Clinical Debrief General Flashcards
Which class of drugs can be prescribed in order to increase protein filtration in the kidneys?
ACE Inhibitors
What is Naloxone used for?
It is a powerful antagonist for opioid receptors, and used in those who have overdosed.
What is pancytopenia?
It is when all 3 of the following are reduced
- Haemoglobin
- White cell count
- Platlets
Which class of drugs should you stop if someone has dehydration / Diarrhoea and Vomiting (D+V)
Use the Mnemonic DAMN (ie. Stop the DAMN drugs) D - Diuretics A - ACE Inhibitors M - Metformin N - NSAIDS
How can you detect hyperkalemia on an ECG?
- Flattened P waves
- Widening QRS complex
- Tall tented T waves
What is aspiration pneumonia?
It occurs most commonly in those with altered mental status who have an affected gag-reflex, and they end up inhaled oropharyngeal contents into the airways. These contents then end up in the lungs, where it is followed by a subsequent infection.
What are the risk factors for aspiration pneumonia?
- Altered mental status (from drugs, alcohol, anaesthesia etc.)
- swallowing dysfunction
- gastrointestinal disease (increases the risk of regurgitation)
- intubation or tracheostomy tube
- older age
- feeding tube
- recumbent position
What investigations would you order on someone with suspected aspiration pneumonia?
- CXR (new infiltrate in dependent lung fields)
- O2 Sats (will be decreased)
- FBC (will be leukocytosis)
- Sputum culture (looking for type of infection so can tailor treatment to it)
How do you treat aspiration pneumonia?
- Antibiotics (can be IV or oral depending on patient status, and the specific antibiotic is dependent on the pathogen detected
- Supportive care (ie. Empyema, if present, may need drainage. Or if part of the lung is now nectrotic, it may need to be surgically removed)
What is empyema?
It is when pus gathers in the pleural space
What is rhabdomyolysis?
It is a serious syndrome due to a direct or indirect muscle injury. It results from the death of muscle fibers and release of their contents into the bloodstream. This can lead to serious complications such as renal failure
How does someone with rhabdomyolysis present?
Classic Triad is
- Muscle pain in the shoulders, thighs, or lower back
- Muscle weakness or trouble moving arms and legs
- Dark red or brown urine or decreased urination
Keep in mind that half of people with the condition may have no muscle-related symptoms.
Other symptoms include
- Abdominal pain
- Nausea or vomiting
- Fever, rapid heart rate
- Confusion, dehydration, fever, or lack of consciousness
How is rhabdomyolysis diagnosed?
Serum creatinine kinase (CK) levels at more than 5 times the upper limit of normal
How is rhabdomyolysis treated?
Patients are given enough fluid via infusion in order to maintain a urine output of 200-300 mL/hour.
If unresponsive to fluids (ie. anuria), then they are put on haemodialysis, which corrects metabolic acidosis and electrolyte disturbances. It is indicated if there is renal failure as well.
What is hyperkalaemia?
A high serum potassium
What is the main complication that you are worried about in someone with hyperkalaemia? How serious is it?
Main complication is cardiac arrhythmias such as ventricular fibrillation, which can be fatal.
Which conditions can cause hyperkalaemia?
Hint. split into conditions and medications
- Acute kidney injury
- Chronic kidney disease
- Rhabdomyolysis
- Adrenal insufficiency
- Tumour lysis syndrome
- Diabetic ketoacidosis / hyperosmolar hyperglycaemic state
Which test is used to diagnose hyperkalaemia?
- U&E’s on a blood test
Other than serum potassium levels, what else do you need to look for in the bloods for someone with hyperkalaemia? Why?
Creatine, urea and eGFR.
This is because you are checking whether there is acute or chronic kidney failure.If there is, it may be necessary to send them for haemodialysis.
On an ECG, what conditions shows up with
- Tall peaked T waves
- Flattened or absent P waves
- Broad QRS complex
Hyperkalaemia
At what concentration of serum potassium do you need to perform an ECG?
6 mmol/L
How do you conservatively manage hyperkalaemia?
Can alter diet and medications
Which medications can cause hyperkalaemia?
- Aldosterone antagonists (eg. spironolactone and eplerenone)
- ACE Inhibitors
- Angiotensin II receptor blockers
- NSAIDS
- Potassium Supplements
IN those who have hyperkalaemia, who requires urgent treatment?
Hint. concentrations
- Potassium ≤ 6 mmol/L with otherwise stable renal function - don’t need urgent treatment, may just require a change in diet and medications
- Potassium ≥ 6 mmol/L and ECG changes need urgent treatment.
- Potassium ≥ 6.5 mmol/L regardless of the ECG need urgent treatment.
What is the mainstay of hyperkalaemia treatment?
- Insulin and dextrose infusion - drive carbohydrates into the cells, which brings potassium with it
- Calcium gluconate - stabilises cardiac muscle cells and reduces the risk of arrhythmias
Other than the 2 main treatment options for hyperkalaemia, what other options do you have?
