Essential Conditions Flashcards
what is a STEMI
complete occulusion of coronary supply
persistent ST elevation in atleast 2 leads
Typical symptoms of unstable angina
chest pain + dyspnoea
classic ECG signs of unstable angina
ST depression + T-wave inversion
what is the acute management for unstable angina
antiplatelet + antithrombotic therapy
reduces myocardial damage and complications
what is unstable angina defined by
absence of troponin rise
>20min angina at rest
or nuance in presentation
risk factors for ACS
female / increased age / positive family history / CAD history / HTN / diabetes / hyperlipidaemia / obesity / smoking
what heart sound is present in unstable angina
4th heart sound
when should the ECG be taken
<10min from chest pain onset
when should troponin be measured and what will the result be in unstable angina
0 hours / 3
no rise in trop
what other bloods should be taken in unstable angina
FBC - would be normal
U+E - baseline + risk stratification
blood sugar - normal
what is gold standard investigation for CAD
coronary angiography
what medications should be given to patients before they arrive to hospital
aspirin + GTN
what medications should be given to patients when they arrive in hospital
Oxygen
aspirin
clopidogrel
morphine
what is the definitive management for a STEMI
primary PCI pr fibrinolytics
what is the timing for fibrinolytic therapy
<30 min
when should PCI be used
<90min
what should happen to trop negative + normal ECG patients
monitor on regular
what are the rules for Beta blocker usage post MI
1st line anti-ischaemic drugs
start within first 24hr
when should beta blockers not be used
signs of HF low output state increased risk for cardiogenic shock heart block active asthma
what is the treatment algorithm for unstable angina
- Oxygen + nitrates + morphine
- Beta blocker
- anti-platelet therapy
what confirms the diagnosis of STEMI
troponin but do not wait for results before starting treatment
what does MSK chest pain present as
pain on palpation
what are classic MSK chest pain symptoms
pain on movement
pain on deep breath / sneeze / coughing
what are examples of MSK chest chest pain
injury costochrondritis tietze's syndrome pulled muscle stress fracture
what is costochrondiritis
inflammation of the cartillage of the rib cage
how does it present
pain on contact or push on certain area of chest cartillage
pain on movement
radiates to back / abdomen
what are the complications of PE
right heart failure + cardiac arrest
how does PE present
dyspnoea
chest pain
hypoxaemia
what are features of a high risk PE
hypotension / syncope / tachycardia
signs of right heart failure
what is the definitive investigation for PE
CTPA
what is the management for haemodynamically unstable patients in PE
immediate reperfusion –> thrombolysis
anticoagulation
supportive care
what are the key risk factors for PE
Active cancer recent surgery / hospitalisation previous DVT pregenancy obesity smoking long-distance travel smoking COCP
what are important investigations for PE
D-dimer
FBC
CTPA
what are main differentials for PE
angina
MI
pneumonia
pericarditis
what are the wells score factors
Clinical signs of DVT Previous PE / DVT HR > 100bpm surgery / immobolisation haemopysis active cancer
what is the management for PE in haemodynamically unstable patients
respiratory support
–> high flow oxygen
Fluid resus
–> 500mL fluid challenge
what is the management for a haemodynamically stable PE
- unfractionated heparin
- Thrombolysis
- Switch to LMWH after a few hours for atleast 5 days
what can be done if thrombolysis fails
surgical embolectomy or purcutaneous catheter
which patients are admitted immediately with PE
pregnant or haemodynamically unstable
what do you do if there is a delay in CTPA
LMWH
what are the symptoms of pneumonia
cough dyspnoea pleuritic chest pain mucopurulent sputum myalgia fever
What is the CRUB-65
confusion - AMTS < 8 Urea > 7mmol RR > 30 BP 90/60< 65 > yo
when should antibiotics be prescribed for patients with pneumonia
within 4 hours of presentation
when should sputum + blood cultures be sent for?
