Clinical Presentations I Flashcards
When to call arrest team in a peri-arrest
If concerned about A B or C
When to call the anaesthetist on D
When GCS <=8
What to do for ABCDE for basic life support
Airway - speak to patient, check in mouth, suction if required, triple airway manouvure
Breathing - listen, look and feel, listen to chest and look for equal expansion, resp rate, non-rebreathe 15 litres, saturations
Circulation - HR, ECG, two wide bore cannulas with IV access and bloods taken off the back, listen to chest
Disability - glucose, eyes, quick neuro exam and GCS
Exposure - remove all clothing, check temp, look for rash
Who usually makes up an arrest team
Leader - registrar, F1 - access/defib and BLS, anaesthetist (airway), nurses - BLS and drugs, timepoints and ECG
What blood test should always try to be achieved in an arrest
VBG
What are the three common ALS drugs
Adrenaline (1mg/10ml -1/10,000), atropine, amiodarone 300mg in 10ml
ALWAYS give with large flush (20ml) to encourage it to go centrally. 99% of things will be found on the trolley
What to do if a shockable rhythm is present
VT/VF –> deliver a shock –> CPR cont. 2 mins –> adrenaline every 3-5 mins –> shock then CPR –> shock then CPR –> amiodarone after 3 shocks.
What should be done by the leader during an arrest
Building picture of patients PMH and ruling out the four Ts and four Hs.
What are the 8 reversible causes (4T’s and 4H’s)
Thrombosis, tamponade, toxins, tension pneumothorax
Hypoglycaemia, hypoxia, hyper/hypo-kalaemia, Hypovolaemia
Things to do if spare in an arrest
Scribe, steady hand for IV access, find patient history
What are the stages of maintaining the airway in ALS
Triple airway manoeuvre
Nasopharyngeal airway (6-7mm) - horizontal with lubrication and safety pin. Don’t use if significant head injury
Oropharyngeal airway - angle of mouth to mandible. Insert upside down and rotate.
Suction - clear if required.
Intubation - anaesthetics.
What are the stages of maintaining breathing in ALS
Usually go for 15litre non-rebreathe with pulse oximeter and resp rates
Simple to advanced -
Nasal cannula (1-4L/min)
Simple face mask (Hudson mask) (5-10 L/min)
Venturi mask (can give exact % - used in COPD with type 2 resp failure)
15 litre non-rebreathe/reservoir
May require salbutamol nebuliser
What are the stages of maintaining circulation in ALS
Defibrillator (monitor mode), IV access large bore both sides with bloods, BP, HR
What are the stages of maintaining disability in ALS
Finger prick glucose
Eyes - RAPD or PEARL
GCS
Neuro exam if possible
What are the stages of maintaining exposure in ALS
Temp
Top to toe inspection and secondary survey for internal bleeding and rashes
What are the parts of the secondary survey
Exposure for injuries - has my critical care assessed patient priorities or next management decision (acronym)
AMPLE - allergies, medications, PMH, last meal, events leading up to presentation
What is the has my critical care assessed patient priorities or next management decision acronym for secondary survey
Has - head/skull
My - maxillofacial
Critical - cervical spine
Care - chest
Assessed - abdomen
Patient’s - pelvis
Priorities - perineum
Or - orifices (PR/PV)
Next - neurological
Management - msk
Decision - diagnostic tests and definitive care
Name 5 places to check for catastrophic bleeding
On the floor and four more -
Floor, long bones, cranium, chest, abdomen
Pulses to check in infant CPR
Brachial
Chest compression ration in any child or infant
15:2
Stages of a neonatal arrest
Dry baby –> assess tone, RR and HR, –> gasping or not breathing then 5 rescue breaths –> 5 rescue breaths –> HR<60 or undetectable CPR
What are the two major differences in an obstetric arrest
Left lateral position 15 degrees
Emergency surgery within 5 minutes if no success as improves chest compression and venous return for the mother. Mother takes priority over baby.