- Nebulised salbutamol - it temporarilty drives potassium into cells
- IV fluids - can be used to increase urine output, which encourages potassium loss from the kidneys (but dont fluid overload patients in renal failure)
- Oral calcium resonium - pulls potassium out of the gut and into stools. It works slowly so is only suitable for mild cases
- Sodium bicarbonate - Used under advice from renal consultants. It drives potassium into the cells as the acidosis is corrected
- Dialysis may be required in severe cases
Why is nebulised salbutamol sometimes given to those with hyperkalaemia?
It temporarily drives potassium into cells, reducing serum levels.
Why are IV Fluids sometimes given to those with hyperkalaemia?
It incourages urine output, which encourages potassium loss from the kidneys.
DO NOT DO FOR THOSE IN RENAL FAILURE AS YOU WILL CAUSE FLUID OVERLOAD
Why is oral calcium resonium sometimes given to those with hyperkalaemia?
It draws potassium from the gut into stools, which removes it from the body. It works slowly so is given for mild cases
Why is sodium bicarbonate sometimes given to those with hyperkalaemia?
It drives potassium into the cells as the acidosis is corrected
What is classed as significant hyperkalaemia?
Greater than 6.0 mmol/L
What is classed as moderate hyperkalaemia?
5.0 - 6.0 mmol/L
When should you do continuous cardiac monitioring in someone with hyperkalaemia?
In anyone with significant hyperkalaemia (greater than 6.0 mmol/L)
What is tumour lysis syndrome?
It is an oncological emergency caused by rapid breakdown of large number of cancer cells and subsequent release of large amounts of intracellular content into the bloodstream. It can occur after any type of cancer treatment
What type of drug is amlodipine?
Calcium channel blocker
At what eGFR level do you stop metformin?
When its below 30
If percussion of the bowel indicates shows hyper-resonance, what condition would you be thinking of?
Bowel Obstruction
What is nephrotic syndrome?
It is when the basement membrane of the glomerulus becomes leaky to protein, allowing it to escape into the urine.
Why does low serum protein lead to oedema?
Protein acts as a magnet for water, drawing it into the blood stream. Without the protein, there is nothing drawing it into circulation, and instead it collects in tissues.
What is frothy urine a sign of?
It is normal every now and then as factors such as speed of urination influence it.
However, if it is persistent, it indicates protein in the urine
What is the classic triad of symptoms that someone with nephrotic syndrome presents with?
- Low serum albumin
- Oedema
- High protein content in the urine
What is the main cause of nephrotic syndrome? How does it cause it?
Minimal change disease (90% of the time this causes it).
It is not clear why it causes nephrotic syndrome.
It commonly affects small children, so if you see a small child with oedema, proteinuria and hypoalbuminemia, then its likely from nephrotic syndrome caused by minimal change disease
How is nephrotic syndrome treated?
- High dose steroids (i.e. prednisolone)
- Low salt diet
- Diuretics may be used to treat oedema
- Albumin infusions may be required in severe hypoalbuminaemia
- Antibiotic prophylaxis may be given in severe cases
What are the complications of nephrotic syndrome? Why?
- Hypovolaemia occurs as fluid leaks from the intravascular space into the interstitial space causing oedema and low blood pressure.
- Thrombosis can occur because proteins that normally prevent blood clotting are lost in the kidneys, and because the liver responds to the low albumin by producing pro-thrombotic proteins.
- Infection occurs as the kidneys leak immunoglobulins, weakening the capacity of the immune system to respond. This is exacerbated by treatment with medications that suppress the immune system, such as steroids.
- Acute or chronic renal failure
- Relapse
What is hypovolaemia?
It is when the blood has a low amount of volume
What second line type 2 diabetes drug is also indicated for weight loss?
GLP-1 agonists. Examples include
- Exenatide
- Exenatide
- Liraglutide
- Lixisenatide
- Dulaglutide
- Semaglutide
What medication are liver failure patients put on to prevent encephalopathy?
Laxatives
If unsure why, look up cirrhosis notes from week 3
What do most liver patients die from?
Ruptured oesophageal varices
What is the difference between gastroenteritis and gastritis?
Gastroenteritis - Inflammation of the stomach and bowel, caused by an infection
Gastritis - Inflammation of the lining of the stomach, and NOT ALWAYS caused by infection
What is spontaneous bacterial peritonitis? How do we check for it?
It is when the fluid in ascites becomes infected. We check for it by taking an ascitic sample from the ascites fluid that comes out the ascitic tap drain.
What is testicular torsion?
Testicular torsion is a urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply and time-sensitive ischaemia and/or necrosis of testicular tissue
How is testicular torsion treated?
- Urgent surgical referral
- Make them NBM in prep for surgery
- Analgesia
- Manual de-torsion whilst waiting for surgery or if surgery cannot be achieved within 6 hours. This is done with the “open book” technique
What is the ‘open book’ technique in the context of testicular torsion?
The technique involves rotating the right testicle counter-clockwise and the left testicle clockwise. In other words, the affected testicle is rotated as if opening a book, hence the ‘open book’
What is epididymitis?
It is inflammation of the epididymis
What is epididymo-orchitis?
It is when the inflammation in epididymitis spreads and involves the testis as well
What would you expect someones glucose levels to do if they had an infection?
They increase as part of the body’s defence mechanism
