Critical Care Flashcards
Dilated pupils Dry mouth and skin Hypotension Urinary Retention Tachycardia
Tricyclic Antidepressant Overdose
Tricyclic antidepressant overdose investigations
ECG: Widened QRS and broad complex tachycardia
ABG: Metabolic acidosis
Tricyclic antidepressant overdose management
IV sodium bicarbonate (50mL of 8.4%)
IV fluids (NS)
ECG monitoring
Right upper quadrant pain Nausea and vomiting Liver failure -Jaundice -Encephalopathy -Lactic acidosis
Paracetamol overdose
Paracetamol overdose investigations
Paracetamol (4 hrs post intake)
↑ ALT
↑PT/INR
Hypoglycemia
Management of paracetamol overdose
Activated charcoal if presented <1h after intake
IV N-acetylcysteine if at 4h after intake, paracetamol value is above the Tx line
IV N-acetylcysteine of staggered dosing or ingestion of unknown amount irrespective of paracetamol value
Liver transplant in case of liver failure
Px with hypophosphatemia, hypomagnesaemia and hypokalaemia in a px that just started with parenteral feeding.
Refeeding syndrome
Management of refeeding syndrome
Correction of electrolyte imbalance
IV fluids
Prevention: Feeds should be given slowly with electrolyte supplementation.
A 21 YO woman with BMI of 12 was admitted to the medical ward for feeding through nasogastric tube. What electrolyte abnormality should be expected?
Hypophosphataemia.
Starvation> Low glucose = low insulin/high glucagon = increased gluconeogenesis
Depletion of phosphate sotres = hypophosphatemia
Refeeding> high glucose = high insulin = increased cellular uptake of phosphate
Hypophosphatemia from starvation and from refeeding (↑ phosphate demand)
Sudden and severe headache (thunderclap headache) with neck stiffness or pain.
Subarachnoid haemorrhage
RF: Hypertension, smoking and polycystic kidney disease (↑berry aneurysm)
A 35 YO man attends ED with a severe headache and vomiting for a day. He has neck stiffness and photophobia. His BP is normal and he has mild tachycardia. His CT shows hyperintense areas in the subarachnoid basal cisterns. Which is the most useful drug in this case?
Aspirin, Clopidogrel, Sumatriptan or Nimodipine?
Subarachnoid hemorrhage (the hyperintense areas in the CT is blood)
In SAH cerebral vasospasm can occur 4-12 days later and it is serious.
To diminish this anticipated vasospasm we give Calcium Antagonist for 5-14 days. (Nimodipine)
A 32YO presents with the worst headache of his life. He has photophobia, neck stiffness and has vomited multiple times. The CT scan shows no evidence of intracranial bleeding. What is the most appropriate next step?
Lumbar puncture.
When suspecting a SAH but the CT is inconclusive then a LP should be done after 12 hours of the onset of the headache.
CSF is bloody then xanthochromic (yellow) due to billirubin.
Skull fracture
Loss of consciousness immediately then lucid interval then deterioration of condition
Blown pupil or pupillary asymmetry due to ↑ ICP
Extradural (epidural) haematoma
Collection of blood between the dura and the skull
The skull fracture causes rupture of the middle meningeal artery
Epidural haematoma investigation
What should I look for?
CT head
Bi-convex or lentiform shaped haematoma
Extradural haematoma management
Craniotomy or burr hole (in big haematomas)
Conservative in small haematomas
Gradually evolving focal neurological deficits, speech difficulties and drowsiness.
It is associated with blunt head injury and may have Hx of anticoagulation.
Subdural haematoma
Subdural haematoma investigation.
What should I look for?
CT-Crescent-shaped haematoma
Mx: Craniotomy or burr hole (big haematomas)
Conservative (small haematoma)
Chest pain Shortness of breath Cough Triggered by infection (most commonly pneumonia) Hx of sickle-cell disease
Acute Chest Syndrome
Acute Chest Syndrome investigations
Chest X Ray
Monitoring oxygen saturation
Acute Chest Syndrome management
Oxygen supplementation
Analgesia
IV fluids
Antibiotics to treat pneumonia
Px with breathlessness, haemodynamic instability and leg swelling.
Massive pulmonary embolism
Leg swelling = DVT
Pulmonary embolism investigation and management
CT pulmonary angiography
Thrombolysis or surgical embolectomy.
Road traffic accident.
Px has chest and abdominal pain. Diminished breath sound on the affected side and the X-ray shows gas bubbles in the pleural cavity.
Diaphragm rupture
Road traffic accident. Px has abdominal pain, tenderness in epigastrium and left flank, hypotension.
Splenic rupture.
A FAST scan should be done and a splenectomy may be needed in severe injury.
Px with diaphragm rupture. What is the most accurate method for checking the correct placement of a nasogastric tube?
Chest X Ray
FAST vs CT scan in a splenic rupture
FAST is done when clinically unstable
CT when clinically stable
Px falls form a ladder and receives a bump on his flank. Has haematuria and is hypotensive. What is the most appropriate management?
IV fluids
Urgent CT scan or FAST if CT is not available.
Px with hx of asthma, acute breathlessness, ↓SpO2 and poor respiratory a effort.
Status asthmaticus
Salbutamol nebulisation + oxygen Then IV hydrocortisone Then Ipratropium bromide nebulisation Then IV magnesium sulphate Then IV salbutamol or aminophylline (by senior clinician) Then Intubation and ventilation (by senior clinician)
A 6YO boy with breathlessness for the past 12 h presents to the ED. He is drowsy with poor respiratory effort and has a silent chest. He has 86% SpO2 with high flow oxygen and has not taken his nebulisers for a day. What is the most appropriate initial management? CPAP IV aminophylline IV magnesium sulphate Intubate and ventilate?
Intubate and ventilate
Desaturating despite high flow O2 + SILENT CHEST+ Going into respiratory failure = intubate
Complications of electrolyte disturbances post massive blood transfusion
(10 or more units of blood within 24h or 1/2 of his blood volume)
Hypocalcaemia
Hypomagnesaemia
Hyper or hypokalaemia
Metabolic alkalosis
The most importat hypocalcaemia and hyperkalaemia
Hypocalcaemia is caused by citrate toxicity. Each unit of blood contains 3g of citrate that binds easily to calcium. A healthy adult can metabolize 3g of citrate within 5 minutes in the liver, however if the transfusion is greater that 1 unit per 5 minutes, citrate accumulates in the blood and binds to calcium leading to hypocalcaemia.