How would you approach a patient with acute chest pain and think about scans or test to do
Hx - SOCRATES, any associating symptoms, pain on eating, postural pain, pain on moving, pain on breathing, cold symptoms, PMH, drugs and allergies
A - patency
B - RR, sats, listen to chest, percuss and feel trachea, O2 if needed
C - ECG, BP, listen to hear, IV access with bloods (FBC, U+E, D-dimer, troponin, LFT, CRP), HR, CRP, fluids if needed
D - glucose, Eyes, GCS, quick neuro exam
E - expose patient and examine, check abdo and legs, temp
Scans - CXR, ECG, bloods, ECHO (wall motion abnormalities)
Call for senior help
Reassess from ABCDE
Medication to give - morphine, cyclizine, treatment for diagnosis
Possible diagnoses for acute chest pain
ACS, pneumothorax, pneumonia, pericarditis, PE, pulmonary oedema, anxiety, costochondritis, peptic ulcer disease, reflux, myocarditis, cardiac tamponade, sickle cell crisis
How to tell the difference between the 3 ACS’s
STEMI - raised ST on ecg and raised troponin
NSTEMI - T wave inversion, q waves, raised troponin
Unstable angina - ST depression, T wave inversion and no elevated troponin
Features that point towards pericarditis/myocarditis on examination
Pericardial rub, fever, recent flu/cold
What to check on examination if suspected aortic dissection
Tearing between scapulas so check if dirrences in both radial pulses.
CXR - widened mediastinum
What is heard in pneumonia on the chest
Basal crepitations
fine - alveoli
coarse - wider airways
When is troponin sensitive for MI
3-12 hours after myocardial necrosis
Other causes of raised troponin
sepsis
hypovolemia
atrial fibrillation
congestive heart failure
pulmonary embolism
myocarditis
myocardial contusion
renal failure
What is the acute treatment for a STEMI
Remember and see if it rests as you investigate and before giving treatment - could be stable angina
MOANAA - Morphine, oxygen, aspirin, nitrites (GTN), atenolol (beta-blocker)
Anti-emetic
PCI <2hrs or thrombolysis
Continuous ECG monitoring thereafter with DVT prophylaxis
What is the secondary prevention for a STEMI
5 As - Aspirin, anti-platelet (clopidogrel), atenolol (BB), atorvastatin, ACEi
What is the acute treatment for a NSTEMI
BATMAN -
Beta blockers, aspirin, ticagrelor, morphine, anticoagulant (LMWH - fondaparinux), nitrates - GTN
Anti-emetic
GRACE score for PCI
What is the difference between unstable angina and NSTEMI
NSTEMI - positive troponin and chest symptoms and ECG signs
UA - negative troponin but chest symptoms and possibly ECG signs
What is the acute treatment for unstable angina
BATMAN -
Beta blockers, aspirin, ticagrelor, morphine, anticoagulant (LMWH - fondaparinux), nitrates - GTN
Anti-emetic
GRACE score for PCI
What is the treatment for stable angina
Investigate as NSTEMI
GTN and morphine
What is the secondary prevention for stable angina
5A’s - atenolol, ACEi, aspirin, anticoagulants (clopidogrel), atorvastatin,
How is an aortic dissection investigated
Radial-radial delay and tearing chest and back pain with hypertension usually.
FBC, troponin, U+Es, CRP, ECG, CXR (widened mediastinum), TOE
How is an aortic dissection acutely managed
Senior help ASAP
If hypotensive - treat as shock, two large bore cannula with bloods and fluid bolus (speak to senior first)
If hypertensive - ACEi or CCB (speak to senior first)
How is an aortic dissection managed long-term
Type A (ascending aorta) - surgery
Type B - (descending aorta) - conservative management
How to manage MSK chest pain
Usually sorer on palpation and movement with negative cardiac investigations
Reassure with simple analgesia
How to manage pericarditis
Pleuritic chest pain worse on lying flat and deep inspiration with recent viral illness and pericardial rub
Reassurance and NSAIDs/paracetamol, settles in 2-4 weeks
How to investigate a tachyarrhythmia emergency
Brief history - pain, associated symptoms, PMH, D+A,
Airway
Breathing - O2, sats, RR
Circulation - listen to heart, CRT, HR, BP, IV access, bloods (FBC, U+E, LFT, TFTs, troponin, CRP, VBG,), ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp
How to treat tachyarrhytmia’s
If shock or syncope - 3 DC shocks –> Amiodarone 300mg IV –> shock –> amiodarone 300mg IV over 24 hrs
Narrow and regular (SVT) - vasovagal –> 6mg –> 12mg –>12mg
Narrow and irregular (AF) - Beta blocker (if HF then amiodarone/digoxin)
Broad and regular (VT) - ALWAYS CHECK FOR CAROTID PULSE (no pulse then CPR) if pulse - Amiodarone 300mg IV over 20-60mins then 900mg over 24 hrs
Broad and irregular - amiodarone
How is AF managed acutely
If shock or syncope - 3 DC shocks –> Amiodarone 300mg IV –> shock –> amiodarone 300mg IV over 24 hrs
If no shock/syncope - Beta blocker/CCB
Unless HF then flecainide/amiodarone or DC cardiovert
Investigate cause
Can do HASBLED and CHADVASC score if time
How is atrial flutter managed
IV access and bloods
Monitor rhythm
Vagal manouvures –> DC cardioversion
What drugs to avoid in WPW syndrome and how to treat
Verapamil and digoxin
Need electrophysiology studies before ablation of the accessory pathway.
