Clinical Interview COPY Flashcards
Hyperkalaemia?
K+ > 5.2
Mild 5.3 - 6.0
Moderate 6.0 - 7.0
Severe > 7.0
ECG changes in hyperkalaemia?
- peaked t-wave
- flat p-waves
- PR prolongated
- Wide QRS
- Pulled up from the t-wave *
ECG changes in hypokalaemia?
t-wave inversion
ST depression
prominent U-waves
pushed down on T-segment
Clinical manifestation of hyperkalaemia? Pathophysiology?
Bradycardia, conduction blocks & cardiac arrest.
Suppressed SA node.
Reduced conduction at AVN / His-purkinje
Causes of hyperkalaemia? (6-themes)
- increased intake (oral/IV)
- increased production [tissue injury -> rhabdo, tumour lysis, burns, ischaemia, comparment syndrome]
- decreased excretion [renal failure, hypoaldosteronism, obstructive uropathy]
- transcellular shift [metabolic/resp acidosis, hyperglycaemia]
- Pseudohyperkalaemia [lab error, haemolysed sample, thrombocytosis]
- Drugs [aldost inhib; inhibition]
Drug causes of hyperkalaemia?
- ACEi / ARB
- Heparin, spironoloactone, BBs
- Digoxin
- Suxamethonium, phenylephrine
Management of hyperkalaemia?
- Cardiac stabilisation - calcium chloride/gluconate
- ECF -> ICF shift - insulin/dex, salbutamol, bicarb
- Removal of K+ - fruse (from urine), resonium (from gut), dialysis (from blood)
Dose of calcium chloride/gluconate?
10mls of 10%
Dose of insulin-dex for HyperK+?
10 units insulin 50g dextrose, IV over 20-30mins
Hypokalaemiea?
Mild 3.0-3.5
Mod 2.5-3.0
Severe <2.5
Causes of hypokalaemiea?
- decreased intake
- Mg depletion -> renal potassium loss
- Mineralocorticoid excess [cushing’s, addison’s, HTN, renin, barters]
- Increased loss [drugs, burns, GI, renal, endocrine, dialysis]
- Transcellular shift [insulin-dex, beta-agonists, alkalosis]
Mx of hypokalaemia?
- non-acute = 10-20mmol/hr
- acute (life threatening arrhythmia) = 20mmol in 10mins
Status epilepticus?
- continuous seizure > 5 minutes
- recurrent seizures without neurological recovery
Causes of status epilepticus?
epilepsy
infective
hypoxic
vascular
metabolic
physical (hyperthermia)
drug induced / withdrawal
Ix in status epilepticus?
- bedside [BM, VBG/lactate]
- laboratory [UEs, toxins, TFTs, LP]
- imaging [CT / MRI brain]
Mx of status epileptics?
1st. Bolus benzodiazepines (IV, IM, buccal, PR)
2nd. Typically requires I+V
- phenytoin, valproic acid, levetiracetam
3rd. Refractory status
- propofol, midazolam, barbituates
4th. thiopentone, volatile, ketamine, lignocaine
Monitor EEG
Generally require HDU/ICU + neurology consult
Principles of mx of status?
Resuscitation, maintain CPP
Terminate seizure
Decrease cerebral metabolic rate
Diagnose + treat cause
Treat copmlications
Complications of status epilepticus?
- aspiration
- neurogenic pulm oedema
- rhabdomyolysis
- hyperthermia
- trauma (HI, post shoulder dislocation)
DKA?
Life threatening complication of DM - insulin deficiency
Diagnostic criteria for DKA?
- pH < 7.3
- Ketosis (ketonaemia/ketonuria)
- HCO3 < 15
- Hyperglycaemia - may be mild/euglycaemic
Pathogenesis of DKA?
- increased glucagon, cortisol, catecholamines, GH
- decreased insulin
—> hyperglycamiea -> hyperosmolality -> electrolye lost -> ketone production from metabolism of triglycerides -> acidosis
Goals of mx DKA?
- establish precipitant + treat
- assess degree of metabolic derangement
- fluid resuscitation
- insulin provision
- electrolyt replacement
Mx of DKA?
-insulin infusion 0.1u/kg/hr
- balanced salt solution fluid resuscitation
- when glucose<15 -> dextrose 5% 100mls/hr
- monitor ketones
- monitor pH
– LOCAL GUIDELINES
Find cause + treat - e.g. infection [cultures, CXR, CT-A/P, bloods etc]
Continue background insulin
Early escalation to medical team/DM, ITU
Classification of tachycardia?
