Core conditions 2 Flashcards
Wound healing
- Haemostasis: vasoconstriction and activation of the coagulation cascade to prevent further bleeding
- Inflammation: neutrophils, macrophages and a range of other cell types enter the wound to maintain its cleanliness and attract other cell types
- Cell proliferation: granulation tissue provides a scaffold for the formation of new blood vessels (re-vascularisation)
- Epithelialisation: epithelial cells migrate from the wound edges to cover the wound defect
- Tissue remodelling: iterative breakdown and rebuilding of the wound’s extracellular matrix resulting in gradual improvement in the tensile strength of the wound
Colours of a wound
- Pink (epithelialisation phase)
- Red (granulation/proliferation phase)
- Yellow (sloughy/granulation phase)
- Black (necrotic tissue/eschar)
- Wounds with signs of infection (e.g. offensive smell, excess pus, spreading erythema
Cleaning the wound
- Disinfect around the wound with antiseptic
- Keep hair out of wound
- If debriding anaesthetize the area
- Clean out foreign material
- Irrigate the area with saline, drinking water or cooled boiled water
- Dress but don’t close the wound
Antibiotics for an open wound
- Contaminated: co-amiclav
- If allergic to penicillin use erythromycin or clarithromycin combined with metronidazole
- 7-10 days of antibiotics
- For wounds with no contamination or foreign bodies use flucloxacillin, if allergic use erythromycin or clarithromycin
- Take swab before starting treatment
When to give human tetanus immunoglobulins
- Wounds that require surgical intervention that is delayed for more than six hours.
- Wounds that show a significant degree of devitalised tissue or a puncture-type injury, particularly where there has been contact with material likely to contain tetanus spores (for example soil or manure).
- Wounds containing foreign bodies.
- Compound fractures.
- Wounds in people who have systemic sepsis.
Give tetanus booster unless fully immunised
What are the two pathways of incident reporting
- Information governance and cyber security incidents
- Health and safety incidents
What are the three types of incidents
Near misses
Incidents
Serious incidents
What are usually the 2 main symptoms of palliative patients
Pain
Difficulty breathing
Confusion screen investigations
Bloods: FBC, U&Es, LFTs, Coagulation/INR, TFTs, Calcium, B12 + folate, Glucose, Blood cultures
Urinalysis
Imaging: CT head, CXR
What are anticipatory medications
Medications to keep a patient comfortable while they are dying
Key anticipatory meds
Pain: Morphine – SC or PO.
Agitation, N+V: Haloperidol – Antipsychotic in agitated delirium.
Agitation, anxiety: Midazolam – BZD can be trialled if very anxious. Do not use opioids as sedation.
N+V: Levomepromazine or cyclizine – used mostly in end of life sickness and agitation
Secretions: hyoscine butylbromide
What are the different levels a patient can be triaged to after coming into the emergency department using the Manchester triage score
Walk in and see
Ambulatory care
High intensity monitoring
Resus
What are the 5 urgency categories in the manchester triage system
Blue- such bad condition that its not worth allocating recources
Green- vomiting, recent mild pain and recent problem
Yellow- pleuritic pain, persistent vomiting, significant cardiac Hx or moderate pain
Orange- severe pain, cardiac pain, acute SOB and abnormal pulse
Red- airway compromise, inadequate breathing and shock
Which patients need further risk assessment for VTE risk after assessing level of mobility on admission?
All surgical patients and medical patients with significantly reduced mobility
What are the patient-related risk factors for thrombosis included in the risk assessment?
Acute cancer or cancer treatment
>60
Dehydration
Known thrombophilias
BMI>30
1+ significant medical comorbidities
PMH or FH VTE
HRT, oestrogen-containing contraceptives
Varicose veins with phlebitis
Pregnant or <6w postpartum
What are the admission related thrombosis risk factors
Significantly reduced mobility for 3+ days
Hip or knee replacement
Hip fracture
Anaesthetic and surgery >90 mins
Surgery involving the pelvis/lower limb with a total anaesthetic and surgery time >60 mins
Acute surgical admission with inflammatory or intra-abdominal condition
Critical care admission
Surgery with significant reduction in mobility
What are the patient related risk factors for bleeding included in the VTW risk assessment
Active bleeding
Acquired bleeding disorders (eg. acute liver failure)
Concurrent use of anticoagulants known to cause bleeding risk (eg. warfarin)
Acute stroke
Thrombocytopenia
Uncontrolled systolic hypertension (230/120)
Untreated inherited bleeding disorder
What are the admission related risk factors for bleeding included in the VTE risk assessment
Neurosurgery
Spinal surgery
Eye surgery
Procedure with high bleeding risk
LP/epidural/spinal anaesthesia in the previous 4 hours
What 3 parts are included in the MUST score
Height and weight to get BMI
% unplanned weight loss
acute disease effect score
Identifies adults that are malnourished, at risk of malnourishment or obese
In the MUST score what gives a patient 2 for the acute disease effect score?
