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Moslers > Acute SIM > Flashcards

Acute SIM Flashcards

1
Q 
ΔΔ + initial Tx?
A - patent, altered mental state
B - RR>24, O2 high flow needed
C - BP<90, HR>100, ↑CRT, ↓urine output, vasodilated
D - rigors, BM 6
E - infected line site
A 
SEPSIS
• broad spectrum Abx
• fluid 500ml bolus, 15 mins
• high flow O2 aim 94-84
• lactate
• blood cultures
• urine output
  • escalate ITU/others if needed
  • further Ix (swabs/samples, bloods, imaging of source)
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2
Q 
ΔΔ + initial Tx?
A - angioedema, snoring noise
B - cyanosed, wheeze
C - HR 110, BP<90
D - T' 36.5, BM 5
E - urticaria,
A 
ANAPHYLAXIS
• secure airway
• high flow O2 +/- intubation
• remove cause
• IM 0.5mg adrenaline (0.5ml of 1:1000)
• IV chlorphenamine 10mg
• IV hydrocortisone 200mg
• 500ml NaCl over 15 mins
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3
Q 
ΔΔ + intial Tx?
A - alert, central crushing chest pain
B - RR 25, O2 sats 92
C - BP 130/80, HR 88, fourth heart sound
D - GCS 15, T 37.5
E - pale, clammy
A

ACS
• ECG + bloods (FBC, U+E, glucose, lipids, troponin)

"MONAT"
• morphine + metoclopramide 10mg IV
• O2 if <95
• nitrates (if high BP)
• aspirin 300mg
• ticagrelor 180mg
  • if STEMI, Sx <12hrs, and PCI available w/n 120mins - primary PCI
  • if STEMI, Sx <12hrs, but would be >120mins - fibrinolysis
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4
Q 
ΔΔ + initial Tx?
A - alert, distressed, sitting forward
B - RR 35, fine lung crackles, wheeze
C - cyanosed, HR 112, pale, sweaty, ↑JVP, triple/gallop rhythm
D - BM 6, T 36.8
E - pale, sweaty
A 
PULMONARY OEDEMA
(ΔΔ asthma, COPD, CAP)
• sit upright
• high flow O2
• diamorphine 2.5mg IV slowly
• furosemide 40mg IV slowly
• GTN spray 2 puffs SL
• if BP>100, isosorbide dinitrate IV
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5
Q 
ΔΔ + initial Tx?
A - distressed, sweaty, panicked
B - O2 sats 91, RR 23
C - ↓BP, ↑JVP, muffled heart sounds (Beck's triad), ↑JVP on inspiration (Kussmaul's sign), pulsus paradoxus (pulse fades on inspiration)
D - T 37
E - scar from previous mastectomy
A

CARDIOGENIC SHOCK - cardiac tamponade
(ΔΔ MI, arrhythmias, PE, tension pneumothorax, endocarditis, myocarditis, etc)
• O2
• diamorphine 2.5mg IV
• if well filled heart, dobutamine 2.5mcg/kg/min IV

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6
Q

ΔΔ + initial Tx?
A - chest pain and palpitations, syncope
B - diffuse crackles heard throughout lungs, RR 21, O2 88
C - ↓BP 86/64, HR 120, ECG shows QRS>3 small sq
D - T 36.8, dropping GCS
E - n/a

A 
BROAD COMPLEX TACHYCARDIA
• O2 if <90
• DC cardioversion
• check + correct K+, Mg++, Ca++
• amiodarone IV 300mg over >20mins
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7
Q

ΔΔ + initial Tx?
A - chest pain and palpitations
B - diffuse crackles heard, RR 28, O2 sats 89
C - HR 130, ischaemia on ECG and QRS<3 small sq
D - BM 6, T 37
E - n/a

A

NARROW COMPLEX TACHYCARDIA
• O2 if <90
• DC cardioversion
• then amiodarone 300mg IV over >10 mins

• if stable pt and irregular?

  • vagal manouvres
  • adenosine 6mg IV bolus, then 12
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8
Q 
ΔΔ + initial Tx?
A - fatigued and dizzy
B - SOB, RR 24, O2 92
C - HR 38, BP 95/72
D - T 36.4
E - cold peripheries, pallor
A 
BRADYCARDIA
• atropine 500mcg IV
• repeat as needed every 3-5mins
\+/-
• percutaneous pacing
• isoprenaline IV
• adrenaline 5mcg/min IV
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9
Q 
ΔΔ + initial Tx?
A - confused
B - RR 16, feeble resp effort, almost silent chest with slight wheeze, O2 sats 89
C - HR 115, CRT >3, BP 86/64
D - T 36.9, BM 5, GCS 10
E - exhausted, cyanosed
A

LIFE THREATENING ASTHMA

"O SHIT ME"
• O2
• salbutamol neb 5mg (repeat 15 mins)
• hydrocortisone 100mg IV/pred 40mg PO
• ipratropium 500mcg  nebulised
  • (theophylline IV)
  • (magnesium sulphate IV 1.2g >20mins)
  • escalate ^!

remember ABG, CXR, ECG

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10
Q

Sx of severe asthma attack?