- regular vs irregular
- narrow vs wide complex
Types of regular narrow complex tachycardia?
- sinus tachy
- atrial tachy
- atrial flutter
- SVT
- AVNRT
- Narrow complex VT
Types of irregular narrow complex tachycardia?
- AF
- Atrial flutter w/ variable blcok
- Multifocal atrial tachy
- Digoxin toxicity
- Tachycardia w/ premarture
Types of regular wide complex tachycardia?
- Monomorphic VT
- Ventricular flutter
- Hyperkalaemia
- Ischaemia
- Regular tachycardia w/ BBB
- Sodium channel blocker toxicity (e.g. TCA, cocaine)
Types of irregular wide complex tachycardia?
- TdP
- Irregular VT
- VF
- Irreg tachy w/ BBB
- AF w/ pre-excitation syndrome
Causes of tachycardia?
- Cardiac dysrhytmia
- Non-cardiac
– Electrolyte imbalance (hypoK/Mg)
– Fever/sepsis
– HyperThy
– Ischaemia
– Pain
– Poisoning
– PE
– Resp diseases (CAP, PTx)
– Shock
– Trauma
– Withdrawal
Management of narrow complex tachycardia?
- vagal manoeuvre
- adenosine 6mg-12mg-18mg IV
- cardioversion
Life-threatening features in tachycardia? (clinically unstable)
- Shock
- Syncope
- MI
- Severe heart failure
If life-threatening features in tachycardia what is management?
- Synchronised DC shock up to x3 attempts
– Under sedation - If unsuccessful - amiodarone 300mg IV over 10-20mins
- Rpt DCCV
Mx of VT?
- amiodarone 300mg IV over 10-60mins
- DC cardioversion
What is Torsades de pointes?
- polymorphic VT due to prolonged QTc interval
Mx of unstable TdP?
Synchronised DC cardioversion
Mx of stable TdP?
IV Mg
Stop causative drugs
Treat other QT prolonging factors - e.g. hypokalaemia
Approach to arrhythmias?
- fast or slow
- ventricular / SVT
- compromised?
- does it need management
- underlying cause? trigger?
- will it recur?
Narrow regular bradycardias?
- sinus
- junctional
- complete AV block
- Atrial flutter with block
Narrow irregular bradycardias?
- sinus arrhythmia
- AF with SVR
- Second degree AV block
Wide complex regular bradycardias?
- idioventricular rhythm
- complete AV bock
Wide complex irreg bradycardias?
- irreg brady w/ BBB
Mx of bradycardia with adverse features?
- Atropine 500mcg IV
– repeat up to max of 3mg - Alternate drugs (isoprenaline, adrenaline)
- Transcutaenous pacing
- Transvenous pacing - expert help
Life threatening signs of bradycardia?
- shock
- syncope
- MI
- HF
Reversible causes of arrest?
Hypoxia, hypovolaemia (think bleeding in post-op/trauma), hyperkalaemia, hypothermia
Tamponade, tension, thrombus (PE/MI), toxin
Shockable vs non-shockable rhythms?
Shockable = VF, pulseless VT
Non-shockable = asystole, PEA
Principles of arrest care?
- Get help! 2222
- High quality chest compression w/ minimal interruptions
- Early defib
- Basic airway –> ?intubation + ventilation
- Adrenaline
- POCUS for diagnosis
How to deliver a shock?
- Chest compressions ongoing
- Pause for 5s for rhythm recognition
- If shockable, continue compressions, charge, then all hands off + O2 mask removed from patient to deliver shock
- Immediately resume CPR - only stop if clinical + physiological signs of ROSC
Shockable algorithm?
- VF / pVT
- 2min cycles of chest compressions
- Up to 3 shocks
- Then adrenaline 1mg IV/IO every 3-5mins
- Amiodarone 300mg IV/IO after shocks
Signs of peri-arrest in arrhythmia?
- Shock (SBP<90) + increased sympathetic activity
- Syncope
- HF (pulm oedema (L), raised JVP (R))
- MI
Indications for cardiac pacing?
Unstable, symptomatic bradycardia refractory to drug therapy
Causes of pancreatitis?
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpions
Hypercalcamiea
ERCP
Drugs [NSAID, thiazides, azathioprine]
Glasgow-Imrie score?
PaO2 < 8
Age > 55
Neutrophils > 15
Calcium < 2
Renal function [Ur>16]
Enzymes [LDH>600 / AST > 2000]
Albumin < 32
Sugar [BM > 10]
Presentation of pancreatitis?
Severe abdominal pain, radiating to back.
