Deck 8 Flashcards
1
Q
Shock definition
A
Life threatening failure of oxygen delivery to tissues (leads to anaerobic respiration)
2
Q
Shock manifestations
A
Skin (
3
Q
Brain IC autoregulation
A
MAP 50-150
4
Q
Kidney pressure autoregulation
A
MAP 70-170
5
Q
Hypovolaemic shock
A
Reduced preload, reduced EDV (low SV and CP impacted, so hypotension)
Compensation by tachycardia, vasoconstriction.
See cold peripheries, tachycardia, hypotension, hypovolaemia.
Haemorhagic is special type that needs RBCs an clotting factors as Tx
6
Q
How much blood lost until BP drops
A
Stage 3, 1500-2000mL loss
7
Q
Distributive shock tpyes
A
Sepsis, anaphylaxis, neurogenic
8
Q
Anaphylactic shock
A
Distributive, but also hypovolaemic. T1HS. Histamine mediated vasodilation and pooling into interstiium. Give adrenaline (0.5mg (0.5mL 1:1000), 10mh chlorphenamine and 200mg steroid) plus fluids as adrenaline wont reverse fluid movement
9
Q
Septic shock
A
distributive and hypovolaemic.
If refractory to fluids then send to ITU for vasopressor
10
Q
Neurogenic shock
A
Spinal injury above T6, leaving vagus unopposed.
Paradoxical bradycardia.
Needs fluid therapy (even though euvolaemic) and vasopressor + ionotropes and chronotopes (Adrenaline)
11
Q
Distributive shock signs
A
hypotension, shock signs, flushed complexion and warm peripheries. May have tachycardia, but bradycardia in neurogenic shock
12
Q
Cardiogenic shock
A
Can be post MI, arrythmias, bradycardia or CHF
Compensatory tachycardia and increased heart contraction. Hypotension, reduced urine, altered GCS and peripheral shutdown. May have fluid overload.
Tx with morphine (2.5mg-5mg for pain, anxiety, dyspnoea), assess fluid balance and give furosemide if pulmonary oedema
13
Q
Obstructive shock
A
Can be tension pneumothorax with mediastinal shift, PE, aortic dissection or cardiac tampoade.
SV impaired, hypotension occurs. Tachycardia and vasoconstriction. Fluid status may be normal.
14
Q
All shock types have
A
hypotension, oliguria/anuria (AKI risk) and altered mental state)
15
Q
peripheral temp cool in shock with
A
All types, except distributive
16
Q
Skin pale in shock?
A
Hypovolaemic and obstructive
17
Q
Skin pale and clammy in ? shock
A
cardiogenic
18
Q
Skin flushed in ? shock
A
distributive
19
Q
Thready pulse in ? shock
A
hypovolaemia and cardiogenic (due to vasoconstriction)
20
Q
Rapid bounding pulse in ? shock
A
Septic shock (wide due to vasodilation)
21
Q
Urine monitoring in shock
A
hourly
22
Q
mast cell tryptase?
A
may test for this in anaphylactic shock
23
Q
sepsis
A
Life threatening response to injury which damages body
24
Q
NEWS2 for sepsis
A
5 or more triggers sepsis screen in presence of RF or concern from HCP
25
Sepsis RF
Age extremes, impaired immunity, recent invasive procedure, broken skin
26
Common causes of sepsis
pneumonia, UTIs, abdominal source, MSK endocarditis, meningitis
27
Red flag sepsis criteria
```
Evidence of altered mental state
Sys BP<90 (or 40 below normal)
HR >130
RR>25
Needs oxygen for min sats
Skin stigmata (rash, cyanosis, mottling)
Lactate >2
Recent chemo
Anuria for 8h/<0.5mL/kg/hr
```
If any ONE of these then sepsis 6
28
Amber sepsis criteria
```
Concern over mental status
"off legs"
Immunosuppressed
Recent surgery/trauma
RR 21-24
BP 91-100
Temp <36
Clinical signs of wound infection
```
Any ONE of these triggers further review
29
Septic shock diagnosis
Technically sepsis AND persistent hypotension, vasopressor to maintain MAP >65 and lactate >2
But vasopressor not available outside CC, so sepsis AND <90 despite fluid AND lactate >2
30
Escalation criteria for sepsis
Lactate >4, or SBP<90 or lactate/SBP abnormal despite 20mL/kg bolus after 1 h
31
Management of septic shock
Broad spec Abx
500mL fluid bolus (up to 20mL/kg)
Take lactate, urine, blood culture
32
Neutropoenic sepsis
Diagnosis is <0.5 10x9
| Consider atypical infection sites (including perianal area, but do not perform PR )
33
Adrenaline dose for anaphylaxis
0.5mL of 1:1000 adrenaline (IM) - 0.3mL if <10.
