Emergency medicine Flashcards
1
Q
What should you look for when assessing of breathing? (B)
A
signs of resp. distress
RR
Assess depth/quality of breathing
chest deformity, raised JVP abdominal distension
Record FiO2 and SpO2
Listen near face: wheeze, coughing, stridor
Palpate, percuss, auscultate
Trachea position
2
Q
How can hyperventilation affect ventilation?
A
Reduces the level of ventilation achieved (just gets rid of CO2)
3
Q
What signs may indicate resp. distress?
A
Increased RR (in SEVERE resp. distress - can become hypoventilation)
accessory muscle use, intercostal and subcostal recession
Agitation (untreated hyperaemia - cerebrally irritated)
Sweating
Pallor/redness/cyanosis
Wheeze
4
Q
What RR indicates that pt. may be near death?
A
> 27
Or v. low
5
Q
What may chest deformity tell you about pt?
A
Existing disease (eg. barrel chest, COPD)
Cause of breathlessness - abdominal breathing, broken ribs, restrictive disease etc.
6
Q
Why is JVP important in resp.?
A
Cardiac cause of resp. problem (pulmonary oedema)
7
Q
What things can cause tracheal deviation?
A
Large pleural effusions
tension pneumothorax
8
Q
What treatments can you give breathless pt.?
A
Oxygen
Salbutamol nebs
GTN or furosemide (in pulmonary oedema - esp. if near arrest)
ABX and steroids (Later management, once pt. stable)
9
Q
Flow rate of Oxygen that can be given when using nasal cannula. What percentage oxygen is delivered?
A
2-6L (usually 4L)/min
24-30%
10
Q
Flow rate of Oxygen that can be given when using Hudson Mask. What percentage oxygen is delivered?
A
5-10L/min
30-40%
11
Q
Flow rate of Oxygen that can be given with non-rebreathe mask. What conc. of oxygen is delivered?
A
12-15L
85% (ideally, would be 100%)
12
Q
What is a benefit of a bag-valve mask?
A
Delivers positive pressure
13
Q
What are CPAP/BiPAP?
A
Types of non-invasive ventilation
14
Q
Should you prescribe O2 for someone who is breathless, but has normal-range O2 sats?
A
NO.
If they do not have oxygen requirement, THEY DO NOT NEED TO BE GIVEN SUPPLEMENTARY OXYGEN
15
Q
What is normal range of sats in COPD pt.?
A
88-92%
16
Q
What is normal range of sats in non-COPD pt.?
A
94-98%
17
Q
62 yr M COPD SOB Productive cough, fever, pleuritic chest pain O2 sats 90%
Does he need Oxygen?
A
NO.
18
Q
25 yr M Operative repair of femur # No PMH ABCDE confirms he's not critically unwell Sats 90%
Differentials What is his O2 target range? Does he need supplementary O2? What delivery system should you use? Why is ABCDE normal?
A
Fat embolism
Hospital-acquired pneumonia
O2 target range: 94-98%
Yes he needs O2
What delivery system? Nasal cannula (commencing on 1L/min up to max of 6L/min) - start small, increase!
ABCDE has shown he’s not critically unwell as he is ACUTELY unwell, not CRITICALLY unwell (critical means near-death). You have time to manage him before he turns critical.
19
Q
What are features of fat embolism?
A
SOB, reduced sats, usually cerebrally confused
20
Q
19Yr M Collapsed at home Vomiting Pyrexial Florid non-blanching purpuric rash Critically unwell Sats on 99% on face mask
Does he need Oxygen?
How should it be delivered?
A
Critically unwell - therefore even if sats in range, need to be on 15L
non-rebreathe reservoir mask
21
Q
78 yr F COPD Long-term O2 therapy Collapse Reduced consciousness In extremis (about to have cardiac arrest) Slow-intermirrent gasping breaths Sats are unrecordable
O2 target range? Does she need supplementary O2? What O2 delivery system would you choose? What might her ABG look like? What do you need to consider?
A
88-92%
Yes
She needs a bag and valve mask - she isn’t breathing, therefore needs ventilation (+ve pressure of bag and valve mask)
Low O2, high CO2 - possible resp. acidosis
Whether she may have a DNACPR, therefore, what you do re. withdrawng care/ continuing resuscitation
22
Q
48 Yr M Pneumonia on ward Increasing SOB On O2 (nasal cannula 6L/min ABCDE: not critically unwell Sats 93%
Does he need O2?
If so, via which O2 delivery system?
A
Yes
Simple fase mask (5L/min - although reduction, this would probably be enough via this method. If not working, titrate up)
23
Q
28 Yr M CF Recovering from pneumonia ABCDE: not acutely unwell Sats: 86% on 60% venturi (V60) mask
What is his target range? Why?
Does he need O2?
Via which delivery system?
Who else might you want involved?
A
88-92
Yes
Non-rebreathe mask
Critical care review, if not HDU (as he is deteriorating and requiring high-flow Oxygen and aggressive treatment)
*in leeds, can’t be in normal ward if you’re on non-rebreathe
24
Q
Who should get a blood gas?
A
ANYONE who’s Critically ill
Unexpected/inappropriate hyperaemia (Sp O2 <94%) Or requiring O2 to maintain normal sats
Deteriorating O2 sats
Increasing SOB with previously stable hyperaemia
Deteriorating pt. who now requires O2 to maintain constant O2 sats
RF for hypercapnia resp. failure, develops acute SOB, reduced O2 sats, drowsiness or other Sx of CO2 retention
SOB and thought to be at risk of metabolic conditions
Acute SOB or critical illness and poor peripheral circulation in whom reliable oximetry cannot be obtained
ANY OTHER EVIDENCE THAT WOULD INDICATE THAT BG WOULD BE USEFUL
Any reduction in O2 sats of 3% or more (even if within target range)
25
What are the benefits of ABG over VBG?
ABG is gold standard for determining the arterial metabolic parameters
Can determine PaO2 (can't do this on VBG)
26
What is a normal pH range on a BG? What is it called if value is:
a) below range
b) above range?
7. 35-7.45
a) acidaemia
b) alkalaemia
27
What is a normal PaO2 range on a BG? What is it called if value is:
a) below range
b) above range?
>10kPA
a) hypoxaemia
b) hyperoxaemia
28
What is a normal PaCO2 range on a BG? What is it called if value is:
a) below range
b) above range?
4-6
a) respiratory alkalosis
b) respiratory acidosis
29
What is a normal HCO3 range on a BG? What is it called if value is:
a) below range
b) above range?
22-30
a) metabolic acidosis
b) metabolic alkalosis
30
What is a normal BXS range on a BG? What is it called if value is:
a) below range
b) above range?
- 2 to +2
a) metabolic acidosis
b) metabolic alkalosis
31
Outline the process of blood gas interpretation
```
How is pt. clinically
O2
pH
PaCO2
BXS or bicarb
```
32
Outline blood gas interpretation
```
How is pt. clinically - KNOW CLINICAL SCENARIO (incl. FiO2)
O2
pH
PaCO2
BXS or bicarb
```
Does your interpretation fit clinical picture
33
```
20 yr M
Tachypnoea
Abdo pain
Vomiting
Confusion
```
What are differentials?
vomit has to be suctioned from airway
```
RR 28
SpO2 99% on air
AE L=R
Pulse 128
BP 95/60
HS I + II + 0
No other obvious abnormal signs
```
Differentials:
DKA
Pneumonia
Sepsis
34
```
20 yr M
Tachypnoea
Abdo pain
Vomiting
Confusion
```
What are differentials?
vomit has to be suctioned from airway
```
RR 28
SpO2 99% on air
AE L=R
Pulse 128
BP 95/60
HS I + II + 0
No other obvious abnormal signs
```
Knowing this, What other differentials might you come up with?
GCS 13/15
ES V4 M6
can he have blood gas?
```
VBG:
pH 6.9
PO2 11.5
PCo2 3.5
HCO3 8
BXS 12
```
What does this tell you?
Are the results a surprise?
Differentials 1:
DKA
Pneumonia
Sepsis
Differentials 2:
Septic shock
Hypovolaemic shock
He needs blood gas: shock and ?metabolic illness
Metabolic acidosis
No, results fit clinical picture
35
What are signs of C02 retention?
Cyanosis
| Confusion
36
What is the definition of shock?
Clinical syndrome caused by inadequate tissue perfusion and oxygenation leading to abnormal metabolic function
37
What are the different types of shock?
Cardiogenic
Hypovolaemic
Obstructive
Neurogenic
Anaphylactic
Septic
38
What are the physiological effects of shock and re-perfusion?
Intracellular calcium overload leading to ↓myocardial contractility, ATP reduction & degradation of ion pumps via free radicals.
H+ excess causing ↓ catecholamine effect and ↓ myocardial function
Metabolism becomes glycolysis dependent leading to↑ FFA and
↑lactic acid
39
What are common causes of hypovolaemic shock
fluid loss eg. excess urination, reduced intake, vomiting, burns
haemorrhage (haemorrhage shock)
40
How should you treat hypovolaemic shock
IV access
IV fluids +/- blood
Treat cause (stop bleeding)
Monitor response
41
What is an anaphylactic shock?
Sudden onset generalised immune condition caused by exposure to a causative substance in a sensitised
person
42
How long after exposure to substance, do Sx of anaphylaxis begin?
depends what source is/route of contact (generally 30 mins)
topical 10-15 mins
eaten 30 mins
IV = matter of minutes
43
How would you treat anaphylactic shock?
1) Adrenaline (IM = thigh, elevate leg)
2) Crystalloid fluids (DO NOT GIVE COLLOID)
3) Hydrocortisone (prevent bi-phasic reactions)
4) Chloramphenamine (anti-histamine)
Ranitidine (H2 blocker)
May need to repeat IM adrenaline after 5 mins
Continue to deteriorate - IV adrenaline bolus (BY A SENIOR)
All anaphylaxis pts. are admitted - at risk of biphasic shock within around 6 hours
44
What is septic shock?
Sepsis accompanied by hypotension and perfusion abnormalities despite adequate fluid resuscitation
45
What is syncope?
transient loss of consciousness
(usually without warning)
Transient global cerebral hypotension
Rapid onset
WITH SPONTANEOUS COMPLETE RECOVERY (if you have lasting Sx, IT IS NOT SYNCOPE)
46
Can a pt. lose consciousness with TIA?
Unlikely that unconsciousness would occur TIA (as would need to effect both halves of brain blood supply at same time)
47
What are the main general categories of causes of TRUE syncope?
Cardiac
orthostatic
neurogenic
48
What are the San Francisco syncope rules? What do they help you decide?
CHESS - IF YOU THINK Pt HAS HAD SYNCOPE, helps you decide who is safe to go home.
```
Hx of congestive HF
Haematocrit <30%
Abnormal ECG
SOB
Triage systolic BP < 90
```
Any of these - high risk of having had cardiac event. Need to be admitted.
49
What is the OESIL risk score?
Risk score
```
Point score of following RF:
Age >65 (1)
Hx of Cv disease (1)
Syncope with prodromes (1)
Abnormal ECG (1)
```
Score of 2 or more implies increased risk of cardiac death
50
What are some more unusual Sx of syncope? How can each of these be told apart from a seizure?
Twitching (for about 5-10 seconds - convulsive syncope)
Tongue biting (at tip - unlikely to be seizure. Tongue biting at side, more likely to be seizure)
51
What should you include in a neurological assessment in a pt. with collapse?
```
Cranial nerves
Peripheral nerves
Cerebellar
Gait
AMTS - best done on first meeting
Fundi
NIHSS
GCS
Pupils
Lateralising signs
Capillary glucose
```
52
What is the NIHSS? What is it used for?
NIH stroke scale
| Scale used to decide whether someone can be thrombolysed
53
What are common causes of hypoglycaemia in diabetic pts.
Hypoglycaemic agents
Decreased glucose intake
Increased glucose utilisation (increased exercise)
Increased insulin sensitivity (weight loss, increased exercise)
Reduced insulin clearance (renal failure)
54
Why would you do CXR if you think pt has PE?
May see wedge infarct
| Rule out differentials (eg. pneumothorax)
55
What are the main two investigations for PE?
```
CTPA
VQ scan (looking for VQ mismatch)
```
56
Which direction do shoulder dislocations most commonly occur in? What are two key things associated with anterior shoulder dislocation that you should make sure you assess/document?
Anterior dislocations
| test regimental badge and document radial artery
57
What are people given when they have been poisoned (if this has occurred within the last hour)?
Charcoal (drink)
58
What are the classical features of an opiate toxidrome?
pin point pupils
resp depression
reduced GCS
59
What can be used to reverse benzo toxicity? Why might you not do this?
flumazanil
60
Why might you NOT give a full dose of naloxone to someone who has suffered a heroine overdose?
Naloxone could recover their RR before the heroin has worn off, therefore pt may leave before the effects of heroin have worn off and you've been able to treat properly
61
What is a common s/e of poppers?
methaemoglobinaemia
62
w
w
63
What scoring system is used for PE? (other than Well's score)
PERC
64
How should you approach a pt. who is acutely unwell?
```
Focussed Hx
Collateral Hx
Focussed examination
Investigation
Working diagnosis, initial treatment
management plan (incl. referral to correct ward)
```
65
How should you approach a pt. who is critical unwell?
ABCDE approach (treat at each stage)
Investigations
Working diagnosis, further initial treatment
Once stable: focussed Hx
focussed Ex
Longer-term management plan (incl. referral to correct ward)
66
List what should be done in A of ABCDE?
Look for signs of airway obstruction
TREAT obstruction (adjuncts)
Give oxygen (if sats require it)
67
List what should be done in B of ABCDE?
```
Look for resp distress
RR
Quality of breathing
Chest deformity
FiO2 and spO2
Listen near face
palpate, percuss and auscultate
Tracheal deviation
```
Initiate treatment
68
List what should be done in C of ABCDE?
```
HR
BP
Fluids (if low BP/CO)
Look at cardiac monitor
Look/feel hands
assess peripheral and central CRT
Assess venous filling (cap. refill)
Central and peripheral pulses
Listen to heart
Look for signs of poor cardiac output, haemorrhage
```
Treat cause of cardiovascular collapse
69
List what should be done in D of ABCDE?
Review and treat ABC - sats and BP esp.
```
GCS/AVPU
Drug chart (drug-induced reduced GCS)
Pupils
Lateralising signs
Capillary glucose
Ensure airway protection
```
70
List what should be done in E of ABCDE?
Examine pt: bruising, breaks etc.
| Temp
71
What should you do after you've done ABCDE assessment of pt.?
```
Take Hx
Review notes
Review results
Consider which level of care required
Reassess response
Documentation
Definitive treatment
```
72
How can causes of collapse be classified to help diagnosis?
Head
Heart
Vessels
Drugs
73
What are 'head' causes of collapse?
```
Hypoxia
Hypoglycaemia
Epilepsy
Affective
Dysfunction of brain stem eg. verterbrobasilar stroke, TIA or migraine
```
74
What are 'heart' causes of collapse?
```
IHD
Emboli
Aortic obstruction (eg. stenosis, HOCM)
Rhythm disorders
Tachyarrhythmias (VT, SVT, QT syndrome)
```
75
What are 'vessel' causes of collapse?
```
Vasovagal
ENT: BBPV, labyrinthitis, meniere's
Situational: micturition/cough syncope
Sensitive carotid sinus
Ectopic pregnancy
Low vascular tone
Subclavian steal
```
76
What are 'drug' causes of collapse?
Anti-Hypertensives eg. beta blockers
| 'Street' drugs
77
What questions do you want to ask a pt. who has come in with collapse?
```
What were you doing at time?
Any associated Sx
Witnesses
Recent illness
On-going illness
Medication
Previous episodes
```
78
What systems do you want to examine in pt. who has come in with collapse?
```
General appearance (sats,
BP/HR/RR)
CV
resp
neuro
head and neck
abdo and pelvis
```
79
What investigations might you want to do for pt. who has come in with collapse?
blood glucose
80
What is cariogenic shock?
Heart unable to pump enough blood to meet body's needs
81
What is neurogenic shock?
Shock caused by disruption of autonomic pathways within spinal cord
82
What is hypovolaemic shock?
Fluid loss means heart cannot pump enough blood around body to meet its needs
83
What is anaphylactic shock?
Severe allergic reaction
| mediators released in allergic reaction cause vasodilation, bronchial restriction, leaky blood valves, depressed HR
84
What is obstructive shock?
Physical obstruction of great vessels or heart itself
85
What is septic shock?
Inflammatory markers and organ damage lead to lowered blood pressure and abnormal cellular metabolism
86
What are some common causes of cariogenic shock?
MI
| Malignant dysrhythmia
87
What are some common causes of obstructive shock?
tension pneumothorax
| cardiac tamponade
88
What types of shock fall under the term 'distributive shock'?
septic shock
anaphylaxis
neurogenic shock
89
What might you find on ABC examination of a pt. suffering from an anaphylactic shock?
A: swelling, hoarseness, stridor
B: rapid breathing, wheeze, fatigue, cyanosis, sats < 92%, confusion
C: pale, clammy, low BP, faintness, drowsy/coma
90
What ratio of adrenaline is given in anaphylactic shock?
1:1000
91
What dose (and volume) of adrenaline is given to adults in anaphylaxis?
500 micrograms IM
| 0.5 mL
92
What dose (and volume) of adrenaline is given to children over 12 in anaphylaxis?
500 micrograms IM
| 0.5 mL
93
What dose (and volume) of adrenaline is given to children 6-12 yrs in anaphylaxis?
300 micrograms IM
| 0.3 mL
94
What dose (and volume) of adrenaline is given to children under 6 in anaphylaxis?
150 micrograms IM (0.15 mL)
95
What volume of CRYSTALLOID fluid is given to a) adults and b) children?
a) 500mL-1000mL
| b) 20 mL/Kg
96
What dose of hydrocortisone is given to pts (IM or slow IV) in anaphylaxis?
a) adult or child >12 yrs
b) child 6-12 yrs
c) child 6 mths - 6 yrs
d) child < 6 mths
a) 200mg
b) 100 mg
c) 50 mg
d) 25 mg
97
What dose of chloramphenamine is given to pts (IM or slow IV) in anaphylaxis?
a) adult or child >12 yrs
b) child 6-12 yrs
c) child 6 mths - 6 yrs
d) child < 6 mths
a) 10mg
b) 5 mg
c) 2.5 mg
d) 250 micrograms/Kg
98
What is BUFALO and what does it stand for? What timeframe should it be completed in?