What is the acute treatment for VT
If pulseless - call arrest team and start BLS
If pulse - IV access, bloods, amiodarone or DC cardioversion
Causes of prolonged QT
Amiodarone, fluoxetine, haloperidol, loratadine, fluconazole, erythromycin and clarithromycin.
Low magnesium, low potassium and low calcium
Sinus brady and complete heart block
SAH
Myocarditis
How to treat torsades de pointes
2g IV over 15 mins of magnesium sulphate
How is a bradyarrhythmia acutely managed
Brief history - pain, associated symptoms, PMH, D+A,
Airway
Breathing - O2, sats, RR
Circulation - listen to heart, CRT, HR, BP, IV access, bloods (FBC, U+E, LFT, TFTs, troponin, CRP, VBG,), ECG, ATROPINE
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp
If shock or syncope risk - atropine 500 micrograms IV - can repeat up to 6 times –> transvenous pacing
If no adverse features - observe
Work out cause
Causes of bradyarrhythmias
Inferior MI (RCA infarction)
Drugs - digoxin, BB, calcium antagonists, amiodarone, ivabradine
Cushings reflex
Thyroid disease
Anorexia
Hypothermia
Type 3 HB
Treat the same way acutely
What is the long-term management of symptomatic bradycardia
Pacemaker
How to treat a hypertensive emergency acutely
Brief history - pain, associated symptoms, PMH, D+A,
Airway
Breathing - O2, sats, RR
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG,), ECG, GET SENIOR HELP
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp
Usually give -
No LVF- labetalol IV
LVF - Furosemide and hydralazine
Give 6 causes of a hypertensive emergency
Pre-eclampsia
Malignant hypertension
Hypertensensive encephalopathy
Phaemochromocytoma
Thyrotoxic storm
Cushing’s reflex
End-organ damage signs of a hypertensive emergency (>200/120)
CNS - reduced GCS, vomiting and headache, confusion
Eyes - visual disturbance, papilloedema
Heart - chest pain, orthopnoea
Aorta - shearing back pain and collapse
Kidney - haematuria and lethargy
How to deal with acute heart failure
Brief history - pain, associated symptoms, PMH, D+A,
Airway
Breathing - O2, sats, RR, CXR, sit up
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG,BNP), ECG, IV furosemide, stop fluids
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp
Treat like pulmonary oedema in acute compensation - Sit up, O2, furosemide
How is chronic heart failure managed
Beta blockers and ACEI –> Increase doses –> spironolactone and ARB –> ivabradine or cardiac resync therapy
What is the chronic management for hypertension
<55/diabetic – ARBs/ACEI thiazide like diuretic/CCB + thiazide-like diuretic/CCB
> 55/ afrocaribbean – CCB ARB/ACEi or thiazide like diuretic ARB/ACEi or thiazide like diuretic
Next is based of K levels –
<=4.5 spironolactone
>=4.5 BB or alpha blocker
How to manage a breathlessness and low SATS emergency
Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A,
Airway
Breathing - O2, sats, RR, CXR, sit up, salbutamol nebuliser
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs!
