Emergency medicine Flashcards
What is epiglottitis?
Acute inflammation of the epiglottis
Causes of epiglottitis?
Bacterial infection is most common
Streptococcus, staphylococcus, Haemophilus influenzae B, pseudomonas, moraxella catarrhalis
Viral; HSV
Thermal injury
Inhaled foreign body
Chemotherapy reaction
Why is epiglottis less common in UK?
Hib vaccination
Symptoms of epiglottitis?
Sore throat
Odynophagia
Dysphagia
Fevers
Dyspnoea
Signs of epiglottis?
Drooling
Hot potato muffled speech
Cervical lymphadenopathy
Tenderness over hyoid bone
Tripod sign
Stridor
Respiratory distress
Differentials for epiglottitis?
Viral pharyngitis
Peritonsillar abscess
Bacterial tracheitis
Croup
Investigations for epiglottitis?
Clinical diagnosis, do not examine if suspected
Lateral neck X-ray; thumb sign
Throat swab
Management of epiglottitis?
A to E assessment
ENT/ Anaesthetic management of airway
Keep patient upright
High flow oxygen
Nebulised adrenaline
IV dexamethasone
Complications of epiglottitis?
Airway obsruction
Death
Abscess formation
Sepsis
Mediastinitis
Pneumonia
Triggers for sickle cell crises?
Infection
Hypoxia
Dehydration
Strenuous exercise
Cold exposure
Stress
Alcohol/ smokking
High altitudes
Presentations of sickle cell crises?
Acute painful crises (vaso-occlusive crises); severe bone pain, swelling of hands/ feet
Acute chest syndrome; cough, SOB, chest pain, fevers
Priapism
Acute anaemia; myalgia, fever, headache, arthralgia, SOB, palpitations, syncope
Acute stroke
Infection
Investigations to diagnose sickle cell crises?
ECG
Urinalysis
PSV swabs, sputum MC&S and viral PCR
ABG
FBC, U+E, LFT, Coagulation, bone profile, CRP, G+S, LDH
Blood cultures
Chest Xray
CT head
Management of acute painful crises?
Pain relief (paracetamol/ NSAIDs, SC morphine)
Keep warm and hydrated
Refer to haematology
Thromboprophylaxis
Management of acute chest syndrome?
Supplementary oxygen to maintain sats over 96%
IV broad spectrum antibiotics (co-amoxiclav, clarithromycin)
Top up/ exchange transfusion
Management of priapism?
Urology
Analgesia
Oral hydration
Encourage to pass urine and catheterise if necessary
Consider drainage
Management of acute anaemia?
Identify causes
Transfusion may be required
Management of acute splenic sequesteration?
Splenectomy
What infections are those on iron chelation more at risk of ?
Yersinia
Klebsiella
What is acute pancreatitis?
Inflammation affecting the pancreas with local/ distant tissue/ organ invovlement
Epidemiology of acute pancreatitis?
Most commonly caused by gallstones
1-3% mortality
80% have mild self limiting disease
Causes of acute pancreatitis?
Idiopathic
Ethanol
Trauma
Steroids
Mumps
Autoimmune disease
Scorpion stings
Hypercalcaemia, hypertriglycerideaemia, hypothermia
ERCP
Drugs; thiazide, azathioprine, sulphonamide
How is severity of acute pancreatitis assessed?
Glasgow score; each of the criteria scores 1 point, 3 or more predicts severe pancreatitis and should be calculated within 48 hours from admission
PaO2 <8kPa
Age >55 years
Neutrophils >15
Calcium <2
Urea >16
LDH >600 or AST >200
Albumin <32
Glucose >10
Signs and symptoms of acute pancreatitis?
Epigastric pain which radiates to the back
Nausea and vomiting
Diarrhoea
Abdominal tenderness
Peritonism, rebound tenderness
Abdominal distention
Fever, tachycardia, hypotension
Grey turner’s sign; bruising in flanks
Cullen’s sign; periumbilical bruising
Fox’s sign; bruising over inguinal ligament
Signs for haemorrhagic pancreatitis?
Grey turner’s sign; bruising in flanks
Cullen’s sign; periumbilical bruising
Fox’s sign; bruising over inguinal ligament
Differentials for acute pancreatits?
ACS
Perforated peptic ulcer
Ruptured abdominal aortic aneurysm
Bowel obstruction
Cholecystitis
Investigations for acute pancreatitis?
ABG, ECG, pregnancy test, capillary blood glucose
FBC, CRP, LFT, amylase, lipase, LDH, bone profile
Blood cultures
Coagulation
Lipid profile
Autoimmune markers
Abdominal USS, CXR, CT with contrast, MRCP
Management of pancreatitis?
Catheterise and monitor urine input/ output
Consider NG tube
IV fluid resuscitation , crystalloids
Analgesia
Antiemetics
Laparoscopic cholecystectomy, debridement of necrotic tissue
Complications of pancreatitis?
Pancreatic pseudocyst
Pancreatic necrosis
Peripancreatic fluid collections
Haemorrhage
Pancreatic fistulae
Acute respiratory distress syndrome
AKI
DIC
Multi organ failure
Hyperglycaemia
What is advanced life support?
Guideline based approach to treating patients who have had a cardiac arrest to improve chances of successful resuscitation and survival
Where can cardiac arrests occur?
Out of hospital
In hospital
Causes of cardiac arrest?
Hypoxia
Hypovolaemia
Hypokalaemia, Hyperkalaemia
Hypothermia, Hypothermia
Thromboembolism
Tamponade
Tension pneumothorax
Toxins
Classification of cardiac arrests?
Depends on whether rhythm is shockable or non shockable
Shockable rhythm; pulseless ventricular tachycardia, ventricular tachycardia
Non shockable rhythm; pulseless electrical activity, asystole
What is PEA?
Organised cardiac electrical activity in the absence of of any palpable pulse
Survival is unlikely unless reversible cause and identified and treated effectively
When should defibrillation not be performed?
If doubt whether rhythm is shockable or non shockable
Management of shockable rhythm?
Attempt defibrillation if VT or VF is identified
Immediately resume CPR after first shock at 30:2
Continue CPR for 2 minutes and pause to check for pulse
If no pulse give a second shock
Continue CPR for 2 minutes and pause to check for pulse
Give a third shock
Continue CPR for 2 minutes and give 1mg adrenaline or 300mg amiodarone
Give repeat doses of adrenaline every 3-5 minutes
After 5 shocks give further dose of 150mg of amiodarone
Management of non shockable rhythm?
Start CPR at 30:2
Give 1mg IV adrenaline, repeat dose every 3-5 minutes
Causes of airway compramise?
Angioedema
Anaphylaxis
Thermal injury
Neck haematoma
Wheeze
Surgical emphysema
Reduced conciousness
Simple manoeuvres to secure airway?
Suction; if visible vomit, blood, secretions, foreign body
Turn patient onto side if actively vomiting
Head tilt/ chin lift
Place pillow under neck
Aim for sniffing position
Jaw thrust
What can be used as airway adjunct?
Oropharyngeal airway; Guedel,
Nasopharyngeal airway
What is a supraglottic airway?
Laryngeal mask airway, i- Gel that sits on top of larynx
What is an endotracheal tube?
Used for prolonged ventilation and acts as a protected airway
Examples of surgical airways?
Tracheostomy
Cricothyroidotomy
What is alcohol withdrawal?
When a patient who is dependant on alcohol suddenly stops or drastically reduces alcohol consumption
Epidemiology of alcohol misuse?
Affects 24% of the UK population
Pathophysiology of alcohol dependance?
Chronic exposure to alcohol causes tolerance to its effects, reduced GABA activity and increased glutamate activity
Signs and symptoms of alcohol withdrawal?
6-12 hours from last drink; Insomnia, tremor, anxiety, agitation, nausea, vomiting, sweating, palpitations
12-24 hours; visual hallucinations, auditory hallucinations, tactile disturbance (sensation of crawling bugs)
24-48 hours; alcohol withdrawal seizures
48-72 hours; delirium tremens
Delirium, agitation, hallucinations, delusions, tachycardia, hypertension, hyperthermia, diaphoresis, coarse tremor
Differentials for alcohol withdrawal?