Moderate / high severity CAP
before antibiotics taken
what causes for pneumonia can be tested for in the urine
legionella + pneumococcal
what are auscultation findings on patients with pneumonia
crackles
decreased breath sounds
dullness to percussion
wheeze
what are the important investigations to request for patients with pneumonia
CxR < 4hrs admission –> consolidation
pulse oximetery
ABG
U+E
Why is it important to monitor the renal system in patients with pneumonia
significant risk factor for mortality
how does the route of antibiotics change based on the patient
high severity = IV
low severity = oral
what do the different CURB-65 scores mean
>3 = admit to hospital 1-2 = refer to hospital 0 = treat at home
what is the supportive care for patients with pneumonia
NIV / CPAP unless they have resp failure
analgesia
what are the classic DVT symptoms
asymmetrical leg swelling unilateral leg pain dilation of superficial veins red skin
what is required for a DVT diagnosis
duplex ultrasound
CT
what is the treatment for DVT
anticoagulation
unfractionated heparin
how long is anticoagulation continued for
3-6 months
what is the wells score criteria
active cancer calf swelling > 3cm than other calf prominent superficial veins pitting oedema swelling of entire leg localised pain along deep venous sytem recent immobilisation recent surgery previous DVT alternative diagnosis least probable
what do the scores from a wells score mean
> 2 DVT likely
< 2 DVT unlikely
what are the invesigations that should be done in DVT
D-dimer duplex ultrasound INR + aPTT U+E LFTs FBC
what is the purpose of anticoagulation treatment for patients with DVT
prevent progression of thrombus
reduce risk of PE
reduce risk of recurrent DVT
what are the three phases of anticoagulation therapy for DVT
- Initiation 5-21 days
arrest active prothrombotic state and inhibit thrombus propagation - Long term
initiation to 3 months
prevent new thrombus formation - extended
prevent new VTE
what is a complication of using anticoagulants
massive haemorrhage
what is the order of preferred treatment for DVT
- DOACs
- warfarin
- LMWH
what is the treatment for DVT
- anticoagulation
- physical activity
- gradient stockings
what is cellulitis key features
indistinct borders
dermis + SC tissue
erythema / oedema / warmth / tenderness
what are risk factors for cellultis
previous cellulitis
ulcer/wound
lymphoedema
venous insufficiency
what are the key investigations to perform
FBC - raised WCC
culture if cellulitis near wound / pustular focus
what is cellulitis treatment for patients that are severely ill
parenteral ABx with MRSA cover
what is the biochemical triad of DKA
hyperglycaemia
ketonaemia
acidaemia
what are the common signs + symptoms of DKA
polyuria polydipsia polyphagia weakness weight loss tachycardia dry mucous membranes poor skin turgor hypotension shock
what are the principles for DKA treatment
fluids
glucose
stable
frequent monitoring
what are complications of DKA treatment
hypoglycaemia hypokalaemia hypoxaemia pulmonary oedema cerebral oedema
what are the risk factors for DKA
poor insulin therapy
infection
MI
drug interactions
what are the key investigations for DKA
plasma glucose >13.9 ABG acidosis urinalysis --> glucose + ketones urea + creatinine --> increased electrolytes --> depleted
when can insulin be applied in patients with DKA
potassium > 3.3
at what rate should fluid be given
1-1.5L/hr
what are indications for ICU admission
haemodynamic instability cardiogenic shock altered mental status respiratory insufficiency severe acidosis hyperosmolar state
how to give insulin therapy safely in DKA patients
exclude hypokalaemia
give infusuin slowly
stop insulin if K+ falls below 3.3
how regularly should DKA patients be monitored
- Hourly
serum glucose + electrolytes - 2 - 6 hours
urea / creatinine / ketones
what are the aims of DKA biochemical treatment
glucose < 11.1
bicarb > 18
pH > 7.3
anion gap < 10
what is the treatment for DKA
IV fluids potassium therapy IV insulin vasopressors bicarb therapy phosphate therapy
how does hypoglycaemia present
nausea / confusion / tremor / sweating / palpitations / hunger
what is the glucose level for hypoglycaemia
<3.3
whats whipples triad for hypoglycaemia
hypoglycaemic symptoms
low glucose
resolution of symptoms once glucose given
what are risk factors fro hypoglycaemia
middle age / female / alcohol consumption / bariatirc surgery
what investigations would you do for a patient with hypoglycaemia
serum glucose
LFT
renal function test
serum insulin
how is hypoglycaemia treated
glucagon + supportive therapy
what is hypoglycaemia management for unconscious patient
15-20mg of quick acting carb
test glucose after 10-15min
if still low repeat 3 times
if still unsucessful try IV glucose
when not to useglucagon in patients with hypoglycaemia
takes up to 15min to work
ineffective in undernourished patients
severe liver disease
how is severe hypoglycaemia treated
IV glucose over 10min
20% 100ml
what are symptoms of paracetamol overdose
asymptomatic
mild GI symptoms
progresses to Liver injury –> liver failure