10mg chlorphenamine by low IV infusion/IM
200mg hydrocortisone slow IV
Also give 15L oxygen, raise legs and give fluid
34
Causes of airway obstruction
CNS depression, physical obstruction, infection, inflammation, bronchospasm, laryngospasm
35
Space for needle decompression in pneumothorax
4/5th IC space above rib with orange/greay cannula
36
Immediate acute asthma management
```
OSHIT
Oxygen (15L)
Salbutamol
Hydrocortisol (IV, or oral pred)
Ipratropium (SAMA if salbutamol not working)
Theophylline (or aminophylline IV)
```
Can also give magnesium sulphate
Escalate
37
Medium concentration oxygen mask
35-80% at 5-8L/min
38
Nasal cannulae
24,28,32,36,40,44 at 1.5L/min
39
Venturi mask
Gives most accurate delivery
| 24,28,31,35,40,60% - valve dependent
40
Higher oxygen venturi
Green
41
Medium oxygen venturi
Yellow
42
Low oxygen venturi
Blue
43
Circulation A_>E
BP, HR, fluid, clotting, ECG, blood test, cap reful
44
Management of ACS
```
MONA
Morphine (5-10mg IV)
Oxygen
Aspirin (300mg, chewable)
Nitrate spray
```
Can also give beta blocker, reassurance,/clopidogrel, enoxaparin, statin
45
Hypoglycaemia symptoms
Pallor, headache, tachycardia
46
If BM <4 and patient swallow ok
15-20g quick carb
60mL glucagon
2x tube of 40% glucose gel
Glucose tablets
Repeat BM after 15 mins, if <4 then repeat up to 3 cycles then escalate
47
If >4 BM following hypo and able to swallow
20g long acting (2 biscuits or 1 slice bread, or carb meal)
Look for cause
Continue insulin
48
If <4BM and not able to swallow
100mL 20% glucose IV over 15 mins
1mg IM glucagon
Repeat BM after 15 mins, if >4 then long acting carb. If not then 100mL 20% glucose 3x
49
DKA diagnosis and management
Glucose >11, ketones (blood >3, urine ++), acidotic or low bicarb
get dehydration, hypovolaemia, hyponatraemia, hyper/hypokalaemia
Give fluid (1L at initial, 1L/2h x2, 1L/4hx2, 1L/8h.
If K 3.5-5.5 then 40mmol/L/L
If <3.5 then senior review.
Give insulin infusion based on weight.
Give glucose once <14mmol/L (10%@125mL/h)
50
Severe DKA
```
Ketone>6
pH <7.1
HCO3 <6
Anion gap >16
K<2.5
GCS<12
SPO2 <98
```
51
DKA complications
hypokalaemia, hypomagnesaemia, hypophosphataemia, cerebral oedema, cardiac arrythmias, aspiration pneumonia thromboembolism
52
Main ketones in DKA
acetone and 2 hydroxybutyric acid
53
HSS
BM>30, lack of Ketones, osmolarity 320+ (2Na+ glucose+ urea)
Gives fluid, generally more slowly
Give insulin once glucose reduction <5mmol/L/hour and then give 1/2 strength
54
Primary Pneumothorax
No underlying lung disease, due to pleural blep rupture (often apical, CT defect at alveolar wall)
Think marfans and young males
55
RF for primary pneumothorax recurrance
60+, smoking
56
Symptoms and signs of primary pneumothorax
Symptoms: minimal/absent, but sudden onset pleuritic pain and dyspnoea. If larger the pallor and tachycardia.
Signs are reduced chest expansion, hyperresonance on percussion, dimished breath sounds on auscultation.
57
Secondary pneumothorax
Underlying lung disease (COPD, asthma, abscess, pumonary fibrosis)
More common 40+ and smoking
58
RF for secondary pneumothorax reoccurance
age, emphysema , fibrosis
59
Symptoms of secondary pneumothorax
Symptoms: more severe than primary, pleuritic, unilateral chest pain, dyspnoea. Pallor and tachycardia
60
Tension pneumothorax symptoms
Tacheal deviation, hypomobility on affected side, cyanosis, severe tachyponoea, tachycardia, hypotension
Clinical diagnosis, decompress immediately
61
RF for tension pneumothorax
Ventilated patient, truama patient, post CPR, acute asthma/COPD, blocked chest drain, hyperbaric oxygen Tx
62
Pneumothorax size
50% volume lung takes 40 days to reabsorb.
