Emergency medicine Flashcards
What should you look for when assessing of breathing? (B)
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
How can hyperventilation affect ventilation?
Reduces the level of ventilation achieved (just gets rid of CO2)
What signs may indicate resp. distress?
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
What RR indicates that pt. may be near death?
> 27
Or v. low
What may chest deformity tell you about pt?
Existing disease (eg. barrel chest, COPD)
Cause of breathlessness - abdominal breathing, broken ribs, restrictive disease etc.
Why is JVP important in resp.?
Cardiac cause of resp. problem (pulmonary oedema)
What things can cause tracheal deviation?
Large pleural effusions
tension pneumothorax
What treatments can you give breathless pt.?
Oxygen
Salbutamol nebs
GTN or furosemide (in pulmonary oedema - esp. if near arrest)
ABX and steroids (Later management, once pt. stable)
Flow rate of Oxygen that can be given when using nasal cannula. What percentage oxygen is delivered?
2-6L (usually 4L)/min
24-30%
Flow rate of Oxygen that can be given when using Hudson Mask. What percentage oxygen is delivered?
5-10L/min
30-40%
Flow rate of Oxygen that can be given with non-rebreathe mask. What conc. of oxygen is delivered?
12-15L
85% (ideally, would be 100%)
What is a benefit of a bag-valve mask?
Delivers positive pressure
What are CPAP/BiPAP?
Types of non-invasive ventilation
Should you prescribe O2 for someone who is breathless, but has normal-range O2 sats?
NO.
If they do not have oxygen requirement, THEY DO NOT NEED TO BE GIVEN SUPPLEMENTARY OXYGEN
What is normal range of sats in COPD pt.?
88-92%
What is normal range of sats in non-COPD pt.?
94-98%
62 yr M COPD SOB Productive cough, fever, pleuritic chest pain O2 sats 90%
Does he need Oxygen?
NO.
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?
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.
What are features of fat embolism?
SOB, reduced sats, usually cerebrally confused
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?
Critically unwell - therefore even if sats in range, need to be on 15L
non-rebreathe reservoir mask
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?
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
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?
Yes
Simple fase mask (5L/min - although reduction, this would probably be enough via this method. If not working, titrate up)
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?
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
Who should get a blood gas?
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)
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)
What is a normal pH range on a BG? What is it called if value is:
a) below range
b) above range?
- 35-7.45
a) acidaemia
b) alkalaemia
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
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
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
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
Outline the process of blood gas interpretation
How is pt. clinically O2 pH PaCO2 BXS or bicarb
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
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
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
What are signs of C02 retention?
Cyanosis
Confusion
What is the definition of shock?
Clinical syndrome caused by inadequate tissue perfusion and oxygenation leading to abnormal metabolic function
What are the different types of shock?
Cardiogenic
Hypovolaemic
Obstructive
Neurogenic
Anaphylactic
Septic
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
What are common causes of hypovolaemic shock
fluid loss eg. excess urination, reduced intake, vomiting, burns
haemorrhage (haemorrhage shock)
How should you treat hypovolaemic shock
IV access
IV fluids +/- blood
Treat cause (stop bleeding)
Monitor response
What is an anaphylactic shock?
Sudden onset generalised immune condition caused by exposure to a causative substance in a sensitised
person
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
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
What is septic shock?
Sepsis accompanied by hypotension and perfusion abnormalities despite adequate fluid resuscitation
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)
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)
What are the main general categories of causes of TRUE syncope?
Cardiac
orthostatic
neurogenic
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.
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
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)
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
What is the NIHSS? What is it used for?
NIH stroke scale
Scale used to decide whether someone can be thrombolysed
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)
Why would you do CXR if you think pt has PE?
May see wedge infarct
Rule out differentials (eg. pneumothorax)
What are the main two investigations for PE?
CTPA VQ scan (looking for VQ mismatch)
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
What are people given when they have been poisoned (if this has occurred within the last hour)?
Charcoal (drink)
What are the classical features of an opiate toxidrome?
pin point pupils
resp depression
reduced GCS
What can be used to reverse benzo toxicity? Why might you not do this?
flumazanil
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
What is a common s/e of poppers?
methaemoglobinaemia
w
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What scoring system is used for PE? (other than Well’s score)
PERC
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)
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)
List what should be done in A of ABCDE?
Look for signs of airway obstruction
TREAT obstruction (adjuncts)
Give oxygen (if sats require it)
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
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
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
List what should be done in E of ABCDE?
Examine pt: bruising, breaks etc.
Temp
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
How can causes of collapse be classified to help diagnosis?
Head
Heart
Vessels
Drugs
What are ‘head’ causes of collapse?
Hypoxia Hypoglycaemia Epilepsy Affective Dysfunction of brain stem eg. verterbrobasilar stroke, TIA or migraine
What are ‘heart’ causes of collapse?
IHD Emboli Aortic obstruction (eg. stenosis, HOCM) Rhythm disorders Tachyarrhythmias (VT, SVT, QT syndrome)
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
What are ‘drug’ causes of collapse?
Anti-Hypertensives eg. beta blockers
‘Street’ drugs
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
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
What investigations might you want to do for pt. who has come in with collapse?
blood glucose
What is cariogenic shock?
Heart unable to pump enough blood to meet body’s needs
What is neurogenic shock?
Shock caused by disruption of autonomic pathways within spinal cord
What is hypovolaemic shock?