```
Septic pt. management:
Blood cultures and septic screen
Urine output (monitor hourly)
Fluid resuscitation
Antibiotics IV
Lactate measurement (ABG)
Oxygen - to correct hypoxia
```
Try to complete within one hour (ASAP)
99
What are the problems with ABGs? (which might make you consider getting a VBG)
```
painful
increased risk of bleeding and haematoma (compared to VBG)
risk of pseudo aneurysm and AV fistula
Increased risk of infection
Nerve injury
Digital ischaemia
Can cause delays in care
Serial exams may be needed
```
(some of these problems are still the case in VBGs)
100
Which elements of a VBG are usually adequate to aid decision making and have good correlation with ABG findings?
pH
PCO2 (if normocapnic - if PvCO2 normal in VBG, then PaCO2 is definitely normal)
HCO3
BXS
101
Other than hypercapnia, when might PCO2 from VBG not be as reliable as an ABG?
severe shock
102
What results on an ABG might indicate metabolic acidosis? What on the ABG might indicate respiratory compensation?
Metabolic acidosis: pH low, HCO3 low, Base excess high
Resp. compensation: CO2 low - pt. is blowing CO2 to try and reduce acidity of blood
103
What results on an ABG might indicate respiratory acidosis? What on the ABG might indicate metabolic compensation?
Resp acidosis: pH low, PaCO2 high
Metabolic compensation: HCO3 high - kidneys retain more bicarb in order to reduce acidity of blood
104
What results on an ABG might indicate respiratory alkalosis? What on the ABG might indicate metabolic compensation?
Resp alkalosis: pH high, PaCO2 low
Metabolic compensation: HCO3 is low - protein buffering in cells (acute) or kidneys excrete more bicarb to increase acidity of blood (chronic)
105
What results on an ABG might indicate metabolic alkalosis? What on the ABG might indicate metabolic compensation?
Metabolic alkalosis: pH high, HCO3 high, BXS low
Respiratory compensation: high CO2 - hypoventilation to increase acid in blood
106
What is included on an ABG?
```
pH
paO2
paCO2
HCO3
BXC
```
```
Lactate
Sodium
Potassium
Hb
glucose
CO
Methaemoglobin
```
107
Flow rate of Oxygen that can be given with venturi mask? What conc. of oxygen is delivered? What is a benefit of the venturi?
Flow rate depends on what type (based on colour)
24-60%
More specific percentage of oxygen can be delivered to pt. (you can be more certain that pt. is getting prescribed %)
108
What are the different flow rates (and %O2 delivered) of the different types of venturi?
```
Blue: 2-4L/min = 24%
White: 4-6L/min = 28%
Yellow: 8-10L/min = 35%
Red: 10-12L/min = 40%
Green: 12-15L/min = 60%
```
109
When might you use a nasal cannula?
non-acute ward or if pt. mildly hypoxic
110
When might you use a Hudson mask?
Step up from nasal cannula
| Doesn't deliver specific % of oxygen like venturi
111
When might you use a venturi?
COPD
| When you want to deliver a more specific amount of O2 to a pt.
112
When would you use a non-rebreathe mask?
acutely unwell pts.
113
When might you use CPAP?
sleep apnoea
| heart failure
114
When might you use BiPAP?
COPD and atelectasis
115
What percentage oxygen is given in invasive ventilation? when might this be used?
100%
| Used in theatre and in intensive care (when pt. in resp. arrest)
116
What should you do if O2 therapy is being use maximally and O2 levels continue to drop?
Involve ICU: view to use non-invasive ventilation, intubation and ventilation
117
Below what level O2 sats should you do an ABG?
92%
118
Why is an Oxygen saturation of below 90% such a big problem?
below sats less than 90%, the oxygen-Hb saturation curve drops significantly - therefore haemoglobin will rapidly become significantly less saturated with small changes in oxygen partial pressure
119
Which patients could be considered 'CO2 retainers'? What happens to these pts?
severe obstructive lung disease (COPD, bronchiectasis and CF)
severe restrictive lung diseases (neuromuscular, severe kyphoscolliosis, severe obesity)
Respiratory drive is normally driven by CO2 levels, but CO2 retainers are desensitised to hypercapnia - rely on hypoxia to stimulate respiratory drive
120
What is the aim of oxygen therapy in CO2-retaining patients?
Increase oxygen level
WITHOUT
causing respiratory drive to decrease
(which will increase CO2, worsening resp. acidosis)
121
What is ACS (acute coronary syndrome)? What are the main classifications within ACS?
Range of heart conditions caused by lack of blood flow to myocardium
2 main divisions:
ST elevation ACS (STE-ACS)
Non-ST elevation ACS (NSTE-ACS) (which can be further divided in to unstable angina and NSTEMI)
122
What is the difference between unstable angina and an MI?
Unstable angina: blood clot or artery narrowing limits blood flow, but does not block it completely - therefore there is NO INFARCT in unstable angina
123
What is the difference between STE-ACS and NSTE-ACS?
STE-ACS: chest pain + ST elevation for >20mins. Most go on to develop STEMI
NSTE-ACS: chest pain WITHOUT persistent ST elevation
Other changes may be present on ECG
124
What features may be present on an ECG in NSTE-ACS?
```
persistent or transient ST-segment depression
T-wave inversion
Flat T waves
Pseudo-normalisation of T waves
no ECG changes at presentation
```
125
What are risk factors for ACS?
Non-modifiable RF for atherosclerosis: age, male, family Hx of premature coronary heart disease, premature menopause.
Modifiable RF for atherosclerosis: smoking, diabetes mellitus (and impaired glucose tolerance), hypertension, dyslipidaemia (raised low-density lipoprotein (LDL) cholesterol, reduced high-density lipoprotein (HDL) cholesterol); obesity, physical inactivity.
Consider non-atherosclerotic causes in younger patients or if there is no evidence of atherosclerosis: coronary emboli from sources such as an infected cardiac valve, coronary occlusion (secondary to vasculitis), coronary artery spasm, cocaine use, congenital coronary anomalies, coronary trauma, increased oxygen requirement (eg, hyperthyroidism) or decreased oxygen delivery (eg, severe anaemia).
126
How might ACS present/what might be important to ask about in the Hx?
```
Chest pain (>15 mins) at rest
Pain in arms, back jaw
sweating
nausea
vomiting
fatigue
SOB
palpitations
syncope
tachycardia OR bradycardia
extra heart sounds
murmur
hypotension
pulmonary oedema
narrowed pulse pressure
raised JVP
```
Limitation of daily activities due to angina (pain on less exertion than previous, pain lasting longer etc.)
Hx of angina
Hx of MI
Cardiovascular RF: smoking, BP, FHx, exercise, diet/weight, kidney problems, Previous cardiac problems/investigations, diabetes
127
Which patients may be less likely to have pain or chest tightness during a STEMI or an NSTEMI? How might this present instead?
Elderly
*Diabetic*
```
Syncope
Pulmonary oedema
Epigastric pain
Vomiting
Acute confusional state
Stroke
Diabetic hyperglycaemia
```
128
What investigations do you need to do in ACS?
ECG
Echocardiography
CXR (cardiomegaly, pulmonary oedema, widened mediastinum)
Coronary angiography
```
Bloods: Troponin I&T (raised (2X) 3-6 hours post-infraction, remain raised for 14 days). Test at 6 and 12 hours after onset of pain. Levels usually raised for about a week.
FBC
Blood glucose
Renal function
Electrolytes
TFTs
CRP
CK (raised in muscle trauma)
Lipids
```
Diagnosis: 2/3 - Hx, ECG changes and raised troponin
129
How would you initially manage a patient presenting with symptoms of ACS?
ABCDE assessment (incl. BP, RR, HR etc.)
A: secure airway if necessary
B: Oxygen (if necessary, 15L non-rebreathe). Get ABG. GTN sublingual (unless BP<90 or HR<50)
C: Get IV access. Get ECG if not done already. Take bloods. Cardiac exam.
Anti-platelet/anti-coagulant - 300 mg aspirin + Ticagralor 180mg loading dose
Fondaparinux (unless angiography due within 24 hours, then give unfractionated heparin)
D: Pain relief - GTN spray (unless R ventricular infarct)
If that doesn't work, IV opioid (+ anti-emetic)
5-10mg morphine + metoclopramide 10mg IV
STEMI: thrombolysis (best within 12 hours) - streptokinase
Beta-blocker - atenolol 5mg IV
ACEi (in STEMI)
Statin
130
What is a normal RR in an adult?
12-20 breaths/min
131
What might you see on an ECG during an episode of unstable angina?
T wave inversion
ST depression
Normal
132
What risk-scoring system is used to predict risk of pt. having future cardiovascular event and six-month mortality?
GRACE score
| Global Registry of Acute Cardiac Events
133
What is an important factor to bear in mind at each stage of ACS management (particularly in terms of prescribing drugs)?
Bleeding risk
| ask re medications eg. warfarin, NOACs etc.
134
When might you consider use of PCI OR CABG in a patient with unstable angina/risk of MI? What are the risks associated with this?
If pt. has a high risk of recurrence
| Risk of procedure-related MI or bleeding
135
After stabilising the pt., what would your more definitive treatment be of a patient who had a medium risk GRACE score? When else might this intervention be offered?
early in-hospital coronary angiography
angiography may also be offered in pts. whose risk is low, but are having recurrent episodes
136
What other differentials might you consider for a pt with ACS-like symptoms?
Cardiovascular: acute pericarditis, myocarditis, aortic stenosis, aortic dissection, pulmonary embolism.
Respiratory: pneumonia, pneumothorax.
Gastrointestinal: oesophageal spasm, gastro-oesophageal reflux disease, acute gastritis, cholecystitis, acute pancreatitis.
Musculoskeletal chest pain.
137
What are features of acute severe asthma?
```
any one of:
RR >=25/min
HR >=110/min
Inability to complete sentences in one breath
PEF 33-50% best or predicted
```
138
What are features of life-threatening asthma? (symptoms and signs)
Any one of:
Resp distress/poor resp effort
Silent chest
Cyanosis
Collapse
tachycardia, Arrhythmia, bradycardia, hypotension
Exhaustion, altered conscious level, coma
139
What investigations would you want to do in pt. presenting with features of acute asthma attack?
Pulse oximetry
ABG (if pt has ANY life-threatening features or SpO2<92%)
PEF (not always necessary)
(ECG and CXR in very specific circumstances)
140
What results would you find from investigations in life-threatening/near-fatal asthma?
Pulse oximetry: Sp O2<92%
PEF <33% previous best or predicted
(severe: 33-50%, moderate: 50-75%)
ABG: PaO2<8kPa
PaCO2 > 6.0 (near-fatal)
Low pH
141
What is the immediate management for acute severe asthma in adults?
A: check airway patent
B: O2 sats, RR, listen to apices and bases, look for cyanosis, ABG, (if well enough: PEF)
Prescribe: Oxygen (15L non-rebreathe): SpO2<94%
Salbutamol (5mg) or terbutaline (10mg) nebuliser (oxygen-driven). Repeat at 15-20 minute intervals
Ipratropium bromide (0.5mg) nebuliser (4-6 hourly)
Write up:
Prednisolone tabs (40-50mg) OR IV hydrocortisone (100mg)
(depends on how ill pt. is)
C: check HR, BP, cap refill
Cannulate
Bloods: FBC, U&Es, glucose
?ECG
D: fingers, toes, eyes, GCS
E: CALVES, rashes, temp.
CXR (once stable)
If life-threatening: discuss with senior clinician/ICU (consider aminophylline infusion)
Consider IV magnesium sulphate (1.2-2g) infusion over 20 mins
salbutamol 10mg continuously hourly
REASSESS
142
What single investigation do you need in pts with life-threatening asthma?
ABG
No other investigations are necessary for immediate management
143
What are the key features of asthma?
```
SOB
Cough (worse at night)
Chest tightness
WHEEZE (usually expiratory, but can also be inspiratory in severe asthma)
Poor Hx of control/recent increase of inhaler use
Possible resp. tract infection
Respiratory distress: Cyanosis
increased RR
Accessory muscle use
```
tachycardia (increased salbutamol use)
prolonged expiratory phase
144
After initial management of severe acute asthma, what should you do?
REASSESS
Pt improving:
Oxygen to maintain SpO2
Prednisolone 40-50mg daily OR IV hydrocortisone 100mg 6 hourly
Nebuliser beta-agonist and ipratropium 4-6 hourly
Pt not improving after 15-30 mins:
Continue oxygen and steroids
Continuous nebulisation of salbutamol (5-10mg/hour)
Continue ipatropium 0.5 mg 4-6 hourly until pt. is improving
```
Pt still not improving:
Discuss with senior and ICU, the use of:
IV Magnesium sulphate 1.2-2g over 20 minutes
IV beta agonist or IV aminophylline
Non-invasive and mechanical ventilation
```
145
What monitoring should be done in pt. with acute severe asthma?
PEF 15-30 mins after starting treatment. Do one before and after B2 agonist treatment and QDS during hospital stay
Oximetry
ABG within 1 hour of starting treatment if:
PaO2 <8 (unless subsequent SO2>92%)
PaCO2 normal/raised
Pt deteriorates
146
When should you transfer a pt. with severe acute asthma to ICU?
```
Deteriorating PEF
Worsening or persisting hypoxia or hypercapnoea
Exhaustion
Altered consciousness
Poor resp. effort or resp. arrest
```
147
What should patients with acute severe asthma have in order to ensure they can be discharged from hospital safely?
Pt. should have been on discharge medication for at least 24 hours
Check inhaler technique
PEF > 75% of best or predicted AND PEF diurnal variability <25%
Oral and inhaled steroids (in addition to bronchodilators)
own PEF meter and written asthma plan
GP follow up arranged for within 2 working days
Follow up with respiratory clinic within 4 weeks
148
What (in basic terms) is the treatment for an acute asthma attack?
OSHITME
```
All together:
Oxygen
Salbutamol 2.5-5mg NEB
Hydrocortisone 100mg IV (or prednisolone 40 mg PO)
Ipratropium 500mcg NEB
```
With senior input:
Theophylline: aminophylline infusion 1g in 1L saline (0.5ml/Kg/h)
Magnesium sulphate 2g IV over 20 mins
Escalate care (intubation and ventilation)
149
What are the key features of life-threatening asthma?
33, 92, chest
```
33: PEF <33% best/predicted
SpO2 < 92%
Cyanosis
Hypotension
Exhaustion
Silent chest
tachycardia
```
150
What PEFR would indicate mild asthma?
> 75%
151
What PEFR would indicate moderate asthma?
< 75%
152
How would you treat an acute COPD exacerbation?
OSHIT
BUT
Give controlled oxygen: 24-28% venturi mask
Consider BiPAP if sats don't improve (and in type 2 resp failure)
ABG after 15 mins
Regular ABGs
ABX: Doxycycline 100mg OD (200mg loading dose)
Chest physio
153
What investigations would you do in someone with exacerbation of COPD?
CXR
ABG
ECG
Bloods: FBC, U&Es, blood cultures
Sputum microscopy and culture
154
What symptoms might you expect from someone with exacerbation of COPD?
Increased cough/sputum production/SOB
Reduced exercise tolerance
Resp distress: accessory muscle use, tachypnoea, cyanosis, wheeze
Confusion
Upper airway symptoms: colds, coughs etc.
Fluid retention
Increased fatigue/malaise
Resp failure
155
How would you manage COPD?
A: check airway patent
B: sats, RR, ABG, auscultate (apices and bases)
Oxygen (venturi 24-28%)
Salbutamol (5mg) NEB 15-20 mins. Air driven.
Ipratropium bromide (500 mpg) NEB. Air-driven.
Hydrocortisone (100mg) IV and Prednisilone (30mg) PO
Theophylline: aminophylline
CXR
C: HR, Cap refill, BP, Cannula, Bloods (incl. blood culture) - FBC, U&Es and glucose.
ECG
D: fingers, toes, pupils, GCS
E: temp, CALVES, Sacrum
156
What should you ask a pt. with COPD in A&E?
```
Assess COPD severity:
Oxygen/nebulisers at home
No. of exacerbations a year/in winter
Do you have a rescue pack
Ever been in to hospital with exacerbation before
Ever been admitted to ICU
```
157
When should you use the PERC (Pulmonary embolism rule-out criteria) score for PE? What is the aim of the PERC score?
Low-risk/pt. unlikely to have PE
Aim of score is to rule out PE.
Pt with score of 0 = rule out PE (<2% chance of PE). Its do not need a D-dimer.
CANNOT rule PE out safely if ANY of criteria are positive
158
What criteria are included in the PERC scale?
```
Age >= 50 yrs
HR >= 100
SpO2 on rom air < 95%
Prior Hx of DVT/PE
Recent trauma or surgery
Haemoptysis
Exogenous oestrogen (OCP, HRT)
Unilateral leg swelling
```
159
What are the symptoms of PE?
```
sudden onset SOB
Shortness of breath
Haemoptysis
Syncope
Cardiovascular collapse (tachycardia, hypotension)
Raised JVP
Hypoxia
(CXR often normal)
```
160
What scoring systems can you use to help you decide on investigations and management in PE?
Don't think pt. has PE: PERC
Think pt. might have PE: Wells score
161
What is included in the PE Wells score? (how many points are given)
DVT Sx (3)
PE primary diagnosis (no alternative diagnosis more likely) (3)
HR >100 (1.5)
Immobile > 3 days or surgery < 4 weeks (1.5)
Previous PE or DVT (1.5)
Haemoptysis (1)
Malignancy (1)
```
<2 = low probability
2-6 = moderate probability
>6 = high probability
```
162
For what PE wells score range would you do D-dimer? What would you do after this?
4=> (PE unlikely)
D-dimer -ve: reassure
D-dimer +ve: LMWH (1.5mg/Kg)
CTPA when possible
CTPA -ve: stop LMWH
CTPA +ve: continue LMWH and start warfarin for 6 months
(Stop LMWH 5-7 days of dual therapy and when INR 2-3)
163
For what PE wells score would you NOT d-dimer?