| 2cm interpleural distance at hilum is 50% volume
63
Pneumothorax management
If primary and young/fit, <2cm then consider disacharge with outpatient FU
IF >2cm and dyspnoea then aspirate
If secondary, over 50, smoking Gx or lung disease then admit all
If <1cm then oxygen and obs
1-2: aspirate and admit
>2cm and dyspnoea then chest drain
Further Tx with chemical pleurodesis/thoractomoy
64
Safety net for pneumothorax discharge
smoking cessation, no air travel for 6 weeks, no scuba ever
65
Upper GI bleed definition
Proximal to ligament of treitz (duodenal/jejunal flexure)
66
Upper GI bleed Ddx
peptic ulcer, varicoel bleed, oesophagitis (GERD or candida), Mallory Weiss tear (epithelial tear), Boerhaave's syndrome (transmural), upper GI malignancy, aortoenteric fistula, AV malformation, Dieulafoy's lesions (abnormally large blood vessel)
67
Key questions in upper GI bleed
blood colour, bolume, clots, retching syncope, pain, bowel symptoms, B lymphomts, surgical Hx, ulcer risk, liver damage drugs, smoking, alcohol, tattoos, liver disease
68
Melaena
Black tarry stools. acute upper GI bleed or sometimes small bowel/right colon
69
Coffee groundvomit
Digested, so ceased or mild bleed
70
Imaging for ulcers
CXR if ? perforation
FBC, u&E, LFT, clotting screen, G&S, VBG
OGD within 24h of acute haematemesis +CT abdo with contrast if active beel in unstable patient
71
Glasgow Blachtford bleeding score
Hb, urea, systolic BP, clinical features (HR, melaena, syncope), clinical features (HF, liver disease)
6+ needs intervention
1+ needs encoscopy
72
Rockall score
rebleed risk post endoscopy
| Looks at age, shock, comorbidities,, endoscopic findings and predicts risk
73
Most common peptic ulcer
Duodenum
74
Peptic ulcer that bleeds more
gastric
75
Which ulcer worse after earing
gastric, duodenal tend to be less painful after eating, moreso 2-4 h later
76
Oesophageal varices management
Endoscopy
If unstable then theatre
Give prophylactic Abx due to sepsis risk
Give terlipressin to reduce poortal HTN
77
Lower GI bleed definition
distal to ligament of treitz
78
Types of bleed
Occult (FIT screen, IDA)
Mod rectal bleed (PR bleed/melaena in haemodynamically stable)
Severe bleed (hypotension and hct drop)
79
Common lower GI bleed in <30
haemorrhoids, anal fissure, IBD
80
>50 lower GI bleed common causes
? colorectal cancer, divetircular disease
81
>65 lower GI bleed
Angiodyplasia, diverticular disease
82
Angiodysplasia
Acquired
Submucosal AV malformations
Aortic stenosis association (and other valve disease
Commonly presents as IDA (occult loss). Often painless, bried, brisk loss
83
Blood mixed with stool
suggests proximal to sigmoid to allow mixing time
84
Blood on stool surface
Suggests sigmoid or rectal source
85
Blood after stool
Suggests anal cause
86
Blood only on paper
suggests fissure
87
Blood lone, no stool
Large bleed that's stimulated bowel
88
paracetamol OD presentation
N&V, RUQ pain, jaundice
89
Benzo OD presentation
CNS depression, ataxia, slurred speech, resp depression
90
opioid OD presentation
resp depression, pin point pupil, coma
91
Alcohol intoxication presentation
slurred speech, ataxia, vomiting
92
Investigations in OD/tox
physical obs and exam (esp neuro), ABG/VBG, ECG, baseline bloods (renal and hepatic), serum level
93
Alcohol effects due to
GABA and 5HT actions
94
Alcohol withdrawal
Seen in people >20 units/ day
| Chlordiazepoxide plus vit D and thiamine
95
Wernicke's
B1 (thiamine) deficiency. Ataxia, ophthalmoplegia, new onset confusion
96
Korsakoff's
Irreversible brain damage on background of Wernicke's. Anterograde amnesia, confabulation, personality change
97
paracetamol toxicity mechanism
saturated glucuraonide conjugation (N acetyl p benziquinoneimine builds up)
N&V initially.
Then loin pain, vomiting, jaundice, abod pain, hypotension, hypoglycaemia, pancreatitis arrythmias
Tx with acetylcysteine (or activated charcoal if recent ingestion)
Use paracetamol level (post 4h - Note LFT wont show damage until 18h) for dose.
