Important management Flashcards
Management hypercalcaemia
- 0.9% NaCl 1L/4h for 24h (then 6 hourly for 2-3 days)
- Bisphosphonates (IV pamidronate or zolandronic acid)
(3. If arrhyth/seizures- calcitonin and corticosteroids)
Initial Mx SVCO
16mg dex
Mx initial of SCC
MRI 24h
16mg dex
additional mx in major acute VARICEAL GI bleed
Terlipressin (reduces portal pressure)
and broad spec Abx.
Scoring systems in GI bleed
Rockall score- mortality (pre and post endoscopy)
Glasgow-Blatchford- is intervention required/ minor vs major
Mx alcohol hepatitis
Conservative
Steroids if Glasgow score >9
Management cholangitis?
Abx
Mx AAA rupture
Vascular
Crossmatch 10-40u and give this or O neg if shock, maintain systolic BP <100
Prophylactic Abx
Mx hypoglycaemia (mild with 15/15 GCS)
Need 15-20g quick acting carb e.g lucozade
or oral glucose gel
Once recovered give long acting carb e.g. toast/biscuits
Mx severe hypoglycaemia
IV glucose stat- 75-100ml 20% or 200ml 10%
Or if no access- IM/SC glucagon 1mg
Later on start 1L 10% glucose over 4-8h IV and monitor CBG every 30-60mins until stable.
Mx pancreatitis
Fluids
NBM
Analgesia
Modified Glasgow score
Mx bowel obstruction
Drip and suck
Analgesia
CT
Investigations for susp ectopic?
Urine HCG +ve –> USS –> empty uterus –> serum HCG –> if >1500 treat as ectopic
If <1500 repeat in 48h- doubled= viable preg, halved = miscarriage. Other - treat as ectopic
Also r/o other causes e.g. UTI
Mx renal colic
Non-oral NSAID
Admit if severe/risk AKI e.g. only one kidney or CKD/pregnant
Could manage at home
Initial management of acute ischaemic limb
O2 and IV access
Morphine
Vascular referral emergency
Mx DVT
Well’s score ± D-dimer and USS
LMWH
Start warfarin at the same time (except Ca pts who continue on LMWH) and stop LMWH when INR is 2-3, treat for 3 months in most.
Initial mx gout
Xray and aspiration
NSAID (or alternative = colchicine)
Rest, elevate, ice joint
Septic joint Mx
Aspiration for MC&S
blood cultures
After these- Abx
Ortho r/v
Acute asthma Mx
Oxygen 94-98%
Salbutamol 2-10 puffs every 10-20mins or neb: O2 driven neb 5mg every 20-30mins
Hydrocort/pred- 30-50mg pred PO
Ipatropium neb 0.5mg 4-6hrly (in acute severe+ or unresponsive to salbutamol initially)
MgSO4 IV 1.2-2g (senior consult first)
Normal PaCO2 in acute asthma is what severity?
Life threatening
Raised PaCO2 in acute asthma is what severity?
near fatal
Why might you do CXR in acute asthma/COPD?
R/o pneumothorax
infection
Exacerbation COPD Mx
Salbutamol neb 5mg/4h (O2 driven unless retainer- used air driven plus nasal O2)
±ipatropium neb 0.5mg/6h
O2 +ABGs!!
IV hydrocort 100mg OR pred 30mg PO 5 days
±antibiotics if infective
(NO RESPONSE- high RR, acidotic, raised CO2:
+ IV aminophylline
+NIV/resp stimulant drug eg doxapram
Intubate and ventilate if appropriate.)
2 things to note about theophylline
Needs levels monitoring
Many interactions
Primary pneumothorax mx
not SOB or >2cm on CXR- discharge r/v 2-4w
SOB ± >2cm on CXR- aspirate- if successful r/v 2-4w if NOT successful- chest drain
Secondary pneumothorax mx
SOB or >2cm on CXR- chest drain
Not SOB or >2cm on CXR but 1-2cm- aspirate (if unsuccessful chest drain, if successful 24h observation)
Not SOB or >2cm on CXR, <1-2cm- admit for 24h obs and oxygen therapy.
How long does a chest drain stay in for?
24h after re-expansion and bubbling stopped.
Mx tension pneumothorax
14-16g needle and syringe partially filled with saline.
2nd IC space MCL
Remove plunger
Until chest drain can be inserted
Possible ECG findings of a PE?