N&V
Anorexia
Often presence of risk factors [gallstones, EtOH, recent ERCP, hypertriglyceridemia]
Signs of pancreatitis?
Tender epigastrium +/- guarding
Cullen’s / Grey-Turner’s
Mx of pancreatitis?
- Supportive [fluid resuscitation, analgesia, anti-emetic. Nutrition]
- Risk stratification [Glasgow-Imrie score OA + 48hrs]
–> Escalation to ITU if severe - Surgical - ERCP/lap chole
Complications of pancreatitis?
Local [pseudocyst, pancreatic necrosis]
Systemic [SIRS, ARDS, AKI, multi-organ failure, death]
DDx RUQ pain?
- GI [PUD, cholecystitis, appendicitis, hepatitis]
- Urinary [pyelonephritis]
- Resp [pneumonia]
DDx epigastric pain?
- GI [PUD, cholecystitis, oesophagitis/perf]
- Cardiac [MI]
DDx LUQ pain?
- GI [PUD, perforation, splenic rupture]
- Urinary [Pyelonephritis]
- Resp [pneumonia]
DDx RLQ pain?
- GI [appendicitis, crohn’s, perforation]
- Gynae [ovarian torsion/abscess; ectopic]
- Urinary [calculus, pyelo]
DDx LLQ pain?
- GI [diverticulitis, hernia, perforation, UC]
- Gynae [ovarian, ectopic
- Urinary [calculus, pyelo]
What is compartment syndrome?
- Limb threatening condition caused by raised pressure within a fascial compartment
- Causes compression of blood vessels, muscles and nerves within the compartment
–> irreversible muscle & nerve damage
Presentation of compartment syndrome?
Caused by?
- pain out of proportion
- 6Ps
- Caused by:
– Trauma [fracture, crush injury, burns]
– External compression [casts, dressings]
– Bleeding disorder
– Reperfusion injury [tourniquests; thrombectomy]
– Extravasation
– Arterial injury
Signs of compartment syndrome?
- pain with passive stretch
- paraesthesia
- tense compartment (woody)
- paralysis
- pulseless
Common locations of CS?
- forearm (esp volar)
- lower leg (esp anterior) - tibial shaft
- thigh
- upper arm
- hand
- foot
- back
- abdomen
- buttocks
Ix in compartment syndrome?
- XR (?fracture)
- Bloods (FBC, UE, CK, G&S)
- Compartment pressure measurement
Mx of compartment syndrome?
- IV access [fluid, analgesia, anti-emetic]
- Relieve pressure
- Reduce + splint any fractures
- Urgent referral to ortho/plastics
–> fasciotomy
Complications of compartment syndrome?
- Local [gangrene, loss of limb, muscle contracture]
- Systemic [rhabdomyolysis, renal failure]
Abdominal compartment syndrome?
- intra-abdominal hypertension with new organ failure
–> compression, thrombosis. Renal failure. Decreased tidal volumes. Decreased CO
Management of abdominal compartment syndrome?
- Monitor IAP
- Improve compliance - sedation, analgesia, neuromuscular block
- NG tube, rectal decompression, enemas
- Correct positive fluid balance
- Organ support
+/- surgery - decompression with delayed closure
What is anaphylaxis?
Severe, life-threatening, systemic hypersensitivity reaction
Characteristics of anaphylaxis?
Rapidly developing airway, breathing and circulation problems associated with skin + mucosal changes
- Pharyngeal/laryngeal oedema
- Bronchospasm / tachypnoea
- Hypotension / tachycardia
Causes of anaphylaxis?
- Allergens (insect stings, nuts, eggs, dairy, fruit)
- Medications (abx, NSAIDs, contrast)
- Unidentified
DDx of anaphylaxis? (conditions which mimic anaphylaxis)
- Urticaria
- Angioedema
- Dystonic reactions
- Carcionoid
- Red-man syndrome (Vanc)
- Acute resp distress
- Shock
Pathophysiology of anaphylaxis?
- IgE mediated hypersensitivity
- Profound histamine and serotonin release from basophils / mast cell degranulation
Symptoms of anaphylaxis?
- angioedema
- stridor
- resp distress
- bronchospasm
- hypotension / collapse
- abdo cramps
- diarrhoea
- flushing
- urticaria
- coagulopathy
Ix in anaphylaxis?
- Clinical diagnosis, but investigations can help in longterm managment
– tryptase, RAST, CAP, skin testing
Mx of anaphyalxis?
- Stop trigger. Get help.
- Supine. 100% O2
- Adrenaline 0.5mg IM (rpt every 5 mins)
- IV access + fluid boluses
- Hydrocortisone IV
- If persistent hypotension after x2 adrenaline -> infusino
Mx of anaphylactic cardiac arrest?
