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YEAR 6 EXAMS > Acute Station Management > Flashcards

Acute Station Management Flashcards

1
Q

ACS - STEMI

A
  1. ABCDE approach
    > A
    > B: oxygen if sats < 94%
    > C: BP, repeat ECG, ABG
    > D: glucose
    > E
  2. Management
    > GTN
    > Stat Aspirin 300 mg
    > Morphine - 5mg (up to 10) + metoclopramide 10 mg
    > Tacregralor 180 mg > immediate PCI (UfH in lab)
    > alteplase if no PCI
  3. Aspirin lifelong 75 mg, clopidogrel 12 months
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2
Q

ACS - NSTEMI/ unstable angina

A
  1. Intermediate to high risk > Terofiban (glycoprotein IIb/IIIa inh) > PCI within 96 hours
  2. Low risk > outpt angioperfusion test and echo 3. Clopidogrel 12/12
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3
Q

Pulmonary Oedema

A

> sit up, 15 L Oxygen non rebreather
> Morphine (5-10 + metoclopramide 10 mg)
> GTN 2 puffs
> IV frusemide 40-80 mg
> CPAP
> Haemodialysis

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4
Q

Broad Complex tachycardia

A
  1. Check pulse - if no pulse begin CPR
  2. Stable - no signs of HF, syncope, shock
    > Check U&Es - Mg and K
    > Amiodarone 300 mg
    > DC cardioversion
  3. Unstable
    > DC cardioversion
    > Amiodarone 300 mg
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5
Q

Narrow Complex tachy (not AF)

A
  1. Intial approach
    > ABCDE + obs
    > Valsalva manouvers
    > Carotid sinus massage
    > Adenosine 6 mg, 12 mg, 12mg (verapamil if asthmatic)
    > DC cardioversion if advers signs (shock, HF, syncope, HR > 200)
  2. Next give:
    > amiodarone 300 mg
    > Digoxin
    > verapamil
    > atenolol
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6
Q

AF

A
  1. <48 hours
    > not worried about cardiac thrombus
    > unstable - DC cardioversion
    > stable - Fleclainide, amiodaron, DC cardioversion
  2. Persistent
    > anticoagulate for 3/52 w/ warfarin/doac
    > Rhythm control: amiodarone/sotalol
    > Rate control:
    - bisoprolol
    - verapamil, diltiazem
    - digoxin
    - amiodarone
    - ablation
  3. Paroxysmal: flecainide
  4. CHADVASc and HASBLED
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7
Q

Bradycardia

A

> HR < 40
> atropine 500 mcg
> more atropine up to 3 mg
> Transcutaneous pacing
> Isoprenaline 5 mcg
> adrenaline 2-10
> Alternative: aminophylline, dopamine, glucagon

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8
Q

Infective Endocarditis

A
  1. ABx
    > 2 if own valve: Fluclox and Gent
    > 3 if prosthetic: Vancomycin, Gent, Rifampicin
  2. Sepsis 6
    > 3 IN: O2, Fluid, ABx
    > 3 OUT: Urine, blood culture (at least three - if septic 2 cultures within 1 hour from 2 seperate sites), lactate
  3. ABx for 4 weeks
  4. Dukes Criteria
    > Major
    - ECHO evidence
    -positive cultures
    > Minor
    - Risk factors
    - Shit cultures
    - Fever
    - Immune phenomena
    - Embolic phenoma
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9
Q

Meningitis

A

> Septicaemic
- IV Cefotaxime
> Meningitic - LP first within 1 hour
- Ceftriaxone
- 10 mg Dex IV
- old (<3/12)/young(>50): amoxicillin

>if in pre-hospital: IM benzylpenicillin

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10
Q

Encephalitis

A

> Septicaemic
- IV Ceftriaxone 2 g BD
> Meningitic - LP first within 1 hour
- Ceftriaxone
- 10 mg Dex IV
- IV acyclovir 10mg/kg TDS

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11
Q

Status epilepticus

A

> Seizing continuous or repeatedly for 30 mins
> Step approach
- 10 mg IV Diazepam (OR Lorazepam 0.1 mg/kg)
- repear after 10 mins
- 10 mg/kg IV phenobarbitol (100 mg/min) OR Phenytoin 18 mg/kg (50 mg/min)
- ESCALATE
- RSI (with thiopentone)

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12
Q

Raised ICP

A
  1. Initial approach:
    > Sit up
    > Neuroprotective hyperventilation (High 02 low CO2)
    > IV mannitol/ Hypertonic Saline
    > Scan head
  2. Treat Cause
    > Burr hole/ craniotomy
    > CT, LP 12 hours later xanthoxromia
    > Nimodipine - prevents vasospasm
    > Platinum coiling
  3. Coning, tonsillar, brain stem death
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13
Q