Benzodiazepine withdrawal
Sepsis
Hepatic encephalopathy
Psychosis
Hypoglycaemia
Investigations to diagnose alcohol withdrawal?
ECG
Capillary blood glucose
FBC, CRP, LFT, Bone profile, blood culture
CXR, CT head
Management of alcohol withdrawal?
Use Clinical Institute Withdrawal Assessment of Alcohol scoring system to assess symptoms and guide prescription of benzodiazepines
Chlordiazepoxide (long acting) is first line
Oxazepam/ lorazepam are used in patients with liver disease
Treat seizures with short acting benzodiazepines, IV lorazepam
Pabrinex to prevent Wernicke’s encephalopathy
What is an anastomotic leak?
Post operative complication which occurs as a result of a defect in the joint between two hollow viscera that allows contents to leak into the abdomen
Epidemiology of anastomotic leak?
Occur 3-5 days post operatively
Frequency depends on location of surgery
Causes of anastomotic leak?
Emergency surgery
Prolonged operative time
Peritoneal contamination during surgery
Immunosuppressant medication
IBD
Smoking
Alcohol excess
Diabetes
Obese/ malnourished patients
Signs and symptoms of anastomotic leaks?
Progressive worsening of abdominal pain
Prolonged ileus
Tenderness on palpation of abdomen
Peritonism
Abdominal distention
Fevers
Tachycardia
Hypotension
Delirium
Nausea and Vomiting
Differentials for anastomotic leak?
Post operative ileus
Surgical site infection
Intra-abdominal abscess
Investigations to diagnose anastomotic leak?
Blood gas; raised lactate
Blood cultures
FBC, CRP, clotting, group and save
CT with contrast
Management of anastomotic leak?
Nil by mouth
IV fluids
Monitor input and output
IV antibiotics
TPN
Surgery/ emergency laparotomy
Complications of anastomotic leak?
Sepsis
Ileus
Abscess formation
Increased postoperative mortality
What is aortic dissection?
Tear in the tunica intima of the aorta creates a false lumen through which blood can flow between inner and outer layers of the aortic walls
Risk factors for aortic dissection?
Hypertension
Connective tissue disease
Valvular heart disease
Cocaine/ amphetamine use
Male over 50 years
Stanford classification of aortic dissection?
Type A; involves ascending aorta, arch of aorta
Type B; involves descending aorta
Clinical features of aortic dissection?
Sudden onset tearing chest pain/ intrascapular pain that radiates to the back
Bowel/ limb ischaemia
Renal failure
Syncope
Signs of aortic dissection?
Radio-femoral delay
Radio-radial delay
Blood pressure differential between arms
Investigations to diagnose aortic dissection?
CT angiogram
ECG
Echo; pericardial effusion
CXR; widened mediastinum
Troponin and D-dimer may be elevated
Prognosis of aortic dissection?
Prompt diagnosis and treatment as rupture carries 80% mortality
Management of aortic dissection?
Resuscitation
Cardiac monitoring
Strict blood pressure control
Type A; requires surgical managements
Type B; managed conservatively with BP control, endovascular/ open repair may be required
Complications of aortic dissection?
Death due to internal haemorrhage
Rupture
End organ damage
Cardiac tamponade
Stroke
Limb ischaemia
Mesenteric ischaemia
What is central abdominal pain?
Discomfort or pain in the mid section of the abdomen
What is a burn?
Injury to skin caused by heat, electricity, chemicals and radiation
Groups at high risk of burns?
Young children, under 5 years
Elderly patients
Reduced mobility/ sensory impairment
Patients with reduced sense of danger (Dementia, learning difficulty)
Causes of burns?
Thermal burns; flames, hot objects
Chemical burns; acids, alkalis, organic compounds
Electrical burns; high/ low voltage
Classification of burns?
Superficial epidermal burns; affects only epidermis, skin is erythematous and painful but not blistered, rapid CRT
Superficial dermal burns; affects epidermis and upper layer of dermis, erythematous, painful blistered skin with delayed CRT
Deep dermal burns; affects all layers of the dermis but not underlying subcutaneous tissue, dry, blotchy, blistered painful skin that does not blanch under pressure
Full thickness burns; extend to SC tissue and may involve muscle and bone, skin is white or black and may feel rubbery/ leathery/ waxy and is not painful
Complex; >15% of BSA or affect critical area (face, perineum, hands, feet, genitals) and all chemical and electrical burns
Non-complex; <15% BSA, partial thickness
Signs and symptoms of burns?
Pain
Erythema
Swelling
Blistering and peeling of skin
Respiratory distress
Hypotension
Tachycardia
Differentials of burns?
Cellulitis
Stevens- Johnson Syndrome
Toxic Epidermal Necrolysis
Pyoderma gangrenosum
What is Wallace rule of 9?
Divides areas of the body into multiples of 9 of the TBSA
Head- 9%
Whole arm-9%
Front of torso-18%
Back of torso-18%
Whole leg-18%
Methods of estimating TBSA?
Wallace tule of 9’s
Palmar method
Lund and Browder method
Complications of burns?
EARLY
Dehydration, hypovolaemic shock
Rhabdomyolysis
AKI
Electrolyte imbalance
Hypothermia
Respiratory distress due to smoke inhalation
Curling’s ulcer
Infection, sepsis
Arrhythmia
Loss of limbs if amputation necessary
Death
LATE
Scarring
Chronic pain
Contractures
Low mood
Anxiety, PTSD
Epidemiology of C-spine injury?
4% of trauma patients
Higher risk in those with decreased consciousness
C2 and C7 are most commonly fractured vertebrae
Causes of C-spine injury?
Road traffic accidents
Falls
Sports related injury
Assaults
Osteoporotic compression fractures
What makes a patient high risk following a C-spine injury as per Canadian C-spine rule?
Age over 65
Dangerous mechanism of injury
Paraesthesia in upper or lower limb
What makes patient low risk following C-spine injury as per Canadian C-spine rule?
Accident is a minor rear end motor vehicle collision
Comfortable in sitting position
No midline cervical spine tenderness
Delayed onset of neck pain
Unable to rotate neck 45 degrees to left and right
Signs and symptoms of C-spine injury?
Neck pain
Mid line cervical tenderness
Focal neurological deficit
Limited range of motion in neck movements
Haematoma/ oedema around cervical vertebrae
Sensory/ motor deficits- paralysis may affect trunk, upper and lower limb
Peripheral paraesthesia
Incontinence
Investigations to diagnose C-spine injury?
Assess high or low risk as per Canadian C-spine rule
CT of neck
If neurological abnormalities do MRI
Management of C-spine injury?
Imobilise and place in neck collar
IV morphine for pain control
Neurosurgical and spinal surgical review
What is choking?
Foreign object becomes lodged in a patients airway causing acute airway obstruction that is life threatening
Risk factors for choking?
Dysphagia
Poor dentition
Eating when not upright
Alcohol intoxication
Extremes of age
Risky foods
Signs and symptoms of choking?
Gagging, choking, distress
Unable to speak, breathe or cough
Clutching or pointing at neck
Stridor
Wheezing
Respiratory distress
Cyanosis
Attempts o cough a quiet or silent
Loss of consciousness
Differentials for choking?
Anaphylaxis
Asthma exacerbation
Syncope
Management of choking?
Encourage coughing
Give 5 back blows between shoulder blades with heel of hand and patient leaning forward
5 abdominal thrusts
Sequence until dislodged
Signs and symptoms of benzodiazepine overdose?
Slurred speech
Lethargy
Ataxia
Reduced levels of consciousness (may compromise airway)
Respiratory depression
Large overdoses may cause hypotension, bradycardia and hypothermia
Management of benzodiazepine overdose?