5=< (PE likely)
Wouldn't bother with D-dimer, JUST TREAT
LMWH (1.5 mg/Kg)
CTPA when possible
CTPA -ve: stop LMWH
CTPA +ve: continue LMWH and start warfarin for 6 months
(Stop LMWH 5-7 days of dual therapy and when INR 2-3)
164
If you can't do a CTPA on a patient, what other scan could you do to confirm/exclude PE?
V/Q scan
165
What investigations can you do to check for severity of PE?
ECG (tachycardia, RV strain: T-wave inversion in R and inferior leads, RBBB, R axis deviation, S1Q3T3, RA enlargement: P pulmonale, RV dilation: dominant R in V1)
CXR (wedge infarcts, regional oligaemia, enlarged pulmonary artery, effusion)
echocardiogram (R heart strain/overload)
bilateral leg doppler (look for DVTs)
166
How would you manage a PE acutely?
A: check airway patent. Sit patient up.
B: RR, sats, ABG, auscultate
Oxygen 15L non-rebreathe
C: HR, BP, cap refill, cardiac monitor
Cannula
Fluid bolus
?inotropic support
D: fingers, toes, eyes
E: temp, CALVES
LMWH
Send for CTPA once stable
Call senior
Consider thrombolysis in:
Massive PE (SBP<90, puleslessness or persistent bradycardia) = STRAIGHT to thrombolysis
Submassive PE (RV dysfunction ot myocardial necrosis) = give LMWH and consider thrombolysis
167
What are some causes of pulmonary oedema?
Ischaemic heart disease: MI/ACS, LV failure
Murmurs: aortic regurg, mitral regurg, SEVERE aortic stenosis
PE
Arrhythmia
Cardiac tamponade
Cardiomyopathy
AKI or CKD
Iatrogenic fluid overload
High-output heart failure eg. sepsis, anaemia etc.
Liver failure, fat embolism, ARDS
neurogenic (after neurological insult e.g. status epileptics, head injury, stroke)
168
What are features of anaphylactic shock?
A: laryngeal/pharyngeal oedema, bronchospasm (stridor), hoarse voice
B: SOB, increased RR, wheeze
C: shock (pale, clammy), hypotension (dizziness, collapse), tachycardia
D: confusion, tiredness, agitation, LOC
```
E: rash/flushing
urticaria
angio-oedema
hypotension and shock
nausea, vomiting or diarrhoea
```
Three key criteria make anaphylaxis v. likely:
- Rapid onset and progression of symptoms
- life-threatening Airway, breathing or circulation problems
- Skin and/or mucosal changes
169
How would you manage anaphylaxis?
Call for help 2222 (at very least anaesthetist)
Lie pt. flat
Raise pt.'s leg (try to raise BP)
Adrenaline 0.5mg IM (0.5mLs of 1:1000). Repeat every 5 minutes.
A: establish airway (nasopharyngeal/LMA/intubation)
B: RR, Sats, auscultation, air entry
15L non-rebreathe (may need intubation)
Wheeze: salbutamol (as in asthma)
C: HR, BP, cap refill
Cannula
Attach cardiac monitor
1) Adrenaline (IM) 1:1000 - 500 micrograms (0.5mL)
2) IV fluid challenge: 500-1000mL (Hartmann's or NaCl)
3) Cloramphenamine 10mg IM (or slow IV)
4) Hydrocortisone 200 mg IM (or slow IV)
Bloods: FBC, U&Es, LFTs, calcium and glucose)
May need inotropes/vasosupressors
D: GCS, pupils, fingers, toes, glucose level
E: Feel abdo
Calves
Temp
170
What would you do for a patient with anaphylactic shock, once they're stable?
Mast cell tryptase (venom-related, drug-related, idiopathic): ASAP after emergency, 1-2 hours after onset, 24 hours after or in f/u.
Observe pt. for 6 hours (risk of another reaction)
WARN PATIENT
Some may need 24 hrs observation
Adrenaline injector as interim measure (before specialist appointment)
Anti-histamine and steroid therapy for up to 3 days
Reassure pt.
Info about how to manage anaphylaxis (incl. how to use adrenaline injector)
Info about biphasic reaction
171
What things would you need to write in the notes re. anaphylactic shock and its management?
```
Clinical features
Time of onset
Circumstances immediately before onset of symptoms
Treatments administered
Results of any tests
Obs
```
172
What differentials might you think about in someone with anaphylaxis-like symptoms?
asthma (esp. in children)
septic shock
vasovagal episode
panic attack
breath-holding episode
non-allergic urticaria or angioedma
173
Which pts. may need observing for 24 hours
```
Severe reactions with slow onset
severe asthma
Hx of biphasic reactions
Pts presenting at evening or night
Pts where access to emergency care is limited
```
174
What are common features of pulmonary oedema?
```
Dyspnoea
Orthopnoea
Pink frothy sputum
Pale, sweaty, distressed pt.
Increased jugular venous pressure
Inspiratory crackles
Wheeze (cardiac asthma)
Triple/gallop rhythm (S3 sounds - fluid overload)
```
175
What findings might you see on an X-ray?
Cardiomegaly
Fluffy bilateral shadowing with peripheral sparing (bats wings)
Kerley B lines
Pleural effusions
176
What is the CURB-65 score used for? What are its components?
estimates mortality for CAP
```
Confusion (1)
Urea >7 (1)
RR >30 (1)
SBP >90 or DBP<60
Age 65 =
```
177
What are the differentials you might consider for someone with shortness of breath (in ED)?
```
Exacerbation of COPD
Asthma
PE
Pneumothorax
Pneumonia
Pulmonary oedema
```
178
How would you manage a patient with pulmonary oedema?
A: sit pt. upright, check airway is patent
B: RR, sats, ABG (if in resp. distress), auscultate, tracheal deviation
O2 (15L NRB)
Salbutamol NEB if wheeze present
C: HR, BP, cap refill, cardiac monitor, CXR
Venous access, bloods - ?culture, FBC, LFTs, U&E, glucose
Treat any arrhythmias
2 sprays GTN or buccal suscard 2-5mg (if SBP>90)
Diamorphine 2.5mg IV (slowly)
Furosemide 40-80mg IV (slowly)
GTN IV 50mg in 50mls 0.9% NaCl 2ml/hr, titrate up to 20ml/hour. Maintain BP at 90
D: GCS, pupils, drug chart and notes
E: calves, abdo, temp
Reassess: no B improvement - CPAP
Senior/critical care outreach/anaesthetists/ICU
179
What are then different types of pneumothorax?
Spontaneous: primary and secondary
Traumatic: following penetrative chest trauma
Iatrogenic: following procedures eg. invasive ventilation, central line placement, biopsy etc.
Catamenial: pneumothorax around time of menstruation due to endometriosis
TENSION PNEUMOTHORAX
180
What are the different types of spontaneous pneumothorax?
Primary: no apparent underlying cause. Occur in young fit people.
Secondary: Associated with underlying lung disease - eg, COPD, TB, sarcoidosis, CF, malignancy, and idiopathic pulmonary fibrosis
181
Why is it important to establish whether a spontaneous pneumothorax is primary or secondary?
The consequences of a pneumothorax in patients with pre-existing lung disease are significantly greater and the management is potentially more difficult.
182
What are the BTS guidelines of working out whether pneumothorax is primary or secondary?
Age > 50 and significant smoking history
| Evidence of underlying lung disease on exam or CXR?
183
What are symptoms of pneumothorax?
Primary spontaneous pneumothorax: Sx minimal or absent
Secondary spontaneous pneumothorax: greater than primary
Sudden onset pain
May be SOB
Can be Sx-less
Distressed and sweating
184
What might you find on examination of a pt. with pneumothorax?
A: airway may be patent
B: Resp distress
Reduced chest expansion on one side
tracheal deviation (towards side of pneumothorax)
Hyper-resonance on percussion over areas of collapse
breath sounds reduced/absent
C: Cyanosis
Tachycardia (>135 = tension)
pluses paradoxical (slows on inspiration)
HypoTN
185
How would you investigate a NON-tension pneumothorax?
CXR
CT in uncertain cases
ABG (if sats <92%)
186
What differentials might you consider in someone with pneumothorax-like symptoms?
Pleural effusion (slower onset and dullness to percussion)
PE (haemoptysis, more common in lower lobes)
Pleuritis
187
How would you measure the size of a pneumothorax on a CXR?
Measure the distance between pleural surface and lung edge (at level of hilum)
2cm or more = pneumothorax of at least 50% of hemithorax. This indicates need for drainage
188
What should you do in the following scenario?
Primary pneumothorax
Size >2cm and/or SOB
If this improves the situation (<2cm and breathing improves), what should you do?
If this does not improve the situation, what should you do?
Aspirate using 16-18g. cannula
Aspirate <2.5L
Consider discharge
R/v in OPD in 2-4 weeks
Chest drain
Admit pt.
189
What should you do in the following scenario?
Primary pneumothorax
Size <2cm and/or not SOB
Consider discharge
| R/v in OPD in 2-4 weeks
190
What should you do in the following scenario?
Secondary pneumothorax
Size >2cm and/or SOB
Chest drain
| Admit pt.
191
What should you do in the following scenario?
Secondary pneumothorax
Size <2cm (1-2cm) or not SOB
If this improves the situation (<1cm and breathing improves), what should you do?
If this does not improve the situation, what should you do?
Aspirate using 16-18g. cannula
Aspirate <2.5L
Admit
High flow oxygen
Observe for 24 hours
Chest drain
Admit pt.
192
What should you do in the following scenario?
Secondary pneumothorax
Size <1cm or not SOB
Admit
High flow oxygen
Observe for 24 hours
193
What are KEY features of TENSION pneumothorax?
Same Sx as above (reduced unilateral expansion etc.)
Hypotension
Trachea deviated AWAY from side of collapse
Distended neck veins
194
How would you manage someone with tension pneumothorax?
```
A: airway patent
B: RR, sats, AUSCULTATION, CHEST EXPANSION, PRECUSSION, TRACHEAL DEVIATION
15L Oxygen NRB
?ABG
C: HR, BP, cap refill
Confirmed diagnosis: Needle decompression 14-16g cannula, 2nd intercostal space, mid-clavicular line, leave in place
D: GCS, eyes, fingers etc.
E: calves, abdo etc.
```
195
What is the definition of HAP?
Pneumonia developed 48 hours after hospital admission
196
Which type of pneumonia has worse prognosis? why?
HAP - generally more comorbidities
| Bugs more resistant
197
What are the common organisms for CAP?
Streptococcus pneumoniae, haemophilus influenzae
| Anaerobes are rare
198
What are the common organisms for HAP?
Gram negative bacilli, staphylococcus aureus
| Drug resistant organisms are more common, and more dangerous
199
What are the rarer causes of CAP?
Chlamydia pneumoniae (common in institutions – e.g. collegues, military camps – mild)
mycoplasma pneumonia
legionella
200
What are common precipitating factors for pneumonia?
```
Strep pneumoniae infection often follows viral infection with influenza or parainfluenza.
Hospitalisation
Cigarette smoking
Alcohol excess
Bronchiectesis (e.g. in CF)
Bronchial obstruction (e.g. carcinoma)
Immunosupression
IV drug use
Dysphagia (both oesophageal and co-ordination disorders – leading to aspiration)
```
201
What are symptoms of a pneumonia?
```
Similar for HAP and CAP cases
SOB
Tachypnoea
Reduced oxygen sats
Tachycardia
Cough (purulent sputum, can be dry in infants and elderly)
Fever
Riggers
Vomiting
Headache
Loss of appetite
Pleuritic chest pain, may radiate to shoulder (if diaphragm is involved)
Upper abdo pain
Increased secretions
```
202
What investigations might you do for someone you suspect has pneumonia? What might you see?
```
BTS guidelines:
Pulse oximetry (may need ABG)
```
CXR: consolidation (may not be present for first 48 hours, but can be present for up to 6-weeks).
Repeat weekly as inpt, then 6 weeks after as f/u (community and hospital)
(may not need initial CXR if in community, if sure of diagnosis and no risk of underlying lung pathology)
ALL suspected CAP in hospital, should be investigated with CXR
```
Bloods:
FBC
WCC (raised)
ESR and CRP (raised)
LFTs
Anaemia
```
```
Microbiological:
Blood cultures (moderate to high severity - start empirical ABX)
Sputum culture (in pts. who do not respond to empirical ABX)
```
Urine antigen investigations (if pneumococcal and legionella suspected)
Pleural fluid aspiration (if they have an effusion))
203
What scoring system would you use to assess the severity of pneumonia?
CURB 65
204
List some complications of pneumonia?
```
Sepsis: resp failure, hypotension
pleural effusion
empyema
Lung absences
Lobar collapse/pneumothorax
```
205
what should you do for a pt. with CURB-65 score of 0-1?
0-1: low severity
Other reason to admit = hospital
No reason to admit = home treatment
Amoxicillin 500mg TDS PO
(or doxycycline 200mg loading dose, 100mg PO)
Can have same dose IV if unable to do PO.
206
what should you do for a pt. with CURB-65 score of 2?
2: moderate severity
Hospital admission (short stay)
Supportive care: Oxygen, fluids, neb saline, chest physio, VTE prophylaxis, analgesia (NSAIDS or paracetamol)
ABX: amoxicillin 500mg-1g TDS PO + clarithromycin 500mg BD PO
Unable to use PO: amoxicillin 500mg TDS IV PLUS clarithromycin 500mg BD IV
(or doxycycline 200mg loading dose, 100mg PO)
207
what should you do for a pt. with CURB-65 score of 3-5?
3-5: high severity
Urgent hospital admission (and senior review)
Supportive care: Oxygen, fluids, neb saline, chest physio, VTE prophylaxis, analgesia (NSAIDS or paracetamol)
ABX: Antibiotics given as soon as possible
Co-amoxiclav 1.2 g tds IV plus clarithromycin 500 mg bd IV
(If legionella strongly suspected, consider adding levofloxacin)
Consider referral to critical care (if score 4/5)
208
What monitoring and follow up would you want to do in a patient with pneumonia?
Inpatient -
Repeat: bloods, X-rays etc after 3 days
24 hours after discharge, obs
6 WEEK FOLLOW-UP INCL. RPT.CXR.
209
What are the different types of aortic dissection?
```
Stanford classification:
Type A (involving the ascending aorta, can extend ad infinitum)
Type B (not involving the ascending aorta - aorta beyond subclavian artery only)
```
(less used) DeBakey Classification:
Type I: aorta, aortic arch, and descending aorta.
Type II: ascending aorta only.
Type III: descending aorta distal to left subclavian.
210
What are some risk factors for aortic dissection?
```
HTN
smoking
raised cholesterol
pre-existing aortic diseases
aortic valve disease
FHx or aortic diseases
Hx of cardiac surgery
blunt chest trauma
use of IV drugs
```
Marfan's
Ehlers-Danlos syndrome
211
What is an aortic dissection?
Tear in inside of aorta
| Blood flow between layers of wall of aorta, forcing layers apart
212
How might aortic dissection present?
```
Chest pain/back pain (ripping/sharp)... also groin. SUDDEN ONSET
MAXIMAL AT ONSET
MIGRATES (as dissection progresses)
Proximal dissections: retrosternal pain
Distal dissections: between scapulae
aortic regurg
```
angina/MI: involvement of coronary arteries
CCF
Pleural effusions
Syncope
Neurological symptoms (acute paraplegia, U/L limb ischaemic neuropathy): involvement of spinal arteries or carotid or distal aortic involvement
AKI
Often presents in two phases:
1st event: severe pain, pulse loss
2nd event: rupture = cardiac tamponde, pleural space or mediastinum
213
What might be a typical presentation of someone with chest pain?
```
man in 60s
HTN
SUDDEN onset chest pain (also groin or back)
retrosternal or between scapulae
'ripping' or 'sharp'
Maximum pain at the beginning
```
214
What differentials might you think about in a patient with ?aortic dissection?
```
ACS (can occur with dissection)
aortic regurg
aortic aneurysms
MSK
pericarditis
mediastinal tumours
pleuritis
PE
cholecystitis
```
215
What investigations would you do on someone with ?aortic dissection?
ECG - MI, normal or non-specific ST-T segment changes
CXR (will not exclude, but may see widened mediastinum)
US echocardiography in unstable pt. (site and extent)
CT angiography is investigation of choice.
216
How is aortic dissection treated?
A and B as necessary
C: control BP and HR (prevent disease extension)
aim: SBP<120 and HR 60
Cannulate
Labetalol IV
analgesia eg. morphine
type a: surgery (stent or graft)
type b: not generally for surgery (managed just by BP) except:
Persistent pain, branch occlusion, leak, continues extension
*risk of paraplegia with surgery
217
What is type A more likely to end up malperfusing?
```
brain
coronary artery
spinal cord
liver
bowel
kidneys
legs
```
218
What is type B aortic dissection more likely to end up malperfusing?
```
JUST
spinal cord
liver
bowel
kidneys
legs
```
219
What are risk factors for aneurysms?
```
Hypertension
Smoking
Age
Diabetes
Obesity
High LDL levels
Sedentary lifestyle
Genetic factors
Co-arctation of the aorta
Marfan’s syndrome, and other connective tissue disorders
Previous aortic surgery
Pregnancy (particularly 3rd trimester)
Trauma
Male
```
220
How might AAA present?
```
Unruptured: no Sx
Pain in back, abdo, loin, groin
(*severe lumbar pain, recent onset = think ?impending rupture)
pulsatile abdo swelling
limb ischaemia
ureterohydronephrosis
```
```
Collapse, syncope or shock (hypotension)
epigastric pain:
radiating to back
(may also get pain in groin, iliac fosse and testicles)
Constant or intermittent
```
rupture into peritoneal space: dramatic, death on arrival
rupture into retroperitoneal space: contained (temporary seal formed)
221
What clinical signs might you find on examination of someone with ?AAA?
Bimanual palpation of abdo: pulsatile
Abdo bruit
retroperitoneal haemorrhage: Grey Turner's sign
222
What investigations might you do for someone ?AAA (non-urgent)?
```
Bloods:
FBC
Clotting screen
renal function
liver function
cross-match (if surgery planned)
ESR/CRP
```
ECG, CXR
US
CT
MRI angiography
223
What investigations might you do for someone ?AAA (urgent)?