Treat appropriately, usually can give salbutamol nebs to help
Life-threatening causes of SOB
PE
AECOPD
Asthma
Pneumonia
Pneumothorax
Pulmonary oedema
MI
Anaphylaxis
Signs of upper airway obstruction and management
Stridor and call anaesthetist
Signs of a lower airway obstruction and management
Wheeze - salbutamol nebs, hydrocortisone, impatropium nebs
Signs of a tension pneumothorax and management
Tracheal deviation and shock
2nd intercostal space wide bore cannula
Signs of pneumonia and management
Asymmetrical coarse crackles, bronchial breathing and reduced air entry
Oxygen, fluids and abx
Signs of LVF and management
Reduced air entry, raised JVP, symmetrical fine crackles
Sputum colour for pulmonary oedema
Pink and frothy
Features of ARDS
Hypoxia, fever, amjor insult (sepsis, surgery, pancreatitis)
New bilateral infiltrates on CXR
How is acute asthma managed
Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A,
Airway
Breathing - O2, sats, RR, CXR, sit up, hyperinflated chest with wheeze, salbutamol nebuliser (every 10-15mins and reassess), ipatropium nebuliser, prednisalone/hydrocortisone, (senior - theophylline, magnesium sulphate, escalate)
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs!
O SHIT ME - oxygen, salbutamol, hydrocortisone, ipatropium, theophylline, magnesium sulphate, escalate
When to call ICU in acute asthma attack
Normal or rising CO2
Poor RR
Exhaustion
Cyanosis
Reduced GCS
Silent chest
Sats <92%
What is the chronic treatment for asthma
SABA +ICS –> SABA,ICS,LABA –> medium ICS, SABA, LABA –> specialist
How would you treat an acute exacerbation of COPD
Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A,
Airway
Breathing - O2, sats, RR, CXR, sit up, hyperinflated chest with wheeze, salbutamol nebuliser (every 10-15mins and reassess), ipatropium nebuliser, prednisalone/hydrocortisone, antibiotics (amox/clarithromycin), theophylline, NIV
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer, blood cultures), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs!
ABG every 30 minutes at least. Consider ICU referral
What is the chronic management for COPD
SABA
ICS if atopy, high esinophils or reversible nature
LABA and LAMA if none of above
SABA, ICS LABA and LAMA 3rd line –? consider long-term O2 therapy
Flu and pneumococcal vaccines.
How is pneumonia acutely managed
Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, RR, CXR, sit up, crepatations in base with purelent sputum and consolidation and bronchial breathing.
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer, blood cultures), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, urine dip for pneumoccocal and legionella antigen
CURB65 score to determine if admission is required. Give antibiotics per local guidelines, IV fluids, anti-emetics, pain relief.
CURB65 score features
new onset confusion; urea >7 mmol/L; respiratory rate ≥30/minute, systolic blood pressure <90 mmHg and/or diastolic blood pressure ≤60 mmHg; and age ≥65 years.
0-1: Treat as an outpatient
2: Consider a short stay in hospital or watch very closely as an outpatient
3-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit
Risk factors for aspiration pneumonia
Reduced GCS
Oesophageal pathology
Dementia
PD
MS
Involve SALT and chest physio
How are pulmonary embolisms managed acutely
Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, RR, CXR, sit up, usually normal
Circulation - listen to heart, CRT, HR (tachy), BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer), ABG, ECG (sinus tachy or S1Q3T3)
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs
Get a wells score for PE, fluids, CTPA, based off BP give enoxaparin or thrombolysis (alectaplase) if systolic <90mmhg.
How is a spontaneous pneumothorax managed
Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, RR, CXR, sit up, hyperresonant on one side with reduced breath sounds, check for tracheal deviation.
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs
Definitive management depends on primary or secondary and size
Tension – 2nd intercostal midclavicular line rapid cannula insertion then chest drain.
Primary –
<2cm and asymptomatic – go home and review in clinic (2-4 weeks)
>2cm and/or symptomatic – stay in and aspirate and if unsuccessful then chest drain.
Secondary –
<1cm – monitor
1-2cm - aspirate
>2cm or SOB – chest drain
How are pleural effusions managed acutely
Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, listen to chest, RR, CXR (loss of costophrenic angle and meniscus line), sit up, stony dull on one side with reduced breath sounds, and unilateral reduced chest expansion check for tracheal deviation.
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer, blood cultures), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs
Chest aspiration to aid diagnosis done by senior. Treat cause
What are the two types of pleural effusions
Lights criteria -
transudates <25g/l - pulomary oedema, nephrotic syndrome and hypothyrodism
Exudates >35g/l - malignancy, infection, RA,
Acidic - empyema (infection)
What is the acute management of pulmonary oedema
Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, listen to chest, RR, CXR (blunting of costophrenic angles, cariomegaly, alveolar oedema, kerly b lines), sit up, crackles bilaterally
Circulation - listen to heart, CRT, HR, BP, raised JVP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, BNP, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, catheter
Give furosemide (40mg, can give up to 120mg) and diamorphine IV. Then guided by blood pressure -
<100 systolic - probs cardiogenic shock so get senior for inotropes
>100 systolic - GTN and IV nitrates
Wheezing - treat like COPD
Once stabilised the patient needs a fluid restriction and daily weights and an ECHO.
