Acute station Flashcards
Define acute AF? How would you approach the management?
AF that started <48 hours ago
1) are they haemodynamically stable? If no –> emergency cardioversion (2nd line = amiodarone)
If yes –>
1) Rate control = b-blocker or diltiazem
2) Rhythm control (ONLY if <48h) = DC cardioversion or amiodarone
3) Start LMWH
Define paroxysmal AF?
How would you manage it?
DEF: self limiting + lasts <7 days
Mx: Anticoagulate + pill-in-pocket + ?rate/rhythm control
Mx of Ventricular tachycardia
Pulseless? –> CPR
Adverse signs (unstable, chest pain, HF) –> sedate + synchronised cardioversion!
No adverse signs –> correct electrolyte abnormalities + Amiodarone
ECG changes in hypokalemia
Prominent U waves
PR prolongation
T wave inversion
TIA - best brain imaging?
Diffusion weighted MRI
TIA - management? 5 aspects
- Antiplatelet: aspirin + clopidogrel
- If cardiac emboli –> Warfarin!
- RF control (anti-HTN, statin, glucose, smoking)
- Assess risk for next stroke = ABCD2 score
- F/U in clinic
What scoring system is used to determine risk of stroke in TIA patients?
ABCD2 Age >60 BP >140/90 Clinical Fx: unilateral weakness (2), speech disturbance w/o weakness (1) Duration Diabetes
Fluid resuscitation formula in burns?
Which fluid?
Parkland formula
4 x wt x % surface area
Give half in first 8 hours
HARTMANN’S, warmed
How to determine % BSA involvement in burns?
1 arm: 9% Head and neck : 9% Front torso: 18% Back torso: 18% 1 leg: 18% Perineum: 1% 1 hand: 1%
Tx of burns (exc fluid resus)
- Analgesia
- Dressing; silver sulfadiazine + sterile film
- Cadaveric skin
- Split thickness skin grafts
- Tangential excision
- Escharotomy (to prevent compartment syndrome)
DKA management summary
FLUIDS: SBP<90 = NS 1L stat
SBP>90 = NS 1L over 1hr
–> add K+ to 2nd bag if <5.5 (40mM/L)
INSULIN: 0.1u/kg/hr Actrapid
–> Aim ketones reduction >0.5mM/hr
LMWH!!!
Definition of DKA
pH<7.3
glucose>11.1
ketones>3.0 (or 2+ on dip)
Definition and Mx of HONK
Hyperglycemia (>35) w/o ketones
Fluids
Potassium in 2nd bag of fluids
LMWH
?consider insulin
In upper GI bleed, how is a pt managed AFTER endoscopy
NBM + stop NSAIDs
IV omeprazole
Daily bloods
H. pylori testing + eradication
ABCDE approach: How would you assess the airway?
If speaking –> patency assumed
Look –> for airway secretions, angioedema
Listen –> gurgling BS or stridor
Feel –> for expired air
- Any evidence that airway is not patent –> HEAD TILT + CHIN LIFT (Jaw thrust if C-spine injury)
- Consider airway adjuncts eg Guedel or nasopharyngeal airway
- If still not achieved –> check pulse + periarrest call!!!
ABCDE approach: How would you assess breathing?
OBS –> Sats, RR, administer 15L 02 non-rebreather mask
Inspection –> accessory muscle breathing, nasal flaring
Palpate –> Tracheal deviation, equal chest expansion
Percussion –> dullness?
Auscultate –> equal air entry, wheeze, crackles
ABG + CXR
ABCDE approach: assessment of circulation?
Obs: CRT, pulse - rate and rhythm, BP in both arms
Ask nurse to help w 12 lead ECG
- 2 large bore IV cannulae
- Bloods: FBC, U+Es, glucose, CRP, Xmatch, G+S, clotting, blood cultures, troponin
- if hypotensive: 500mL 0.9% saline bolus, then reassess BP. Call for help if still hypotensive
ABCDE approach: assessment of disability?
- Pupils: equal + reactive to light?