- Extended CPR
- Raise legs
- 2L IV fluids stat
- Increasing adrenaline
- H1/H2 antagonist
Mx of persistent bronchospasm / angioedema in anaphylaxis?
- Bronchospasm [as per asthma emergency]
- Angioedmea [nebulised adrenaline; ETT; cricothyrdoiotomy/tracheostomy]
What are biphasic reactions?
- Recurrence of anaphylaxis symptoms soon after the initial episode
- may occur >24 hrs after initial episode, usually less severe
Risk factors for biphasic anaphylaxis reactions?
- delayed adrenaline
- slow response to adrenaline
- repeated doses of adrenaline
Does of adrenaline in anaphylaxis in kids?
- IM adrenaline 1:1000 (1mg/mL) 0.01mg/kg
- Repeat every 3-5mins
What is sepsis?
- Life threatening organ dysfunction due to dysregulated host response to infection
– qSOFA (sequential organ failure assessment) ‘HAT’
— Hypotension
— Altered mental status
— Tachypnoea
Septic shock?
- Sepsis +
– Persistent hypotension - requiring vasopressors
– Lactate >=2
Criteria for SIRS?
- Systemic inflam response syndrome
- > =2 of the following
T >38 or <36
HR>90
RR>20 / PaCO2 < 32mmHg
WCC>12
Sepsis = SIRS + confirmed infection
Mx of sepsis?
- Resuscitation
- Sepsis 6 (Lactate, BCs, UO; abx, IVI, O2)
- Source control
- IVI. +/- vasopressors
Causes of APH? Features?
- Abruption - bleeding, painless
- Praevia - small bleeds, painless
- Uterine rupture - painful, fetal distress, no UO
Causes of PPH?
- Uterine atony - assos w/ multiples, prolonged labour, polyhydramnios
- Retained PoC / placenta
- Genital tract trauma
- Uterine inversion
- Ac-/In-/Per- Creta
Causes of haemorrhage in pregnancy? (Ts)
- Tone
- Trauma
- Tissue
- Thrombin
Management of haemorrhage in pregnancy?
- MDT [obstetrics, haematology, radiology, GenSurg, blood bank; neonatologist; ODPs/orderlies]
- Left lateral tilt
- CTG
- O2
- IV fluids +/- O- blood (6 Units)
- Warming
- Correct coagulopathy (TXA, RBCs, FFP, Cryo, Platelets)
- Uterotonics [bimanual copmression; syntocinon; ergometrine; carboprost]
- Surgery [embolistaion; clamp iliacs; caesarian hysterectomy]
Mx of Obstetric arrest?
- Left lateral position / manual displacement of uterus (relieves aortocaval compression)
- O2, IV access, fluids etc
- Algorithm is the same as non-pregnant women (DCCV & drug doses the same)
- If no response at 4 minutes -> peri-mortem CS
DDx of maternal collapse?
- Anaphylaxis
- PE
- Amniotic fluid embolus [collapse during labour]
- APH (abruption, praevia, rupture, ectopic)
- Eclampsia
- Intracranial haemorrhage
ROTEM?
Rotational thromboelastography
- gives information about bloods ability to clot
(rather than individual components values)
What types of analgesia are there?
Huge variety. Different classes, different routes. depending on patient situation - acute / chronic; duration required
- Simple (paracetamol. COX-inhibitors: aspirin, diclofenac, ibuprofen, parecoxib)
- Weak opiate (codeine, dihydro-, tramadol)
- Strong opiate (morphine, fentanyl)
- Neuropathic (amitriptyline,
- Sedative (ketamine)
- Inhaled (NO2, penthrox)
- Regional (local anaesthetics; regional)
- Spinal (opiates/ anaesthetics)
– Given by doctors/nurses (PO, IV, SC)
– Patient administered (PCA, PCEA)
What is adrenal crisis?
- Acute deterioration with hypotension, resolving with IV steroid
- Chronic adrenal insufficiency + trigger
OR - Acute adrenal sufficiency
Causes of chronic adrenal insufficiency?
- Chronic steroid therapy
- Chronic adrenal grand dysfunction (Addison’s, malignancy, infection)
- Chronic anterior pituitary dysfunction (granulomatous disease [TB/sarcoid], neoplasm, iatrogenic)
Acute stressors precipitating adrenal crisis?