How is SVC syndrome managed acutely
Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway (distended facial veins), stridor (senior help immediately including anaesthetist)
Breathing - O2, sats, RR, CXR, sit up,
Circulation - listen to heart, CRT, HR, BP, raised JVP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, BNP, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs
Rx - dexamethasone IV and diuretics with quick senior input.
How is stridor managed acutely
Do NOT take history - medical emergency but try to find out if theyre choking
Airway, stridor (senior help immediately including anaesthetist and ENT), dont examine neck,
Breathing - O2, sats, listen to chest, RR, CXR, sit in any position comfortable, give nebulised adrenaline
Circulation - listen to heart, CRT, HR, BP, raised JVP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, BNP, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, rashes? anaphylaxis
Give some life threatening causes of stridor
Infection
Tumour
Trauma
Foreign body
Post-op
Anaphylaxis
How is massive haemoptysis managed
Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, CXR, sit up,
Circulation - listen to heart, CRT, HR, BP, raised JVP, IV access, blood (FBC, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer, blood cultures), ABG, ECG, fluids if in shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs
Refer to resp team for CT throax and bronchoscopy
How is bronchiectasis managed acutely
Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, CXR, sit up, salbutamol nebs and corticosteroids, antibiotics, BIPAP
Circulation - listen to heart, CRT, HR, BP, ECG, raised JVP, IV access, blood (FBC, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer, blood cultures), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, chest physio
How to manage abdominal pain acutely
Brief history - pain, associated symptoms (bowel movements, vomiting, dysphagia, haematemsis, malena, last menstrual period, bleeding pattern), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, erect CXR (perforation), sit up
Circulation - listen to heart, ECG, CRT, HR, BP, raised JVP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer), ABG, ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, rebound tenderness, suprapubic tenderness, hernia check, bruits and bowel sounds, PR, urine dip and PREGNANCY TEST
Pain relief, anti-emetics, AXR/CT KUB non-contrast, PR exam and NBM, abx if peritonitic or abdominal sepsis, AAA -USS at bedside, urgent senior review
Give some life-threatening causes of abdo pain
AAA rupture
AAA dissection
Ectopic rupture
Bowel obstruction
Ulcer perforation
Strangulated hernia
Testicular/ovarian torsion
Acute pancreatitis
Acute cholangitis
Appendicitis
MI
How is bowel perforation managed acutely
Brief history - pain, associated symptoms (bowel movements, vomiting, dysphagia, haematemsis, malena, last menstrual period, bleeding pattern), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, erect CXR (perforation), sit up
Circulation - listen to heart, CRT, HR, BP, raised JVP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer), ABG, ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, rebound tenderness, suprapubic tenderness, hernia check, PR, bruits and bowel sounds, urine dip and PREGNANCY TEST
Abx (co-amoxiclav), fluids, anti-emetics (cyclizine), analgesia, NBM, NG tube and catheter with urgent senior review - gen surgery (likely ask for CT abdo and ready for surgery)
How to manage bowel obstruction acutely
Brief history - pain, associated symptoms (bowel movements, vomiting, dysphagia, haematemsis, malena, last menstrual period, bleeding pattern), PMH, D+A
Airway
Breathing - O2, sats, RR, ECG, listen to chest, erect CXR (perforation), sit up
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer), ABG, ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, rebound tenderness, suprapubic tenderness, hernia check, PR, bruits and bowel sounds, urine dip and PREGNANCY TEST
Small bowel - Drip and suck - fluids (remember K replacement) and reverse NG tube to decompress the stomach. Give anaelgesia too. If doesnt work after 2/3 days then surgery. Refer early. Likely ask for a CT abdo.
Large bowel - drip and suck and will likely need surgery so refer. Likely ask for CT abdo.
Paralytic ileus - drip and suck with med review and electrolyte review to rule out causes. Usually not painful unlike true small and large bowel obstruction.