Bloods:
FBC
Group and save/cross-match
U&Es
Plain abdo x-ray
US (may not need if emergency, may go straight to theatre)
CT angiography
224
How would you manage someone with ruptured AAA?
large bore IV access
group and cross-match
*SURGICAL REFERRAL IMMEDIATELY - emergency endovascular aneurysm repair
225
How would you manage a patient with uncomplicated AAA?
<5.5cm: monitor (US)
>5.5cm:surgery
manage risk factors: statins, anti-platelets (if not at risk of bleed)
Other indications for surgery: onset of sinister symptoms (back or abode pain), rapid expansion and RUPTURE
226
How might alcohol withdrawal present?
Hx of alcohol abuse
Collapse
```
Within a few hours: Tremor
Nausea
Sweating
Agitation
Tachycardia
Palpitations
Hypertension
```
```
after 24-48 hours:
Delusions
Confusion
Diarrhoea
convulsions
auditory hallucinatinos
```
After 48 hours:
delirium tremens
227
How might delirium tremens present?
Someone (generally) with a v. long drinking history - can also occur after a few months of drinking
3-4 days after withdrawal
```
Sx:
Restlessness
Fear
Paranoia
Confusion/reduced consciousness
Terror-stricken face
Sweaty/tachycardia/pyrexia/flushing/pallor
Visual hallucinations (lilliputian), formication
Auditory hallucinations
```
228
How do you treat delirium tremens?
MEDICAL EMERGENCY: DEATH IN 10-15% (35% if untreated)
Benzo: sedation and anti-convulsant. Give up to 10 days, at night - avoid nightmares
B vitamins (pabrinex): reduce risk of encephalopathy
Fluid replacement
Dextrose (avoid hypoglycaemia)
Be aware of infection and head injury
On recovery: check for signs of alcohol brain damage, assess motivation for permanent change
229
what causes death in delirium tremens?
Epileptic seizure
self-injury
infection
230
How long does delirium tremens usually go on for?
3-4 days
| Anxiety can go on for months
231
Why does delirium tremens occur?
Long term changes occur in the brain with long-term/excessive alcohol use: decrease in GABA receptors (as tolerance develops)
When alcohol is withdrawn, patient is left with a v. low number of inhibitory receptors and nothing acting on them
This is why there is over-activity of the CNS
232
What is Wernicke's encephalopathy? what are the symptoms?
Acute syndrome (neurological symptoms) caused by thiamine deficiency
Ocular palsies (esp. abducens nerve)
Ataxic gait
Nausea
Memory problems
(can be caused by all types of thiamine deficiency, not just alcohol)
If someone presents with Wernicke's, and it continues chronically, it becomes Korsakov's syndrome. Can also present at same time as Korsakov's = wernicke-korsakov syndrome
233
What is Wernicke's triad?
eye signs: nystagmus and ophthalmoplegia
Ataxic gait
Confusion
234
What is korsakov's syndrome and how does it present?
Chronic condition caused by thiamine deficiency (also called korsakov's psychosis) - impaired memory function following signs of Wernicke's encephalopathy.
Anterograde memory disorder (can't consolidate new memories). Able to recall facts immediately, within a few minutes. No ability to get this info in to long-term memory.
Little/distorted sense of time
Make up events (confabulation)
Anser questions in a very laid-back manner
Memory recall for events before the syndrome are usually fine
No clouding of consciousness
Peripheral neuropathy
235
What are the differentials for alcohol/alcohol-withdrawal problems?
Withdrawal (no dangerous features)
Delirium tremens (more common than Wernicke's - no neurological symptoms)
Wernicke's encephalopathy
Korsakov's syndrome
Acute brain syndromes of miscellaneous cause
Chronic brain syndromes (different pattern of memory loss - incl. long-term memory)
Chronic alcohol intake can lead to chronic brain syndrome due to atrophy of the cerebrum
236
How would you treat Wernicke's encephalopathy?
Thiamine and other B vitamins (IM or IV) - PABRINEX
Sedation (benzodiazepines) - chlordiazepoxide
Fluids/electrolytes
237
How would you treat Korsakov's?
Life-long chronic illness
No real treatment
Thiamine supplements don't really help after acute phase
Eventually, patients will require care
238
What's the prognosis of wernicke's and other alcohol related brain syndromes?
Palsies: usually clear with appropriate treatment
Ataxia: usually resolve on its own over several months
Neuropathy: resolve slowly
Amnesia: 1/2 all patients recover from this
239
What are features of opiate withdrawal?
```
Dilated pupils
High BP
Sweaty
Runny nose
Cramps
```
240
What are features of benzo withdrawal?
Hypersensitivity
Hyper-reflexia
Depersonalisation
241
What are features of psychostimulant withdrawal?
Agitation
| restlessness
242
What are features of heroin withdrawal?
Cold/shivery
flu-like symptoms
Body pain
CANNOT KILL YOU
243
What are symptoms of third degree (complete) heart block?
```
Light-headedness
Dizziness
Fainting
Fatigue
Chest pain
bradycardia
Palpitations
```
244
What is complete heart block?
Electrical signal can't pass normally from the atria to the ventricles.
P and QRS waves conducted at different speeds, no connections between them
245
What are the features of complete heart block on an ECG?
P waves about 90/min (more P waves than QRS waves). Regular.
QRS about 36/min
Regular.
BUT NO LINK BETWEEN THE TWO.
Variable PR intervals
Abnormally shaped QRS due to abnormal spread of conduction throughout ventricles. Generally broad.
Right axis deviation.
246
What are different causes of complete heart block?
MI
Chronic - fibrosis of bundle of His or BBB in both branches (eg. old age)
Fibrosis more common than ischaemia
247
How would you investigate whether someone may have complete heart block?
ECG
If well enough to go home, 24 hour tape
248
How would you treat heart block?
Withdraw any medications that may be causing, aggravating condition eg.
Anti-hypertensives/anginal/anti-arrhythmic and heart failure medications cause AV block
Oxygen (if necessary)
Monitor ECG, BP, SpO2
Bloods: ABG, FBC, U&Es,
Identify and treat reversible causes (drug chart, electrolytes etc.)
if have adverse features (shock, syncope, MI or heart failure):
ATROPINE 500 mcg IV
If no response: repeat atropine 500 mcg IV to max of 3 mg
alternatives to this:
isoprenaline or adrenaline
Transcutaneous pacing
If successful: observe (unless risk of: systole, mobitz-type-2 block, broad QRS and ventricular pause >3 secs - then complete above)
Long term: pacemaker
249
What alternative drugs can be given to atropine in complete heart block?
isoprenaline and adrenaline
Glycopyrrolate
aminophylline
dopamine
GLUCAGON (if beta-blocker or CCB overdose)
250
What are the different classifications of hypoxia?
Hypoxic hypoxia - reduced O2 supply
Anaemic hypoxia - reduced haemoglobin function
Stagnant hypoxia - inadequate circulation
Histotoxic hypoxia - impaired cellular O2 metabolism (eg. carbon monoxide/cyanide poisoning)
251
What is the oxygen delivery equation?
delivery of oxygen = cardiac output x conc. of oxygen in the blood
252
How can you maximise oxygen delivery in trauma?
Increase cardiac output:
fluids
oxygen
BLOOD (reduce risk of coagulopathy)
253
What is the triad of death?
```
Coagulopathy (causes lactic acidosis)
metabolic acidosis (causes decreased myocardial performance, causing hypothermia)
hypothermia (halts the coagulation cascade = COAGULOPATHY)
```
254
What is clinically significant hypothermia?
Body temp <36 for 4 hours or more
255
What is cerebral perfusion pressure (CPP)?
pressure gradient causing cerebral blood flow (CBF) such that CBF=CPP/CVR
(CVR: cerebrovascular resistance)
OR MORE COMMONLY AS:
CPP = MAP-ICP
256
How do you work out MAP?
(2 x diastolic BP + systolic BP)/3
257
What is the Monro-Kellie Doctrine?
Cranial compartment volume is fixed
Cranium and its constituents (blood, CSF and brain) are in a state of volume equilibrium
Increased volume in one of the cranial constants must be compensated by a decrease in volume of another
258
What are the main buffers in the MKD?
CSF
(to a lesser extent) blood volume
If there is an increase in volume requirement (eg. extradural haematom), there will be downward displacement of CSF in to the spinal canal, reduction in cerebral venous blood and stretch of falx cerebri between hemispheres and the tentorium between the hemispheres and the cerebellum.
These compensatory changes able to maintain normal ICP for changes in volume of less than 100-120mL
259
What does the Monro-Kellie Doctrine tell us about changes in volume?
Small increases do not lead to an immediate increase in ICP.
Once ICP reaches about 25mmHg, small increases in brain volume can lead to marked increases in ICP as threshold for intracranial compliance is passed (CRITICAL VOLUME)
260
What are some features of raised ICP?
Changes in LOC
Eyes: papilloedema, pupillary changes, impaired eye movement
Posturing: decerebrate, corticate, flaccid
Changes in speech
Headache
Seizures
Impaired sensory and motor function
Changes in vital signs - cushion's triad: High systolic BP, low pulse, irregular resp.
Vomiting
261
What is Cushing's triad? Why does it happen? What does it tell you?
High systolic BP
Low HR
irregular breathing pattern
Body trying to increase CPP by raising BP and dilating cerebral blood vessels, but this increases intracranial haemorrhage, which raises ICP further
Very close to dying
262
Why is raised ICP associated with higher mortality rates in TBI?
Raised ICP = cerebral ischaemia = infarction
263
What can a very high ICP caused by a unilateral space-occupying lesion (eg. haematoma) result in?
Midline shift
Hydrocephalus or brain herniation
Herniation is usually uncle or tonsillar
Brainstem compressed = coning
264
What clinical signs might you begin finding in someone with raised ICP?
Dilated pupil - sluggish then fixed (CNIII palsy)
| Aphasia
265
How would you manage a TBI clinically?
ABCDE - URGENT INTUBATION is first priority
Prevent secondary brain injury
266
How might you prevent secondary brain injury?
Prevent: hypoxia
hypocarbia
hypoglycaemia
hypotension
267
Who should you immobilise following a head injury/trauma? How long should they remain immobilised for?
```
GCS < 15
Neck pain or tenderness
Focal neurological deficit
Paraesthesia in extremities
Any clinical suspicion of cervical spine injury
```
Remain immobilised until full risk assessment incl. clinical assessment and imaging (if necessary) have deemed it is safe to remove immobilisation device
268
What is the purpose of the Canadian C-spine rules?
Assessment tool used to RULE OUT cervical spine injury in LOW-RISK patients (obviating need for radiography)
Use for all alert (GCS 15) and stable trauma patients where cervical spine injury is a concern
269
What are the high-risk factors which mandate radiography of C-spine (according to C-spine rules)?
Age >= 65 years
Dangerous mechanism
Parasthesia in extremities
Yes to any one of these = radiography necessary
No to all of these, move on to consider low-risk factors
270
What are the low-risk factors which allow safe assessment of range of motion? (according to Canadian c-spine rules)
Simple rear-end motor vehicle collision
Sitting position in ED
Ambulatory at any time
Delayed onset neck pain
Absence of midline c-spine tenderness
If patient doesn't have these features, they are at risk of having a cervical spine injury, radiography is needed.
If they do have one of these features, move on to consider whether they can actively rotate their neck
271
Does a patient need radiographic imaging if they are able to rotate neck 45 degrees L and R?
No (if other criteria have been fulfilled eg. no high risk and some low risk features)
Radiography needed if unable to move neck
272
Outline the Canadian c-spine rules.
1. any high-risk factor which mandates radiography (age >=65 years, dangerous mechanism or parasthesia in extremities)
2. any low-risk factors which allow safe assessment of range of motion (simples rear-end MVC, sitting position in ED, ambulatory at any time, delayed onset neck pain, absence of midline c-spine tenderness)
3. Assess whether able to actively rotate neck 45 degrees L and R
273
How should you manage someone with a head injury?
ABC - stabilise these
GCS <8 - involve anaesthetist very urgently
Assess whether at high risk of brain injury or cervical spine injury - decide whether to image or not (using Canadian C-spine/NICE guidelines). Assess neck movement IF APPROPRIATE
If decide not to image, re-assess patient in one hour
Manage pain (as this can lead to raised ICP) - small doses of IV opioids
274
What are the criteria for performing a CT head scan in someone with a head injury?
Any of the following risk factors = perform a CT head scan within one hour of risk being identified:
GCS less than 13 on initial assessment at ED
GCS less than 15 at two hours post-injury
Suspected skull fracture
Any sign of basal skull fracture: haemotympanum, panda eyes, cerebrospinal fluid leakage from ear to nose, Battle's sign)
Post-traumatic seizure
Focal neurological deficit
More than one (SEPARATE) episodes of vomiting
*If patient is on warfarin treatment*
OR any of the following risk factor with LOC or amnesia since injury:
65yrs or older
Any Hx of bleeding or clotting disorders
Dangerous mechanism of injury
more than 30 mins retrograde amnesia of events immediately before the head injury
275
What are the NICE criteria for performing a CT cervical spine in adults following a head injury?
Any of the following risk factors = CT should be completed within one hour
```
GCS < 13 on initial assessment
Pt. intubated
Plain X-rays technically inadequate
Plain x-ray suspicious/abnormal
Need definite diagnosis
High risk Canadian c-spine factors
```
276
When would you admit someone with a head injury?
Patients with new, clinically significant abnormalities on imaging
Patients whose GCS has not returned to 15 after imaging, regardless of imaging results
Pt has indications for CT scanning, but this cannot be done within appropriate period
Continuing worrying signs eg. persistent vomiting, severe headaches)
Other causes for concern eg. drug/alcohol intoxication etc.
277
What are symptoms and key features of hyperglycaemic hyperosmolar state?
```
Generally T2DM
v. high blood sugar levels
increased urination, thirst
nausea
dry skin
disorientation, drowsiness and LoC
weakness, leg cramps, visual impairment
```
Key features:
Hypovolaemia (eg. confusion, sunken eyes, longitudinal furrows of tonge, extremity weakness, raised urea, tachycardia, hypotension)
Hyperglycaemia (BG 30 or more)
WITHOUT hyperketonaemia (<3) OR acidosis (pH>7.3, bicarb >15)
Osmolality usually >320
May get HHS and DKA at same time
278
what are the goals of treatment of HHS?
```
normalise osmolality
Replace fluid and electrolyte losses
Normalise blood glucose
Prevent arterial/vnous thrombosis
Prevent other complications
Prevent foot ulceration
```
279
How do you calculate osmolality?
2Na + glucose + urea
280
How would you manage a patient with HHS?
A - ensure airway is stable
B - RR, sats, oxygen if desaturating. ?CXR if suspect chest infection
C - cannula, fluids, bloods, BP, HR etc. listen to heart sounds. ECG. Fluid output. urinalysis.
D - GCS, pupils, BLOOD GLUCOSE. Neuroexamination
E - full body exposure, looking for infection/rashes or abdo problems
Check for thyroid enlargement
Temp.
Address fluid balance, give 0.9% saline (with potassium if required)
Calculate osmolality every hour
Try to replace half of fluid (3-6L) loss within first 12 hours, and other half in second 12 hours
Aim for decrease in glucose of 4-6 mmol/Hr
Target glucose: 10-15.
Aim for normalisation within 72 hours
No ketonaemia = no insulin
Only start insulin if BG does not decrease following fluid replacement therapy.
Potassium over 5.5 = do not infuse saline with potassium
Potassium 3.5-5.5 = 40mmol/L infusion
below 3.5 = senior review/HDU
LMWH for full duration of admission
281
What investigations would you do for someone with probable HHS?
```
Bloods:
FBC
U&E
ABG/VBG
blood glucose
CRP (looking for infective source)
blood cultures
```
Urine: urinalysis
urine dip
CXR
ECG
282
What are common differentials for HHS?
delirium
Poisoning
Sepsis
Lactic acidosis or other causes of metabolic acidosis
283
What are some complications of HHS?
Ischaemia of any organ esp. MI or cerebral
DVT/PE
ARDS
SIC
Rhabdomyolysis
Fluid overload/hypoglycaemia (caused iatrogenically)
284
What are some causes of HHS?
```
MI
Infections
stroke/TIA
Hyper/hypothermia
PE
AKI
Acute abdo
Burns
```
```
Medication: metformin, diuretics, beta blockers, H2 receptor antagonists
CCB
APs
steroids
Anti-convulsants
Substance misuse
```
First presentation of diabetes
Poor diabetic control/non-compliance
285
What are some risk factors for seizures?
Fever
Head injury
Alcohol/drugs - excessive or withdrawal
Brain infection
Ischaemic stroke or intracranial haemorrhage
eclampsia
pro-convulsive drugs (tramadol, theophylline, baclofen)
Specific stimuli: strobe lights, reading, psychological stress or sleep deprivation
286
Following a suspected seizure, what examinations should you do for a patient?
cardiac
neurological
mental state
287
what are some features of a seizure?
Temporal lobe: feeling frightened, deja vu, strange taste/smell, rising sensation in stomach, staring, lip-smacking, confusion
Frontal lobe: moving head or eyes to one side, not being aware of surroundings, screaming/swearing/laughing, unusual body movements, repeated movements
Parietal lobe: numbness, tingling, sexual sensations, sensation of body distortion, feeling out of your body, feeling dizzy, seeing things, language difficulty
Occipital lobe: seeing things, visual changes, seeing image repeatedly, eye pain, uncontrollable sideways movement of eyes, nystagmus
Aura: focal seizures acting as a warning of generalised seizure
```
generalised seizure: rigid muscles
Voilent muscle contractions
Loss of consciousness
Biting cheek/tongue
Clenched teeth or jaw
Incontinence
Stopped/difficulty breathing
Blue skin colour
```
```
After seizure: confusion
drowsiness
amnesia
headache
weakness on one side of body (mins-hours. Todd's paresis)
```
288
What are some differential diagnoses for
```
syncope (post-anoxic convulsion)
TIA (although no LoC generally)
Metabolic encephalopathy
Night terrors
Sleep-walking
Migraines
Arrhythmias
Psychogenic non-epileptic seizures
```
289
How would you investigate a seizure?