what is the treatment of paracetamol overdose
acetylcysteine
what is defined as a paracetamol overdose
4g in 24hours
what are the signs of hepatic failure in paracetamol overdose patents
RUQ pain
jaundice
confusion
astexis
what are risk factors for paracetamol overdose
history of self-harm
inducers of p450
what investigations would you do for patients with paracetamol overdose
serum paracetamol AST / ALT pH / lactate U+ E prothrombin time + INR urine drug screen
what is the management for acute paracetamol overdose
acetylcysteine supportive care anti-emetic activated charcoal evaluation for liver transplant
what are symptoms of alcohol withdrawal
anxiety nausea vomitting insomnia autonomic dysfunction
what are severe symptoms of withdrawal
seizures
psychaitric disturbance
delrium tremens
what is the treatment for alcohol withdrawal
chlorpiazode
when do alcohol withdrawal symptoms present
6-12 hours after last drink
what are diagnostic factors for alcohol withdrawal
tremor finger tips / whole hand moving tachycardia sweating palpitations headache anorexia depression
what investigations for alcohol withdrawal
VBG glucose FBC U+E --> hypomagnesaemia / hypokalaemia / hypophosphataemia LFT bone profile coagulation study
what is the key medical management for alcohol withdrawal
benzo thiamine add antipsychotic consider rapid tranq CT head
what is the supportive care for alcohol withdrawal
quiet room monitor for deterioration rehydrate patient correct electrolyte imbalance correct BG
what quantity should patients try and reduce their alcohol by
25% every 2 weeks
social treatment for alcoholism
regular meetings self-help groups family + carer involvement regular monitoring long term plan
what should be done within an hour of suspected sepsis
2 sets of blood cultures serum lactate on ABG measure urine output hourly IV broad spectrum Abx fluids oxygen
where are the most common sources of sepsis
resp urinary upper GU SSRI surgical site
what are the key symptoms of sepsis
NEWS > 5 tachypnoea high temp tachycardia altereed mental status low oxygen sats hypotension poor cap refill cyanosisi
what are the investigations for sepsis
blood cultures - before Abx sample/ two different sites ABG - lactate hourly urine output FBC U+E glucose CRP LFT clottingscreen ECG
what is the rule for giving fluids for patients with sepsis
500ml crystalloid with sodium over 15min
repeat if clinically indicated
do not exceed 30mL/kg
what is AKI associated with
hypovolaemia
hypotension
nephtotoxic
urinary outflow obstruction
when should you suspect AKI
rise in serum creatinine
fall in urine output
what are complications of AKI
hyperkalaemia
uraemic encephalopathy
pericarditis
what is the principle of managing AKI
supportive care treat underlying cause optimise volume status correction of acidaemia electrolyte complications avoidance of nephrotoxins relief of any obstruction
what is the treatment for severe AKI
RRT
What are the risk factors for AKI
> 65
CKD
previus AKI
NSAID / aminoglycoside ABx / ACEi/ diuretic
what sort of patients does AKI effect
acutely ill
what to look out for in AKI
reduced urine ouput
what are the key investigations for AKI
U+ E –> acute rise in creatinine
urine output decrease
what is stage 1 AKI
SCr rise of > 26 within 48hrs
what is stage 2 AKI
SCr increase > 3 times baseline
what is stage 3 AKI
SCr increase to ≥3 times baselineor
SCr rise to ≥354 micromol/Lor
Patient initiated on RRT (irrespective of AKI stage at time of initiation)
what is management for hypovolaemic AKi
- fluid resus
- review medications and stop nephrotixic
- identify and treat underlying causes
what does STOP AKI stand for
sepsis - implement buffalo
toxins - stop/avoid nephrotoxins
O - optimise BP –> fluids / hold antihypertensive meds + diuretics + consider vasopressors
P -prevent harm - relief Urinary tract obstruction / hyperkalaemia / acidosis
how to treat obstructive cause of AKI
ultrasound
bladder catheter
refer to urology
how to manage hyperkalaemia
monitor ECG immediate calcium gluconate IV insulin / glucose withold causing agent RRT if severe
what is delirium
acute / fluctuating change in mental status / altered level of consciousness
4 defining features of delirium
disturbance in attention
change in cognition
acute
evidence of change from history / exam / lab findings
types of delirium
- Hyperactive
- heightened arousal
- restlessness / agitation / hallucinations / inappropriate behaviour - Hypoactive
- lethargy / reduced motor activity / incoherent speech - mixed
- both
differentials for delirium
dementia Stroke Mi hypoglycaemia hyperglycaemia hypercapnia
causes of delirium
D - drugs E- poor hearing + vision L - low O2 I - infection R- retention I -ical state U - under-hydration/ nutrition M - metabolic
common differentials for confusion
stroke head injury siezures MI CHF ventricular arrthymias
what are the key investigations for delirium
MMSE - rule out dementia CT head - rule out vascular causes ECG / trop - rule out cardiac cause FBC - rule out infection U+E- rule out metabolic causes Blood glucose - rule out hypo/hyperglycaemia LFT - hepatic encephalopathy
