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TCD Renal > Acutely Unwell Patient > Flashcards

Acutely Unwell Patient Flashcards

1
Q

Which pathologies are relevant to the right hypochondrium abdominal quadrant? (5)

A

Acute hepatitis
Biliary colic
Cholangitis
Cholecystitis
Pneumonia (referred pain)

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2
Q

Which pathologies are relevant to the left hypochondrium abdominal quadrant? (5)

A

Pneumonia (referred pain)
Splenomegaly
Splenic abscess
Splenic infarction
Splenic rupture

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3
Q

Which pathologies are relevant to the epigastric abdominal quadrant? (4)

A

Acute myocardial infarction
Acute/chronic pancreatitis
Gastroesophageal reflux disease
Peptic ulcer

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4
Q

Which pathologies are relevant to the right iliac fossa abdominal quadrant? (3)

A

Appendicitis
Hernias
Renal calculi

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5
Q

Which pathologies are relevant to the left iliac fossa abdominal quadrant? (3)

A

Diverticulitis
Hernias
Renal calculi

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6
Q

Which pathologies are relevant to the hypogastric (suprapubic) abdominal quadrant? (2)

A

Bladder retention
Cystitis

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7
Q

Which pathologies are relevant to diffuse abdominal pain? (9)

A

Acute/chronic mesenteric ischaemia
Adrenal insufficiency
Bowel obstruction
Constipation
Inflammatory bowel disease
Ketoacidosis
Perforation of GI tract
Spontaneous bacterial peritonitis
Viral gastroenteritis

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8
Q

What combination of symptoms indicates an upper urinary tract infection? (4)

A

Acute colicky abdominal pain
Dysuria
Fever
Vomiting

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9
Q

What is the Rockwood Frailty Scale?

A

A global clinical measure of a person’s level of vulnerability; can be used to identify patients at high risk of poor outcomes or determine eligibility of patients for invasive interventions or ICU admission.

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10
Q

What is septic shock?

A

A subset of sepsis, which describes circulatory, cellular and metabolic abnormalities which are associated with a greater risk of mortality than sepsis alone.

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11
Q

What diagnostic features indicate septic shock? (2)

A

Sepsis with persistent hypotension despite fluid correction and inotropes, and a serum lactate of greater than 2mmol/ L.

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12
Q

Describe appropriate initial fluid resuscitation in a patient with sepsis.

A

A crystalloid given as a bolus over less than 15 minutes (i.e 500 ml of 0.9% sodium chloride over 10 minutes).

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13
Q

What is the difference between crystalloid and colloid IV fluids?

A

Crystalloids - solutions containing small molecules in water (e.g sodium chloride, glucose, Hartmann’s)
Colloids - solutions with large molecular weight substances (e.g albumin, gelatins)

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14
Q

What does the BNF indicate as an appropriate antimicrobial choice for treatment of an infection of likely urinary source?

A

Ceftriaxone

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15
Q

What does raised lactate in a venous blood gas (VBG) indicate in a sepsis patient?

A

There has been tissue hypoxia as a result of the sepsis, and due to organ hypoperfusion cells subsequently turn to anaerobic metabolism; lactate above 4.0mmol/L is considered a high risk criteria for sepsis (these patients are at high risk of deterioration).

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16
Q

What ECG changes can be seen in hyperkalaemia? (3)

A

Tall, tented T waves
Broad QRS complexes (>0.12ms)
No discernible P waves

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17
Q

What are three common causes of hyperkalaemic blood test results?

A

Reduced renal excretion of potassium
Increased circulating serum potassium (exogenous or endogenous)
Pseudohyperkalaemia (not a true elevation of serum potassium)

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18
Q

What are three common causes of endogenous increased circulating serum potassium?

A

Tumour lysis syndrome
Rhabdomyolysis
Burns

19
Q

When do most guidelines suggest hyperkalaemia requires urgent treatment? (2)

A

When serum potassium exceeds 6.5, and/or there are ECG changes.

20
Q

What are the three priorities when managing acute hyperkalaemia?

A

Protecting the cardiac membrane
Shifting potassium intracellularly
Stopping any contributing medications

21
Q

How can the cardiac membrane be protected in a patient with acute hyperkalaemia?

A

Administration of IV calcium gluconate, which rapidly reduces membrane excitatory effects of potassium on cardiac tissue, therefore reducing potential for cardiac arrhythmias.

22
Q

How can potassium be shifted intracellularly in a patient with acute hyperkalaemia? (2)

A

-Administration of 10 units insulin with 25g glucose.
-Nebulised salbutamol 10-20mg is given alongside in severe, life-threatening hyperkalaemia (but should be avoided if tachyarrhythmia present).

23
Q

Name two classes of medication that can contribute to acute hyperkalaemia.