- Infection [especially gastro]
- Trauma/surgery
- Reduced steroid dose [non-adherent, tapering]
- Stress
- Pregnancy
- Drugs
Causes of acute hypothalamic-pituitary-adrenal axis? (Rare)
Pituitary failure
- Pituitary apoplexy [post-partum / adenoma]
- Complication of neurosurgery
Adrenal gland failure
- Waterhouse-Friedrichsen [adrenal infarction due to DIC]
- Checkpoint-inhibitor immunotherapy
Signs & symptoms of adrenal crisis?
- Hypotension, vasodilatory shock
- Fever
- Nausea/vomiting
- Abdo pain + tenderness
– Can mimic abdominal sepsis/pancreatitis - Delirium
- Features of trigger [trauma/surgery/infection]
Signs in chronic adrenal insufficiency?
- Hyperpigmentation
- Vitiligo
- Chronic fatigue
- Anorexia
- Vomiting
- Weight loss
Mineralocorticoid deficiency leads to..?
Occurs in primary adrenal insufficiency (Addisons)
- Hyperkalaemia
- Non-anion gap metabolic acidosis
Glucocorticoid deficiency leads to..?
- Hyponatraemia
- Hypoglycaemia
Renin-angiotensin-aldosterone axis?
- Renin released due to high K+
- Catalyzes production of angiotensin
- Angiotensin stimulates adrenals to secrete aldosterone
- Aldosterone signals kidney to excrete potassium
Diagnosing adrenal insufficiency?
- Random cortisol
- ACTH stimulation test (synacthen)
Mx of adrenal crisis?
- Treat trigger
- IV Hydrocortisone 100mg stat
– 50mg IV Hydrocortisone QDS - Resuscitation with fluid +/- vasopressors
Prevention of adrenal crisis?
- Maintenance steroids (hydrocortisone, fludrocortisone)
- Sick day rules (double dose)
- Severe stress (major surgery, severe infection) - 50mg IV Hydrocortisone QDS
Pathophysiology of adrenal crisis?
- Cortisol and aldosterone deficiency
– Aldosterone deficiency -> Na wasting; retentino of K+ & H+ -> Hypotension, hyperkalaemia, metabolic acidosis (non-anion-gap)
– Cortisol deficiency -> increased inflam cytokines, vasodilation, hypoglycaemia, decreased fatty acids
What does adrenal gland produce?
- Zona Glomerulosa -> mineralocorticoids -> aldosterone
- Zona Fasciculata -> glucocorticoids -> cortisol
- Zona Reticularis -> sex steroids -> testosterone
- Adrenal medulla -> catecholamines -> adrenaline
Effects of cortisol?
– Released in response to ACTH
- Suppress inflammation (cytokines)
- Vasoconstriction (w/ catecholamines)
- Catabolism (gluconeogenesis, production of free fatty acids & amino acids)
Mx of STEMI?
- Monitored resus bed
- IV access, bloods, ECG
- O2 >93%
- Analgesia (IV morphine titrated to effect) + antiemetic
- GTN, anti-platelet (aspirin 300mg + ticagrelor 180mg)
- Reperfusion strategy: PCI vs thrombolysis
- PPCI within 2 hours of medical contact
- Secondary prevention
When to use fibrinolysis in STEMI?
- <12 hours of symptoms
- PCI not possible in 2 hours
Mx of NSTEMI?
- Monitored resus bed
- IV access, bloods, ECG
- O2 > 93% (or if pt shocked)
- Analgesia titrated to effect; + antiemetic
- GTN, DAPT (aspirin 300, ticagrelor 180); anticoagulation (fonda)
Mx of acute asthma?
- O2 > 92%
- Beta-agonist - salbutamol neb/MDI/IV
- Anticholinergic - ipratropium neb
- Corticosteroids - HC / pred
- Aminophyline
+/- adrenaline, Mg
Markers of severe asthma?
- Accessory muscle use
- HR > 110
- RR 25-30
- PEFR < 50%
- SpO2 < 92%
Markers of imminent resp arrest in acute asthma?
- Altered mental status
- Paradoxical respiration
- Bradycardia
- Silent chest
- High pCO2 on ABG
Causes of pulmonary oedema?
- Cardiogenic
– acute heart failure, MI, - Non-cardiogenic
– ARDS, reperfusion, neurogenic, transfusion reaction (TRALI), allergic alveolitis, HAPE, contusion
Problems with ventilation in acute asthma?
- Breath stacking (dynamic hyperinflation)
– Barotrauma -> PTx
– Increased intrathoracic pressure -> obstructive shock -> arrest
Emergency mx of acute cardiogenic pulmonary oedema?
