
  • ARDS (resp deterioration)
  • Cardiomyopathy (pale, clammy, faint peripheral pulses, low blood pressure, arrythmia)
  • Encephalopathy (altered mental state)
  • GI dysfunction
  • Hepatic dysfunction
  • Acute neurological dysfunction
  • Coagulopathy and bone marrow suppression
  • Fever, tachycardia
  • Tachypnoea
52
Q

Describe investigations for multi organ dysfunction syndrome

A
  • Widespread inflammation in the body
  • FBC (raised white blood cells)
  • Low BP, arrythmia, tachycardia
  • Dysfunction in 2 or more organs (U and Es, liver function)
  • Sepsis 6 (blood culture, lactate, urine output)
  • ABG
  • GCS
  • Imaging (eg. CXR, AXR, abdo ultrasound, diagnostic laproscopy - for cause)

Year 3 - Diseases (27 decks)

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