- GCS: if <8 (or AVPU = P), call for an anaesthetist
- GLUCOSE
- Gross neuro assessment: plantar reflexes, sensation, power, grip
- Drug chart + possessions for evidence of OD
Causes of shock
CHOD
CARDIOGENIC: MI, arrhythmia
HYPOVOLEMIC:
- Haemorrhage
- Endocrine: DKA, addisonian crisis
- Excess loss: burns, diarrhoea
- 3rd spacing: pancreatitis
OBSTRUCTIVE:
- PE
- Tension pneumothorax
DISTRIBUTIVE:
- Sepsis
- Anaphylaxis
Causes of hypovolemic shock:
- Haemorrhage
- Endocrine: DKA
- 3rd spacing: Pancreatitis
- Excess loss: burns, diarrhoea
How to differentiate between cardiogenic vs hypovolemic shock?
Cardiogenic = high JVP Hypovolemic = low JVP
How to differentiate between septic shock vs hypovolemic shock
septic = warm peripheries
Pathophysiology of anaphylaxis
Type 1 IgE mediated hypersensitivity reaction
Mast cell degranulation –> histamine release
–> inc vascular permeability + bronchoconstriction
Dose of adrenaline in anaphylaxis?
IM adrenaline 500micrograms
How often can you repeat IM adrenaline in anaphylaxis?
every 5 mins
Define a pneumothorax
Accumulation of air in the pleural space
Classification of a pneumothorax
Open: defect in chest wall: communication btw PTX + exterior
Closed: chest wall is intact. air from lung –> pleural cavity
Tension: one way valve –> mediastinal compression
Causes of pneumothorax
SPONTANEOUS: primary (no underlying lung disease) or secondary (Marfan’s, COPD, pulmonary fibrosis)
TRAUMA: penetrating or blunt trauma w rib #s
IATROGENIC: Central line insertion, CPAP, transbronchial biopsy
How on earth can PTX lead to surgical emphysema
Broken rib –> damaged pleura –> air from lung enters pleural space –> air in pleural space enter subcut tissue
Ix for suspected pneumothorax
Basic obs
ABG
CXR
USS (more sensitive than supine CXR!)
Mx of tension pneumothorax
No CXR!
10L oxygen through non-rebreather mask
Large bore cannula in 2nd ICS, MCL (just above the rib!)
Mx of pneumothorax in pt with no underlying lung disease (or<50yo)?
If the patient SOB or PTX>2cm —> needle aspiration
- if aspiration fails -> chest drain
If pt is not SOB + <2cm –>10L oxygen + observation
Mx of secondary pneumothorax
If pt is SOB or >2cm: CHEST DRAIN
If pt is asymptomatic:
<1cm: admit for 24hrs + 10L oxygen
1-2 cm: needle aspiration (+ chest drain if this fails)
Causes of surgical emphysema
Rib fracture
Iatrogenic: CPAP, any chest surgery, thoracotomy
Infection
safe triangle for intercostal drain
- Lat border of pec major
- Ant border of lat doors
- 5th ICS (level of nipple)
Asthma attack: Mx?
Basic obs
Breathing: ABG + O2 via non-rebreathe mask
- 5mg salbutamol nebs
(order CXR)
Circulation: FBC, U+Es, CRP, blood cultures.
+/- fluid resus
- Oral pred 50mg/IV hydrocort 100mg
Nebs in acute asthma - how frequently?
Salbutamol: 15 mins
Iptropium: 4-6 hourly
Monitoring in acute asthma
- Sats>92%
- PEFR every 15-30 mins
- ABG if the initial PCO2 is normal or high
Acute COPD exacerbation: you have already given SABA and SAMA nebs + steroids. What can you do next if they’re not responding?
Repeat nebs
?IV aminophylline
?BIPAP
ECG changes in hyperkalemia
Tented T waves
Small p waves
widened QRS
Causes of hyperkalemia
- AKI
- Drugs: ACEIs, spironolactone, ARBs, Heparin!!