- A - positioning
- B - High flow O2, consider early CPAP
- C - nitrates, furosmide
- D - morphine
- E - positionging
Presentation of acute pulmonary oedema?
- Breathless, sweaty, agitated
+/- precipitating event (cardiac ischaemia, MVR, arrhythmia, sepsis)
Define anaphylaxis?
Life threatening generalised hypersensitivity reaction
Characteristics of anaphylaxis?
Life threatening, rapidly developing A/B/C problems.
Usually associated with mucosal/skin change
Mx of anaphylaxis?
- STOP trigger
- Call for help
- O2 15L NRB
- Adrenaline 0.5mg IM, repeat at 2 mins, onto infusion if no improvement
- Fluids
- Consider steroid / antihistamine
Classification of hyponatraemia?
Brief explaination?
- Hypovolaemic (Na loss > water loss)
- Normovolaemic
- Hypervolaemic (increased TBW relative to Na -> oedematous)
- Pseudohyponatraemia [hyperglycaemia; hyperlipidaemia; hyperproteinaemia]
Causes of hypovolaemic hyponatraemia?
- Renal (urine Na > 20)
– Addisions; CKD; RTA; diuretics; cerebral salt wasting - Extra-renal (urine Na < 20)
– 3rd space losses [burns; pancreatitis; SBO; cirrhosis]; sweating/D&V with continued water intake
Causes of euvolaemic hyponatraemia?
- SIADH (Urine Osm > Serum Osm)
- Exercise
- Iatrogenic
- Amphetamines
- Tea & toast diet
- polydipsia (water/beer)
Causes of hypervolaemic hyponatraemia?
- Renal failure
- Heart failure
- Cirrhosis
- Nephrotic syndrome
- Hepato-renal syndrome
Causes of SIADH?
Malignancy [SCLC]
ADH secretion
Drugs [SSRI, carbamaz, amitrip]
CNS disease [meningitis, SAH]
Hormone deficiency [Thyroid/ Addisions]
Other
Pulmonary
Mx of Hyponatraemia?
ASYMPTOMATIC
- SLOW correction
- Water restriction
- Demeclocycline
SYMPTOMATIC
- Hypertonic saline
Complications of hyponatraemia?
- Cerebral oedema
- ECG changes
- Pontine myelinolysis in overcorrection
What is necrotising fasciitis?
- Severe rapidly progressing bacterial soft tissue infection of subcut tissues + fascia
Causative organisms of Nec Fasc?
- Strep (grp A)
- Staph aureus
- Clost. pefringes
- Vibrio vulficians
Risk factors for Nec Fasc?
- DM
- EtOH
- PVD
- Renal failure
- Malignancy
- Skin trauma including surgery
Symptoms/signs of Nec Fasc?
- Rapid spreading cellulitis
- Sepsis + haemodynamic instability
- Pain out of proportion
- Erythema -> tense swelling -> dark blisters -> gangrene
- Crepitus
– Rapid spread
Investigations in Nec Fasc?
- Do not delay surgical intervention!
- Bloods [cultures; full panel; CRP; CK]
- Imaging [XR/CT/MRI will reveal subcut gas]
Management of Nec Fasc?
- Supportive resuscitation
- Extensive surgical debridement
- Broad spec abx as per local guidelines
- Often require ITU post-op +/- hyperbaric O2
What is in a massive transfusion pack?
- Packed RBCs
- Platelets
- Fresh frozen plasma
Ratio of 2:1:1
5 commonest causes of critical bleeding?
- Trauma
- GI haemorrhage
- Ruptured AAA
- Obstetric haemorrhage
- Surgical
What is trauma’s lethal triad?
In the context of bleeding
- Hypothermia
- Coagulopathy
- Acidosis
How does Tranexamic Acid work?
- Antifibrinolytic; competitively inhibits plasminogen -> plasmin
What are recommendations for TXA in trauma?
CRASH2 trial showed improved survival in trauma patients given TXA
1g loading dose, 1g infusion
What is damage control surgery in trauma?
Damage control surgery = abandonment of definitive surgery, rapid haemostasis, packing and closure -> transfer to ICU for warming, correction of coagulopathy and inotropes -> definitive treatment undertaken later
- Used when ongoing bleeding after 10 U RBC; pH<7.2 / T<35
MDT involved in Obstetric haemorrhage?
- Anaesthetics + ODP
- Obstetrics
- Haematology / blood bank
- Radiology
- GenSurg/Urology
- Neonatologists
- Orderlies
Causes of major haemorrhage in trauma?
- Blunt vs penetrating trauma
- Chest
- Abdomen
- Pelvis
- Long bones
- Retroperitoneum
Define critical bleeding?