A
  • unable to complete sentences in one breath
  • RR >25
  • HR > 110
  • PEFR 33-50 percent predicted/best
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11
Q

Sx of life-threatening asthma attack?

A 
• PEFR <33 percent predicted
• silent chest, cyanosis, feeble resp effort
• arrhythmia/hypotension
• exhaustion, confusion, coma
• ABG:
- normal/high CO2
- low pH
- O2 <8, or sats <92
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12
Q 
ΔΔ + initial Tx?
A - alert, unable to complete sentences
B - widespread wheeze, RR 28, PEFR 45 percent predicted, O2 sats 94
C - HR 134
D - T 37.4, BM 5
E - accessory muscle use
A

SEVERE ASTHMA

"O SHIT ME"
• O2
• salbutamol neb 5mg (repeat 15 mins)
• hydrocortisone 100mg IV/pred 40mg PO
• ipratropium 500mcg  nebulised
  • (theophylline IV)
  • (magnesium sulphate IV 1.2g >20mins)
  • escalate ^!

remember ABG, CXR, ECG

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13
Q

ΔΔ + initial Tx?
A - coughing, visibly SOB, accessory muscle use
B - RR 25, wheeze, hyperinflated chest, hyperresonant percussion, ↓expansion and cricosternal distance
C - ↑JVP, oedema, HR 98, BP 105/78
D - T 37.6
E - cyanosed

A

COPD EXACERBATION
(ΔΔ asthma, pulmonary oedema, PE, anaphylaxis, URT obstruction)
• O2 24-28, aim sats 88-92
• salbutamol 5mg neb
• ipratropium 500mcg neb
• hydrocortisone IV 200mg and prednisolone 30mg PO
+/-
• Abx - amoxicillin 500mg PO/clarithro/doxy
• aminophylline IV
• NIPPV

remember CXR, ABG, ECG, sputum culture, bloods +/- culture

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14
Q 
ΔΔ + initial Tx?
A - alert. distressed, SOB
B - tracheal deviation to L, ↓expansion, hyperresonant percussion, ↓breath sounds on R side, O2 94
C - HR 133, BP 85/45
D - T 37.1, BM 6
E - distended neck veins,
A 
TENSION PNEUMOTHORAX
• large bore (14-16G) needle with syringe
• partially filled with NaCl
• 2nd intercostal interspace
• midclavicular line
(or use a venflon)

then
• CXR and chest drain

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15
Q

when to NIPPV in COPD?

A

• RR >30
• pH <7.35
• CO2 rising
despite best medical Tx

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16
Q 
ΔΔ + initial Tx?
A - pleuritic chest pain, confused
B - RR 32, dull percussion note, ↑vocal resonance, bronchial breathing, pleural rub, O2 86
C - cyanosed, HR 110, BP 92/72
D - T 38.3
E - rigors
A 
PNEUMONIA
• O2 (<88)
• 500ml fluid bolus NaCl
• Abx + analgesia
• CURB-65 score

Ix = CXR, ABG, bloods, cultures/swabs, urine pneumo and legionella antigen

17
Q 
ΔΔ + initial Tx?
A - pleuritic chest pain
B - RR 30, O2 sats 92
C - BP 86/58, HR 125, gallop rhythm, ↑JVP, loud P2, R ventricular heave, pleural rub, 
D - BM 6, T 37.5
E - cyanosed, red swollen left calf
A

PE
• O2 15L
• 500ml fluid bolus NaCl
• LMWH/fondaparinux (eg 200units/kg dalteparin)
• morphine 10mg IV
+/-
• vasopressors (dobutamine 2.5mcg/kg/min IV or NA) if persistent BP<90
+/-
• thrombolysis if haemodynamically unstable (alteplase 10mg IV bolus)

Ix = Wells score, bloods, ECG, CXR, ABG, d-dimer, CTPA

18
Q 
ΔΔ + initial Tx?
A - haematemesis, fainting
B - RR 25, O2 sats 95
C - BP 86/58 (worse on standing), HR 125, ↓JVP, ↓urine output, CRT 3, 
D - ↓GCS. BM 6, T 36.5
E - cool and clammy, telangiectasia
A 
ACUTE UPPER GI BLEED
• protect airway + NBM
• two large bore (14-16G) cannulae
*• IV fluid bolus, repeat <2L
*• +/- O Rh-ve blood transfusion
• bloods, U+E, LFTs, clotting, crossmatch 4-6 units
• correct clotting (vit K, FFP, plts)
*• terlipressin IV 2mg
*• broad spectrum Abx

• notify ICU and surgeons (endoscopy post resusc)

19
Q

ΔΔ + initial Tx?
A - headache, getting sleepy
B - RR 19, O2 sats 95
C - CRT 4, ↓BP 90/76, HR 110
D - T 38.6, ↓GCS, photophobic on pupil test
E - cold hands, evolving petechial non-blanching rash

A 
MENINGITIS (septicaemic bc CRT, BP, cold hands, DIC)
• IV fluid NaCl 500ml bolus
• O2 if requirement +/- airway support
• blood cultures, lactate
• IV ceftriaxone 2g/12hr
• urine output (aim >30ml)
• +/- inotropes and vasopressors

• LP when stable

20
Q

ΔΔ + initial Tx?
A - Hx: headache, stiff neck, GCS dropping
B - RR 19, O2 sats 95
C - CRT<2, BP 101/86, HR 90
D - T 38, ↓GCS<12, photophobic, papilloedema, BM 5
E - seizures, focal neuro Sx, no rash

A

MENINGITIS (meningitic, not septic - neck stiffness, photophobia, no shock or DIC)
• sign of ↑ICP?
- papilloedema, seizures, focal Sx, GCS<12
- IV ceftriaxone 2g/12hr
- IV dexamethasone 10mg
- IVT, nurse at 30 degrees
- LP when stable

• sign of ↑ICP?