If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days
What are the different BMI scores in the MUST tool
> 20 = 0
18.5-20 = 1
<18.5 = 2
A high MUST score is 2 or more
What NEWS score indicates sepsis risk
5 or more
Acute management of anaphylaxis
Adrenaline and supportive measures.
- Adrenaline should be given IM unless the physician is experienced in IV adrenaline use. The dose is 0.5 ml 1:1000 solution IM (0.5 mg), it can be repeated as required every 5min.
- Supportive: 100% O2, intubate if obstruction is imminent, 0.9% NaCl STAT (may up to 2L), and if there is wheeze treat for asthma
Diabetes care plans
Patients carry them to all their visits. Components include:
- Advice on Lifestyle: exercise, diet, weight, not smoking, flu vaccination
- BP: 140/80 or less
- Cholesterol and CKD Prevention: Less than 5 mmol/l, kidney tests
- Diabetes Control: HbA1c: 58 mmol/l (7.5%) or less
- Eyes: Check yearly at least
- Feet: Check yearly at least
- Guardian Drugs e.g: ACE inhibitors against kidney disease failure
Also list of meds/insulins, BM testing information, and contact information for the MDT.
Diabetes care plans
Patients carry them to all their visits. Components include:
- Advice on Lifestyle: exercise, diet, weight, not smoking, flu vaccination
- BP: 140/80 or less
- Cholesterol and CKD Prevention: Less than 5 mmol/l, kidney tests
- Diabetes Control: HbA1c: 58 mmol/l (7.5%) or less
- Eyes: Check yearly at least
- Feet: Check yearly at least
- Guardian Drugs e.g: ACE inhibitors against kidney disease failure
Also list of meds/insulins, BM testing information, and contact information for the MDT.
Level 1 of hospital care
Patients at risk of their condition deteriorating or those recently relocated from higher levels of care whose needs can be met on an acute ward with additional advice and support from the critical care team
Level 2 of hospital care
Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those ‘stepping down’ from higher levels of care- HDU
Level 3 of hospital care
Patients requiring advanced respiratory support alone or monitoring and support for two or more organ systems. This level includes all complex patients requiring support for multi-organ failure- ICU
What should a discharge summary include
- Reason for hospitalization
- PC/main presentingcondition - Significant findings/diagnoses
- Procedures and treatment provided:
- main events of hospital stay
- main consults experienced
- any procedures
- drugs, allergies, allergic reactions - Patient’s discharge condition:
- documentation of health status at discharge - Patient and family instructions:
- discharge meds, activity orders, therapy orders, dietary instructions, plans for follow-up… - Attending physician’s signature
Symptoms of dehydration
Initial: impaired cognitive function, reduced physical performance, headaches, fatigue, sunken eyes and dry, less elastic skin
Serious effects: circulating blood volume decreases causing hypotension, tachycardia, weak pulse, cold peripheries, oliguria, then organ failure and death
What elements of blood chemistry are helpful for checking hydration status
Na (increased), K, Cl, HCO3 and blood urea
What is the gold standard hematologic parameter to detect dehydration?
Plasma osmolality
> 300 mOsm/kg is the threshold for dehydration
qSOFA score
Altered mental status: GCS <15
Respiratory rate: >22
Systolic BP: <100
Quick sequential organ failure assessment score for sepsis
What should be used for fluid rescusitation
500ml of 0.9% NaCl over 15 mins or less
What NEWS score is concerning
5+ total or 3 in one area
Medium risk: 5-6
High risk: 7 or more
What’s a central line
Reason: a form of venous access.