A to E assessment
Consider risk of aspiration pneumonia
Flumazenil
What medication is used to counteract benzodiazepines?
Flumazenil- useful in iatrogenic overdose
Caution of use of Flumazenil?
Risk of seizures, used in ITU/ HDU
Avoid in epilepsy, chronic benzodiazepine use
Signs and symptoms of beta blocker overdose?
Small overdoses may be asymptomatic
Bradycardia
Hypotension
Drowsiness
Confusion
Seizures
Coma
Bronchospasm
Cardiac arrest
ECG changes in beta blocker overdose?
Prolonged PR interval
Bradycardia (most common)
Heart block
QRS widening (especially propranolol) which may progress to ventricular arrhythmias
QT prolongation (especially sotalol) with risk of torsades de pointes
Management of beta blocker overdose?
Resuscitation
Correct glucose
Activated charcoal if within 1 hour
Symptomatic bradycardia; atropine
Glucagon
High dose insulin
Signs and symptoms of NMDA toxicity?
Nausea and vomiting
Hallucinations, agitation and psychosis
Delirium
Hyperreflexia
Tremor
Hyperthermia
Diaphoresis
Flushing
Mydriasis
Tachycardia
Hypertension
Complications of NMDA toxicity?
Arrhythmias
Rhabdomyolysis
Seizures
Cardiovascular collapse
Hyponatraemia
Serotonin syndrome
Acute renal failure
Disseminated intravascular coagulation
Coma
Management of NMDA toxicity?
Resuscitation
Benzodiazepines
Cooling if hyperthermic
If hyponatraemic fluid restriction and hypertonic saline
Labetolol
Dantrolene
Management of organophosphate poisoning?
Remove clothing
Protect airway
Intubation and ventilation
Gastric lavage
Give IV atropine
Pralidoxine
Signs and symptoms of cyanide poisoning?
Nausea and vomiting
Headache
Tachycardia
Hypertension
Tachypnoea
Loss of consciousness
Seizures
Respiratory depression
Management of cyanide poisoning?
Decontamination
Intubation and ventilation
High flow oxygen
Dicobalt edetate
Antidote for cyanide?
Dicobalt edetate
Sensitive indicator for cyanide poisoning?
Lactate over 10
What is compartment syndrome?
Inflammation of injured muscle causes an increase in pressure within fascial compartment
As pressure rises circulation is cut off leading to tissue damage and necrosis
Cause of compartment syndrome?
Fractures; commonly tibial, forearm, wrist
Crush injuries
Constrictive dressings/ plaster casts
Prolonged immobilisation
Reperfusion of ischaemic limb
Signs and symptoms of compartment syndrome?
Severe pain out of proportion of initial injury
Passive stretching of affected muscles exacerbates pain
Paraesthesia
Pallor
Pulselessness
Paralysis
Coolness of the affected limb
The area may feel tense on palpation
Differentials for compartment syndrome?
DVT
Cellulitis
Acute limb ischaemia
Investigations to diagnose compartment syndrome?
Measure intracompartmental pressures- typically around 40mmHg
Creatinine kinase
U+E, FBC, LFT, clotting, group and save
ECG
Management of compartment syndrome?
Surgical management; fasciotomies
Analgesia
Monitor neurovascular status
Monitor other limbs
Complications of compartment syndrome?
Rhabdomyolysis
Limb amputation
Volkmann contracture
Triggers of asthma exacerbation?
Cold air and exercise
Pollution and cigarette smoke
Allergens
Chemical irritants
Medications; NSAIDs, beta blockers
What type of reaction is an acute asthma exacerbation?
Type 1 hypersensitivity reaction
Symptoms of acute asthma attack?
Wheeze
Difficulty breathing
Struggling to eat, speak or sleep due to breathlessness
Cough
Chest tightness
Dizziness
Signs of acute asthma attack?
Tachypnoea
Increased work of breathing
Hyperinflated chest
Expiratory polyphonic wheeze throughout the lung fields
Decreased air entry
Cyanosis
Tachycardia
Altered mental state, e.g. drowsiness or confusion
Exhaustion
Hypotension
Differentials for acute asthma?
Pulmonary embolism
Vocal cord dysfunction
Acute exacerbation of COPD
GORD
Anaphylaxis
Investigations for acute asthma?
PEFR
ABG
ECG
FBC, CRPU+E, LFT
Blood cultures
CXR
Complications of acute asthma?
Respiratory failure
Pneumothorax
Status asthmaticus
Death
Management of acute asthma asthma?
ABCDE
Maintain O2 sats 94-98%
Nebulised salbutamol 5mg
Ipratropium bromide 500mcg 4-6 hours
Prednisolone 40-50mg and continue for atleast 5 days
IV magnesium sulphate; 1.2-2g over 20 minutes
Aminophylline
Signs and symptoms of ACS?
Chest pain - typically central and crushing in nature. May radiate to left arm/neck/jaw
Shortness of breath
Nausea +/- vomiting
Sweating and clamminess
Syncope
Atypical presentations are more likely in some groups (e.g. the elderly or patients with diabetes who may not experience chest pain)
Pain may be epigastric rather than in the chest, or there may be no pain
Acute confusion or hyperglycaemic crises are examples of atypical ACS presentations
Differentials for ACS?
Myocarditis
Pericarditis
PE
Costochondritis
Aortic dissection
Investigations to diagnose ACS?
ECG
Troponin, repeat after 4-6 hours
U+E, HbA1c, lipid, FBC, CRP, coagulation
CXR
Echo
Management of STEMI?
Loading dose of aspirin 300mg
Second antiplatelet agent; prasugrel, clopidogrel
Sublingual GTN
Morphine
PCI; primary if presented within 12 hours and can be offered in 2 hours
Management of NSTEMI and UA?
Loading dose of aspirin
Antithrombin; fondaparinux
Risk stratification; GRACE score
Low risk patients managed medically; aspirin + ticagrelor
Intermediate/ high risk managed with PCI and DAPT
Complications of ACS?
Ventricular arrhythmia
Acute mitral regurgitation
Acute heart failure
Heart block
Cardiogenic shock
Cardiac tamponade
Ventricular septal defect
Dressler’s syndrome
What is an acute exacerbation of COPD?
Acute worsening of patients baseline symptoms beyond expected day to day variation
Causes of exacerbation of COPD?
Viral; rhinovirus, influenza, parainfluenza, coronavirus, adenovirus, RSV
Bacterial; haemophilus influenza, streptococcus pneumonia, moraxella catarrhalis, staphylococcus aureus, pseudomonas aeurginosa
Nitrogen dioxide, particulates, sulphurdioxide
Pneumothorax, PE, intra-abdominal pathology, heart failure, metabolic disturbance
Signs of exacerbation of COPD?
Worsening shortness of breath
Reduced exercise tolerance/not coping at home
Worsening cough (especially if increased sputum production/change in colour)
Worsening wheeze and chest tightness
Infective symptoms (e.g. sore throat, coryza, fevers)
Lethargy
Confusion
Ankle swelling
Signs of exacerbation of COPD?
Tachypnoea and respiratory distress
Tripod positioning (where patient leans slightly forward with arms propped up in front - reduces work of breathing and allows greater use of accessory muscles)
Pursed lip breathing
Reduced oxygen saturations from baseline
Tachycardia
Cyanosis
Asterixis
On auscultation: wheeze, reduced air entry, prolonged expiratory phase, crackles
Investigations to diagnose exacerbation of COPD?
ABG
Sputum culture
ECG
FBC, CRP, U+E
Blood culture
CXR
Differentials for exacerbation of COPD?
Pneumonia
Pneumothorax
Pulmonary embolism
Acute exacerbation of asthma
Exacerbation of bronchiectasis
Acute heart failure
Exacerbation of interstitial lung disease
Lung cancer
Tuberculosis
Management of exacerbation of COPD?
Oxygen saturations between 88-92%
Salbutamol 2.5-5mg
Ipratropium 0.5mg QDS
Steroids; prednisolone 30mg for 5 days, if unable to swallow IV hydrocortisone
IV aminophylline
Consider antibiotics if infectious
What is acute angle closure glaucoma?