Bloods: glucose, U&E, calcium, renal function, liver function, urine biochem)
12 lead ECG
CT/MRI
EEG - within 24-48 hours of first seizure or see-deprived
If to support diagnosis of epilepsy, do after second seizure
DO NOT PERFORM IN PROBABLE SYNCOPE because possible false-positive produced
290
How would you manage a seizure acutely?
Keep pt from falling, guide them to floor, move objects that might cause them harm
TIME THE SEIZURE
Try to get them on to their side, but don't be too hard
Pay close attention to what is happening
(in community, after 5 mins, ring ambulance and give buccal midazolam if pt. has it)
Post seizure: get pt on side if not already, loosen clothing around neck and waist
move anything from front of mouth out
wait with patient until come around fully
291
What would you have to tell the patient/patient's family?
How to recognise and manage seizures
Reporting further attacks
Stop driving
Avoid swimming or bathing without supervision
Driving is permitted after one year's freedom from seizures after an unprovoked seizure and on a case-by-case basis on provoked seizures
Commercial driving not usually allowed for 10 years freedom from seizure with AED
292
How would you manage someone with a seizure in the long term?
investigations
refer to specialist in management of epilepsies
patient education
293
How do you manage status epileptics?
A - ?nasopharyngeal
B - oxygen 15L NRB
C - IV access, bloods: FBC, U&E, LFTs, calcium, magnesium, glucose
294
How do you manage status epileptics?
A - ?nasopharyngeal
B - oxygen 15L NRB
C - IV access, bloods: FBC, U&E, LFTs, calcium, magnesium, glucose, blood cultures if suspect sepsis
D - pupils, AVPU
E - injuries, temperature etc.
Time the seizure
After 5 mins: 1-2mg lorazepam IV
Repeat after 5 mins if necessary (max of 4 mg can be given).
If seizures continue: IV phenytoin 20mg/Kg (max 2g), give at 50mg/min. Monitor ECG and BP
Continues seizures: anaesthetic sedation.
295
What causes appendicitis? What happens if it is untreated?
Obstruction of appendical lumen - once obstructed, there can be: bacterial overgrowth, distention, ischaemia and inflammation
If untreated: necrosis, perforation, abscess formation and gangrene
296
What are the clinical features of someone with appendicitis?
'classic' symptoms only in about 50% of patients
Pain: usually Epigastric or periumbilical THEN localises to RLQ
Pain migration due to different innervation of layers.
Peritonitis: wash-board rigidity. Pain exacerbated by slightest movement.
Rebound tenderness at McBurney's point (2/3 of way along imaginary line from umbilicus to R anterior superior iliac spine)
Rousing's sign: pain in LRQ when LLQ palpated
Psoas sign: increased pain on passive extension of right hip
Obturator sign: pain felt on passive internal rotation of flexed hip
```
Nausea/vomiting
Anorexia
Low-grade fever
Reduced bowel movements
Urine dip may show WBC or RBCs
```
297
What investigations might you want to do for someone with ?appendicitis?
Bloods: FBC, U&E, LFTs, CRP
Pregnancy test
Urine dip
USS ( would see aperistaltic and non-compressible structure with diameter >6 mm)
Contrast CT (good sensitivity and specificity, able to diagnose other differentials BUT takes time to arrange)
Laparotomy
298
How would you manage a patient with appendicitis?
Pain relief!
Appendectomy under GA
Keyhole or open
Contraindicated in IBD involving the caecum and possibly elderly or severely ill.
Unable to have appendectomy: IV antibiotics (not curative, reduce mortality in 50%, therefore buy time).
May consider IV ABX and appendectomy a few weeks later if patient has an appendix mass (fatty mass around appendix)
299
What are the complications associated with appendicitis?
Perforation with/without peritonitis
Abscess formation
300
What are the differentials for someone with ?appendicitis?
```
Gastroenteritis
IBS
constipation
bladder or urine infections
Crohn's disease
pelvic infection
```
*ECTOPIC PREGNANCY*
301
What are the two different types of appendicitis?
Simple appendicitis—Inflamed appendix, in the absence of gangrene, perforation, or abscess around the appendix
Complicated appendicitis—Perforated or gangrenous appendicitis or the presence of periappendicular abscess
302
what are some risk factors for cholecystitis?
```
GALL STONES or biliary sludge
Female gender
Age
Obesity
Rapid weight loss
Pregnancy
Crohn's disease
Hyperlipidaemia
```
303
how might cholecystitis present?
```
epigastric or RUQ pain
vomiting
fever (high-swinging fever - riggers and chills)
raised WCC
Jaundice
Murphy's sign
```
chariot's triad: RUQ pain, jaundice, fever
304
What investigations might you do for someone with ?cholecystitis?
FBC - WCC raised
LFTs (often mildly abnormal)
U&Es
USS - thickened GB wall, pericholecystic fluid or air
(thickened GB wall, but no gallstones = calculus cholecystitis)
305
What are risk factors for gall stones?
```
Fair
Fat
Fertile
Female
Forty (increasing age)
+ve family history
Sudden weight loss
diabetes
Oral contraception
```
306
How might someone present with gall stones?
biliary colic (most common presentation - cause by gallstone impacting in cystic duct or ampulla of Vater)
cholecystitis (second most common presentation, caused by distention of GB)
pancreatitis
obstructive jaundice
307
How does biliary colic present?
Sudden onset pain in epigastrium or RUQ, may radiate from back into intrascapular region
subsides spontaneously with analgesics
nausea or vomiting
308
What are differentials for biliary-tract obstructions/infections?
reflux
ulcers
IBS
pancreatitis
309
How would you manage biliary colic and acute cholecystitis?
Pain relief: morphine, pethidine parenterally or diclofenac suppository
IV ABX
Fluids (if electrolyte/hydration imbalance)
refer for laprascopic cholecystectomy
unfit for cholecystectomy: percutaneous cholecystectomy (surgical drainage of GB)
310
Which intestine is more likely to become obstructed? Large or small?
Small bowel
311
What are some risk factors for small intestinal obstruction?
adhesions (from prior operations)
strangulated hernia
malignancy (usually caecum)
volvulus
312
What are some risk factors for large intestinal obstruction?
```
colorectal malignancy (worse the lower down the bowel)
older age
```
risk of perforation
313
What are some risk factors for sigmoid and caecal volvulus? (rotation of gut)
elderly
psychiatric illness
African/Asian (higher incidence)
314
What are some risk factors for paralytic ileus? (condition in which bowel ceases to function - no peristalsis)
Intestinal pseudo-obstruction = ogilvie's syndrome
```
Chest infection
Acute MI
Stroke
AKI
Puerperium
Trauma
Severe hypothyroidism
Electrolyte disturbance
Diabetic ketoacidosis
```
Post-operative
315
What are different types of bowel obstruction?
mechanical obstruction eg. adhesions, malignancies etc.
volvulus (rotation of gut)
paralytic ileus/ogilvie's syndrome (lack of peristalsis)
316
What are symptoms of bowel obstruction?
nausea/vomiting:
early in presentation =high-level obstruction
faeculant vomiting = low obstruction
dysphagia
abdo pain - diffuse, colicky, central (may be less/absent in paralytic ileus)
Severe pain and tension: suggest ischaemia or perforation
failure to pass bowel movements = earlier in lower obstruction
No flatus and no bowel movement: paralytic illeus
abdo distention:
Lower the level of obstruction = more
tympani
high-pitched bowel sounds
pseudo-obstruction presents like large bowel obstruction, but other medical history may indicate true nature.
317
What might you find on examination in ?bowel obstruction?
Dehydration: poor peripheral perfusion, tachycardia, hypotension
pyrexia - perforation or infarction of bowel
Abdo distension
Peristalsis may be visible
Distended bowel: resonant on percussion
Abdo mass may be palpable
Peritonism (tenderness and guarding) = strangulation or perforation
Hernial orifices
Tinkling bowel sounds = obstruction
Silence = reduced OR SILENT bowel sounds
318
How might you investigate someone for ?bowel obstruction?
Fluid charts - monitor fluid input and output
NG tube
```
Bloods: FBC
U&Es
Creatinine
Group and cross-match
Glucose
Amylase (rule out pancreatitis)
```
Abdo X-ray (supine and erect)
US (to exclude small bowel obstruction)
ct scanning
319
What differentials might you consider for someone presenting with symptoms of ?bowel obstruction?
Gastroenteritis (wouldn't necessarily get bloating and reduced bowel movement)
ischaemia of gut - usually bloody diarrhoea
Acute pancreatitis (can get associated paralytic ileus)
peptic ulcer, perforated diverticular disease, perforated carcinoma
TB
```
MI (small bowel)
Ovarian cancer (large bowel)
```
320
How would you manage bowel obstruction?
All:
ABCDE management
Uncomplicated: conservative - fluid resuscitation, electrolyte replacement, intestinal decompression (via NG tube) and bowel rest, analgesia, anti-emetic
Antibiotics (prophylactic against bacteria)
Steroids (if inflammatory cause)
Illeus: stop medications that slow colonic motility
Endoscopy: decompression, dilation of strictures, stents
^ final treatment OR to allow for delay until elective surgical therapy
Emergency surgery (eg. complete small-bowel obstruction, closed loop obstructions, TOXIC MEGACOLON, bowel ischaemia and volvulus = surgical emergencies). Consider surgery if any signs of ischaemia, perforation, peritonitis
321
What are symptoms/features of toxic megacolon?
Symptoms may come on suddenly
Background of IBD
```
Abdo pain
distended abdo
abdo tenderness
fever
tachycardia
shock
bloody or profuse diarrhoea
painful bowel movements
```
322
What is diverticulitis?
diverticular inflammation with or without localised symptoms and signs
323
What are the symptoms/features of diverticulitis?
```
LLQ pain (asians: RLQ)
intermittent or constant
change in bowel habit
fever
tachycardia
(hypotension and shock are unusual)
Anorexia, nausea and vomiting may occur
Localised tenderness, palpable mass
```
Bowel sounds may be normal or increased
Rectal examination may show tenderness or a mass
may present with complications of diverticulitis
324
What are the complications of diverticulitis? (pts may present with these)
perforation: peritonitis
abscess: tender mass or persistent fever despite ABX
fistula
stricture/obstruction
Colovesical fistulas: pneumaturia (bubbles and dysuria) or faecaluria
colovaginal fistulas: frequent vaginal infections or copious vaginal discharge
bleeding - GI haemorrhage. abrupt painless bleeding, cramps, bloody stool
325
What examinations would you do for someone with ?diverticulitis?
```
Bloods:
FBC (WBC raised in diverticulitis, raised platelets, anaemia)
CRP
LFTs
U&Es
```
CXR - detect pneumoperitoneum
Abdo xray - demonstrate small or large bowel dilation/obstruction, ileum, pneumoperitoneum, soft-tissue density (abscesses)
pelvic ultrasound (in women - investigate gynae problems)
?colonoscopy (or risk of perforation)
CT
326
How would you manage a patient with diverticulitis?
Mostly managed at home: ABX, paracetamol, fluid-only diet for 2/3 days, followed by low-fibre diet (reduce faeces produced)
admit if: pain cannot be controlled by paracetamol
unable to drink enough fluids to keep hydrated
unable to take ABX PO
general health is poor
weakened immune system
suspected complications
symptoms failing to improve at home
ABCDE
Rehydration, symptomatic relief (pain killlers), IV ABX (metronidazole)
drainage of abscesses
elective surgery for removal of diverticula (4-6 weeks after diverticulitis attack)
emergency surgery: peritonitis, visceral perforation, sepsis, undrainable abscess, bowel obstruction or lack of improvement/deterioration with initial medical management
327
What is pancreatitis?
acute inflammation of pancreas
release of exocrine enzymes which cause auto digestion of the organ.
Other local tissues and distant organs can also be involved
328
What are the most common causes of pancreatitis?
```
I GET SMASHED
idiopathic/iatrogenic
gall bladder disease
excess alcohol consumption
trauma (post ERCP, blunt)
```
```
Steroids
Mumps
autoimmune
scorpion stings
Hyperlipidaemia, hyperparathyroidism (hypercalcaemia))
ERCP
drugs
```
Ischaemia
IBD
329
How does acute pancreatitis present?
```
Symptoms:
upper abdo pain (LUQ), penetrates to back (could also be general abdo)
sudden onset
vomiting
pain increases over 72 hours
```
```
Signs: temperature (generally raised)
tachycardia, pt. unwell and dehydrated
jaundice may be present
abdo rigidity (epigastric or general)
bowel sounds usually present in early phase. Can get paralytic ileum (causing absent bowel sounds)
```
Severe cases: hypotension, pyrexia, tachypnoea, ascites, pleural effusion, Cullen's sign, Grey Turner's sign (due to retroperitoneal haemorrhage... pancreas is the retroperitoneum)
hypoxaemia
330
What investigations would you want to do on a patient with ?acute pancreatitis?
```
Bloods:
FBC
U&Es
glucose
CRP
ABG (PaO2 and calcium - for GLASGOW score and may also get hypocalcaemia)
LFTs (raised bilirubin and/or serum aminotransferase suggest gallstones)
May see hypocalcaemia
Amylase (3x normal or more)
Lipase (more sensitive and specific)
```
Abdo xray - exclude other causes, may see calcification, elevated hemidiaphragm, pleural effusion
CT scan
US - see presence of gall stones (but otherwise not that helpful)
Endoscopic ultrasound
331
How would you manage a patient with mild acute pancreatitis?
Manage on general ward
Pain relief: pethidine or buprenorphine with/without benzos
NOT MORPHINE.
IV fluids, nil by mouth
NG tube for severe vomiting
ABX for specific infections
No other treatment, No CT necessary
pain, Sx and bloods under control: oral fluids, then solids resumed. Gallstones are the cause = consider common bile duct clearance
332
How would you manage a patient with severe acute pancreatitis?
Treat in ITU or HDU
Fluids (maintain urine output >0.5 ml/kg)
Oxygen if necessary
IV ABX for 7-14 days (cef and met or AMG) if there is necrosis
Evidence of pancreatic necrosis, IV antibiotics
NG tube feeding
ERCP for patients with co-existing cholangitis or biliary obstruction
Surgery (if there is infection and necrosis)
Percutaneous catheter drainage
333
What are the complications of pancreatitis?
```
pancreatic necrosis
infected necrosis
acute fluid collections
pancreatic abscess
acute pseudo-cyst
pancreatic ascities
acute cholecystitis
```
334
How does paracetamol overdose cause toxicity?
Paracetamol metabolised by P450 system: 95% metabolised into harmless metabolites
5% becomes NAPQI
glutathione makes NAPQI harmless
Overdose increases NAPQI levels, run out of glutathione
NAPQI builds up
Hepatocytes damaged
335
What should you do for patients presenting with paracetamol overdose?
ABCDE
Hx from patient
Look on toxbase (might need to make phonemail to NPIS - national poisons information services)
management of overdose depends on time after ingestion
Consider sectioning under 5(2) MHA (if on acutes, cannot do in ED)
336
What are the important parts of the history?
```
HPC: How much has been taken
Time of first tablet (to last tablet)
Any other substances taken
what happened - fell, unconscious etc.
Precipitating factors
```
Current symptoms: N+V, LOC, RUG pain
DH: Any regular meds, O/C
illicit drugs or alcohol alongside or regularly
ANYTHING INTERACTING WITH P450
PMH: anorexia, alcoholism (reduced glutathione stores)
PSYCH and social Hx
337
How would you treat paracetamol overdose?
< 1 hour since start of overdose: CHARCOAL
have to wait until 4 hours to take PCM level
4-8 hours: take level
higher than line on graph, treat with parvolex
8 hours or more: start on parvolex treatment
take PCM measurement
If above line, continue treatment
If below line, stop treatment
15+ hours: treat with parvolex
no need to do PCM level
338
What investigations would you want to do on a patient presenting with paracetamol overdose?
FBC
U&E
LFTs
PCM level - whether need to give parvolex
CLOTTING FACTORS (INR) - tells you about synthetic function of liver
339
Under what circumstances can you use the PCM level graph?
UNstaggered overdose (taken within less than an hour)
Know time of first tablet
After 4 hours
340
What is the treatment regimen for Parvolex in paracetamol overdose?
first bag: over 15mins
second bag: over 4 hours
third bag: over 16 hours (may need to give several of the third bags, until clotting returns to normal)
341
What adverse reactions might you see in a patient who has been given parvolex? How would you manage this?
mock allergic reaction (red and itchy)
Piriton
Start parvolex at half dose
342
What signs might you see in a patient with paracetamol overdose?
N+V within 24 hours
24-72 hours: jaundice
72 + hours: jaundice, bleeding and encephalopathy
343
What are some red flags of lower back pain?
TUNAFISH
T: TRAUMA, TB
U: UNEXPLAINED WEIGHT LOSS, NIGHT SWEATS
N: NEUROLOGICAL DEFICIT, INCONTINENCE or retention, saddle anaesthesia, hip/leg weakness, NIGHT PAIN
A: AGE (<20 or >55)
F: FEVER
I: IVDU, infection
S: STEROID USE OR IMMUNOSUPPRESSED
H: Hx OF CANCER, EARLY MORNING STIFFNESS (pain at rest)
344
What symptoms would make you think a patient might have a spinal cord compression? how would you treat this?
```
back pain
leg weakness
limb numbness
ataxia (+ve Romberg's)
urinary retention (with overflow)
hyper-reflexia
extensor plantars
clonus
```
Where possible: decompression of the spinal cord
345
What symptoms would make you think a patient had caudal equina?
```
bilateral leg pain
back pain
urinary retention
perianal sensory loss
erectile dysfunction
reduced anal tone
```
346
How would you investigate a patient that you thought might have a serious back problem (presented with red flags)?
Myeloma screen
```
Bloods: FBC
U+E
Calcium
CRP
ESR
```
plain Xray (esp. if suspect osteoporosis/infection - not routine)
MRI
(CT if MRI not available)
347
What are some causes of acute low back pain?
```
compression fractures to spine from osteoporosis
Cancer involving spine
fracture of spinal cord
muscle spasm
rupture or herniated disk
sciatica
spinal stenosis
spine curvatures
strain or tears to muscles or ligaments supporting back
```
```
AAA leaking
Arthritis conditions
Infection of spine
Kidney infection or kidney stones
pregnancy
Conditions affecting female reproductive organs
```
348
What would you recommend for someone who has lower back pain, but does not appear to be due to sinister causes?