Fluid loss means heart cannot pump enough blood around body to meet its needs
What is anaphylactic shock?
Severe allergic reaction
mediators released in allergic reaction cause vasodilation, bronchial restriction, leaky blood valves, depressed HR
What is obstructive shock?
Physical obstruction of great vessels or heart itself
What is septic shock?
Inflammatory markers and organ damage lead to lowered blood pressure and abnormal cellular metabolism
What are some common causes of cariogenic shock?
MI
Malignant dysrhythmia
What are some common causes of obstructive shock?
tension pneumothorax
cardiac tamponade
What types of shock fall under the term ‘distributive shock’?
septic shock
anaphylaxis
neurogenic shock
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
What ratio of adrenaline is given in anaphylactic shock?
1:1000
What dose (and volume) of adrenaline is given to adults in anaphylaxis?
500 micrograms IM
0.5 mL
What dose (and volume) of adrenaline is given to children over 12 in anaphylaxis?
500 micrograms IM
0.5 mL
What dose (and volume) of adrenaline is given to children 6-12 yrs in anaphylaxis?
300 micrograms IM
0.3 mL
What dose (and volume) of adrenaline is given to children under 6 in anaphylaxis?
150 micrograms IM (0.15 mL)
What volume of CRYSTALLOID fluid is given to a) adults and b) children?
a) 500mL-1000mL
b) 20 mL/Kg
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
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
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)
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)
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
Other than hypercapnia, when might PCO2 from VBG not be as reliable as an ABG?
severe shock
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
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
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)
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
What is included on an ABG?
pH paO2 paCO2 HCO3 BXC
Lactate Sodium Potassium Hb glucose CO Methaemoglobin
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 %)
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%
When might you use a nasal cannula?
non-acute ward or if pt. mildly hypoxic
When might you use a Hudson mask?
Step up from nasal cannula
Doesn’t deliver specific % of oxygen like venturi
When might you use a venturi?
COPD
When you want to deliver a more specific amount of O2 to a pt.
When would you use a non-rebreathe mask?
acutely unwell pts.
When might you use CPAP?
sleep apnoea
heart failure
When might you use BiPAP?
COPD and atelectasis
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)
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
Below what level O2 sats should you do an ABG?
92%
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
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
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)
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)
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
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
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
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).
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
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
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
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
What is a normal RR in an adult?
12-20 breaths/min
What might you see on an ECG during an episode of unstable angina?
T wave inversion
ST depression
Normal
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
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.
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
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
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.
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
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
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)
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
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
What single investigation do you need in pts with life-threatening asthma?
ABG
No other investigations are necessary for immediate management
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
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
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
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
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
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)
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
What PEFR would indicate mild asthma?
> 75%
What PEFR would indicate moderate asthma?
< 75%
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
What investigations would you do in someone with exacerbation of COPD?
CXR
ABG
ECG
Bloods: FBC, U&Es, blood cultures
Sputum microscopy and culture
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
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
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
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
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
What are the symptoms of PE?
sudden onset SOB Shortness of breath Haemoptysis Syncope Cardiovascular collapse (tachycardia, hypotension) Raised JVP Hypoxia (CXR often normal)
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
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
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)
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)
If you can’t do a CTPA on a patient, what other scan could you do to confirm/exclude PE?
V/Q scan
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)
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
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)
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
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
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
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
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
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
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)
What findings might you see on an X-ray?
Cardiomegaly
Fluffy bilateral shadowing with peripheral sparing (bats wings)
Kerley B lines
Pleural effusions
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 =
What are the differentials you might consider for someone with shortness of breath (in ED)?
Exacerbation of COPD Asthma PE Pneumothorax Pneumonia Pulmonary oedema
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
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
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
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.
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?
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
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
How would you investigate a NON-tension pneumothorax?
CXR
CT in uncertain cases
ABG (if sats <92%)
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
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
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.
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
What should you do in the following scenario?
Secondary pneumothorax
Size >2cm and/or SOB
Chest drain
Admit pt.
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.
What should you do in the following scenario?
Secondary pneumothorax
Size <1cm or not SOB
Admit
High flow oxygen
Observe for 24 hours
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
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.
What is the definition of HAP?
Pneumonia developed 48 hours after hospital admission
Which type of pneumonia has worse prognosis? why?
HAP - generally more comorbidities
Bugs more resistant
What are the common organisms for CAP?
Streptococcus pneumoniae, haemophilus influenzae
Anaerobes are rare
What are the common organisms for HAP?
Gram negative bacilli, staphylococcus aureus
Drug resistant organisms are more common, and more dangerous
What are the rarer causes of CAP?
Chlamydia pneumoniae (common in institutions – e.g. collegues, military camps – mild)
mycoplasma pneumonia
legionella
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)
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
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))
What scoring system would you use to assess the severity of pneumonia?
CURB 65
List some complications of pneumonia?
Sepsis: resp failure, hypotension pleural effusion empyema Lung absences Lobar collapse/pneumothorax
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.
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)
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)
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.
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.
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
What is an aortic dissection?
Tear in inside of aorta
Blood flow between layers of wall of aorta, forcing layers apart
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
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
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
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.
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
What is type A more likely to end up malperfusing?
brain coronary artery spinal cord liver bowel kidneys legs
What is type B aortic dissection more likely to end up malperfusing?
JUST spinal cord liver bowel kidneys legs
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
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)
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
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