DKA

A
  1. Acidosis < 7.3, ketones > 3 mM, glucose > 11.1 mM
  2. 0.9% NS
    > BP < 90 - 1 L stat
    > BP > 90 - 1L over 1 hour
    > 1L/2 hr (x2). 1L/4 hr (x2), 1L/6 hr
    >Start potassium in 2nd bag
    - >5.5 mM - nil
    - 3.5-5.5 mM - 40 mM/L
    - <3.5 mM - senior review
    > fixed rate insulin - Actrapid 0.1u/kg/hr
    > Continue giving their basal insulin regimen of their long-acting to prevent rebound hyperglycaemia
    >Swap to dextrose once BM < 15 (insulin MUST be continued to turn off ketogenesis)
  3. Resolution
    > pH > 7.3
    >ketones < 0.3
    > If they can eat and drink then you can start basal bolus regimen
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14
Q

HHS

A
  1. Hyperosmolarm Hyperglycaemic state
  2. Give
    > NS - may need up to 9L
    > may need insulin in one hour
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15
Q

Hypoglycaemia

A
  1. Alert and Oriented
    > Oral Carbs
  2. Drowsy/Confused + NR swallon
    > Hypostop/ Glycogel
    > Consider IV access
  3. Unconsious
    > 100 m 20% glucose
  4. Insulin induced/ no access
    > 1 mg glucagon
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16
Q

Addisonian Crisis

A

> LOW Bp, confused, drowsy, LOW Na, HIGH K
> Hydrocortisone 100 mg IV QDS
> 0.9% NS
> septic screen

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17
Q

Thyrotoxic storm

A
  1. precipitants
    > recent thyroid surgery
    > infection
    > MI
    > trauma
  2. Management
    > Fluid resus and NGT
    > b-blocker
    > Carbimazole
    > lugol’s iodine
    > hydrocortisone
    > treat cause
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18
Q

Phaeo

A
  1. Presentation
    > HTN crisis
    > sense of impeding doom
    > N&V
    > headache
  2. Treatment
    > phentolamine (a-blocker) (to avoid unopposed a-agonism and sever vasoconstriction)
    > Labetalol (b-blocker)
    > 4-6/52 after a-blocker: surgery
  3. 10% rule
    > bilateral
    > malignant
    > part of MEN
    > extra-adrenal
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19
Q

IECOPD/ T2RF and NIV - Management

A

> Oxygen titrated to 88-92% (Venturi mask 24 %)
> Neb salbutamol 5 mg/ Ipratropium Bromide 0.5 mg
> IV hydrocortisone 200 mg/ oral pred 30 mg
> IV theophylline
> BiPAP if pH < 7.37
> invasive vent if pH < 7.26

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20
Q

IECOPD/ T2RF and NIV - Follow up

A

> oral pred 30 mg 5 days post
> 1/52 review with GP, 1/12 review in clinic
> prescribe amoxicillin 500 mg tds for 5 days
OR if true allergy, doxycycline 200 mg on first day then 100 mg OD (total of 5 days)
OR if both ci’d, prescribe clarithromycin 500 mg BD for 5 days

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21
Q

Asthma - Acute presentation

A

> O2
> salbutamol neb 5 mg
> IV hydrocortisone 100 mg OR oral pred 30 mg
> ipratropium bromide neb 5 mg
> IV theophylline
> Mg Sulphate 2g IV/20 mins
> ESCALATE
> IV salbutamol

22
Q

Asthma - Long term Management

A

> ICS + SABA (serotide)
> add LABA
> increase ICS (± LABA)
> Trial LRA (leukotriene receptor antagonist)
OR LAMA
OR SR Theophylline
> High dose ICS + 4th drug (e.g. above or b-agonist tablet)
> Oral steroids
> REFER

23
Q

Pneumonia

A

> CAP: Amoxicillin / Clarithromycin (add Fluclox if suspect Staph infection, e.g. influenza)
> HAP:
- ≤ 5 days admission: Co-amoxiclav OR Cefuroxime
- > 5 days of admission: piperacillin with tazobactam
> Atypicals: Clarithromycin (/Rifampicin)
> PCP: Co-trimoxazole

24
Q

PE

A
  1. ABCDE approach
    > ECG, ABG (or else automatic fail)
    > Wells Score
    - If low: d-dimer (if d-dimer high - CTPA)
    - If high: CTPA 2. Treatment
    > Thrombolysis if unstable/saddle embolus
    - if unstable: give UfH and do CTPA THEN thrombolyse
    - don’t give LMWH if trombolyse
    - alteplase
    > LMWH
    - enoxaparin
    - tinzaparin
    > Warfarin from 24 hours but keep LMWH for 5 days until INR in range
    - provoked: 3 months
    - unprovoked: 6 months
    - ongoing: ongoing
25
Q