Blockage of the angle formed by the cornea and the iris which prevents the humour from draining resulting in progressive increase in intra-ocular pressure
Risk factors for acute angle closure glaucoma?
Anatomical variations
Older age
Female sex
East Asian ethnicity
Medications e.g. oxybutynin, amitriptyline, tropicamide
Hypermetropia (farsightedness)
Family history of AACG
Pupillary dilation e.g. being in a dark room
Symptoms of acute angle closure glaucoma?
Rapid onset of severe eye pain
Blurred vision which may progress to visual loss
Nausea and vomiting
Headache
Coloured haloes around lights
Signs of acute angle closure glaucoma?
Conjunctival injection in the affected eye
Haziness of the cornea
Mid-dilated or fixed pupil that is not reactive
Globe feels hard and is tender on palpation
Differentials of acute angle closure glaucoma?
Open angle glaucoma
Acute anterior uveitis
Anterior scleritis
Investigations to diagnose acute angle closure glaucoma?
Slit lamp examination
Ophthalmoscopy
Gonioscopy; allows assessment of the angle between the iris and cornea
Tonometry; >30mmHg
What is the gold standard for for acute angle closure glaucoma?
Goldmann applanation tonometry
Management of acute angle closure glaucoma?
Conservative management;
Lie patient flat with their face up without pillows to relieve pressure on the angle
Referral to ophthalmology
Monitor symptoms and ensure analgesia and antiemetics
Medical management;
Dorzolaminde (carbonic anhydrase inhibitor) and timolol (beta blocker)
Apraclonidine; alpha-2 agonist
Polocapine; cholinergic agonist
Acetazolamide
Surgical management;
Peripheral iridotomy
Treat both eyes
What is anaphylaxis?
Rapid onset of life threatening airway, breathing or circulatory dysfunction as a result of an immunological reaction when patient is exposed to allergen
Epidemiology of anaphylaxis?
20-30 deaths per year, about half are iatrogenic due to penicillin
Causes of anaphylaxis?
Insect stings
Nuts
Other foods such as eggs or milk
Latex
Antibiotics (e.g. penicillins)
Intravenous contrast agents
Other medications (such as NSAIDs)
Signs and symptoms of anaphylaxis?
Airway; difficulty swallowing, breathing, stridor, hoarse voice, swelling of tongue and lips
Breathing; difficulty breathing, wheeze, cough, respiratory distress, respiratory arrest
Circulation; dizziness, pallor, clamminess, tachycardia, hypotension, arrhythmias, anaphylaxis, cardiac arrest
Disability; sense of impending doom, confusion, agitation, loss of consciousness
Exposure; erythematous patches, urtrcaria, angioedema
GI manifestation; abdominal pain, incontinence, vomiting
Differentials for anaphylaxis?
Life threatening asthma exacerbation
Other causes of angioedema; ACE inhibitors, histamine, bradykinin mediation
Panic attack
Vasovagal episode
Investigations for anaphylaxis?
ECG, ABG, mast cell tryptase
Management of anaphylaxis?
Remove triggers
Lie patient flat and elevate legs
IM adrenaline into anterolateral aspect of thigh
Secure airway
High flow oxygen
Inhaled salbutamol/ ipratropium
IV fluid bolus
Repeat IM adrenaline after 5 minutes if no response
Once stabilised;
Oral non sedating antihistamine
Observe for biphasic reaction
What should patients who have had anaphylaxis be given upon discharge?
2 adrenaline auto injectors
Advice on trigger avoidance
Refer for follow up in specialist allergy service
What is a biphasic reaction?
When symptoms of anaphylaxis reoccur without further exposure to trigger
Causes of atrial fibrillation?
Cardiac causes;
Ischaemic heart disease
Hypertension
Valvular heart disease (including rheumatic heart disease, typically affecting the mitral valve)
Heart failure
Cardiomyopathies
Myocarditis and pericarditis
Recent cardiothoracic surgery
Non-cardiac causes;
Electrolyte disturbances (e.g. hypokalaemia, hypomagnesaemia)
Acute infections e.g. pneumonia, sepsis
Pulmonary embolism
Hyperthyroidism
Alcohol excess
Smoking
Medications (e.g. lithium)
Classification of AF?
Paroxysmal; episodes last < 7 days and are intermittent
Persistent; episodes last > 7days
Permanent; lasts > days, no further attempts to get sinus rhythm are attempted
Symptoms of AF?
Palpitations
Chest pain or tightness
Shortness of breath
Reduced exercise tolerance
Light-headedness
Syncope
Fatigue
A complication of AF e.g. a stroke or transient ischaemic attack
Signs of AF?
Irregularly irregular pulse
Radial- apical deficit
Variable intensity of first heart sound on auscultation
Haemodynamic instability; tachycardia, hypotension, loss of conciousness, acute pulmonary oedema
Differentials for AF?
Sinus tachycardia
Atrial flutter
Supraventricular tachycardia
Multifocal atrial tachycardia
Investigations to diagnose AF?
ECG; absence of p waves irregularly irregular QRS
Bloods; FBC, CRP, U+E, bone profile, TFT, HbA1c, LFT, Lipids, clotting screen, blood cultures
CXR
Echocardiogram
CTPA
Management of AF?
AF with adverse signs;
A to E approach
DC cardioversion
If 3 attempts are unsuccessful give 300kg IV amiodarone followed by another shock and 900mg amiodarone infusion over 24 hours
Stable patients
Synchronised DC cardioversion with sedation or general anaesthetic
Pharmacological cardioversion with flecainide
Rate control
Ongoing management;
Anticoagulation; DOAC
Complications of AF?
Embolic event
Hear failure
Myocardial ischaemia
Tachycardia induced cardiomyopathy
Increased risk of vascular dementia
Which groups of patients are more sensitive to CO poisoning
The elderly
Young children
Pregnant women
People with anaemia
People with cardiovascular disease
Signs and symptoms of carbon monoxide poisoning?
Headache
Dizziness
Lethargy
Flushing
Myalgia and weakness
Confusion
Nausea and vomiting
Cherry red skin (rare)
Tachycardia and hypotension
Seizures
Differentials for carbon monoxide poisoning?
Migraine
Viral infections
Diabetic ketoacidosis
Investigations to diagnose carbon monoxide poisoning?
Pulse oximetry
Blood gas
ECG
Capillary blood glucose
Bloods; FBC, U+E, CK, Troponin, lactate
Management of carbon monoxide poisoning?
A to E assessment
100% oxygen
IV fluids
Complications of CO poisoning?
Emotional lability and personality change
Difficulty concentrating
Insomnia
Lethargy
Movement disorders such as chorea and Parkinsonism
Memory impairment and dementia
Psychosis
Neuropathy
What is cardiac tamponade?
Compression of heart by fluid accumulation in the pericardial sac which impairs cardiac filling during diastole compromising cardiac output leading to cardiac arrest
Causes of cardiac tamponade?
Trauma; especially penetrating injuries
Iatrogenic causes; cardiothoracic surgery
Pericarditis which can be secondary to malignancy, myocardial infarction, HIB, TB, connective tissue disease, radiation, CKD
Aortic dissection
Medication; minoxidil, hydralazine
Cardiac perforation
Pneumopericardium
Symptoms of cardiac tamponade?
Fatigue
Dyspnoea
Cold and clammy peripheries
Confusion
Signs of cardiac tamponade?
Beck’s triad (raised jugular venous pressure, hypotension and muffled heart sounds)
Pulsus paradoxus (a decrease in systolic blood pressure by more than 10 mmHg during inspiration)
Tachycardia
Tachypnoea
Altered mental state
Hepatomegaly
Pericardial friction rub
Cyanosis
JVP shows an absent Y descent (due to reduced diastolic filling of the ventricles)
What is Beck’s triad?
Raised JVP
Hypotension
Muffled heart sounds
Differentials for cardiac tamponade?