How is bowel ischaemia/infarction managed
Brief history - pain, associated symptoms (bowel movements, vomiting, dysphagia, haematemsis, malena, last menstrual period, bleeding pattern), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, erect CXR (perforation), sit up
Circulation - listen to heart, ECG, CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer), ABG (acidosis), ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, rebound tenderness, suprapubic tenderness, hernia check, PR, bruits and bowel sounds, urine dip and PREGNANCY TEST
NBM, antibiotics, heparin, IV fluids and analgesia, might need surgery.
How is appendicitis managed
Brief history - pain, associated symptoms (bowel movements, vomiting, dysphagia, haematemsis, malena, last menstrual period, bleeding pattern), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, erect CXR (perforation), sit up
Circulation - listen to heart, ECG,CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, CRP, VBG), ABG (acidosis), ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, rebound tenderness, suprapubic tenderness, hernia check, PR, Rosving positive, bruits and bowel sounds, urine dip and PREGNANCY TEST
Inform senior - NBM, IV fluids, analgesia, IV abx, immediate surgery only if peritonitic.
How is dyspepsia managed
Hx - ask about pain, acid reflux, nausea, vomiting, back passage
Ex - abdo exam - epigastric pain, peritonitis, PR
Ix - ALARM or 55 and above then urgent endoscopy, urea breath test (No PPI for 2 weeks beforehand), bloods
Rx - treat triple therapy (amox, clarithromycin and lansoprazole), weight loss and stop smoking, antacids
How is diverticular disease managed
Hx - pain (LIF), bowel habit, fever, diet, blood, bloating
Ex - RIF pain, PR, fever, peritonitis
Ix - Bloods, colonoscopy (only to exclude other causes)
Rx - high fibre diet, abx and fluids if infection, laxatives and buscapan
How is renal colic managed
Hx - flank to groin pain, haematuria, fever, dysuria, vomiting
Ex - flank tenderness, positive urine dip
Ix - urine dip, Bloods, CT-KUB, pregnancy test if female
Rx - depends on size of stone, IM diclofenac, opiods, fluids, abx (if infection signs), urology opinion for stones >5mm and/or hydronephrosis (nephrostomy)
How is biliary colic managed
Hx - colicky abdo pain in RUQ, no jaundice, vomiting, nausea
Ix - USS abdo, bloods
Rx - elective cholecystectomy and analgesia
How is acute cholecystitis managed
Hx - RUQ pain, unwell and vomiting, Murphys sign positive
Ix - USS abdo, LFTs, FBC, CRP
Rx - NBM, analgesia, abx, ERCP
How is acute pancreatitis managed
A - idiopathic, gall stones, alcohol, steroids, mumps, SV, ERCP
S - severe epigastric pain radiating to back, vomiting, anorexia, shock, epigastric tenderness, turners sign.
Ix - FBC, Lipase, amylase, glucose (up), low calcium, deranged clotting, LFTs, USS for gallstones, CT abdo if doubt, glasgow-eimre score
Rx - IV fluids, oxygen analgesia, NBM and NG tube, ERCP, close monitoring.
How is chronic pancreatitis managed
S - weight loss, steatohrrea, anorexia, DM, bloaing, epigastric tenderness
Ix - gkucose, stool elastase, USS, CT/MCRP
Rx - avoid alcohol, fat soluble vitamins, high protein diet, pancreatic enzymes (creon), coeliac plexus block, pancreatectomy
How is an overdose managed
Brief history - pain, associated symptoms, what the took, when they took it, how much they took, how they were found, any alcohol consumed too, MSE, PMH (previous overdoses), D+A, SH (who they live with and relationships with friends and family
Airway - beware of vomiting
Breathing - O2, sats, RR, listen to chest, sit up
Circulation - listen to heart, ECG,CRT, HR, BP, IV access, blood (FBC, U+E, LFT, CRP, VBG), ABG, ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation
Inform senior, gastric lavage if within an hour, look on toxbase for treatment and antedote, get in touch with liaison psych, MHA needed?