Stay as active as possible
exercises and stretches for back pain
NSAIDS (if safe)
Hot or cold compression packs for short term relied
Physiotherapists
349
How would you treat caudal equina?
URGENT surgery - relieve pressure on nerves
Other treatment depends on cause eg. infections = ABX, cancer = radiotherapy
350
What are the Ottawa ankle rules?
Guidelines for clinicians to help decide whether patient needs X-ray for foot or ankle:
Ankle - pain in the malleolar zone and any one of the following:
- Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
OR
- Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
OR
- An inability to bear weight both immediately and in the emergency department for four steps.
Foot - any pain in the midfoot zone and any one of the following:
- Bone tenderness at the base of the fifth metatarsal (for foot injuries)
OR
- Bone tenderness at the navicular bone (for foot injuries)
OR
- An inability to bear weight both immediately and in the emergency department for four steps.
351
What does the surviving sepsis campaign bundle say should be completed within three hours of presentation?
Measure lactate level
Blood cultures (X2)
Administer broad-spectrum antibiotics - one hour in septic shock/severe sepsis
Administer crystalloid for hypotension or lactate >=4.
Essentially, buffalo
352
What are red flag features for herniated nucleus pulpous?
Major muscle weakness
| foot drop
353
What can cause peptic ulcer disease?
```
H. pylori
NSAIDS
pepsin
smoking
alcohol
bile acids
steroids
stress
```
354
How might peptic ulcer disease present?
```
epigastric pain and tenderness (usually 1-3 hours postprandial)
Pain may wake patient at night
Pain may radiate to back
relieved by food
Nausea
Oral flatulence
bloating
distention
intolerance of fatty food (like in gall stones)
Heartburn (may be GORD)
Pain may be relieved by antacids
succussion splash on auscultation of abode
```
355
What are the differential diagnoses for someone with ?peptic ulcer disease?
```
AAA
GORD
Gastric cancer
Gall stones
Chronic pancreatitis
Crohn's disease
Diverticular disease
IBS
Drub-induced dyspepsia
Hepatitis
Acute ulcers
Zollinger-Ellison syndrome
Coronary heart disease
```
356
What investigations might you do for someone with suspected peptic ulcer disease?
```
Bloods:
FBC (may show iron-deficiency anaemia)
U+Es
LFTs
CRP
```
Carbon-13 urea breath test or stool antigen (to test for H. pylori)
```
Endoscopy - only necessary if patient presenting for the first time is 55yrs< or warning signs:
iron-deficiency anaemia
chronic blood loss
weight loss
progressive dysphagia
persistent vomiting
epigastric mass
```
```
In pts. aged over 55 (not presenting for first time), also do endoscopy if:
previous gastric ulcer
previous gastric surgery
pernicious anaemia
NSAID use
family history of gastric carcinoma
```
357
How would you manage a patient with peptic ulcer disease?
Stop or replace causative drugs/ ask patient to take with food or alendrotnic acid
Cardiac risk pts: continue low-dose aspirin and full-dose naproxen
encourage cessation of smoking
H.pylori positive: eradication therapy
NSAID-induced: first line - PPI for two months
Second line - 8/52 of standard dose H2-receptor antagonist (ranitidine 150mg BD)
not H. pylori or drug-induced: may need sample of ulcer
Bleeding ulcer: endoscopic intervention with ablative/mechanical treatment
follow up endoscopy 6-8 weeks later
358
What are the first-line drugs recommended for eradication therapy (for H. pylori)?
7 day PPI plus amoxicillin 1g and either clarithromycin 500mg or metronidazole 400mg (all BD). Clarithro + metro if pt. penicillin allergic
359
what are some risk factors for urinary tract stones?
```
abnormal kidneys/ureters
FHx
HTN
gout
Hyperparathyroidism
Immobilisation
Relative dehydration
increased excretion of solutes
cystinuria
drugs: diuretics and vit D supplements
```
360
How might renal colic present (if symptoms are present)?
sudden onset severe pain (may begin as dull ache)
loin pain, moves to groin
tenderness of login or renal angle
haematuria
stone high (in renal capsule): flank pain
pain may radiate down to testis, scrotum, labia and anterior thigh
```
rigors and fever (if infection is present)
dysuria
haematuria
urinary retention
nausea and vomiting
hypotension may be present
```
361
What investigations might you want to do for someone with ?renal colic?
Bloods: FBC, CRP, renal function, electrolytes, calcium, phosphate, rate and creatinine
Prothrombin time and INR (if intervention planned)
Urine:
urine dip for blood, white cells, nitrites, ph<7 (urea-splitting organisms) ,<5 (uric acid stones)
microscopy, culture and sensitivities
US
CT
KUB
362
How would you manage a patient with renal colic (at hospital)?
NSAIDS: diclofenac IM or PR = first line
opiates only if severe pain NOT PETHIDINE
Anti-emetics
Conservative management for up to 3 weeks (unless infection of obstruction is present)
Medical expulsive therapy to help passage of stone: nifedipine or tamsulosin + steroid
May need surgical removal:
stent (if obstruction present)
extracorporeal shock wave lithotripsy (ESWL - shock waves break up stones)
other types of surgery available too.
363
For what reasons would you admit someone with renal colic?
fever
solitary kidney
inadequate pain relief or persistent pain
inability to take fluids due to nausea and vomiting
anuria
pregnancy
poor social support
inability to arrange outpatient follow-up
over 60 yrs if concerned about clinical condition
364
When might you consider managing a patient with renal colic as an outpatient?
patient has been relieved
patient able to drink large amounts of volume
good social circumstances
no complications evident
365
what complications can be associated with renal colic?
reduced eGFR
sepsis
ureteric stricture
pyelonephritis
366
What is a lower UTI?
Infection of bladder (cystitis)
367
What is an upper UTI?
pyelitis and pyelonephritis
368
What's an uncomplicated UTI?
infection by usual pathogen in a person with usual urinary tract with normal kidney function
369
What's a complicated UTI?
anatomical, functional or pharmacological factors predispose patient to persistent infection, recurrent infection OR treatment failure
370
What pathogens most commonly cause UTI?
E. coli
Staphylococcus saprophticus
proteus mirabilis
enterococci
371
What are less common causes of UTI? (eg. in patient with predisposition)
Klebsiella
Proteus vulgaris
Candida albicans
Pseudomonas
372
What are some risk factors for UTI?
```
Increasing age
female
instrumentation in renal tract
abnormality of renal tract
incomplete bladder emptying
sexual activity
use of spermicide
diabetes
catheter
institutionalisation
pregnancy
immunosupression
genetic
```
373
What are some common symptoms of UTI?
```
frequency
painful frequent passing of small amounts of urine
dysuria
haematuria
foul-smelling +/- cloudy urine
urgency
incontinence
suprapubic or loin pain
riggers
pyrexia
N+V
acute confusional state (esp. in elderly patients)
```
374
How would you investigate someone for UTI?
Dipstick analysis of urine
(not for catheters). Treat fas bacteria if positive for nitrites and/or leukocytes
Urine microscopy
Urine culture (to exclude diagnosis, or high-risk, or failing to respond to empirical treatment)
ultrasound of upper UT (rule out obstruction and renal stone disease in acute pyelonephritis)
Febrile 72 hours post treatment: further imaging (?CT)
375
Which patients with UTI should be refered for imaging or cystoscopy?
Persistently not responded to treatment
Hx of renal tract disease or anomaly
Haematuria
WOMEN with recurrent infections, not responding to preventative measures
MEN with 2=< episodes in 3 mths
376
When might you investigate a patient for cancer if they present with UTI-like symptoms? How would you investigate this?
MALE nocturne, urinary frequency, hesitancy, urgency or retention OR visible haematuria: DRE and PSA
Refer under 2-week wait if: person under 45 has had unexplained visible haematuria without UTI OR visible haematuria which persists after successful treatment of UTI OR
60 or over unexplained non-visible haematuria and either dysuria or raised WCC on blood test OR
over 60 with recurrent/unexplained UTI
377
How would you treat a UTI?
lower UTI: Trimethoprim or nitrofurantoin
3 days in uncomplicated women
7 days for men
Pyelonephritis: ciprofloxacin 7-10 days. Co-amoxiclav is an alternative.
Asymptomatic bacteria should not be treated in adults with catheters or non-pregnant women
378
What can cause an acute ischaemic leg?
Embolism - gas, solid or liquid (most commonly of cardiac origin)
Thrombosis - peripheral vascular disease
Rarely: dissection or trauma
379
What are symptoms and signs of acute limb ischaemia?
```
Pain
Pallor (but could also be red)
Paresthesias
Perishingly cold
Pulelesness
Paralysis
```
Skin changes: mottling (signifies irreversible changes)
Development of gangrene (late sign)
380
How long may a patient have had limb ischaemia for it to be called 'acute'?
Less than 2 weeks
381
What investigations would you do for someone who you suspected had an acute ischaemic leg?
Bloods: FBC (ischaemia is aggravated by anaemia)
U+E (dehydration, K+ usually raised if tissue necrosis is occurring)
ESR (inflammatory disease causing ischaemia)
CK (raised if ischaemia has occurred)
Glucose
Lipids
Thrombophilia screen (clotting)
Group and save
ABG/VBG (acidosis secondary to ischaemia)
HAND-HELD DOPPLER US scan
Diagnosis in doubt: angiography (CT)
ECG (source of emboli)
Echo
Aortic ultrasound
Popliteal and femoral artery ultrasound
382
How would initially manage an acute ischaemic leg in the emergency department?
Analgesia: IV morphine
Oxygen
IV Heparin
IV fluids
tPA (tissue plasminogen activator) - given for 8-24 hours via Fogarty Catheter (arterial catheter) <2 weeks.
Refer to vascular specialist urgently. Delay risks the limb (if sensorimotor impairment). Thrombolysis or surgery!
383
What are the different stages of the Rutherford classification for acute limb ischaemia?
Stage 0: asymptomatic
Stage 1: mild claudication (salvageable)
Stage 2: moderate claudication (salvageable with immediate reconstruction)
Stage 3: severe claudication (major tissue loss or permanent nerve damage)
Stage 4: rest pain
Stage 5: ischaemic ulceration (not exceeding ulcer of digits of foot)
Stage 6: sever ischaemic ulcers or frank gangrene
384
How can you tell the difference between thrombosis end embolism in lower limb ischaemia (generally)?
Thrombosis onset: hours to days
Embolism onset: minutes
Upper limb effected: thrombosis = rarely, embolus = commonly
Multiple sites affected: not usually in thrombus
can occur in embolus
Previous claudication usually present with thrombus
Obstruction usually complete in embolus (no collaterals), but collaterals in thrombosis
385
What are some symptoms and symptoms might you see in someone with cellulitis?
```
Swollen area
Red
Well-defined border
Warm
Tender to touch/pressure
Usually unilateral
Pain onset: gradual
```
```
Malaise
Chills
Fever
Tachycardia
Tachypnoea
Hypotension
Skin sloughing
Skin anaesthesia or high levels of pain
Violaceaous bullae
Lymphangitis spread
```
386
What elements of previous medical history might be in-keeping with a diagnosis of cellulitis?
```
General debility
Immunocompromised
Hx of infection
DM (esp. if ulcerated or cut foot)
Cancer
Venous stasis
Chronic liver disease
Peripheral arterial disease
CKD
```
387
What investigations would you do for someone you suspected have cellulitis?
```
Bloods: blood culture
FBC, U+E and LFTs (baseline level)
Creatinine (high)
creatinine phosphokinase (high)
CRP (high)
VBG - bicarb (low)
```
Purulent lesion: debride and culture
Imaging: US
X-ray
CT (if concerned about necrotising fasciitis)
388
How would you manage a patient with cellulitis?
MARK AREA WITH SKIN-MARKING PEN
Analgesia (NSAIDS)
ABX: flucloxacillin 500mg QDS = first line
Erythromycin 500mg QDS if patient is penicillin allergic
Clindamycin is second-line treatment
Steroids (for anti-inflammatory)
Emollient
hydration
389
What is the difference between gout and pseudo gout? How can you tell this difference?
Gout: urate crystals
Psuedogout: calcium phosphate crystals
Differentiate by aspirating the joint
390
What is gout?
Crystal arthritis
High concentration of uric acid in blood stream
Not all patients with high blood urate level get gout
Low blood urate level doesn't rule out diagnosis
391
What causes gout?
```
genetic susceptibility
diet: meat and alcohol, food with high conc. of purine
SE status
Larger BMI
Drugs: diuretic (esp. thiazide)
```
392
How might gout present?
mono arthritis - v. hot, red, swollen joint.
MTP is join affected in most patients (also PIP and DIP)
wakes patient at night
Tophi (urate crystal deposits in skin) - if long term
Synovitis
Pyrexia
Stone formation in kidney and bladder (may cause other symptoms)
393
What investigations might you do for someone you suspected had gout?
```
Bloods: FBC (WCC raised), U+E
Serum urate (raised in 60% of cases)
ESR (often raised)
```
Synovial fluid aspiration
x-ray (if assessing long-term damage)
394
How would you manage a patient with gout?
NSAIDSs
Colchicine
(allopurinol once episode has passed)
remove triggers
395
How does pseduogout usually present? How would you investigate this? How would you manage it?
Presents like gout
BUT knee most commonly affected (and bigger joints)
Joint aspiration
Radiographs (may show chondrocalcinosis)
Treatment: NSAIDS less effective than in gout
INTRA-ARTICLUAR INJECTIONS OF STEROIS useful in treating acute presentation
396
What are the symptoms of amphetamine overdose?
```
Tachycardia and arrhythmias
Mydriasis
Euphoria
Formication
Agitation or pacing
Tremor
Dilated pupils (sluggish response to light)
Convulsions
Hypertension
HYPERTHERMIA (can get dangerously high)
clenched jaw/jaw rigidity
rapid speech
Flushed face
Hyper vigilance and paranoia
```
397
How would you investigate someone with suspected amphetamine toxicity?
A: airway
B: RR etc.
```
C: Bloods: U+Es
Renal function
LFTs
creatine phosphokinase
ECG
Urine dipstick
```
D: blood sugar
CT head if Hx of head injury or altered consciousness
Assess for serotonin toxicity
398
How would you manage a patient with amphetamine toxicity?
A-E assessment
sedation: benzodiazepines
Fluids
Airway management, Oxygen, rapid calling etc. if necessary. Seizure control with benzodiazepines
399
How would opioid overdose present?
Opioid overdose triad:
pinpoint pupils
unconsciousness
respiratory depression
400
How should you manage a patient with opioid overdose?
A-E assessment
Naloxone (IV, IM, SC or intranasal). Start low (0.04-2mg IV) can give up to 4mg at a tim (if pt. severely poisoned)
IM if patient threatening to self-discharge
Can also be given as an infusion
Toxbase
401
How would you investigate a patient with opioid toxicity?
Urine drugs test
Bloods (baseline): FBC, metabolic screen, SK and ABG
CXR if pulmonary oedema suspected
ECG
402
How might tricyclic antidepressant overdose present?
```
Sedation (+/- apnoea)
Confusion/delerium
Arrhythmia
Seizure
Hypotension
Anticholinergic effects: hyperthermia, flushing, dilated pupils
nausea and vomiting
headache
```
403
How would you investigate someone with TCA overdose?
ECG: sinus tacky, prolonged QRS, unusual R wave, prolonged QTc
```
Bloods: FBC
U+E
LFTs
(baseline)
ABG/VBG
```
404
How would you manage a patient with TCA overdose?
Airway management: may require intubation (GCS>8)
B: hyperventilate pt. to blow off CO2
C: IV access - sodium bicarb rapid bolus. Repeat until ECG changes seen. May want to set up infusion.
May need to give magnesium.
Fluids to raise BP, may need vasopressors (noradrenaline)
IV bentos for seizures
D: NG tube
E: temp
405
What is testicular torsion?
Torsion of spermatic cord
Occlusion of testicular blood vessels
Rapidly lead to ischaemia and loss of testis
406
How might testicular torsion present?
Usual neonatal or post-pubertal (but can be any age)
L more common than R
Bilateral = rare
```
Acute swelling of scrotum
Sudden onset, severe pain
Lower abdo pain
Pain onset during physical activity
May be history of this happening before and resolving
Nausea and vomiting
```
407
What might you see in testicular torsion, when examining the testicle?
Redenning scrotal skin
Swollen, tender testis, retracted upwards
Lifting testis over symphysis increases pain
epididymis may be in anterior position
'bell-clapper position'
Absence of cremasteric reflex
408
What investigations would you do for someone with suspected testicular torsion?
COLOUR DOPPLER
MRI
Urinalysis (eliminate other differentials)
Clinical suspicion high, surgical intervention should not be delayed
409
How would you manage a patient with suspected testicular torsion?
surgical exploration for anyone with high suspicion of torsion
Pt should be NBM
may be able to reduce torsion manually
Bilateral orchiopexy to fix testis in place
410
How might an ankle sprain present?
Severity depends on severity of sprain
Tenderness and swelling
Bruising
Functional loss (eg. pain on weight-bearing)
Mechanical instability (if severe)
Marked bruising (may indicate ligament tear or fracture)
411
What are differentials of acute ankle pain?
```
Achilles tendon injury
Joint pathology
Tendon injury
Stress fractures
Fracture
```
412
How can you classify (lateral) ankle sprains? (lateral ankle sprains make up 85% of sprains)
Grade I-III
Grade 1: ligament stretched mild swelling
no/little functional loss
no joint instability.
Pt can partially weight bear.
Grade 2: ligament stretched,
partial tearing,
swelling mod-severe, moderate function loss, mild-mod joint instability. Difficulty weight-bearing.
Grade 3: ligament is completely ruptured
swelling is immediate and severe
ecchymosis
Patient cannot weight bear or not without SEVERE pain
Mod-severe instability of the joint
413
How would you manage someone with an ankle sprain?
```
Pain relief
Functional support (rather than immobilisation, unless severe e.g.. grade 3)
```
For the first 72 hours: PRICE
P: protection from further injury (eg. bandage, ankle tape, brace, high-top lace shoes)
R: rest ankle joint for 48-72 hours after injury. Consider crutches in this period.