Acute heart failure
Constrictive pericarditis
Pulmonary embolism
Tension pneumothorax
Investigations to diagnose cardiac tamponade?
ECG; electrical alternans where height of QRS complexes alternate due to movement of heart in pericardial space
FBC, CRP, U+E, coagulation, HIV testing, group and save, troponin
Imaging; echocardiogram, CXR, CT
Pericardiocentesis fluid for cytology
Management of cardiac tamponade?
Supportive therapy; oxygen, IV fluids, inotropes
Pericardiocentesis
Open surgical drainage
Percutaneous balloon pericardiotomy, pericardiectomy
Treat underlying cause
What is the triad for diabetic ketoacidosis?
Hyperglycaemia; >11mmol/L
Ketosis; >3 mmol/L
Acidosis; pH <7.3
Causes of DKA?
Insulin deficiency leads to hyperglycaemia which are converted to ketones which leads to ketosis
What proportion of T1DM first presentation is DKA?
10-20%
Triggers for diabetic ketoacidosis?
Infections
Dehydration and fasting
Missing doses of insulin
Medications e.g. steroid treatment or diuretics
Surgery
Stroke or myocardial infarction
Alcohol excess or illicit drug use
Pancreatitis
When should patients with DKA be considered to higher dependency care?
Blood ketones > 6mmol/L
Bicarbonate < 5mmol/L
Blood pH < 7
Anion gap above 16
Hypokalaemia on admission
GCS less than 12
Oxygen saturations < 92% in air
Systolic BP < 90mmHg
Brady or tachycardia (heart rate < 60 or > 100bpm)
Symptoms of DKA?
Nausea and vomiting
Abdominal pain
Polyuria
Polydipsia
Weakness
Signs of DKA?
Dry mucous membranes
Hypotension
Tachycardia
Altered mental state (drowsiness, confusion, coma)
Kussmaul’s breathing (deep, sighing breathing to compensate for metabolic acidosis by blowing off carbon dioxide)
Fruit-like smelling breath (due to ketosis)
Investigations to diagnose DKA?
Capillary blood glucose
Blood or urinary ketones
Urine dip and MSU
ECG
Venous blood gas
U+E, FBC, CRP
Blood cultures
HbA1c
Management of DKA?
A to E assessment
Ensure IV access
Consider urinary catheterisation and monitor fluid balance
IV fluids
Potassium replacement
Insulin 0.1 units/ kg/ hour
What is ethylene glycol poisoning?
Chemical in antifreeze or radiator coolant
Signs and symptoms of ethylene glycol poisoning?
Early;
Apparent intoxication (similar to that of alcohol)
Nausea and vomiting
Haematemesis
Seizures
Ataxia
Ophthalmoplegia
Papilloedema
Raised anion gap metabolic acidosis
Pulmonary oedema
Late;
Acute tubular necrosis
Flank pain
Oligouria
Hypocalcaemia
Hyperkalaemia
Hypomagnesaemia
Differentials for ethylene glycol poisoning?
Alcohol intoxication
Poisoning with other substances
Acute renal failure
Investigations to diagnose ethylene glycol poisoning?
Urine sample
ECG
Blood gas; metabolic acidosis with raised anion gap
U+E, LFT
Bone profile, hypocalcaemia
Magnesium, hypomagnesaemia
CT head
Management of ethylene glycol poisoning?
A to E assessment
Monitor urine output
Gastric lavage, NG aspiration
Fomepizole
Ethanol
Haemofiltration
Treat any electrolyte imbalance
Mechanism of action of fomepizole?
Competitive inhibitor of alcohol dehydrogenase
What is hyperosmolar hyperglycaemic state?
Complication of T2DM commonly seen in older patients with known diabetes
Key features of hyperosmolar hyperglycaemic state?
Blood glucose ≥ 30 mmol/L
Serum osmolality ≥ 320 mOsm/kg
Significant hypovolaemia
Blood ketones ≤ 3 mmol/L
pH ≥ 7.3 and bicarbonate ≥15.0 mmol/L
Factors that can cause hyperosmolar hyperglycaemic state?
Infection
Recent trauma or surgery
Acute events like stroke or MI
Medications; steroids
Symptoms of hyperosmolar hyperglycaemic state?
Polyuria
Polydipsia
Nausea
Lethargy
Weakness
Confusion
Drowsiness
Loss of consciousness
Signs of hyperosmolar hyperglycaemic state?
Tachycardia
Hypotension
Altered mental state
Sunken eyes
Dry mucous membranes
Investigations to diagnose hyperosmolar hyperglycaemic state?
Capillary glucose; over 30
VBG
Capillary blood ketones
ECG
Urine dip
Serum osmolality, glucose, U+E, FBC, CRP, LFT
Bone profile
Blood cultures
CXR
Management of hyperosmolar hyperglycaemic state?
Fluid resuscitation; 1L of 0.9% saline over 1 hour
Potassium replacement
Monitor glucose, ketones, U+Es hourly and calculate serum osmolality every hour
VTE prophylaxis
Refer to diabetes specialist
Complications of hyperosmolar hyperglycaemic state?
Hypovolemic shock
Cerebral oedema
Thromboembolic events
Acute kidney injury
Cardiac arrhythmias
Respiratory failure
Long-term neurological sequelae
What is pericarditis?
Inflammation of the pericardium
Causes of pericarditis?
Idiopathic
Viral; echovirus, enterovirus, cocksackievirus, adenovirus
Bacterial; pneumococcus, staphylococcus, mycoplasma
TB
Dresslers syndrome
Autoimmune; rheumatoid arthritis, SLE, scleroderma
Uraemic pericarditis
Malignancy
Drugs; isoniazide, hydralazine
Trauma
Signs and symptoms of pericarditis?
Acute onset pleuritic chest pain; relieved by leaning forward, retrosternal may radiate down left arm/ shoulder
Pericardial friction rub
Fever
Cough
Arthralgia
Investigations to diagnose pericarditis?
ECG; acute phase PR depression, global saddle shaped ST elevation
FBC, CRP, Troponin, U+E,
Echo
CXR
Management of pericarditis?
NSAIDs
Low dose colchicine
Steroids in uraemic pericarditis, connective tissue disorders
Aspirin is used in pericarditis post MI
High risk features of pericarditis?
Large pericardial effusion or tamponade
Myopericarditis (elevated troponin)
Immunosuppression
High fevers (>38 degrees)
Trauma
On oral anticoagulants
Subacute cause
Not responding to initial treatment (after 1-2 weeks)
What is a pneuothorax?
Collection of air in the pleural cavity which may cause collapse of underlying lung parenchyma
How is pneumothorax classified?
Spontaneous
Traumatic
Tension
Symptoms of pneumothorax?
Sudden onset shortness of breath
Pleuritic chest pain
Dry cough
Tachypnoea and increased work of breathing
Signs of pneumothorax?
Unilateral reduced expansion
Unilateral hyper-resonance to percussion
Reduced or absent breath sounds
Reduced vocal resonance or tactile vocal fremitus
Tracheal deviation to the contralateral side
Tachycardia
Hypotension
Distended neck veins
Investigations to diagnose pneumothorax?
CXR
ABG
CT chest
Needle aspiration
Management of tension pneumothorax?
Insertion of large bore cannula into second intercostal space, mid clavicular line
Thoracostomy
Chest drain
Follow up requirements for pneumothorax?
OPD in 2-4 weeks
Smoking cessation
No flying until 7 days post pneumothorax resolution
No underwater diving
Triad of PE?
Sudden onset shortness of breath
Pleuritic chest pain
Haemoptysis
Symptoms of PE?
Sudden onset Shortness of breath
Pleuritic chest pain
Haemoptysis
Cough
Syncope
RV ischaemia -> retrosternal chest pain
Signs of PE?
Tachypnoea
Crackles o auscultation
Tachycardia
Hypoxia
Low grade pyrexia
How to interpret wells score?