Major haemorrhage that is life threatening and likely to require massive transfusion.
OR smaller volume of bleeding into critical area/organ - intra-cranial, spinal or occular
Goals of management of major trauma?
- Find the bleeding + stop the bleeding
- Rapidly restore blood volume
- Maintain blood composition (and so function)
- Avoid hypothermia
What is Rhesus disease?
- Rh(-) mother exposed to Rh(+) blood will produce Anti-D antibody which can cross placenta and cause abortion of a Rh(+) foetus
- can occur with: incompatible blood or foetal-maternal haemorrhage
What are transfusion reactions?
Adverse event associated with transfusion of blood products. Can be classified as: acute (<24hrs) or delayed (>24hrs); and as immunological or non-immunological
Acute, immunological transfusion reactions?
- ABO incompatibility
- Haemolytic
- Febrile
- Urticaria
- Anaphylaxis
- TRALI
Pathophysiology of Transfusion Related Acute Lung Injury?
TRALI -> activated pulmonary neutrophils leads to non-cardiogenic pulmonary oedema; fever & shock
Symptoms of ABO incompatibility?
- chest pain, jaundice, shock, DIC
- rapid intravascular haemolysis
Acute, non-immunological transfusion reactions?
- TACO
- Sepsis
Pathophysiology of TACO?
- Increased intravascular volume -> pulmonary oedema
Define massive transfusion?
- > half of circulating volume in 4 hours
- Whole circulating volume in 24 hours
(Circulating vol is approx 70mls/kg)
Complications of massive transfusions?
- Air embolism
- Hypothermia
- Hypocalcaemia
- Citrate toxicity
- Lactic acidosis
How is blood stored?
- Fridge approx 4’C
- Solution: saline, adenine, glucose, mannitol
- Citrate
– Binds Ca++ preventing clotting
Treatment for tension pneumothorax?
Life threatening emergency.
- O2 (15L NRB)
- Urgent needle decompression -> cannula, 2nd intercostal space in mid-clavicular line
- Progress to chest drain
What is a pneumothorax?
Air in the pleural cavity
Types & causes of pneumothorax?
- Spontaneous
– Primary (thin, smoker)
– Secondary to Resp disease (COPD, bullae) - Traumatic
– Blunt
– Penetrating - Iatrogenic
– Ventilation - barotrauma
– CPR
– CVC
Treatments for recurrent pneumothoraces?
- Pleurodesis
- Surgery (thoracostomy, pleurectomy)
Contraindication to pleurodesis? Why?
- Cystic Fibrosis
- May require lung transplant in future, pleurodesis makes this complicated/impossible
What is asthma?
Chronic, reversible airway inflammation / obstruction due to bronchoconstriction.
Sensitivity to variety of stimuli.
Extrinsic - allergic
Intrinsic - non-allergic
Pathophysiology behind acute asthma attack?
- Early = bronchospasm
- Later = airway oedema and mucus
Indications for intubation in acute asthma?
- Hypoxia (PaO2 < 8)
- Hypercapnia (PaCO2 > 6)
- Drowsiness/tiring
When to refer acute asthma to ITU?
- Early!
- Acute severe / life-threatening, failing to respond to therapy
– i.e [reduced PEFR; persistent/worsening hypoxia; hypercapnia; acidosis; exhaustion; drowsiness] - Have a high index of suspicion if prev ITU admissions
Management of acute asthma?
- A-E
- Risk stratify mild / mod / severe / life-threatening
- Neb salbutamol
- PO/IV steroid
- Neb ipratropium
- IV salbutamol
- IV Mg
- Regular ABG monitoring + early escalation to critical care
Management of chronic asthma?
1) B agonist
2) + ICS
3) + LABA
4) + LTRA
5) Daily steroid
What is shock?
- Life threatening state of cellular + tissue hypoxia most commonly occurring due to circulatory failure
- If untreated -> organ dysfunction + death
Types of shock?
CHODE
- Cardiogenic
- Hypovolaemic
- Obstructive
- Distributive (due to vasodilation eg sepsis)
- Endocrine
Causes of acute renal failure?
- Pre-renal: hypovolaemia; sepsis; low CO
- Renal: ATN; hypoxia/hypoperfusion; toxin/drugs; abdominal compartment syndrome; hepatorenal syndrome
- Post-renal: obstructive uropathy
Signs of shock?
- Drowsiness
- Reduced cap refil
- Oliguria
- Hyperlactaemia
Causes of cardiogenic shock?