I: apply ICE for about 10-30 mins after injury (NOT directly next to skin). Limits pain, inflammation and bruising)
Try for 15 mins every 2 hours (NOT during sleep)
C: compression bandage, limit swelling
E: elevation to limit and reduce any swelling
Range of motion exercises once not too painful
grade 3 spain may recover better with period of immobilisation first
advise to go to GP if no improvement
414
What things should you advise a patient to avoid in ankle sprain?
HARM
Heat
Alcohol
Running
Massage
All increase bleeding and swelling risk
415
What is the common cause of a Colle's fracture?
FOOSH
416
How would a Colle's fracture present?
Dorsal displacement and deformity (dinner fork deformity)
| Ulnar styloid tenderness
417
Other than the obvious dinner-fork deformity, what else should you check in a patient with ?Colle's fracture?
```
Ulnar styloid for tenderness
Examine elbow (for co-exisiting radial head fracture)
Neuromuscular function
```
418
How would you investigate a Colle's fracture?
Xray (at least lateral view)
419
How would you manage a Colle's fracture?
Analgesia (but careful as pt. may need to be NBM)
Reduce in emergency department (under sedation): longitudinal traction (pulling wrist) and dorsal pressure
Sedation: midazolam +/- fentanyl (ketamine in children)
Apply back slab
RE-XRAY to check bone alignment (may need to repeat if it is not)
Severely displaced/open-fracture: open surgical repair
Healing time 6-8 weeks
420
What are the complications of Colle's fracture?
Medial and ulnar nerve damage
acute carpal tunnel syndrome
compartment syndrome
malunion/non-union
long term: deformity/loss of function/osteoarthiritis
421
How would you investigate someone with suspected hip fracture?
```
Bloods: FBC
U+Es
LFTs
Group and save
INR (if on warfarin)
Clotting
```
ECG
X-ray hip and pelvis
422
How might a hip fracture present?
Hip pain
Hx of fall/trauma
Leg: shortened and externally rotated
423
How would you manage someone with hip fracture?
Urgent X-ray of the pelvis
(within an hour)
Pain relief +++ (fascia iliac block - local nerve block)
Minimal movement
Pressure sore care
Fluids etc. if necessary
C-spine immobilisation (if trauma)
call to surgeons - hemiarthroplasty
VTE prophylaxis (stockings)
424
What is Gardener's classification of hip fractures?
Categorises fractures into severity, guiding management
Also predicts development of AVN
Garden stage I : undisplaced incomplete, including valgus impacted fractures.
Garden stage II : undisplayed complete
^ stable fractures, treated with internal fixation
Garden stage III : complete fracture, incompletely displaced
Garden stage IV : complete fracture, completely displaced
^unstable fractures treated with arthroplasty (semi or total)
425
What is septic arthritis?
Infection producing inflammation in native or prosthetic joint
Can be acute or chronic
426
Which groups might be more likely to get septic arthritis?
```
Children (under 5)
Immunosuppressed
Diabetics
IVDU
Prosthetic joints/joint surgery
(old)
```
427
How might septic arthritis present?
```
single swollen joint with pain on active or passive movement
warm joint
Fevers or rigors may be present
vomiting
hypotension
may have an abscess
bacteraemia
chest wall pain (if infected joint around chest)
```
Triad of fever, pain and impaired range of motion
OFTEN PRESENTS IN THE KNEE
immunosuppressive disease
recent steroid injection
STD
IVDU
428
What are the differential diagnoses of septic arthritis?
```
rheumatological disorders
gout/pseudogout
vasculitis
drug-induced arthritis
reactive arthritis
lyme disease
infective endocarditis
```
429
How would you investigate a patient with ?septic arthritis?
Bloods: FBC (raised WCC)
ESR and CRP
Synovial fluid examination:
aspirate - crystals, white cells and culture
DON'T ASPIRATE PROSTHETIC
```
Blood culture
Tissue culture
PCR
Test for lyme disease
Immunology
```
?imaging (X-ray, then ?CT) (for prosthetic joint)
430
How would you manage a patient with septic arthritis?
Consult microbiologist
Prescribe broad spectrum ABX that covers S. aureus and strep. Flucloxacillin, clindamycin if penicillin allergic.
MRSA - vancomycin
IV 2-3 weeks, switched to oral for 2-4 weeks
431
How might otitis media present?
More common in children
Ear features: Acute onset ear pain (otalgia)
Middle ear inflammation
Eardrum features:
Effusion or Purulent discharge (can be bloody) - reduce pain once this occurs
Bulging or erythematous tympanic membrane
Fluid level behind tympanic membrane
Perforated tympanic membrane
Hearing features:
Conductive deafness
Tinnitus
Other general features:
previous URTI
Fever
Imbalance
432
How would you manage a patient with otitis media?
Analgesia (NSAIDS etc).
Early otitis media:
Symptomatic treatment
+/- ABX (if pt. is well, analgesia and symptomatic relief)
ABX: co-amoxiclav
Bulging otitis media:
ABX (co-amoxiclav)
If these fail (or recurrent) = myringectomy (incise tympanic membrane to release fluid build up)
Discharging otitis media:
Antibiotics based on swab and culture
(most resolve within 7-14 days)
Recurrent = gromit insertion
433
What are common causes of otitis media?
Strep
| H. influenza
434
What are common causes of tonsillitis?
30% bacterial
70% viral
(99% will recover without antibiotics)
Group A streptococcus
435
What are the symptoms of tonsillitis?
Sore throat, red and inflamed
Enlarged tonsils
Fever
Malaise/lethargy
436
What investigations might you do for someone with tonsillitis?
Generally no investigations done
| throat swab, but this takes time
437
What investigations might you do for someone with tonsillitis?
Generally no investigations done
throat swab, but this takes time
General obs (check for systemic illness)
438
How would you manage patient with tonsillitis?
Paracetamol and ibuprofen
Avoid giving ABX unless meet censor criteria OR systemically unwell
```
Penicillin V (phenoxymethylpenicillin) used if meet criteria
Erythromycin if penicillin-allergic
```
439
Which ABX should you not give to a patient with tonsillitis? Why?
Amoxicillin
Can cause rash if patient has glandular fever
440
What are the red flags of tonsilitis/sore throat?
```
Persistent sore throat for > 6 weeks
Excessive drooling
Trismus
Unilateral facial swelling
Dysphagia
Dyspnoea
Immunosuppressant medication such as carbimazole
Persistent unilateral tonsillar enlargement
Neck stiffness
Photophobia
Non-blanching rash
```
cancer, agranulocytosis
441
What are the two main presentations of meningococcal disease?
Meningococcal meningitis
Meningococcal septicaemia
442
What are the features of a meningitis prodrome?
Fever
Nausea and vomiting
Malaise
Lethargy
443
What are the features of meningococcal meningitis?
Severe headache
Neck stiffness (not always present in young children)
Photophobia
Drowsiness/confusion/impaired consciousness
Seizures (late sign)
Focal neurological deficit, incl. cranial nerve involvement and dilated/unequal/poorly-reactive pupils (late sign)
444
What generally kills people with meningococcal meningitis?
Raised ICP
445
What are features of meningococcal septicaemia?
```
Limb/joint pain
Cold hands and feet
Prolonged cap refill
Plae/blue/mottled skin
Tachycardia
Tachypnoea, labour breathing, hypoxia
Riggers
Oliguria/thirst
Rash (non-blanching)
Abdominal pain (+/- diarrhoea)
Drowsiness/confusion/impaired consciousness
Hypotension
Rapid deterioration
```
446
What generally kills people with meningococcal septicaemia?
Cardiovascular failure
447
How would you manage a patient with meningococcal septicaemia or meningitis?
A: airway may be needed
```
B: 15L NRB O2 (acutely unwell)
Breathing sounds
RR
Sats
ABG
```
```
C: blood cultures
Cannula
IV ABX - ceftriaxone +/- vancomycin (travel abroad or long-term ABX use). Up to 7 days.
Fluids (restrict if raised ICP)
Anticoagulants if patient has DIC
corticosteroids
```
D: Neurological assessment (incl. pupils)
Blood glucose
AVPU/GCS
E: expose to look at/for rash
feel abdo
May need HDU/ICU bed
448
On top of treating the patient with meningococcal disease, what else must you do as a clinician?
Contact consultant in communicable disease control or public health medicine
Prescribe ciprofloxacin to close contacts + vaccinations
(prevents further spread FROM contacts as opposed TO contacts)
449
What investigations might you do on someone who's ?mengingococcal disease
```
Blood cultures
FBC (WCC and platelets )
CRP
U+Es
Renal function tests
LFTs
Clotting (aPTT, fibrinogen) - investigating ?DIC
```
PCR for N. meningitidis (use earliest sample possible)
Pharyngeal swab
Lumbar puncture (once stable) - check for ICP. Microscopy, culture, glucose and PCR. DO THIS EARLY IF MENINGITIS SUSPECTED, LATER IF SEPTICAEMIA
450
Which signs in meningococcal disease require URGENT review by senior +/- critical care review?
Rapidly progressive rash
Capillary refill time > 4 secs,
oliguria or systolic BP
< 90mmHg
Respiratory rate < 8 or >30
Pulse rate < 40 or >140
Acidosis pH < 7.3 or Base excess worse than -5
White blood cell count <4x109/L
Lactate > 4 mmol/L
Glasgow coma scale <12 or a drop of 2 points
Poor response to initial fluid resuscitation
451
what are some causes of diarrhoea?
Short-term:
virus
Bacterial (eg. food poisoning)
parasites (eg. giardiasis)
```
Anxiety
Alcohol excess
Allergy
Appendicitis
Radiotherapy
```
```
Drugs:
ABX
Antacids (containing magnesium)
Chemo
NSAIDS
SSRIs
Statins
Laxatives
```
```
Long term:
IBS
IBD
Coeliac disease
Bile acid malabsorption
Chronic pancreatitis
Diverticular disease
Bowel cancer
```
452
What counts as diarrhoea?
Stools more than 3 times a day
| Stools become loose or watery
453
How would you manage diarrhoea?
Fluids (if dehydrated)
Loperamide
454
What is giant cell arteritis?
systemic immune-mediated vasculitis affecting medium and large-sized arteries
455
How might giant cell arteritis present?
Temporal headache (recent onset). Severe. Sometimes worse at night.
myalgia
malaise
fever
Jaw or tongue claudication
Enlarged, beaded or pulseless temporal artery
Scalp tenderness
Raised ESR
Anaemia
Visual disturbance (inflammation of ophthalmic artery, ischaemic optic neuritis): blurred vision, amaurosis fugax, transient or permanent visual loss, diplopia. Ischaemic changes may be seen on fundoscopy)
```
Classic presentation:
over age of 50
scalp tenderness
transient visual symptoms
unexplained facial pain
```
CAN RESULT IN LOSS OF VISION
Systemic symptoms: weight loss, fever, sweats, carotid bruits
456
What investigations might you do for someone with ?GCA?
Bloods: FBC (normocytic normochromic anaemia)
LFTs
ESR
CRP
Temporal artery biopsy
Colour duplex ultrasonography
457
What criteria must be present to diagnose someone with GCA? How many need to be met to make the diagnosis?
Age of disease onset: >=50 yrs
New onset headache
Temporal artery abnormality
ESR >= 50 mm/hr
Abnormal artery biopsy
3/5 must be present to make the diagnosis
458
How would you manage a patient with GCA?
High dose corticosteroids
40mg prednisilone daily unless patient has iscahemic symptoms
Claudication/ischaemic symptoms: 60 mg
Visual symptoms: IV methyprednisilone
Once symptoms reduce - reduce slowly.
Low dose aspirin 75mg + PPI
459
How does a subarachnoid haemorrhage present?
```
Sudden onset headache (usually occipital)
INTENSE from start
Neck stiffness
Vomiting
Extensor plantar responses
Impaired consciousness (usually shortly after onset, but can be after several hours)
Cranial nerve signs
Hemiplegia
Hypertension
```
(sentinel headache)
Symptoms of stroke (following vasospasm after SAH - causing ischaemia)
460
What investigation would you do for someone with ?SAH?
CT (able to detect >90% lesions within 48 hours of onset). NON-CONTRAST
bleed found: angiography
Lumbar puncture (if CT negative, but strong clinical suspicion) - looking for xanthochromia (yellow CSF)
ECG
Bloods: Billirubin
461
How should you manage a a patient with SAH?
Call:
Med reg
neurosurgeon on call
anaesthetist (depending on GCS)
Stabilise patient haemodynamically
A-E
Prevent re-bleeding: nimodipine 60mg 4-hrly
low dose nitroprusside (vasodilator) and labetalol - maintain cerebral perfusion (but not enough to encourage re-bleeding)
Analgesia
Anti-emetics
Surgery: clipping (craniotomy) and coiling (clips around aneurysm via femoral catheterisation)
462
What is a stroke?
Sudden onset of brain dysfunction
| Caused by alteration in cerebrovascular blood supply
463
How might a stroke present? (generally speaking)
Rapid, acute onset neurological changes eg. hemiplegia
464
What are the two main types of stroke?
```
Brain ischaemia (80-90%)
Haemorrhage (10-20%)
```
465
What are the main causes of stroke?
Arterial embolism
| Haemorrhage (cerebrum itself or SAH)
466
What are some risk factors for stroke?
```
Afro-carribean/asian
Male
Age
HTN
Smoking
AF
Diabetes
Alcohol
hypercholesterolaemia/hyperlipideamie
Obesity
heart disease
FHx
```
467
When do most strokes occur?
BP lowered during the night whilst asleep
| On waking, BP rises, more likely to dislodge any embolism
468
Where is the most common location for cerebral infarct to occur? How would this present?
Middle cerebral artery
```
Hemiparesis
hemiplegia
floppy limbs, lack reflexes reduced/absent
Facial weakness
hemianopia
aphasia
```
symptoms usually develop rapidly. Recovery will occur gradually, over days, weeks etc. Longer time = worse prognosis
not usually a headache (if present, implies swelling, implies haemorrhage)
not usually any LOC
seizure v. rare
Reflexes reappear, but exaggerated
Extensor plantar response
469
What symptoms might you see in patient with anterior cerebral artery infarct?
weak leg +/- shoulder
| CONTRALATERAL side
470
What symptoms might you see in patient with posterior cerebral artery infarct?
eye problems
471
What symptoms might you see in patient with a brainstem infarct?
(depends on location, but selection of symptoms):
```
semi/tetraparesis
sensory loss
diplopia
facial numbness
facial weakness
nystagmus and vertigo
dysphagia and dysarthria
hornet's syndrome
altered consciousness
```
coma
locked-in syndrome (loss of all motor neurone function)
pseudo bulbar palsy (dysarthria and dysphagia)
472
What symptoms may present with lacunar infarct?
Often symptomless
Very localised symptoms eg. purely sensory or purely motor
aphasia
hemiparesis
hemisensory loss
unilateral ataxia
473
How would you investigate suspected stroke?
CT:
infarctions = wedge shape
haemorrhage = blood appears bright white initially, gets darker over time. 1-2 weeks later = indistinguishable from normal brain tissue
New stroke <2 hours old, may not show up at all. 6-12 hours, will be clearly visible.
BP (manage)
ECG (looking for AF)
CXR (heart size), echo
```
Blood (rule out differentials):
ESR (raised - ?GCA)
FBC/platelets/clotting
glucose
cholesterol/lipids
```
474
How might a cerebral haemorrhage present?
Similar to infarct picture BUT
more likely to lose consciousness, headache
progressive neurological defects
Hydrocephalus (blood leaks in to ventricular system)
475
How would you manage ischaemic stroke?
A-E
Thrombolysis (if possible)
If unable to thrombolyse: 300mg aspirin for 2 weeks then 75mg a day (if not aspirin, clopidogrel)
Dipyridamole
Warfarin or NOAC in long-term
476
How would you manage haemorrhage stroke?
A-E
Mostly supportive
If anticoagulants and antiplatelets have been given, reverse with fit K, fresh frozen plasma and platelet transfusions
haemorrhagic mass >3cm = surgery (drain or craniotomy)
Manage BP is SBP>185mmHg
477
What are the clinical features of a DVT?
(result of obstruction to venous drainage)
Limb pain
Tenderness along line of deep veins
Swelling of calf or thigh (usually unilateral)
Bilateral - thrombosis in iliac bifurcation, pelvis veins or vena cava
Pitting oedema
Distension of superficial veins
Warm limb
Skin discolouration (erythema or cyanosed)
Palpable cord (hard, thick palpable vein)
Severe DVT: cellulitis-like
can also have cellulitis (as secondary to DVT or primary, leading to DVT)
478
What differentials might present similar to DVT?
```
Trauma
Superficial thrombophlebitiis
peripheral oedema, heart failure, cirrhosis, nephrotic syndrome
venous/lymphatic obstruction
vasculitis
cellulitis
septic arthritis
```
479
How would you investigate a patient with suspected DVT?
Depends on level of risk (calculated by a two-level Well's score)
```
General bloods:
FBC
PT
INR/APTT
Renal function
LFTs
```
480
How would you investigate a patient who has suspected DVT and a LIKELY two-level DVT Well's score? (>=3)
Doppler US leg
| D-dimer (if doppler -ve)
481
How would you investigate a patient who is at low risk of DVT? (<3 on two-level Well's score)
D-dimer test
If positive: doppler US leg
(wouldn't be done if D-dimer was negative)
If doppler US is negative and Wells score 1-2, reassess using US scan in 5-7 days time.
482
How would you manage someone with DVT?
Analgesics (avoid aspirin and NSAIDS)
LMWH (deltaparin, enoxaparin, tinzaparin) - start this immediately if diagnosis of DVT is likely on clinical grounds before definitive investigation
OR
Fondaparinux
For at least 5 days (or until INR 2
483
What are some contra-indications to anticoagulation that you need to consider when prescribing LMWH?
```
Active peptic ulceration
alcohol excess
liver disease
PT>2 secs beyond normal range
Thrombocytopenia (platelets <80)
Uncontrolled hypertension (>180/100)
Ophthalmic/neurosurgical intervention recently
Hx of haemorrhage stroke
biopsies
pregnancy
```
484
What is included in Two-level DVT Wells score?