Less than 4; PE unlikely, perform D dimer
More than 4; PE likely, CTPA or V/Q scan
Investigations for PE?
ECG; sinus tachycardia
ABG
D-dimer
FBC
CRP
U+E
LFT
Coagulation
Troponin
CXR
CTPA
V/Q scan
TTE
What is seen on CXR in PE?
Fleischner sign; enlarged pulmonary artery
Hampton’s sign; peripheral wedge shaped opacity
Westermark sign; regional oligaemia
Management of PE?
Anticoagulation
Embolectomy
Catheter directed thrombolysis
Cause of status epilepticus?
Withdrawal/ interruption or change in anti-epileptic medication
Non compliance with medication
Seizure threshold lowering medications
Intercurrent illness
Metabolic abnormalities
Infection
Brain injury; trauma, stroke, subarachnoid haemorrhage
Withdrawal from benzodiazepines, alcohol
Signs and symptoms of convulsive status epilepticus?
Abrupt generalised muscle stiffening (tonic phase) followed by rhythmic jerking of the muscles (clonic phase)
Loss of consciousness
Tongue biting - typically lateral tongue
Urinary or faecal incontinence
Clenched jaw
Erratic eye movements
Drooling
Cyanosis
Signs and symptoms of non convulsive status epilepticus?
Reduced levels of consciousness
Catatonia
Behavioural changes/psychosis
Subtle motor signs e.g. myoclonus, eye deviation or twitching
Autonomic dysfunction
Speech disturbance e.g. aphasia or perseveration
Features of non epileptic seizures?
Last longer
Eyes closed
Emotional vocalisation; crying, screaming
Limbs moving in phase with each other
Head and trunk moving side to side
React to external stimuli
Incontinence and tongue biting
Causes of non convulsive status epilepticus?
Encephalitis
Hypoglycaemia
Psychogenic pseudocoma
Alcohol/ benzodiazepine withdrawal
Transient global amnesia
Stroke
Investigations to diagnose status epilepticus?
Capillary glucose
Blood gas; electrolytes, lactate
Urine toxicology
Pregnancy test
ECG
FBC, CRP, U+E, bone profile, magnesium LFT, clotting, serum anticonvulsant levels, blood cultures
CT head, chest x ray
Lumbar puncture
Management of status epilepticus
Ensure patient safety
Airway adjunct
High flow oxygen via non-rebreather
Check glucose and give pabrinex is concern around alcohol excess
At 5 minutes give 4mg of IV lorazepam (rectal diazepam or buccal midazolam)
At 10 minutes repeat benzodiazepine
At 15 minutes IV infusion of levetiracetam, phenytoin, sodium valproate
If 30 minutes GA and intubate
What is supraventricular tachycardia?
Tachycardia originating above the level of bundle of his with narrow complex QRS
Management of SVT?
Unstable;
DC cardioversion if signs of shock, syncope, heart failure, myocardial ischaemia
Stable
Vagal manoeuvre; carotid sinus massage, valsalva manoeuvre
IV 6mg adenosine, 12mg then 18mg if unsuccessful
Continuous ECG
If adenosine fails, beta blocker or CCB with DC cardioversion
Short term effects of adenosine?
Difficulty breathing
Chest tightness
Flushing
What is torsades de pointes?
Polymorphic ventricular tachycardia characterised by twisting and gradually changing amplitude QRS complexes around isoelectric line on ECG as a result of QT prolongation
Causes of torsades of pointes?
Congenital long QT syndrome
Stress, fear, exercise
Toxins; heavy metals, insecticides
Ischaemia
Medications; erythromycin, ketoconazole, TCA, methadone, antipsychotics
Electrolyte abnormalities; hypokalaemia, hypocalcaemia, hypomagnesaemia
Subarachnoid haemorrhage
Symptoms of torsades de pointes?
Upto 50% are asymptomatic
Palpitations
Lightheadedness
Syncope
Chest pain
Nausea
Cold sweats
Dyspnoea
Sudden cardiac death
Investigations to diagnose torsades the points?
ECG
VBG
Troponin
Echo
Genetic testing
Management of torsades de pointes?
IV fluids
Correct any electrolyte imbalance
IV magnesium 2g
DC cardioversion
Defibrillation
What is an upper GI bleed?
Haemorrhage in the GI tract anywhere between oesophagus and duodenum at the ligament of treitz
What is the most common cause of upper GI bleed?
Peptic ulcer disease
Causes of upper GI bleed?
Oesophageal causes;
Oesophageal varices
Oesophagitis
Mallory- Weiss tear
Oesophageal cancer
Stomach causes;
Peptic ulcer
Gastric varices
Gastritis
Gastric cancer
Vascular malformation
Duodenal causes;
Peptic ulceration
Aortoenteric fistula
Scoring systems to classify upper GI bleed?
Glasgow blatchford score
Rockall score
Symptoms of upper GI bleed?
Haematemesis
Coffee ground vomit
Melena
Lightheadedness
Syncope
Abdominal pain
Fatigue
Shortness of breath
Decreased exercise tolerance
Palpitations
Signs of upper GI bleed?
Tachycardia
Hypotension
Prolonged capillary refill time
Altered mental state
Abdominal tenderness
Melaena or haematochezia (fresh red blood) on rectal examination
Stigmata of chronic liver disease; spider naevi, gynaecomastia, palmar erythema, caput medusae
Investigations to diagnose upper GI bleed?
VBG
ECG
FBC
U+E
LFT
Coagulation
Group and save
Cross match
OGD
CXR
Which blood thinner can be continued in upper GI bleed?
Aspirin
All other anticoagulation is discontinued
Management of upper GI bleed?
Major haemorrhage protocol
Airway support
Ensure adequate IV access, bloods and blood gas
Fluid bolus and blood transfusion if Hb under 70 (target 70-100)
Correct coagulopathy/ anticoagulation
Band ligation
Sclerotherapy
PPI
Complications of upper GI bleed?
Rebleeding
Aspiration of haematemesis
Complications of endoscopy; perforation
Death
What is ventricular tachycardia?
Broad complex tachycardia with HR over 100bpm, and QRS width over 120ms
What is myxoedema coma?
Severe decompensated hypothyroidism characterised by profound hypothermia, decreased mental status, systemic manifestations of severe hypothyroidism
Epidemiology of myxoedema coma?
Very rare
More common in elderly women
Cause of myxoedema coma?
Severe untreated hypothyroidism
Infection
Myocardial infarction
Stroke
Trauma
Heart failure
Drugs
Exposure to cold temperatures
Signs and symptoms of myxoedema coma?
Profound lethargy or coma
Hypothermia (typically below 35°C)
Bradycardia and hypotension
Hypoventilation leading to respiratory failure
Hypoglycaemia
Hyponatraemia
Generalized myxoedema
Differentials for myxoedema coma?
Sepsis
Stroke
Drug overdose
Investigations to diagnose myxoedema coma?
TSH, free T4
FBC
U+E
Blood glucose
ABG
Management of myxoedema coma?
ITU/HDU care
IV T3/T4
50-100mg IV hydrocortisone
Mechanical ventilation and oxygen - if hypoventilation
IV fluid - to correct hypovolaemia
Correction of hypothermia
Correction of hypoglycaemia
Treatment of any heart failure
What defines an AKI?
Increase in serum creatinine by 26.5 mmol/l within 48 hrs
Increase in serum creatinine > 1.5 times baseline in last 7 days
Urine output under 0.5ml/kg/hr for 6 hours
Risk factors for AKI?
Patients with CKD
Elderly patients
Previous AKI
Malignancy
Medical conditions increasing risk of urinary obstruction (e.g. benign prostatic hyperplasia)
Cognitive impairment and disability (may be reliant on others for fluid intake)
Recent use of medications such as NSAIDs or ACE inhibitors
Recent administration of iodine-containing contrast media
Causes of AKI?