- critically ill patients
- prolonged IV therapies/more reliable vascular access
- caustic meds that would harm a smaller peripheral vein (e.g. amiodarone, chemo)
- obtain blood tests, administer fluid or blood products for large volume resus
- measure central venous pressure
- dialysis
Where are central lines usually inserted
- MOST COMMON right internal jugular
- chest (subclavian or axillary)
- groin (femoral)
- arms (aka PICC line or peripherally inserted central catheter)
Dont give any drugs via an arterial line
What are the possible complications from having a central line
Bloodstream infections, pneumothorax, alteration in heart rhythm, air embolus, haemothorax, arterial haemorrhage, thrombosis and malfunction of the central line itself
What are the most common causes of the arterial lines
role: direct BP monitoring, ABGs
places:
- radial (MOST COMMON) or ulnar artery (wrist)
- brachial artery (elbow)
- femoral artery (groin)
- dorsalis pedis artery (foot)
What are the possible complication of an arterial line
Temporary vascular inclusion, thrombosis, ischaemia, hematoma formation, local and catheter related infection, and sepsis
What is enhanced recovery
- evidence-based approach
- helps people recover more quickly after major surgery
e.g. research shows the earlier a person gets out of bed and starts walking, eating, and drinking after having an operation, the shorter their recovery time will be
Key components of pre/post op care
PRE-OP
Diet, exercise, relax, cut smoking and alcohol
POST-OP
- Monitor obs
- Wound care/surgical site care
- Demonstrate being able to breathe normally, drink, and urinate
- Arrange transportation (can’t immediately drive)
- Analgesia
- PT
- Safety netting
- Stay active, fluids, healthy diet, enhanced recovery diary…
Who addresses yellow card reports
The medicine and healthcare regulatory agency (MHRA)
All medicines incl. vaccines, blood factors and immunoglobulins, herbal medicines and homeopathic remedies.
All medical devices available on the UK market.
Safety concerns associated with e-cigarette products.
Suspected counterfeit or fake medicines or devices.
What drugs are commonly found in the emergency drugs trolley
Adrenaline, atropine, amiodarone, CaCl, saline, naloxone and sodium bicarbonate
Fasting instructions pre-surgery
Stop eating - 6 hours before
Stop dairy products (including tea and coffee) - 6 hours before
Stop clear fluids - 2 hours before
Drugs to stop before surgery
[I LACK OP]
Insulin/oral hypoglycaemics (special rules for DM)- metformin day of, others 24h prior
Lithium
Anti-coagulant warfarin – usually 5d prior (bleeding risk) and commence therapeutic dose LMWH (note surgery often only goes ahead if INR <1.5, so may need reversal w/ Vit K if INR remains high the night before)
Clopidogrel – 7d prior (bleeding risk). Aspirin and other anti-platelets often continued (minimal effect on surgical bleeding).
K-sparing diuretics
Oral contraceptive pill/HRT – 4w prior (DVT risk). Advise patient to use alternative contraception during this period.
Perindopril (and other ACE-inhibitors)
Drugs to stop before surgery
CHOW
- Clopidogrel. 7 Days before due to bleeding risk. Aspirin OK.
- Hypoglycaemics. (used in T2DM)
- Oral contraceptive pill and HRT. 4 Weeks before due to DVT risk.
- Warfarin. 5 days prior due to bleeding, replace with LMWH, INR needs <1.5 for surgery, consider VitK if not.
Drugs to start before surgery
LMWH – VTE Risk Assessment & prescribe appropriately
TED stockings – all patients (except vascular patients). CI - PVD, peripheral neuropathy, recent skin graft, severe eczema.
Abx prophylaxis – in orthopaedic, vascular, or GI surgery usually.
Laxatives and enemas in some GIT surgeries
Drugs to alter before surgery
Subcutaneous insulin – (special considerations for DM patients)
Long-term steroids – MUST CONTINUE (risk of Addisonian crisis). If patient can’t take PO, switch to IV
Peri-operative care of patients with T1DM: night before and morning of
All T1 patients should be 1st on the list and may need admitting on the night before (depending on how major the procedure is)
Night before: Reduce their SC basal insulin dose by 1/3rd.
Morning of:
- Omit morning insulin
- Commence an IV variable rate insulin infusion pump – usually contains 49.5mL saline w/ 50 units Actrapid.
Peri-operative care of patient who is T1DM: while patient is NBM
Prescribe 5% dextrose 125mL/h while NBM.
Check BM every 2h and alter infusion rate accordingly.
Continue until the patient is able to eat and drink.
Peri-operative care of patient who is T1DM: once patient can eat and drink
Overlap their IV variable rate insulin infusion stopping and their normal SC insulin regimens starting. To do so, give SC rapid acting insulin ~20 minutes before a meal and stop their IV infusion ~30-60 minutes after they’ve eaten.
Peri-operative care of patients with T2DM (medications)
If diet-controlled, no action required.
If controlled by oral hypoglycaemics:
- Metformin should be stopped the morning of surgery
- All others should be stopped ~24h before the op.
- Put these pts on IV variable rate insulin infusion along with 5% dextrose 125mL/h (as for T1DM).
What needs to be measured 1-6 hours after suspected anaphylaxis
Serum tryptase- this confirms the diagnosis
What is keppra (levetiracetam) used to treat
Seizures (epilepsy)