  • LP <1hr
  • THEN IV ceftriaxone
  • IV dexamethasone 10mg
21
Q 
ΔΔ + initial Tx?
A - confused, acting bizarrely, now GCS dropping
B - RR 22, O2 sats 96
C - HR 95, CRT<2, BP 94/73
D - T 38.5, GCS 12, BM 5
E - seizures
A

ENCEPHALITIS
• start aciclovir 10mg/8hr IV, within 30mins
• supportive Tx - O2, IVT, etc, if required
• phenytoin for seizures

Ix:
• bloods - culture, viral PCR, throat swabs, MSU, toxoplasma IgM, malaria film, contrast CT THEN LP

22
Q 
ΔΔ + initial Tx?
A - seizures
B - O2<90, RR 26
C - CRT<2, HR 115, BP 104/76
D - BM 6
E - seizing for >30mins
A 
STATUS EPILEPTICUS
• open + secure airway +/- suction
• high flow O2
• IV lorazepam 4mg slow bolus (repeat 10-20 mins)
• OR buccal midazolam 10mg
• IV phenytoin 15mg/kg if seizures continue
\+/-
• IV thiamine 250mg (alcoholism)
• IV glucose (if low)
• IV fluids (if hypotensive)

Ix:
• pregnant? - BP, urine dip (PET)
• glucose, ABG, U+E, Ca++, FBC, ECG
+/- tox screen, LP, blood + urine cultures, EEC, CT, CO level

23
Q 
ΔΔ + initial Tx?
A - alert, with headache and V
B - RR 18, O2 sats 96
C - HR 88, BP 85/64
D - drowsy, irritable, pupil constriction then dilation +/-papilloedema
E - n/a
A 
RAISED ICP
• IV fluid if hypotensive
• if intubated, hyperventilate
• IV mannitol 0.25g/kg over 20mins
• if tumour - dexamethasone 10mg IV
\+/- sedation, AEDs, hypothermia
24
Q 
ΔΔ + initial Tx?
A - drowsy
B - deep breathing, RR 24, O2 sats 91
C - BP 92/65, HR 108, CRT 3
D - BM 33, T 37.8, GCS dropping
E - pear drop breath, recent V, abdo pain, reduced skin turgor
A

DKA
• IV fluid 500ml bolus (BP<90)
• 1 litre IV fluid over 1 hour
• tests - ketones, glucose, VBG (pH), U+E (K+), ECG
• 50 units insulin in 50ml NaCl 0.1 unit/kg/hr
• +/- K+ replacement
• 10 glucose when BM<14

25
Q 
ΔΔ + initial Tx?
A - alert, aggressive
B - RR 18, O2 sats 98
C - HR 128, BP 105/76, CRT<2
D - BM 2.6, T 36.9
E - sweaty
A

HYPO
• alert? 10-20g glucose (gel, orange juice)
• unconscious? 200ml glucose IV 10 percent, 15 mins
- or, IM glucagon 1mg

26
Q 
ΔΔ + initial Tx?
A - confusion
B - RR 14, O2 91
C - HR 34, BP 85/64
D - BM 3, T 35.5, GCS dropping
E - hyporeflexive, goitre, cyanosed,
A 
MYXOEDEMA COMA
• O2
• glucose 20 percent
• T3 IV
• 100mg hydrocortisone IV
• IV Abx if infection preceded
• blankets, etc
27
Q 
ΔΔ + initial Tx?
A - agitated, confused, D+V
B -  RR 18, O2 sats 96
C - HR 140 irregular
D - T 37.8, BM 7  
E - goitre
A 
THYROTOXIC STORM
• IV fluids if dehydrated
• chlorpromazine 50mg PO (sedation)
• propanolol 60mg PO
• carbimazole 15mg PO + hydrocortisone 100mg IV
• IV Abx if needed
28
Q

ΔΔ + initial Tx?
A - confused
B - RR 22, O2 94, crackles heard
C - HR 110, BP 82/65 on standing esp., CRT 3
D - T 38, BM 3
E - peripherally vasoconstricted, wearing medical alert bracelet

A 
ADDISONIAN CRISIS (probs 2' to CAP)
• IV hydrocortisone 100mg stat
• IV fluid bolus 500ml
• glucose IV if hypoglycaemic
Ix
• U+E (↑K+, ↓Na+) (Tx if needed)
• culture
• Tx infection

Moslers (3 decks)

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