Acute station Flashcards
Define acute AF? How would you approach the management?
Acute AF is 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 if chronic
4) Treat underlying cause
Define paroxysmal AF? How would you manage it?
DEF: self limiting + lasts <7 days
Mx:
Acute: Medical
Anticoagulate + rate/rhythm control
Rate control: diltaziam or a beta blocker (Eg Bisoprolol)
Rhythm control: amiodarone
Treat underlying cause
Mx of Ventricular tachycardia
If haemodynamiacally unstable, ie pulseless? –> CPR Adverse signs (Chest pain, HF) –> sedate + synchronised cardioversion!
If haemodynamically stable (ie no signs, pulse present)
-Beta blockers (Bisoprolol)
- Amiodarone, IV (Antiarrythmic)
- Correct electrolyte abnormalities
- TTE (Transthoracic echocardiogram)
- Optimal heart failuire therapy, if indicated
Ix:
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!
- Risk factor control (anti-HTN, statin, glucose, smoking)
- Assess risk for next stroke = ABCD2 score
- Follow Up in clinic
What scoring system is used to determine risk of stroke in TIA patients?
ABCD2 Age >60 BP >140/90 Clinical Findx: 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)
///////////////////////////////////
“Burns, a dress could split, tits exposed”
DKA management summary
(Assuming its confirmed with pH, blood glucose and ketones)
INSULIN: 0.1 U/kg/hr Actrapid infusion with 0.9% Saline
-Aim ketones reduction >0.5mM/hr
FLUIDS:
If SystolicBloodPressure < 90 = 0.9% Saline 1L stat (Over 15 minutes)
If SBP > 90 = 0.9% Saline 1L over 1hr –> add K+ (potassium) if <5.5 (20mM/L)
Consider 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?
Depends on cause:
- Peptic ulcer
- IV bolus omeprazole 80mg
- then 8mg/hr for. 48 hours
- Endoscopic therapy
- Consider surgery
- Bleeding varices
- Vasoconstrictors (Octreotide/ terlipressin)
- Endoscopic therapy
/////////////OG answer
NBM + stop NSAIDs IV omeprazole Daily bloods H. pylori testing + eradication
ABCDE approach: How would you assess the airway?
Ensuring a patent airway
If speaking –> patency assumed.
Look –> for airway secretions, angioedema
Listen –> gurgling Breathe Sounds 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?
Ensuring target saturations are met
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?
- Ensure patient is haemodynamically stable
- Ie BP normal, pulse present, well perfused.
- -(This is good phrasing because you’re not supposed to move on from C until it’s stabilised)*
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
“Could Someone Hurry On down?”
CARDIOGENIC:
- MI
- Arrhythmia
SEPTIC:
HYPOVOLAEMIC:
- Haemorrhage
- Endocrine: DKA, addisonian crisis
- Excess loss: burns, diarrhoea
- 3rd spacing: pancreatitis
OBSTRUCTIVE:
- PE
- Tension pneumothorax
DISTRIBUTIVE (ie 3rd spacing):
- Sepsis
- Anaphylaxis
- Pancreatitis
- Burns
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
//////////////////////////
Cardiogenic: JVP: high, peripheries: cold
Sepitc: JVP: low, peripheries: warm
Hypovolaemic: JVP: low, peripheries: cold
How to differentiate between septic shock vs hypovolemic shock
Septic: warm peripheries
Hypovolaemic shock: cold peripheries
///////////////////////
Cardiogenic: JVP: high, peripheries: cold
Sepitc: JVP: low, peripheries: warm
Hypovolaemic: JVP: low, peripheries: cold
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 2. Parapneumonic effusion –> empyema 3. Respiratory failure 4. 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: Atropine
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
Mx of Anaphylaxis?
- Ensure Airway is clear
- High Flow Oxygen
- Request anaesthetic input if intubation needed.
- Establish Venous access
- IM Adrenaline, 500 mcg
- Repeat every 5 minutes if no improvement
- IV Chlorphenamine, 10mg
- IV Hydrocortisone, 200mg
- IV Haartman’s solution, 1000ml
- Escalate:
- Senior medical reg on call
- If no improvement: referral to critical care outreach team
/////////////
“Oysters Attack Chloe’s Heart”
“AOV ACHE”
Mx of upper GI bleed?
- “I would start by stabilising the patient and treating life-threatening pathologies using an A to E approach”
- Call switchboard 2222 and state “Major Haemorrhage”, name of hospital and location
- Admit to HDU
- Brief history for co-morbidities
A: -
B: -
C:
-Establish IV access with 2 large bore cannula (14-16g)
-Monitor pulse and blood pressure half hourly
- Ix: FBC, Us&Es, LFTs, Coagulation. Group and save and cross match 2 units.
- If shocked: CVP line
- Consider blood transfusion
- When stable: urgent Endoscopy
- Escalate to senior Medical registrar on call
- Most important differentials:
- Peptic ulcer disease: PPI + endoscopic therapy
- Varices: vasocontrictors + endoscopic therapy
//////////////////////////////////////////////////////////////
“HDU, Venous access, Monitor BP, Ix, Central line, Transfusion, Endoscopy, Escalate”
“HV MIC TEE”
Call switchboard 2222 and state “Major Haemorrhage”, name of hospital and location. Also call 5555 for Porter. Blood Bank will automatically thaw 4 units of FFP. Further units issued once clotting screen received in lab and discussion with medical staff.
Chest pain: Whats important to rule out?
Pulmonary embolism (PE) (D-dimer, CXR)
Acute Coronary Syndrome (ACS) (Troponin T, ECG)
Pneumothorax (CXR, Resp Ex)
Aortic dissection (/How to rule out?)
///////////////////
“PAPA”