How is a salicylate/aspirin overdose managed
S - vomiting, increased RR, tinnitus, vertigo, sweating
Ix - resp alkalosis then metabolic acidosis, deranged glucose, high salicylate levels, routine bloods, ECG
Rx - activated charcoal if <1hr, sodium bicarbonate and haemodilaysis if severe
How is a trycyclic antidepressant overdose managed
S - dilated pupils, blurred vision, reduced GCS, seizures, tachycardia, dysrhythmia
Ix - ABG (acidosis), ECG (prolonged PR and QRS), routine bloods
Rx - activated charcoal if <1hr, sodium bicarbonate
How is a digoxin overdose managed
S - nausea, confusion, yellow haloes around lights
Ix - routine bloods (hypokalaemia), ECG (reverse tick/upsloping ST segment)
Rx - digibind/dogoxin specific antibody
How is an opioid overdose managed
S - low RR, low GCS, pinpoint pupils, constipation
Ix - ABG (resp acidosis), routine bloods, opioids on urine drug screen
Rx - naloxone, can be repeated or given as a continuous infusion and fluids given to flush out opioids
How is a benzodiazepine overdose managed
S - low GCS, low bp, low tone, hypoflexia
Ix - ABG (resp acidosis), blood and urine toxicology
Rx - activated charcoal if <1hr, flumenazil
How is a ecstasy/cocaine overdose managed
S - thirst, confusion, agitation, tremor, dilated pupils, high HR, BP and temp
Ix - urine toxicology, ECG arrhythmias
Rx - lorazepam/diazepam
What is the criteria used to assess the risk after a suicide attempt
SAD PERSONS criteria
How is a paracetamol overdose managed
Brief history - pain, associated symptoms, what the took, when they took it, how much they took, how they were found, any alcohol consumed too, MSE, PMH (previous overdoses), D+A, SH (who they live with and relationships with friends and family
Airway - beware of vomiting
Breathing - O2, sats, RR, listen to chest, sit up
Circulation - listen to heart, ECG,CRT, HR, BP, IV access, blood (FBC, U+E, LFT (raised ALT), CRP, VBG), ABG, ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation
Inform senior, charcoal if within an hour, get in touch with liaison psych, MHA needed?, start NAC if staggered dose or above the treatment level.
How is vaginal bleeding managed
S - pain SOCRATES, associated symptoms (amount of blood, clots, LMP, chances of pregnancy, difference in discharge, any lumps trauma, weight loss, effect on lifestyle, anaemia symptoms - SOB, dizziness, fatigue, headache), PMH (previous epsisodes, pregancies, miscarriges, last smear, D+A (COCP, HRT, tamoxifen, anticoagulants), feel for pelvic masses, speculum exam, prolapse, rashes
Ix - BhCG, FBC, CRP, clotting, U+Es, LFT, USS (transvaginal), genital swabs if infection
Rx - treat shock if present, if positive pregnacy test assume ectopic until proven otherwise (two large bore cannulas, Cross-match 4 units, laproscopy), if post-menopasal then refer to PMB clinic
Give some possible causes of vaginal bleeding
Ectopic
Miscarriage
Dysfunctional uterine bleeding
Fibroids
Endometrial cancer
PID
Ectropion/erosion
Polyps
Cervical cancer
Ovarian cancer
Clotting abnormality
How is cervicitis/vaginitis managed
S - itching, vaginal discharge, dysuria, abnormal odour, small amounts of bleeding, vaginal/cervial erythema
Ix - genital swabs
Rx - treat cause with abx/antifungals or oestrogens (atrophic vaginitis)
How is an ectopic pregnancy managed
S - pain in shoulder and back, SOCRATES, associated symptoms (PV bleeding, recent amenorrhoea, dizziness, shock, amount of blood, clots, LMP, chances of pregnancy, difference in discharge, any lumps trauma, weight loss, effect on lifestyle, anaemia symptoms - SOB, dizziness, fatigue, headache), PMH (previous epsisodes, pregancies, miscarriges, last smear, D+A (COCP, HRT, tamoxifen, anticoagulants), feel for pelvic masses, speculum exam, guarding, cervical excitation
Ix - BhCG (serum and uterine), routine bloods, G+S and crossmatch, clotting, transvaginal USS (Sac and free fluid)
Rx - surgical - (2 large bore cannula, IV fluids, urgent gynae referral for laproscopic salpingectomy)/ medical (methotrexate if <3.5cm and no pain)
How is dysfunctional uterine bleeding managed
S - heavy bleeding during periods only, interfering with daily activities, otherwise well, normal systemic and gynae exam
Ix - routine bloods (iron deficiency anaemia possibly)