- Impaired contractility (MI, cardiomyopathy)
- Dysrhythmia
- Valvular dysfunction
- Left ventricular outflow obstruction
Causes of obstructive shock?
- Intravascular: PE, other emboli (Eg air)
- Extravascular: tamponade, tension PTx, hyperinflation (severe asthma), abdominal compartment syndrome,
Causes of hypovolaemic shock?
- Haemorrhage.
— Traumatic
— Non-traumatic (GI bleed, obstetric, epistaxis, coagulopathy) - Fluid loss
— DKA
— Burns
— 3rd space (pancreatitis, burns, anaphylaxis)
— Iatrogenic
Causes of distributive shock?
- Neurogenic
- Liver failure
- Adrenal insufficiency
- Anaphylaxis
- Sepsis
- Drugs
Endocrine causes of shock?
- Adrenal insufficiency
- ## Hypothyroid
Uterotonic management options?
- Bimanual compression
- Syntocinon
- Ergometrine
- Carboprost
Causes of venous thromboembolism?
Virchow’s triad
- Circulatory stasis
- Vessel wall injury
- Hypercoagulable state
Risk factors for VTE?
Primary
- coagulant deficiency
- Factor V Leiden
Secondary
- immobility, surgery, malignancy, smoking, pregnancy, COCP
ECG findings in right ventricular strain?
- T-wave inversion in II, III, aVF, V1-V4
Treatment options for PE?
- LMWH
- Thrombolysis if clinically massive PE + haemodynamic compromise
- IVC filter if anti-coag contraindiciated
Causes of cirrhosis?
- Alcohol
- NAFLD
- Congenital: haemochromatosis, wilson’s
- Autoimmune: PBC/PSC, hepatitis
Causes of ascites?
- Portal HTN
- CCF
- Intra-abdominal malignancy
Causes of abdominal distension?
- Fat
- Fluid
- Faeces
- Flatus
- Foetus
Complications of cirrhosis?
- Portal HTN
- Varices
- Coagulopathy
- Encephalopathy
- Hepatorenal syndrome
- HCC
ECG changes in Tricyclic Antidepressant overdose?
- QRS prolongation
- Right axis deviation of terminal QRS
– often also tachycardia, RBBB
Presentation of TCA overdose?
- CNS: agitation, seizures, coma
- CVS: tachycardia, broad complex tacyhydysrhhythmia
- Anticholinergic:
Treatment of TCA overdose?
- Intubation + ventilation - hyperventilation for pH > 7.5
- IV Sodium Bicarbonate
- IV fluids
- ITU
Patholophysiology of TCA overdose?
- Blocks fast Na+ channels (most common in right heart)
- Anti-cholinergic
Antibiotic use in neutropenic sepsis?
- Broad spectrum (Gent / Pip/Taz)
- If abdominal source + metronidazole
- If MSRA+ -> + vancomycin
- If failure to improve -> + anti-fungal
- Remove indwelling lines
- Reverse barrier nurse in side room
Causes of hypercalcaemia?
- Hyperparathyroid
- Malignancy (lysis of bone or PTHrP)
- Drugs (thiazide)
- Hyperthyroidism
- Addison’s
- Sarcoid
Symptoms of hypercalcaemia?
- Bone pain
- Depression
- Abdominal pain
- Renal stones
Symptoms/signs of hypocalcaemia?
- Tingling
- Cramps
- Chvostek (tap -> mouth twitch)
- Trousseau’s (carpopedal spasm with BP cuff)
- Hyperreflexia
- Seizure
Calcium regulation?
- PTH
- Calcitonin
- VItamin D
what is myeloma?
- Haematological cancer
- Proliferation of plasma cells
- Treatable but not curable
Complications of sickle cell disease?
- Vaso-occlusive crisis
- Aplastic crisis
- Sequestration crisis
- Haemolytic crisis
Pathophysiology of vaso-occlusive crisis in sickle cell disease?
- Sickle-shaped RBCs obstruct capillaries and restrict blood flow –> ischaemia, pain, necrosis, organ damage
Management of vaso-occlusive crisis?
- Supportive
- Analgesia
- RBC transfusion
Causes of haemolysis?
- Acquired [autoimmune; prosthetic valves; malaria; drugs]
- Congenital [hereditary spherocytosis; G6PD deficiency; sickle cell; thalassaemia]
What is sickle cell disease?
- Congenital
- HbS haemoglobinopathy causing rigid, distorted & dysfunctional erythrocytes
Precipitants to sickle cell crisis?
- Infection
- Dehydration
- Hypoxia
- Drugs
What triggers aplastic crisis in sickle cell?
- Parvovirus