A

ACE inhibitors
Potassium-sparing diuretics

24
Q

What are the kidneys main functions? (3)

A

-Filter and excrete nitrogenous waste products
-Maintain acid-base balance, by controlling reabsorption and excretion of electrolytes
-Produce certain hormones (erythropoietin, renin, calcitriol)

25
Q

Why is creatinine a useful marker of glomerular filtration?

A

Among the kidneys’ waste products, creatinine, in particular, is a useful marker of glomerular filtration because it is completely filtered in the glomerulus. When there is damage to the kidneys, creatinine levels rise.

26
Q

Describe the relationship between Glomerular Filtration Rate (GFR) and creatinine.

A

Glomerular Filtration Rate (GFR) is proportional to 1/creatinine

27
Q

What is the renin-angiotensin-aldosterone system (RAAS) in the juxtaglomerular apparatus?

A

A protective mechanism to maintain glomerular filtration and intravascular volume; acts to increase overall effective circulating volume (ECV) by:
Increasing reabsorption of sodium ions, and
Vasoconstricting the efferent arterioles.

28
Q

What is acute tubular necrosis (ATN)?

A

A condition usually resulting from a combination of factors which cause renal ischaemia and toxicity, where sloughing of the renal tubular epithelium causes dilation and obstruction of the tubules and some mild leukocyte infiltration.

29
Q

What are the three phases of acute tubular necrosis (ATN)?

A
  1. Oligouric phase - kidneys produce < 500mls urine/day.
  2. Maintenance phase - patient is no longer oligouric and this increase in urinary output helps maintain fluid and electrolyte balance.
  3. Polyuric recovery phase - kidneys produce large amounts of dilute urine (patient can sometimes become hypovolaemic and unwell).
30
Q

Describe the creatinine levels during the three phases of acute tubular necrosis (ATN).

A
  1. Oligouric phase - creatinine levels usually rise quite rapidly.
  2. Maintenance phase - creatinine levels are usually stable or rise very slowly.
  3. Polyuric recovery phase - creatinine levels fall swiftly.
31
Q

What are the two direct impacts of the loss of the kidneys’ homeostatic functions in acute kidney injury (AKI)?

A

The kidneys are unable to:
Regulate acid-base balance —> leading to hyperkalaemia, fluid retention and metabolic acidosis.
Excrete metabolic waste products —> leading to build up of urea and creatinine in the blood.

32
Q

Give an overview of the systemic effects which can be caused by a severe acute kidney injury (AKI). (6)

A

Encephalopathy
Heart failure
Intestinal and microbiota disruptions
Bone marrow and immune system effects
Liver dysfunction
Lung injury

33
Q

Why is blood clotting measured in a patient with sepsis?

A

Sepsis can be a cause of disseminated intravascular coagulation (DIC).

34
Q

What is the definition of an acute kidney injury (AKI)?

A

A clinical syndrome characterised by an acute reduction in renal function, leading to a rise in serum creatinine and/or decline in urine output.

35
Q

What are the serum creatinine criteria for each of the KDIGO guidelines acute kidney injury (AKI) stages?

A

Stage 1: 1.5-1.9 times increase from baseline OR >26.5micromol/L increase.
Stage 2: 2.0-2.9 times increase from baseline
Stage 3: 3.0 times increase from baseline OR >353.6micromol/L increase

36
Q

What investigations should always be done for a patient with an acute kidney injury (AKI)? (3)

A

Obtain a urine dipstick
Monitor urine output
Compare the current renal function to historical records if available.

37
Q

What proteinuria result indicates intrinsic renal disease?

A

> 3+

38
Q

What urine dipstick results may indicate glomerulonephritis?

A

Blood and protein positive urine dipstick.

39
Q

What are the main urgent indications for starting dialysis in patients with acute kidney injury (AKI)? (5)

A

If any of the following features are present AND are refractory to medical therapy:
-Hyperkalaemia
-Pulmonary oedema
-Severe metabolic acidosis
-Uraemia (uraemic pericarditis or encephalopathy)
-Ingestion of certain toxins

40
Q

What is acute interstitial nephritis (AIN)?

A

A clinical syndrome characterised by inflammatory infiltrates in the renal interstitium in response to a drug, infection or autoimmune process.

41
Q

How is the shock index calculated?

A

Shock index = heart rate/blood pressure

42
Q

What is a normal shock index?

A

0.5-0.7 suggests the patient is haemodynamically stable (higher index predictive of shock).

43
Q

What are the different categories of causes of shock? (4)

A

“how FAST you FILL the PUMP and SQUEEZE”

Heart rate (fast)
Blood volume (fill)
Heart (pump)
Blood pressure (squeeze)

44
Q

What two measurements can be used to diagnosis acute kidney disease (AKI)?

A

Raised serum creatinine
Decreased urine output.

TCD Renal (4 decks)

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