Psychiatric assessment once stable
98
acetycysteine side effects
rash, oedema, hypotension, bronchospasm - manage with IV chlorphenamine
99
OD assess,emt
current state, events prior to OD, planning, concealment, substance abuse at time, access to means for repeat
100
Self harm RF
Men at 25-34, women at 15-24, personality disorder, drug/alcohol abuse
101
Suicide RF
psychiatric illness, statement of intent, access to means, Hx of self harm/violence, FHx self harm/suicide, significant life events, painful physical illness, impulsive personality, male, older age, post partum psychosis
102
High risk/low risk suicide
low risk is first attempt, impulsive, non violent, relieved at rescue, unsure of outcome
High risk is concealment, notes, violent means, previous attempts
103
% of body weight that's water
60 (55 in women)
104
Proportion of body water intra/extracellular
2/3s intracellular, 1/3 extracellular
105
% of extracellular water that's intravascular/interstitial
25% intravascular, 75% interstitial
106
Hydrostatic pressure gradient causes
circulatory pressure, oedema, mechanical restrictions (plaster cast, infection, bandaging)
107
Neonate/children water %
70-80%
108
Metabolic fluid
400mL/day (often not counter for fluid balance)
109
Average adult fluid needs
2-2.5L
110
Adult daily insensible loss
500-800mL
111
Guideline for IV fluid (NICE)
25-30mL/kg/day (around 2L)
112
Electrolyte need/day (NICE)
1mmol/kg/day Na/Cl/K (~70mmol)
113
Glucose need per day in fluid (NICE)
50-100g/day glucose (limits ketosis)
114
GI losses /day
100mL/day (more in GI upset)
115
Minimum obligatory urine production
0.5mL/kg/hr (~840mL/day)
116
Typical ward fluid regime
1L saline with 20mmol KCl/8h
| 1L 5% dextrose with 20mmolKCl/8h x 2
117
Sweating electrolyte
sodium
118
Diarrhoea electrolyte loss
sodium, potassium, bicarb
119
vomiting electrolyte loss
potassium, chloride, hydrogen
120
Urine output suggestive of dehydration
<1mL/kg/hour
121
Hypervolaemia symptoms
cough, frothy sputum, fluid in serous cavities, HTN, peripheral oedema, pulmonary oedema, dyspnoea, raised JVP, S3/S4 , tachycardia
122
Hypovolaemia symptoms
headache, absent/low JVP, decreased skin turgor, dry mucous membrane, low BP, oliguria/anuria, orthostatic hypotension, peripheral shutdown, prolonged cap refil, shock.
Urine output below 1mL/kg/hour suggests dehydration.
123
Isotonic fluid (crystalloid) properties
0.9%NaCl stays in EC space
124
Hypertonic fluid
e.g. 3% NaCl/mannitol draws fliud out
125
Hypotonic fluid
e.g. 0.45% NaCl lowers serum osmolarity
126
Properties of 0.9%NaCl
154mmol Na and 154 mmol Cl
| 25% ditributes intravascular, 75% interstitial. so in 1L, 250mL intravascular
127
Glucose solution properties
Generally 5% (50g/L). ISomolar with plasma. 2/3s intracellular, 1/3 extracellular. Only 8% stays IV
128
Colloids
Blood, dextrans, gelatin, human albumin HES.
| Draws fluid into IV compartment. Higher cost, anaphylaxis risk
129
NICE colloid recommendation
4-5% human albumin only in severe sepsis. 20% should not be used as too rapid.
130
4Ds of fluid therapy
drug, dose, duration, de-escalation
131
Fluid therapy initiating
```
Sys<100
HR>90
CAP>2s/cold peripheries
RR>20
NEWs5+
Passive leg raise suggests fluid responsiveness
```
Giv e 500mL 0.9%NaCl in 15 mins.
132
Tx in fluid overload
Stop fluids
furosemide
sublingual nitrate (reduce preload)
IV nitrates (reduces pre and afterload but needs BP monitoring)
CPAP (improves gas exchange and recruits collapsed alveoli - needs critical care)
133
Blood transfusion
ID checks crucial
Verbal consent
Administer 1.5-2h/unit
FFP at 30mins/unit
134
Hypertensive emergency
Signs
Papilloedema on fundoscopy
May show enlarged blind spot in visual field test
May see retinal haemorrhage
135
Hypertensive emergency investigation
```
FBC
U&E (renal function)
Glucose level
Cholesterol profile
LFT
Calcium (?PTH)
cortisol +/- dex suppression
Renin/aldosterone
urine protein:creatinine ratio
Urine metanpehrrines (?phaeochromocytoma)
imaging (ecg, echo, USS, CT, MRI, MRA)
```
136
Malignant HTN pathology
- Cerebral infarction, IC haemorrhage, subarachnoid haemorrhage
- MI, HF, AAA
- Acute renal failure
Retinopathy
137
Cardiac arrest protocol:: shockable
VF/VT
1 shock, CPR for 2 mins
After 3 shocks, 10mL 1:10000 IV adrenaline, 300mg amiodarone
Repeat adrenaline 3-5 mins
138
Non shockable Cardiac arrest
10mL 1:10000IV adrenaline
| 30:2 CPR
139
Reversible causes of cardiac arrest
Toxins
Tamponade
Tension pneumothorax
Thombosis (coronary or pulmonary)
Hypoxia
Hypovolaemia
Hypothermia (note that hypothermia inhibits clotting factors)
Hyperkalaemia/hypokalaemia