Pre-renal;
Hypovolaemia; dehydration, haemorrhage, GI losses, burns
Renal artery stenosis
Medications; NSAIDs, ACE-i, ARB, diuretics
Hypotension
Renal;
Glomerulonephritis
Nephritic syndrome
Acute tubular necrosis; ischaemia, toxins, rhabdomyolysis
Renal vein thrombosis
Vasculitis
Post renal;
Ureteric stones
Blocked catheter
Urethral/ ureteric strictures
Ureteric carcinomas
Abdominal/ pelvic tumours
BPH
Classification of AKI?
Stage 1 if any of;
Creatinine rise over 26 micromol/L in 48 hours
Creatinine rise to 1.5-1.99 times baseline within 7 days
Urine output < 0.5ml/kg/hr over 6 hours
Stage 2 if any of;
Creatinine rise to 2-2.99 times baseline within 7 days
Urine output < 0.5ml/kg/hr over 12 hours
Stage 3 if any of;
Creatinine rise to 3x baseline or higher within 7 days
Creatinine rise to 354 micromol/L or more with either
Acute rise of 26 micromol/L or more within 48 hours or
50% or more rise within 7 days
Urine output < than 0.3 mL/kg/hour for 24 hours
Anuria for 12 hours
Symptoms of AKI?
Symptomless
Fatigue
Confusion
Anorexia
Pruritus
Nausea and vomiting
Signs of AKI?
Hypertension
Bladder distention
Hypotension and dehydration
Signs of fluid overload; raised JVP, pulmonary/ peripheral oedema
Fevers, sepsis, rashes, vasculitis
Pericardial rub
Investigations to diagnose AKI?
Urinalysis
ECG
Blood gas
U+E, FBC, U+E,
Clotting, bone profile
Creatinine kinase
CRP
Bladder scan
USSKUB
Renal biopsy
Consider acute renal screen;
ANA
Double-stranded DNA
Anti-nuclear cytoplasmic antibodies
Anti-GBM antibodies
Erythrocyte sedimentation rate
Serum immunoglobulins
Serum electrophoresis
Serum free light chains
Complement levels (C3 and C4)
HIV screening
Hepatitis B and C serology
Management of AKI?
IV fluids
Assess fluid balance
Catheter
Screen for complications; hyperkalaemia, acidosis, pulmonary oedema
Suspend nephrotoxic drugs; NSAIDs, aminoglycosides, ACE-i, ARB
Consider renal replacement therapy if;
Acidosis; <7.2
Electrolyte imbalance
Intoxication
Oedema
Uraemia
Causes of addisonian crisis?
Infection
Surgery
Injury
Dehydration
Sudden withdrawal of exogenous steroids
Sudden loss of endogenous steroids; bilateral adrenal haemorrhage, pituitary apoplexy
Causes of primary adrenal insufficiency?
Autoimmune
Surgical removal of adrenal glands
Trauma
Infectious disease; TB
Haemorrhage
Infiltration; malignancy, sarcoidosis, amyloidosis
Medications
Congenital adrenal hyperplasia
Causes of secondary adrenal insufficiency?
Pituitary tumours (e.g. adenomas)
Pituitary surgery
Post-traumatic hypopituitarism
Hypophysitis (autoimmune inflammation)
Sheehan’s syndrome (avascular necrosis of the pituitary secondary to massive postpartum haemorrhage)
Radiotherapy
Congenital causes
Pituitary apoplexy
Causes of tertiary adrenal insufficinecy?
Exogenous steroid administration (most common)
Hypothalamic tumours
Traumatic brain injury
Symptoms of addisonian crisis?
Fatigue
Malaise
Abdominal pain
Nausea and vomiting
Myalgia and muscle weakness
Headaches
Signs of addisonian crisis?
Dehydration
Hypotension
Hypovolaemic shock
Low-grade fever
Confusion or coma
Seizures
Signs of chronic hypoadrenalism e.g. hyperpigmentation due to increased ACTH in Addison’s disease
Investigations to diagnose addisonian crisis?
Capillary glucose
ECG
VBG, ABG
U+E, FBC, CRP, LFT, Cortisol, Bone profile, ACTH, TFT
Short synacthen test
Autoantibodies
CT/ MRI
Pituitary MRI
Management of addisonian crisis?
A to E
IV/ IM hydrocortisone 100mg
Regular fludrocortisone 50mg IV QDS
IV glucose to correct hypoglycaemia
Causes of acute pulmonary oedema?
Cardiogenic; CAS, heart failure, mitral regurgitation, acute arrhythmia, myocarditis, post partum cardiomyopathy, NSAIDs, hypertensive crisis
Non-cardiogenic; ARDS, renal artery stenosis, AKI, fluid overload, high altitude, neurogenic pulmonary oedema
Symptoms of acute pulmonary oedema?
Severe dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea (PND)
Anxiety
Diaphoresis
Cough - may be dry or productive of pink frothy sputum
Nausea
Signs of acute pulmonary oedema?
Respiratory distress
Tachypnoea
Tachycardia
Raised jugular venous pressure (JVP)
Inspiratory crepitations on auscultation
Gallop rhythm (3rd heart sound)
Peripheral oedema and hepatomegaly if secondary to right heart failure
Hypotension and oliguria if in cardiogenic shock
Differentials for acute pulmonary oedema?
Acute exacerbation of COPD
Pneumonia
Pulmonary embolism
Investigations to diagnose acute pulmonary oedema?
ECG
ABG
FBC, CRP, U+E, LFT, BNP
CXR, Echo
Symptoms of aspirin overdose?
Nausea and vomiting
Tinnitus
Epigastric pain
Confusion
Dizziness
Signs of aspirin overdose?
Hyperventilation
Tachycardia and a bounding pulse
Diaphoresis
Fevers
Pulmonary oedema
Seizures
Coma
Investigations to diagnose aspirin overdose?
VBG, capillary glucose
ECG
Urinary pH
Salicylate levels
U+E
Paracetamol levels
Management of aspirin overdose?
If less than 1 hour ago give activated charcoal
Fluids
Correct hypokalaemia
Manage hyperthermia
Haemodialysis
Causes of digoxin toxicity?
Accidental or intentional overdose
Deterioration in renal function
Dehydration
Medication interactions (e.g. macrolides, antifungals, verapamil)
Electrolyte derangement (hypomagnesaemia, hypercalcaemia, hypokalaemia)
Elderly patients are at greater risk of digoxin toxicity
Signs and symptoms of digoxin toxicity?
Dizziness
Nausea and vomiting
Diarrhoea
Anorexia
Palpitations
Syncope
Blurred vision
Yellow-green discolouration of vision
Visual haloes
Confusion
Signs of digoxin toxicity on ECG?
Supraventricular tachycardias
Atrioventricular block
Frequent premature ventricular contractions
Sinus bradycardia
Slow atrial fibrillation
Ventricular tachycardia
Investigations to diagnose digoxin toxicity?
ECG
VBG
Capillary blood glucose
Digoxin level
U+E, magnesium, bone profile, CRP, FBC
Management of digoxin toxicity?
A to E
Charcoal if within 1 hour of ingestion
Correct electrolyte abnormality
DigiBind or DigiFab
Magnesium sulphate until antidote is available
What is hypoglycaemia?
Blood glucose below 3.5 mmol/L
What is Whipple’s triad?
A low blood glucose level
Symptoms or signs of hypoglycaemia
Resolution of symptoms/signs once blood glucose normalises
Causes of hypoglycaemia?
Alcohol
Insulin
Oral hypoglycaemic medications such as sulphonylureas
Decreased oral intake
Excessive exercise
Insulinomas
Adrenal insufficiency
Reactive hypoglycaemia (e.g. after upper gastrointestinal surgery)
Self-induced hypoglycaemia
Signs and symptoms of hypoglycaemia?
Hunger
Anxiety/irritability
Tremor
Sweating
Headache
Double vision
Slurred speech
Confusion
Decreased level of consciousness
Management of hypoglycaemia?