PTX

A
  1. Tension
    > ABCDE
    > large bore cannula 2nd ICS mid clavicular line (upper border of lower rib)
    > chest drain (safety triangle - (L) dorsi, Pec major, axilla, 5th ICS)
  2. open injury
    >3-sided wet dressing
    > lets air out but not it
  3. Spontaneous
    > Primary:
    - <2cm: consider discharge with outpt CXR
    - >2cm: Aspirate (if fails chest drain)
    > Secondary: admit for 24 hours
    - if pt >50 nd rim of air >2cm ∨ SOB - chest drain
    - if rim 1-2 cm: attempt aspiration (if fails drain)
    - if rim <1cm: oxygen
26
Q

Acute Upper GI bleed: General

A

> Resus
> Major Haemorrhage protocol
- Porter gets 0neg blood
- crash team
- surgical team
> Protect airway 100% 02
> Up to 4 litres of fluid before blood
> Glasgow-Blatchford Bleeding Score (if 0 send home - otherwise OGD)
> Rockall score
- Pre-endoscopy score > 3: surgery
- Post-endoscopy score > 6: surgery

27
Q

Acute Upper GI bleed: Varices

A

> occur at L gastric and inferior oesophageal veins anastomose
> ABC
> correct clotting: FFP, Vit K
> IV terlipressin
> Sengstaken–Blakemore tube (SB tube)
> OGD: 2 of:
- Band ligation (superior)
- Sclerotherapy
- Adrenaline
> Open surgery (track vein back and sclerotherapy) if:
- rebleed
- bleeding despite transfusion of 6 units
- rockall > 6
- failed endoscopy
> TIPS (trans-jugular intrahepatic portosystemic shunt) - if pt rebleeds

28
Q

Acute Upper GI bleed: PUD

A

> OGD:
- clips and adrenaline
- thrombin and adranaline
- thermal coag and adrenaline
> Post endoscopy PPI + H.pylori eradication
- lansoprazole 30 mg
- clarithromycin
- metronidazole or amoxicillin

29
Q

Acute Upper GI bleed; other causes

A

> Oesophagus
- mallory-weiss
- oesophageal cancer
- boerhaave syndrome (full thickness tear post heavy vomiting)
- oesophagitis
> Stomach
- cancer
- peptic ulcer
- gastritis
- AVM

30
Q

Decompensated Liver disease - Sx/Signs

A

> Jaundice
> Asterixis
> Hypoalbuminaemia
> Bleeding
> Hypoglycaemia
> Ascites + SBP

31
Q

Decompensated Liver Disease - Investigations

A

> FBC - elevated WCC
> PT/INR
> Diagnostic parecentesis
- MC+S - SAAG (serum ascites albumin gradient)
*>1.1: portal HTN
*<1.1: cancer, pancreatitis, infection
- absolute neutrophil count > 250 cells/mm3
> blood cultures
> CT/USS, CXR, AXR

32
Q

Decompensated Liver Disease - Management

A

> analgesia
> antiemetics
> ABx
- tazocin/ cefotaxime
- cipro long term
> therapeutic paracentesis
> IV albumin

33
Q

Decompensated Liver Disease associated:

A

> Hepatorenal syndrome
- IV albumin 20%
- Terlipressin
- TIPS
- Liver transplant
> Encephalopathy
- Lactulose
- Phosphate enemas
- Rifaximine (removes nitrogen-forming bowel bacteria)
- Avoid sedatives

34
Q

Chronic Liver Disease

A

> Palmer erythema
> Dupuytren’s
> spider naevi (SVC area)
> Caput medusae
> hepatomegaly

35
Q

IBD - Cronh’s and UC: Acute flare

A
  1. Supportive
    > NBM - Parenteral nutrition
    > Dietician input (elemental diet in Cronh’s)
  2. Medical acute flare up
    > IV hydrocortisone
  3. induction of remission:
    > UC
    - 5 ASA - sulfasalazine enema/ oral
    - pred enema/ oral
    > Cronh’s
    - pred 1st line
    - 5 ASA
36
Q

IBD - Cronh’s and UC: Maintenance

A

> UC
- sulfasalazine
- azathioprine
- infliximab
- subtotal/panproctocolectomy
> Cronh’s
- Azathioprine (1st line)
- Methotrexate
- infliximab

  1. Surgical
    > if toxic megacolon/ perf/ haemorrhage/ not responding to medication
    > Subtotal/total colectomy: end ileostomy/ ileorectal anastomoses
    > panproctocolectomy: ileoanal pouch
    > Hartmann’s (cronh’s)
37
Q

