Critical Care Flashcards
When given information about a patient from an external source, what are 3 things that you must always consider?
Severity?
Is the patient suffering from what is claimed?
Never accept anything at face value.
What is focal neurology?
A neurological impairment that affects a specific region of the body.
What is the single most appropriate action when sepsis is suspected?
IV access and fluid resuscitation.
What are the 2 categories of fluids? And what is the difference?
Crystalloids (same as plasma concentration) and colloids (synthetic HIGHER osmotic pressure).
In reality there is little difference in terms of resuscitation.
What dictates the maximum rate of bolus delivery in fluid resuscitation?
Size of cannula.
How fast would you infuse someone with fluid?
500-1000ml over 10-20mins.
Why do you do a head CT before a lumbar puncture?
If there is ICP present, coning can occur - this is brainsteam compression as brain moves to fill space created by LP.
What are some signs of ICP? (4)
Papillodoema
Headache that changes on movement
Nausea and vomiting
Deteriorating neurological function
What treatment would you give for meningitis:
- in hospital?
- in a GP?
- Ceftriaxone 2g IV
- Benzylpenicillin 1.2g IM (in the bum)
Where do you perform a lumbar puncture?
L5 ish
Where does the spinal cord end?
L1/2
What would you expect the protein and glucose levels be in a LP of a bacterial meningitis patient?
High protein, low glucose
Meningitis:
When looking at lumbar puncture results, how would you determine whether
Virus or bacteria
Bacteria are large with lots of protein in them, viruses might have SOME protein in them
Bacteria make it gunky
Bacteria like glucose, so glucose levels likely to be low, with viruses it can be normal
Red cells are in subarachnoid haemorrhage
What is SIRS?
Systemic Inflammatory Response Syndrome
Temp 38
HR > 90bpm
RR > 24
White cells 12
What is sepsis?
When a patient amount a SIRS to an infectious pathogen (OR - PE, anaphylaxis, acute pancreatitis, recent surgery)
What is septic shock?
Ongoing hypoperfusion (low BP, raised lactate, organ dysfunction) despite aggressive fluid resuscitation Patient should always be assessed for ITU.
What is the morality of septic shock?
50%
What are the sepsis 6? When should they be done?
NB - take 3, give 3. In first hour.
Oxygen
Blood culture
ABG (v useful to assess how sick - especially LACTATE levels)
IV antibiotics
Fluid
Catheter
What is a significant ingestion of paracetomol?
And in patients with liver dysfunction?
Ingested dose 12g or more/24h
Ingested dose >150g/kg
What bloods do you request in suspected paracetomol OD and why? (4)
Paracetamol level
LFTs
U&Es (prognosis - is there kidney damage?)
INR (liver damage can affect clotting function)
Which enzymes are raised in liver damage?
ALT, AST, gamma GT
When is ALP raised?
Obstruction in the biliary system.
What is naloxone?
An opiate antidote
What would you give to patients with a paracetamol OD who are above the treatment line (or high risk for hepatotoxicity treatment line)?
N-acetylcycsteine
When would you give charcoal in an overdose?
Within first hour to hinder absorption.
How does N-acetylcysteine work?
It replenishes glutathione so that toxic metabolite (NAPQI - created by P450) is broken down faster into cysteine and mercapturic acid conjugate (non-toxic)
Which patients have enhanced hepatotoxic risk? (4)
Underlying liver disease
Liver enzyme inducing drugs (HIV drugs, anti epileptics, rifampicin)
Alcohol intake
Glutathionine depleted liver - eating disorder….finish
What should you look out for when infusing N-acetylcysteine?
Reaction - anaphylaxis, rash, wheeze
If this happens, can give piriton (proper name?), adrenaline if v bad.
Airway Assessment? (ABCDE)
‘Patent’
Full sentences, stridor.
Breathing Assessment? (ABCDE)
Chest expansion Resp rate Laboured breathing? O2 sats ABG Tracheal deviation Cyanosis
Circulation Assessment? (ABCDE)
HR BP CRT JVP Pulse - rate, rhythm, character, where? ECG Urine output IV access
Disability Assessment? (ABCDE)
CBG
GCS/AVPU
Temp
PEARL/neuro
ABCDE, what does it stand for? What is the significance of the order?
Airway, Breathing, Circulation, Disability, Exposure
This is the order of things that will cause the most serious harm to the patient - so you must ALWAYS do something about an abnormality before you move onto the next thing.
How is blood pressure sensed and controlled?
Fiiinnndddd Aterial constriction (angiotensin II, sympathetic, adrenaline) Venous constriction
What
Gastric mucosa and prostaglandins
Risk for gastric problems
NSAIDS
How do PPIs work?
Sodium potassium pump within parietal cells inhibited
NSAIDs - how do they
COX-1 inhibition, anti-platelet, reduced prostaglandins
How does H Pylori cause gastric damage?
Inflammation and stimulation of G cells.
Name some fluids
Hartmann’s, normal saline
What should you do if you suspect a GI bleed?
Give them blood!
What is ‘group and save’?
Provide 2 pink bottles of blood, taken 5 mins apart.
They will check patient’s blood and antibodies, and then if you need blood later, the group is there so that you can cross match at a later date. Lasts for about a year.
Cross matching
The same 2 pink bottles of blood.
They cross match there and then and find blood. Takes half an hour.
What is the major haemorrhage protocol?
If half an hour required is too long to cross match blood, you can activate it. A registrar comes and OKs the protocol, O negative blood is then provided.
What else might you need to give if you are giving a large transfusion
Platelets, plasma, clotting factors etc. Because the blood provided is just red cells.
What is the danger of increasing blood pressure too much in a patient with a bleed?
It might make the bleed worse. Aim for systolic of 100 ish.
PPIs - when can you not give them
If going for surgery??
Who would deal with an upper GI bleed?
Medical team
How do they deal with an upper GI bleed?
Put in an endoscope. Can then put a band, clips, glue etc to stop the bleed if necessary.
4 key ways in which the body maintains adequate blood pressure?
Venoconstriction
Arterioconstriction
Incr HR
Incr stroke volume
Go back and read this stuff
In a suspected GI bleed, what should you consider when you are administering medications?
Give them IV, because they might need to do an endoscopy.