- Rhabdomyolysis
- Addison’s
- Metabolic acidosis
(Haemolysed sample)
stages of AKI
stage 1: Creatinine 0.5-1x normal (oliguria for 6 hours)
stage 2: creatinine 1-2x normal (oliguria for 12 hours)
stage 3: creatinine >2x normal (olig for 24 hours/anuria)
Investigations for pneumonia
Sputum MC+S, cytology
Urine: cold agglutinins
FBC (wcc), U+Es (Na, urea), CRP (trend), LFTs (mycoplasma, legionella),
Blood cultures
ABG
CXR, ECG
Management of pneumonia
O2, fluids, analgesia, antibiotics
F/u:
CXR @ 6 weeks
if >65 –> pneumovax
Smoking cessation
Complications of pneumonia
- Septic shock
- Parapneumonic effusion –> empyema
- Respiratory failure
- Abscess
Def of Hospital acquired pneumonia
> 48 hrs after hospital admission
Commonest causative organisms of hospital acq pneumonia
Pseudomonas
MRSA
Anatomical classification of pneumonia? which one is more common?
Bronchopneumonia (patchy, in diff lobes) vs lobar pneumonia
Bronchopneumonia = atypical
Commonest causative organisms of community acq pneumonia
Strep pneumonia
Mycoplasma
Viral
Mx of hospital acquired pneumonia
Co-amoxiclav or taz+vanc
Commonest causative organisms of atypical pneumonia
Mycoplasma, Legionella, Chlamydia
CURB 65
Confusion
Urea>7
RR>30
BP<90
> 65yo
Define SIRS
Inflammatory response with >=2 of:
HR: >90
Temp: >38 or <36
RR: >20 or PaCO2<3.6
WCC: >12 or <4
Shockable rhythms vs non-shockable rhythms
non-shockable: PEA, asystole
shockable: VF, pulseless VT
Mx of asystole
cannot shock!
CPR 2 mins + IV adrenaline 1mg
- repeat adrenaline at every other cycle
management of pulseless VT
CPR
1 shock
CPR 2 mins
IV adrenaline 1mg + amiodarone 300mg after 3rd shock
Repeat adrenaline at every 3rd cycle
Crucial Ix in patient with an unprovoked DVT
CT abdo pelvis
- look for malignancy!!!
Features of benzodiazepine OD? Mx?
Respiratory depression
Reduced GCS
Mx = flumazenil
beta blocker OD - fx? mx?
Fx: bradycardia + hypotension
Mx: fAtropine
Carbon monoxide poisoning - fx?
Fx: dizziness, nausea, headache
PaO2 is low but sats are high
Metabolic acidosis
Digoxin OD - 3 fx? mx?
Arrhythmia
Yellow green halos
Reduced GCS
Mx: anti-digoxin antibodies
Mx of Heparin OD?
Protamine
Lithium OD - fx?mx?
Fx: coarse tremor, confusion, N+V, POLYURIA
Mx: Saline
Mx of organophosphate poisoning?
Atropine
Fx of amitriptyline (TCA) overdose?
Anticholinergic: hyperthermia, palpitations
Metabolic acidosis
PROLONGED QT - CARDIAC MONTOR
Mx of amitriptyline overdose
IV sodium BICARBONATE (they have met acidosis)
Mx of warfarin overdose
IV vitamin K
Prothrombin complex
AKI - Initial Mx
ABC - O2 + large bore cannula + CATHETER + fluid monitoring
Routine bloods, ABG, Urine dip, ECG/cardiac monitor!!!
CXR, US kidneys
CHECK DRUG CHART (NSAIDs, ACEis, vanc, gent, contrast)
- correct instability w fluid bolus
Life threatening complications of AKI
Hyperkalemia
Pulmonary oedema
Acidosis
Clearing the C-spine - what is it? how?
ensuring pt doesn’t have a C-spine fracture
1) ensure pt is in stiff neck collar
2) CLnical assessment:
- Neuro deficit
- Spinal tenderness
- Altered GCS
- Intoxication
- Distracting injury (eg long bone #)
3) if any of th above: do X ray
4) if X-ray is abnormal, do CT