Alcohol detoxication (e.g. delirium tremens)

A

> Pabrinex
- b12
- vit C
- thiamine
> Chlordiazepoxide: tappering regimen
> Acamprosate/baclofen: decrease cravings
> Disulfiram: aversion therapy

38
Q

Gastroenteritis

A

Supportive

39
Q

AKI and Dialysis - Management

A
  1. RIFLE Criteria
    > Urine output < 0.5 ml/kg/hr over 12 hours
    > Serum creatinine x 2-3 baseline
    > GFR decreased
    > 50%
  2. Treat complications
    > Acidosis and Uraemia: dialyse
    > Hyperkalaemia (other card)
    > treat pulm oedema
  3. Investigations
    > helical CT KUB - stones
    > USS
40
Q

AKI and Dialysis - Causes

A

> pre-renal
- dehydration
- shock
- drugs (NSAIDs - afferent/ ACEi - efferent)
> renal
- Glomerular nephritis
- Tubular interstitial nephritis
- pyelonephritis
- ATN (e.g. rhadbo)
> post-renal
- retention
- stone, prostate, bladder Ca
- blocked catheter
- neurogenic (cauda equina)

41
Q

Hyperkalaemia

A

> ECG:
- Tented T waves
- Prolonged PR
- Broad QRS (± VT)
> 10 ml 10% Calcium gluconate
> 10 U actrapid and 100 ml 20% glucose
> neb salbutamol 5 mg
> calcium resonium

42
Q

Hypokalaemia

A

> Treatment K level:
- >3: Sando-K oral (x2)
- <3: 20-40 mmol/L over 3-4 hours (central line)
> Features
- U waves
- small/absent t waves (occasionally inversion)
- prolong PR interval
- ST depression
- long QT

43
Q

Hypernatraemia

A

> 0.9% NS or Dextrose
> Decrease by < 12 mmol/day
> hydrate
> treat cause
- dehydration
- GI/ renal losses
- DI
- RAAS (Conn’s, Cushing’s)

44
Q

Hyponatraemia

A
  1. Hypovolaemia:
    > Tx: 0.9% NS
    - N&V
    - Diuretics
    - Salt-losing enteropathy
  2. Euvolaemic:
    > Tx: fluid restrict, tolvaptan in SIADH
    - SIADH
    - Hyperthyroid
    - Addison’s
  3. Hypervolaemia
    > Tx: fluid restrict
    - HF
    - Renal failure
    - Liver failure
45
Q

Anaphylaxis

A

> O2/intubate + legs up
> 0.5 ml of 1:1000 IM (repeated every 5 mins if necessary)
> IV access
> IV chlorphenamine 10 mg
> IV hydrocortisone 200 mg
> salbutamol/ipratropium bromide nebs

> mast cell tryptase

46
Q

Acute poisoning - TCA

A

> Sx
- Long QT
- Metabolic acidosis
- Anticolinergic effects
> IV bicarb
> Treat arrhytmia: Mg 2 mg

47
Q

Acute poisoning - Digoxin

A

> Sx
- YELLOW GREEN haloes
- ST depression
- inverted t waves
- Inverted tick
> Digibind
> Correct hypokalaemia

48
Q

Acute poisoning - Benzo

A

> Flumenazil: often used in iatrogenic OD
> Other ODs managed supportively because giving Flumenazil in chronic user can cause withdrawal seizures

49
Q

Acute poisoning

A

> B blockers
- Atropine
> Cyanide
- 100% O2
- Almonds
> Iron
- Desferroxamine
- Bleed
>Opiates
- Naloxone
> Organophosphate poisoning
- atropine
- S/Es: Salivary, Lacrimation, Urination, Diarhhoea (SLUD)

50
Q

Acute poisoning - Warfarin

A

> STOP WARFARIN
>vitamin K 1-3 mg
> Immediate reversal: prothrombin complex concentrate (PCC) (if not available then fresh frozen plasma (FFP)
> restart warfarin when INR < 5

51
Q

Acute poisoning - Paracetamol

A

> NAPQI: bad metabolite of paracetamol
> Plot on a nomogram: 4h and 15 hr
- plasma level falls above the line then give acetylcysteine as detailed below.
> NAC: 150mg/kg 1st infusion
> Signs for transplant: King’s college criteria
- pH <7.3
- OR ALL 3 of:
* Creatinine > 300
* PT > 100
* Grade 3/4 encephalopathy

52
Q

Acute poisoning - Salicylate

A

> Gastric lavage/irrigation
> Monitor UO
> Correct acidosis with bicarb: IV with 1.26% solution
> Dialysis: > 700mg/L
> Resp alkalosis

YEAR 6 EXAMS (3 decks)

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