If conscious and able to swallow;
15-20g of fast acting carbohydrate
40% glucose gel
Once over 4mmol/L give long acting carbohydrate
If unconscious and unable to swallow;
A-E
100mls of 20% glucose or 200mls of 10% IV
If no IV access 1mg of IM glucagon
Symptoms of phaeochromocytoma?
Episodic hypertension
Anxiety
Weight loss
Fatigue
Palpitations
Excessive sweating
Headaches
Flushing
Fever
Difficulty breathing (dyspnea)
Abdominal pain
Signs of phaeochromocytoma?
Hypertension
Postural hypotension
Tremor
Hypertensive retinopathy
Differentials for phaeochormocytoma?
Anxiety disorder
Hyperthyroidism
Essential hypertension
Investigations to diagnose phaeochromocytoma?
Plasma metanephrines
Adrenal imagine; CT, MRI if needed
PET scan
Management of phaeochromocytoma?
Alpha blockade; phenoxybenzamine
Beta blockade
Surgical removal
Causes of spinal cord compression?
Trauma
Malignancy
Infection
Epidural haematoma
Intervertebral disk prolapse
Signs of spinal cord compression?
Back pain, which is typically:
Severe
Progressive
Aggravated by straining e.g. coughing
Difficulty walking
Weakness below the level compressed (typically bilateral and symmetrical)
Numbness below the level compressed
Urinary or faecal incontinence
Urinary retention
Constipation
Signs of spinal cord compression?
Hypertonia
Hyperreflexia (although reflexes may be absent at the level compressed)
Clonus
Upgoing plantars
Sensory loss (a “sensory level”)
Differentials for spinal cord compression?
Transverse myelitis
Cauda equina syndrome
Peripheral neuropathy
Spinal metastases
Sciatica
Investigations to diagnose spinal cord compression?
MRI whole spine
Whole body CT
Bladder scan; retention
Tumour markers
Biopsy
Management of spinal cord compression?
Management depends on the underlying cause as well as the patient’s background
Patients with traumatic spinal cord injuries should be transferred to a major trauma centre
General principles include:
Immobilise the patient and nurse with spinal precautions (e.g. log-rolling)
Regular repositioning to prevent pressure ulceration in immobile patients
Analgesia for pain
VTE prophylaxis
Catheterise if in urinary retention
Counselling and rehabilitation is key, with multidisciplinary input (e.g. physiotherapy)
16mg dexamethasone and PPI cover
Epidemiology of thyrotoxic storm?
More common in women and those with Grave’s disease
Triggers for thyrotoxic storm?
Acute illness
Surgery
Trauma
Radioactive iodine therapy
Symptoms of thyrotoxic storm?
Tachycardia
Fever
Altered mental status
Sweating
Tremor
Nausea and vomiting
Differentials for thyrotoxic storm?
Sepsis
Acute coronary syndrome
Phaeochromocytoma
Investigations to diagnose thyrotoxic storm?
TFT
Cardiac monitoring
Sepsis 6
Management of thyrotoxic storm?
Symptom control;
IV propanolol or digoxin if propanolol is contraindicated
Reduce thyroid activity;
Propylthiouracil
Carbimazole
Lugol’s iodine- 4 hours after Propylthiouracil
IV hydrocortisone
If pregnancy Propylthiouracil in first trimester, carbamizole in later pregnancy
Causes of epistaxis?
Trauma
Oxygen via nasal cannulae
Recent ENT or maxillofacial surgery
Tumours
Inflammation, nasal polyp
Illicit drug use, alcohol
Medications; nasal steroids
Bleeding disorders
Inhaled irritants, temperature, humidity
Management of epistaxis?
Direct compression
Sit patient forward, breathe through mouth and pinch cartilaginous part of nose for 10-15 mins
Topic antiseptic; naseptin, mupirocin
Cautery
Lidocaine with phenylephrine
Nasal packing
Embolisation
Tranexamic acid
Complications of epistaxis?
Anaemia
Recurrent epistaxis
Hypovolaemia
Aspiration of blood and airway compromise
Nasal cautery may cause septal perforation
Nasal packing may lead to sinusitis, septal haematoma or pressure necrosis
Causes of GI tract perforation?
Upper GI tract;
Oesophageal/ gastric malignancy
Peptic ulcer disease
Boerhaave syndrome
Ingestion of sharp or caustic materials
Iatrogenic
Lower GI tract;
Diverticulitis
Colorectal cancer
Bowel obstruction
Colitis (e.g. inflammatory bowel disease)
Appendicitis
Infection (e.g. toxic megacolon secondary to C. difficile infection)
Iatrogenic (e.g. abdominal surgery or colonoscopy)
Mesenteric ischaemia
Invasion of the bowel by other tumours
Symptoms of GI perforation?
Abdominal pain, which is sudden in onset and severe
Nausea and vomiting
Malaise
Lethargy
Signs of GI perforation?
Peritonism e.g. guarding, rebound tenderness, rigidity on palpation of the abdomen
Hypotension
Tachycardia
Tachypnoea
Fevers
Differentials for GI perforation?
Non specific abdominal pain
Spontaneous bacterial peritonitis
Appendicitis
Pancreatitis
Investigations to diagnose GI perforation?
Blood gas
Pregnancy test
FBC, CRP, LFT, U+E, Group and save, blood cultures
CT with contrast
CXR
Abdominal Xray
Management of GI perforation?
Conservative;
Make the patient nil by mouth
Urgent surgical review
May require critical care input e.g. in cases of organ failure secondary to sepsis
Consider nasogastric tube insertion e.g. in severe vomiting
Medical;
Start IV broad spectrum antibiotics
IV fluid resuscitation as required
Give analgesia and antiemetics - may need to be parenteral
Certain cases of perforation may be managed with medical treatment only, for example a localised diverticular perforation in a well patient
Surgical;
Most cases of perforation will require surgical management with a laparotomy
This usually involves a thorough washout, identifying the cause of perforation and repairing the defect
For example, cases of bowel perforation would usually be managed with a bowel resection and formation of a temporary stoma to protect the site of repair
What is hyperthermia?
Core body temperature over 38 degrees
Causes of hyperthermia?
Heatstroke
Sepsis
Endocrine; hyperthyroidism, phaeochromocytoma, adrenal crisis
Drugs
Malignant hyperthermia
Neuroleptic malignant syndrome
Serotonin syndrome
Anticholinergic toxicity
Status epilepticus
Encephalitis
Intracranial haemorrhage
Stroke
Risk factors for hyperthermia?
Extremes of age (young children and the elderly)
Obesity
Physical exertion
Impaired sweating
Cognitive impairment
Dehydration
Symptoms of hyperthermia?
Thirst
Fatigue
Weakness and lethargy
Dizziness
Headache
Nausea and vomiting
Sweating (skin may be dry in severe hyperthermia or due to certain causes e.g. anticholinergic toxicity)
Muscle cramps
Confusion and agitation
Signs of hyperthermia?
High body temperature
Tachycardia
Hypotension
Tachypnoea
Oliguria
Impaired consciousness
Slurred speech
Seizures
Management of hyperthermia?
A to E
Fluid resuscitation with cooled fluids
Catheterise
Remove excess clothing
Place ice packs and spray cool water
Fan skin
Cold water immersion
Bladder/ Gastric lavage
Complications of hyperthermia?
Rhabdomyolysis
Lactic acidosis
Disseminated intravascular coagulation
Acute kidney injury
Arrhythmias
Liver failure
Non-cardiogenic pulmonary oedema
Hyperkalaemia
Hypocalcaemia
Death
What is hypothermia?
Core body temperature below 35 degrees
Symptoms of hypothermia?
Shivering
Hunger
Dizziness
Chills
Slurred speech
Paradoxical undressing
Signs of hypothermia?
Tachycardia
Tachypnoea
Cool peripheries
Hypotension
Ataxia
Reduced level of consciousness
Fixed and dilated pupils
Management of hypothermia?
A to E
Passive rewarming; remove wet/ cold clothing, blanket
Active rewarming; bair hugger, warm IV fluids
Cardiac monitoring, rectal temperature
Extracorporeal rewarming