Rx - tranexamic acid/ COCP/Mirena coil
How is cervical ectropion managed
S - postcoital bleeding, intermenstrual bleeding, menorrhagia, red flare or ring around external cervical orofice on speculum exam
Ix - clinical and smear test
Rx - change of contraception, usually none though
How is cervical/endometrial polyps managed
S - menorrhagia, intermenstrual, postcoital or postmenopausal bleeding, visible on speculum exam
Ix - hysteroscopy and polypectomy
Rx - surgical removal with silver nitrate
How are fibroids managed
S - may be asymptomatic, menorrhagia, dragging feeling, prolonged periods, urinary incontinence or increased frequency, INFERTILITY, palpable mass on abdo or vaginal exam
Ix - routine bloods (may have anaemia), pelvic USS
Rx - GnRH agonists, embolization, myomectomy or hysterectomy
How is endometrial cancer managed
S - post-menopausal or intermenstrual bleeding, menorrhagia, watery vaginal discharge, lower abdo pain, dyspareunia, weight loss, usually no signs on examination
Ix - transvaginal USS (endometrial thickness), pipelle biopsy, hysteroscopy for further biopsies
Rx - hysterectomy and bilateral salpingo-oophrectomy, radiotherapy and palliative treatment with radiotherapy may be an option
How is cervical cancer managed
S - young women usually but can be middle aged too, asymptomatic is common as comes up on smear, postcoital bleeding and pain, ulceration, mass on examination, post-menoapusal bleeding or intramenstrual bleeding
Ix - cervical smear, colposcopy, biopsy, CT/MRI for staging
Rx - low stage is surgery and radiotherapy and high grade is chemo and radiotherapy
How is ovarian cancer managed
S - lower abdo pain, weight reduction, bloating, irregular periods, postmenopausal bleeding, urinary infrequency, adnexal mass, abdo mass, ascities, pleural effusions, DVT
Ix - CA125, alpha fetoprotein, BHCG, USS pelvis and CT thorax, abdo, pelvis for staging
Rx - surgery +/- chemo
How is PID managed
S - lower abdo pain, vaginal discharge, intermenstraul/postcoital bleeding, pyrexia, dysuria, dysparenuia, nausea, vomiting, infertility, general malaise, abdo tenderness, adnexal tenderness, cervical excitation
Ix - MSSU, genital swabs for MC+S, routine bloods, USS (excludes ovarian cyst)
Rx - IV fluids, analgesia, remove IUCD, IV abx, refer to GUM
How is ovarian cyst/torsion managed
S - severe, sudden lower abdo pain, radiating to flank and causing nausea and vomiting, fever, abdo tenderness, may have signs of shock
Ix - serum BhCG, routine bloods, urine dipstick and MSSU, pelvic USS
Rx - immediate gynae referral, IV fluids and analgesia, urgent laproscopy
How is endometriosis managed
S - painful periods, pelvic pain before and durign periods, deep dysparenuia, infertility, rectal pain, generalised abdo pain
Ix - laproscopy
Rx - medical (COCP or GnRH agonists)/ surgery (laproscopic diathermy or excusion, bilateral salpingooopherectomy and hysterectomy)
What are the 5 options for contraception
Barriers - condoms, femidoms
IUCD - mirena coil (progesterone only) or copper IUD (both can cause bleeding, ectopics and perforations)
Oral - COCP or POP
Hormones - implants (3 years) and injections (3 months)
Sterilization - more effective in males
Give some side effects and cautions for oral contraceptive pills
S/E - acne, altered menstrual pattern, breast tenderness, bloating, weight gain, mood changes, nausea, DVT/PE, hypertension, migraines
Cautions - smokers, DM, hypertension,>35years old, BMI>30
COCP advice for missed pills
1 missed pill - take immediately then no extra precautions needed
> 2 - take next pill at normal time and other contraception for 7 days. Start another pack without a break if due to finish pack within 7 days. Emergency contraception if in last 7 days
POP advice for missed pills
If >12hrs take missed immediately and continue as normal contraception if within 48hr
What is the advice for oral contraception if patient has diarrhoea or vomiting
Barrier contraceptions until 7 days after resolution of symptoms
What is the risks of taking HRT
PE/DVT
Stroke
Breast cancer
Ovarian cancer
Endometrial cancer
What is the treatment options for emergency contraception
Levonorgesterel - 3 days
Copper IUD - 5 days
Ulipristal - 5 days
