ASSCC 4 Flashcards
What is Cushings triad?
1) Bradycardia
2) Increased systolic BP (increased pulse pressure)
3) Irregular respiratory pattern
7 steps to manage pt with high ICP:
1) ABC
2) Intubate if GCS <= 8
3) Sit up
4) Mannitol / furosemide / manage Na+
5) Hyperventilate
6) External ventricular drain
7) Decompressive craniectomy
Old lady, critically ill, LIF pain + tenderness. Give 6 ddx:
1) Gastroenteritis
2) Diverticulitis
3) Sigmoid volvulus
4) Acute constipation
5) Pelvic tumour
6) Ureteric colic
Define shock:
Acute circulatory failure, with inadequate tissue perfusion causing cellular hypoxia
Define sepsis:
Life-threatening organ dysfunction caused by dysregulated host response to infection
Quick SOFA score looks at which 3 parameters to assess organ dysfunction?
1) RR >22
2) sBP <100
3) Altered mentation/ reduced GCS
Septic shock defined by 3 states:
1) Infection + persistent hypotension after fluid resuscitation
2) Infection + persistent lactate >2 after resuscitation
3) Infection + vasopressor requirement to maintain MAP > 65 in absence of hypovolaemia
Mortality of septic shock:
40%
Sepsis 6:
1) Give high flow O2
2) Take blood cultures
3) Take blood for serum lactate + Hb
4) IVI fluid resuscitation
5) Measure urine output
6) Give IV Abx
Management options of septic pt + diverticular abscess:
1) IR drainage
- No wound infection, less hospital stay, ability to insert pig-tail catheter
- Less adequate drainage, no ability to create stoma
2) Open drainage
- Peritoneal wash-out, ability to create stoma if necessary
- Risk wound infection, high morbidity
Risk of performing surgery on 34wk pregnant female:
1) IUFD
2) DVT
3) Pre-term labour
Define pre-load:
End diastolic volume which stretches the right or left ventricle to its greatest dimensions
What is the body response to decreased blood pressure?
1) Baroreceptors stimulate SNS = ^HR, ^SV, ^SVR = maintains CO + BP
2) Catecholamines from adrenal medulla = peripheral vasoconstriction = ^SVR
3) Mineralocorticoids from adrenal cortex = salt and water retention = maintain BP
What are baroreceptors?
- Mechanoreceptors detect pressure change via change in stretch of arterial wall
- Located in carotid sinus + aortic arch
- Supplied by carotid branch of CN IX
5 factors affecting venous return:
1) Muscle pump
2) Posture
3) Circulating blood volume
4) Venous tone
5) Inspiration (drop in intrathoracic P = ^venous return)
Devices used in DVT prophylaxis:
1) TED stockings
2) Intermittent pneumatic compression devices (flowtrons)
Polytrauma pt, assess Airway:
- Cervical spine control, sandbag + tape/hard collar
- If can speak = secure
- If cannot speak:
- Look in mouth for FB
- Assess face for maxillofacial injury
- Jaw thrust
- Oropharyngeal airway
- ETT
- Cricothyroidotomy
- Tracheostomy
Polytrauma pt, assess Breathing:
- Inspect any obvious chest injury + symmetrical chest wall mvt
- Count RR
- Palpate for central trachea and surgical emphysema
- Percuss + auscultate for obvious pneumo/haemothorax
- High flow O2
- Needle thoracotomy or chest drain
- Occlusive dressing for open pneumothorax
What kind of shock in pneumothorax?
Obstructive
Tension pneumothorax prevents blood from entering right heart during diastole
How to assess circulation?
- Inspect any obvious source bleeding
- Pulse rate and character
- Blood pressure
- Class of haemorrhage shock
How to manage circulation in polytrauma pt:
- Stop any obvious source of bleeding
- 2 large bore cannula
- Take blood for FBC, U&Es, LFTs, Clotting, G&S, XM, Lactate, Glucose
- XM 4 units
- IV fluid resuscitation
- Blood transfusion if no response to fluid
- Consider Tranexamic acid
Polytrauma pt, HR 125, ?class of shock?
Class 3
Polytrauma pt, RR 42 ?class of shock?
Class 4
Polytrauma pt, HR 112, RR 22, ?class of shock?
Class 2
Polytrauma pt, HR 143 ?class of shock?
Class 4
What is the estimated blood loss in each class of shock?
Class 1: <750 ml
Class 2: 750-1500ml
Class 3: 1500 - 2000ml
Class 4: >2000ml
Grades of liver injury:
Grade 1: Sub-capsular haematoma <10% SA or <1cm capsular tear
Grade 6: Vascular: hepatic avulsion
Mx of liver tear:
Conservative: blood transfusion, monitoring
Operative: damage control (perihepatic packing), repair, resection
4 areas examined for free fluid on FAST scan:
1) Perihepatic space
2) Perisplenic space
3) Pericardium
4) Pelvis
Normal bilirubin levels:
3-30 umol/l
At what bilirubin level is jaundice apparent?
> 35 umol/l
Why is clotting deranged in liver damage?
- Liver synthesises most clotting factors
- Vit K required to activate clotting factors 2, 7, 9, 10
- In severe liver damage or biliary obstruction = reduced absorption of vitamin K
= Increased prothrombin time
What is alkaline phosphatase?
- Enzyme
- Found in bile canaliculi + bone + placental tissue
- Increases in cholestasis
What is the function of bile?
- Emulsification of fat into micelles
- Providing greater SA for enzyme pancreatic lipase
What are the constituents of bile?
- Water
- Bile pigment (bilirubin + biliverdin)
- Bile acid
- Bile salt
- Cholesterol
- Lecithin (phospholipid)
Give example of bile salt / acid
Sodium glycocholate
Sodium taurocholate