Each score one point, except final point, which is -2
Active cancer (treatment on-going or within 6 months OR palliative)
Paralysis, paresis or recent plaster immobilisation
Recently bed-ridden for 3 days or more
Major surgery within 12 weeks, requiring general or regional anaesthesia
Localised tenderness long distribution of deep venous system
Entire leg swollen
Calf swelling at least 3x larger than asymptomatic leg
Collateral superficial veins (non-varicose)
Previously documented DVT
An alternative diagnosis is at least as likely as DVT (-2)
485
What can cause vasovagal syncope?
Emotional: feat, pain, phobia, sudden unexpected sight sound or smell
Orthostatic: prolonged standing, hot places
486
What might people described in a history of vasovagal syncope?
Brief LOC
Warning: light-headedness, nausea, sweating, weakness, visual disturbance
No chest pain or SOB, not during exercise
Almost immediate restoration of appropriate behaviour and orientation (pt. might be v. tired)
Might be Hx of new medications
Syncope may be more likely in morning
487
Differential diagnosis?
```
Other causes of syncope
Epilepsy
Narcolepsy
Drop attacks
TIA
```
488
How would you investigate a patient with ?vasovagal syncope?
Many investigations to rule-out serious causes of harm.
BP measurement (lying and standing)
Bloods: FBC, blood glucose
ECG
489
What would you want to know about a patient to determine risk of severe cardiac problems in syncope?
```
coronary heart disease
ECG changes (broad QRS, prolonged QT interval, non-sustained VT)
Syncope during exercise or supine
palpitations
FHx of sudden cardiac death
HR<50
```
490
How would you manage a patient with Vasovagal syncope?
Reassure and educate:
Avoid prolonged standing in warm environments
Avoid hot baths
At first sign of collapse: Lie down, legs in air
Sit agains wall, head between knees
squat down on heels
get up very carefully, return to position if feeling unwell again
491
How would you manage someone with high-risk NSTEMI or STEMI?
A-E assessment and management
MONAT
```
Morphine
Oxygen (if sats <94% or 90% (COPD))
Nitrates (usually IV in NSTEMI/unstable angina)
Aspirin (300 mg)
Ticagrelor
```
After acute event, when stable:
beta-blocker
ACEi
Statins
492
How would you manage a patient with unstable angina?
A-E assessment and management
MONA
Morphine
Oxygen (if sats <94% or 90% (COPD))
Nitrates
Aspirin
493
What should your first actions be in cardiac arrest?
Call for help (ask them to call 2222)
Begin CPR
Administer oxygen if available
Attach defib, establish rhythm
494
Which rhythms are shockable in cardiac arrest?
VF
| VT
495
If after sticking on Defib, you are told your rhythm is shockable, what should you do?
administer defibrillation
Immediately resume CPR for 2 mins
Establish vascular access
Recheck shockable rhythm after 2 mins. Shockable: shock.
Give 1mg IV adrenaline every 3-5 mins
Consider ET tube
Continue CPR for 2 mins
Check shockable rhythm: shock
CPR 2 mins
Amiodarone 300mg (after 3rd shock)
Establish and treat reversible cause
496
Which rhythms aren't shockable?
PEA
| Asystole
497
Once you've found out a rhythm isn't shockable in cardiac arrest, what would you do?
Resume CPR for 2 mins
Establish IV access
Give IV adrenaline 1mg every 3-5 mins
Consider ET tube
Check whether rhythm shockable: no = return to CPR for 2 mins
establish and treat reversible causes
Continue to give IV adrenaline 1mg every 3-5 mins
Repeat process until shockable rhythm, ROSC or calling
498
What should you do if your rhythm suddenly becomes shockable/un-shockable in cardiac arrest?
Switch to other half of algorithm
499
What are the key drugs and doses to remember in cardiac arrest?
Adrenaline 1 mg every 3-5 mins
(give immediately in non-shockable, give after 2 shocks in shockable)
Amiodarone 300 mg first dose
2nd dose 150 mg
Give after third shock
500
What are the reversible causes of cardiac arrest?
5 H's and T's
```
H
Hypoxia
Hypovolaemia
Hydrogen ions (acidosis)
Hypo/hyperkalaemia
Hypothermia
```
```
T
Tamponade
Tension pneumothorax
Toxins
Thrombosis (cardiac or pulmonary)
Trauma
```
501
How would you manage a patient with HR>=150 (with pulse) with adverse features? (shock, syncope, MI or heart failure)
Cardioversion - synchronised DC shock. Up to 3 attempts.
After this, seek expert help.
Give amiodarone 300 mg IV over 10-20 mins
Repeat shock
Give amiodarone 900mg IV over 24 hours
502
How would you manage a patient with a regular broad QRS complex HR>=150 (with pulse) with NO adverse features? (shock, syncope, MI or heart failure)
VT (or uncertain rhythm):
amiodarone 300mg IV over 20-60 mins
THEN
900mg over 24 hours
(If SVT+BBB, treat like narrow-complex tachy)
503
How would you manage a patient with a irregular broad QRS complex HR>=150 (with pulse) with NO adverse features? (shock, syncope, MI or heart failure)
CALL FOR HELP
504
How would you manage a patient with a regular narrow QRS complex HR>=150 (with pulse) with NO adverse features? (shock, syncope, MI or heart failure). What are the likely causes of this rhythm?
```
Vagal manoeuvre: head down or blow in to syringe
Adenosine 6mg rapid IV bolus
no effect: 12 mg
No effect: 12 mg
(monitor with ECG continuously)
```
Sinus rhythm achieved -
record ECG of sinus rhythm
consider anti-arrhythmic prophylaxis
Probably re-entry paroxysmal SVT
If sinus rhythm NOT achieved - seek expert help
Consider rate control (beta-blocker)
?consider cardioversion
Probable atrial flutter
505
How would you manage a patient with a irregular narrow QRS complex HR>=150 (with pulse) with NO adverse features? (shock, syncope, MI or heart failure). Which rhythm is likely to cause this?
AF
Control rate with beta blocker or diltiazem
In heart failure: digoxin or amiodarone
Assess VTE risk, consider anticoagulation
506
What are the different types of SVT?
```
Regular:
sinus tachy
atrial flutter
Sinus node re-entrant tachy
Atrioventricular re-entry tachycardia (AVRT eg. WPW syndrome)
AV nodal re-entry tachycardia (AVNRT)
Automatic junctional tachycardia
```
Irregular:
AF
atrial flutter with variable block
507
How would you initially treat someone with bradycardia with adverse features? (shock, syncope, myocardial ischaemia, heart failure)
```
A-E assessment
Oxygen
IV access
ECG
BP
SpO2
Identify and treat reversible causes.
```
Atropine 500 mcg IV
508
How would you initially treat someone with bradycardia with NO adverse features? (shock, syncope, myocardial ischaemia, heart failure)
```
A-E assessment
Oxygen
IV access
ECG
BP
SpO2
Identify and treat reversible causes.
```
```
Work out risk of asystole:
recent asystole
mobitxz II AV block
Complete heart block with broad QRS
Ventricular pause >3s
```
No risk: observe
```
Risk: Atropine 500 mcg IV repeat to max of 3mg
OR
Isoprenaline 5mcg/min IV
Adrenaline 2-10mcg/min IV
alternative drugs
OR
transcutaneous pacing
```
Seek expert help
509
What would you do if initial management of someone with symptomatic bradycardia (atropine 500mcg IV), didn't work?
```
Atropine 500 mcg IV repeat to max of 3mg
OR
Isoprenaline 5mcg/min IV
Adrenaline 2-10mcg/min IV
alternative drugs
OR
transcutaneous pacing
```
Seek expert help
510
How might shoulder dislocation present?
Hx of trauma
Pain
Anterior: Externally rotated arm
loss of shoulder roundness
anterior bulge
humeral head palpable anteriorly
abduction and internal rotation are resisted
may have loss of sensation in regimental badge area
Posterior: arm adducted and internally rotated
Posterior bulge
humour head palpable below acromion process
abduction and external rotation are painful
inability to externally rotate to neutral position and supinate
511
What things should you check on examination of someone with ?anterior shoulder dislocation?
radial pulse (assess vascular injury)
regimental badge area (axillary nerve damage)
thumb, wrist and elbow weakness on extensions and sensation on dorm of hand (radial nerve function)
rotator cuff (once joint is reduced)
512
How would you investigate shoulder dislocation?
x ray (AP and axillary or transcapular view)
513
How would you manage someone with shoulder dislocation?
Analgesia and sedation:
opiate and benzo
reduction
fracture dislocation: surgery
514
List some causes of AF
```
Cardiac:
HF
MI
hypertension
mitral valve disease
congenital
```
Pulmonary:
PE
pneumonia
bronchocarcinoma
```
Other:
hyperthyroidism
alcohol
post-op
sepsis
caffeine
anti-arrhythmias
hypoK
hyperMg
```
LONE
515
How might AF present?
```
palpitations
chest pain
SOB
dizziness
syncope
```
Irregularly irregular pulse
apical pulse rate > radial pulse rate
signs of LV dysfunction
516
What might you find on an ECG of someone with AF?
```
no P waves
irregular QRS - regular shape
HT 75-190 bpm
normal T waves
V1 looks like atrial flutter
```
517
What investigations should you do for someone with AF?
ECG
Bloods: FBC (rule out anaemia as cause of palpitations)
U+Es
TFTs
Cardiac enzyme
Echo
518
How might you manage someone with an acute presentation of AF?
<48 hours after onset of symptoms
A-E
treat underlying cause
Control rate
Initiate anticoagulation (heparin)
Consider DC or chemical cardioversion
Acutely unwell: cardioversion in ITU with sedation
519
what drug is given for chemical cardioversion in AF?
Amiodarone IV 5mg/Kg in 1 hr, then 900mg-1.2g in a 24 hour period
Amiodarone PO 200mg/8hr for 1 week then 200mg/12hr for one week then 200mg/day maintenance
Can also use flecainide
520
What can cause atrial flutter?
```
atrial dilation
open heart surgery
HTN
obesity
alcohol abuse
COPD
cardiomyopathy
atrial myxoma
pericarditis
thyrotoxicosis
electrolyte imbalance
sleep apnoea
```
521
How might atrial flutter present?
```
palpitations
fatigue
dyspnoea
chest pain
dizziness
syncope
heart failure
TIA/stroke
Pulse may be regular or irregular or regular pulse tachycardia
signs of underlying cause
HF
hypotension
```
522
How would you investigate someone for ?atrial flutter?
```
Bloods: FBC
U+E
TFTs
ESR
LFTs
coagulation screen
```
ECG: saw-tooth flutter waves II, III and aVF
Echo
523
How would you manage a patient with atrial flutter?
rate control - medications or cardioversion
treat underlying conditions
anticoagulation (like in AF)
524
What is cerebral venous sinus thrombosis?
acute thrombosis in dural venous sinuses (which drain blood from brain)
525
List some symptoms of cerebral venous sinus thrombosis
Headache (sudden to gradual onset)
ophthalmoplegia (papilloedema) and/or diplopia (usually unilateral to start with)
seizures (can be unilateral)
stroke-like symptoms: hemiparesis, lower limb weakness, aphasia and ataxia
Facial pain
pulsatile proptosis
hornet's syndrome
Raised ICP: reduced consciousness, HTN, reduced HR
526
List some causes of venous sinus thrombosis
```
thrombophilia
nephrotic syndrome
chronic inflammatory diseases
pregnancy and puerperium
oestrogen-containing contraception
meningitis and ENT infections
```
527
How would you investigate someone with ?cerebral venous sinus thrombosis?
Bloods: FBC (Hb may be elevated, WCC and platelets may be elevated)
U+E
LFTs
D-dimer
Urine dip
CT venogram (normal CT often appears normal)
ECG
528
How would you manage a patient with venous sinus thrombosis?
Elevate hear 30-40 degrees to help reduce intracranial pressure
anti-convulsants if seizures present
LMWH initially IV or SC
warfarin once patient stable
Severe: thrombectomy, endovascular therapy
529
What are signs of raised ICP?
headache: nocturnal, starting on waking, worse on coughing or moving head, altered mental state
Changes to mental state: lethargy, irritability, slow decision making, abnormal social behaviour
Vomiting
Pupillary changes
Fundoycopic changes eg. blurred disc margins, haemorrhages
unilateral ptosis
hemiparesis
raised BP, widened pulse pressure
bradycardia
530
How can raised ICP present acutely?
```
Head injury
syncope
headache
meningism
focal neuro deficit
seizures
```
talk and deteriorate - talk and then go in to coma
531
How would you investigate a patient with suspected raised ICP?
GCS
CT scan
532
How would you manage a patient with raised ICP?
```
avoid pyrexia (hypothermia)
manage seizures
CSF drainage (intraventricular catheter)
elevation of head
analgesia and sedation
neuromuscular blockade (reduce muscle activity, which can cause raised ICP)
```
Mannitol: intravascular osmotic agent
Hypertonic saline (3-30%)
Hyperventilation
decompressive craniotomy
533
How might a space-occupying lesion in the cerebellum present?
```
cerebellar ataxia
intention tremor
past-pointing
dysdiadochokinesis
nystagmus
staccato speech
```
534
How might a space-occupying lesion in the temporal lobe present?
```
depersonalisation
epilepsy
deja vu
dysphasia
visual field defects
forgetfulness
fugue
```
535
How might a space-occupying lesion in the frontal lobe present?
anosmia
change in personality
dysphasia
hemiparesis or fits on contralateral side
536
How might a space-occupying lesion in the parietal lobe present?
```
hemisensory loss
two-point discrimination
stereognosis
extinction
neglect
dysphasia
```
537
How might a space-occupying lesion in the occipital lobe present?
visual defeat - specific one depends on whereabouts lesion is
538
How might a pituitary tumour present?
homonymous hemianopia
| endocrine changes
539
How would you investigate someone for a space-occupying lesion?
```
Bloods:
FBC
U&E
LFTs
CT head
Biopsy of lesion
```
If unsure of primary tumour: CXR
mammography/ultrasound
540
Causes of space-occupying lesions:
```
malignancy
haematoma
hydrocephalus
cerebral abscesses (RF: COPD)
Cysts
```
541
How would manage a space-occupying lesion?
treat underlying cause
manage raised ICP
treat complications and symptoms of raised ICP
542
What is AKI?
Rise in serum creatinine >26 within 48 hours
OR
rise in serum creatinine 1.5 x baseline value within 1 week
OR
urine output <0.5ml/Kg/hr for 6 consecutive hours
543
What are the criteria for stage 1 AKI?
Rise in serum creatinine greater than 26 µmol/L within 48 hours
or
Rise in serum creatinine greater than 1.5-1.9 × baseline value
or
Urine output less than 0.5 ml/kg/hr for 6 hours
544
What are the criteria for stage 2 AKI?
Rise in serum creatinine greater than 2-2.9 × baseline value
or
Urine output less than 0.5 ml/kg/hr for 12 hours
545
What are the criteria for stage 3 AKI?
Rise in serum creatinine greater than 3 × baseline value
or
Rise of serum creatinine greater than 354 µmol/L
or
Commenced on renal replacement therapy
or
Urine output less than 0.3 ml/kg/hr for 24 hours or anuric for 12 hours
546
What are some risk factors for AKI?
Age greater than 75 years
Chronic kidney disease (estimated glomerular filtration rate < 30)
Hypertension (one or more anti-hypertensive drugs)
Cardiac failure
Liver disease
Diabetes Mellitus
Nephrotoxins (e.g. NSAIDs, gentamicin, iodinated contrast)
Hypovolaemia
Sepsis
547
List some pre-renal causes of AKI:
Hypovolaemia (vomiting, diarrhoea, burns, haemorrhage)
Hypotension
Sepsis
Cardiac failure
548
List some intrinsic caused of AKI:
```
Prolonged hypo-perfusion
Nephrotoxins
Glomerulonephritis
Vasculitis
Interstitial nephritis
```
549
List some post-renal causes of AKI:
Obstruction (renal stones, retro-peritoneal fibrosis, bladder cancer, pelvic mass, enlarged prostate)
550
How might AKI present?
Reduce urine output
Other signs of hypovolaemia: Hypovolaemia - assess volume status (capillary refill time, pulse, blood pressure, jugular venous pressure, skin turgor, pulmonary oedema, peripheral oedema, urine output, weight)
Palpable bladder?
Signs of vasculitis (weight loss, fever, rash, uveitis, haemoptysis, joint swelling)
Bruits (renal artery stenosis)
551
How would you investigate someone you suspect has AKI?
```
FBC
U&Es
Bicarbonate
LFTs
Calcium
Phosphate
Consider blood cultures if sepsis suspected
```
Urine dipstick (presence of blood and protein suggests infection or vasculitis)
Chest X-Ray (pulmonary infiltrates could indicate fluid, infection or haemorrhage)
Renal tract ultrasound (assess renal anatomy and exclude renal tract obstruction)
552
How would you manage someone with AKI?
STOP V:
Sepsis - complete BUFALO if suspected
Toxins - stop/avoid nephrotoxins eg. gentamicin, NSAIDS, iodinated contrast
Optimise blood pressure
Prevent harm - treat complications eg. hyperkalaemia, pulmonary oedema, acidosis, pericarditis
identify cause and treat
review all medications and doses
refer if renal replacement therapy necessary
monitor: daily volume assessment, fluid balance, U+Es and bicarbonate
553
What are common indications for renal replacement therapy?
```
intractable hyperkalaemis
pH <7.15
intractable pulmonary oedema
uraemia pericarditis
encephalopathy
```
554
What is acute urinary retention? How might it present
inability to urinate in presence of painful bladder
Bladder might be distended, dull to percussion
well above symphysis pubis, almost at level of umbilicus
infected or malformed genitals
faecal impaction
reduced lower limb power and perineal sensation (cord compression or prolapsed disc)
555
What are common causes of acute urinary retention?
children: abdo pain, drugs
young people/adults: drugs, surgery, UTI, trauma, haematuria, constipation, kidney injury
elderly: surgery, tumour, BPH, kidney injury
556
How would you investigate someone for acute urinary retention?
Bloods: FBC
U+Es
creatinine
Urine: MSU
Bladder scan (quantify urine retained)
cystography
urodynamics
557
How would you manage someone in acute urinary retention?
catheterisation
treat underlying cause