Sinus tachycardia
RBBB
AF
RA deviation
S1Q3T3
Signs of PE on examination
Hypotension
Tachcardia
Tachypnoea
Gallop rhythm
raised JVP
RV heave
Pleural rub
Cyanosis
AF
What score should be done in a patient at low risk of PE?
PERC score- if any criteria +ve then do a Well’s. If all -ve then only a 2% chance of PE
PE diagnosis and initial Mx
Wells score
> 4- Immediate CTPA or treat with LMWH if delay
<4- do a D dimer - negative excludes PE, positive treat as above
O2
Morphine
Start LMWH/fondaparinux
Consider thrombolysis (alteplase)
What would you see on a PE CXR?
Decreased vascular markings, wedge shaped infarct
When would you do a V/Q scan instead of CTPA in PE?
If CTPA unavailable
If the pt is well and CXR normal
But nb it is not as accurate
LT PE management
Anticoags- DOAC (direct switch from LMWH) or warfarin (stop LMWH when INR >2)
Provoked: 3m
Unprovoked: >3m
Malignancy: 6m/until cure of ca
Preg: until end of pregnancy
Mx pulmonary oedema
Loop diuretic (furos 40-80mg IV slowly) Morphine Nitrate (GTN 2 puffs unless sys BP <90, if sys BP >100 start nitrate infusion) O2 Position (sit up)
What should you do in pulmonary oedema if sys BP <100?
If systolic BP <100 treat as cardiogenic shock –> ICU
Longer (ish) term management/monitoring of pul oedema?
Daily weights- reduction 0.5kg/day
+repeat CXR, oral switches
Random other risk factors for MI you might ask about
cocaine
connective tissue disorders
rheumatic fever
NSTEMI/angina management
MONA
Low risk- discharge
High risk- fondaparinux
ticagrelor
IV nitrate
Beta blocker
cardio r/v
What makes an NSTEMI/angina high risk?
ECG changes
High GRACE score
diabetes/ckd
low LVEF
troponin raised
STEMI management
MONAC (+clopidogrel/ticagrelor)
> 12h since onset- anticoag
<12h- PCI if within 120mins + heparin. If too far away- thrombolysis with heparin/fondaparinux (as long as not C/I)
Discharge drugs for NSTEMI and STEMI
Lifestyle
Aspirin
betablocker
ACEi
Statin
Two types of aortic dissection
Type A- ascending aorta (70%)
Type B- no involvement of ascending aorta (30%) (mx less clear)
Symptoms of aortic dissection
sudden tearing chest pain radiating to back
Syncope?
Carotid affected- hemiplegia
Unequal arm pulses
Acute limb ischaemia
Anterior spinal affected- paraplegia
Renal arteries affected- anuria
Aortic valve incompetence, inf MI, cardiac arrest if it moves proximally
Mx aortic dissection
Urgent cardiothoracic advice
X match 10u
CT ± TOE
ICU
IV beta blockers (labetalol/esmolol) or CCB if C/I
Morphine
What might CXR show in thoracic aortic dissection
widened mediastinum
Four broad causes of collapse
Head, heart, vessels, drugs
When after the last drink does alcohol withdrawal occur?
10-72hrs
What scoring system can you use to assess risk of serious outcome in someone who has recovered from syncope?
San Francisco Syncope score
Mx alcohol withdrawal
Day 1-3: chlordiazepoxide 10-50mg/6h PO + additional PRN
Day 5-7: see total dose used and wean down.
ALSO give Pabrinex (thiamine) -
2 pairs high potency ampoules IV or IM over 30 mins 8 hourly for 2 days
THEN 1 pair OD for 5 days THEN oral supplements until no longer at risk.
Wernicke’s three sx
Confusion
Ataxia
Nystagmus
If someone with alcohol withdrawal has concurrent hypoglycaemia, do you give the glucose before or after the pabrinex?
Pabrinex first as glucose can precipitate wernickes.
Diagnostic criteria for DKA
Acidotic on VBG
> 11BM OR known diabetic
Ketonaemia >3 or ketonuria >2+
Mx DKA
- Fluids- 0.9% saline- 1L/1h, 2L/2h, 2L/4h, 2L/6h (if sys BP initially <90 then give bolus)
- Insulin- 50u Actrapid in 50ml 0.9% saline. Infuse at 0.1u/kg/hr. Continue regular long acting as normal to prevent refractory hyperglycaemia.
- ?potassium- don’t add to first bag. After that do it according to the most recent VBG. If 3.5-5.5 give KCL, <3.5- ICU. Only DON’T give if >5.5. Can only give at 10mmol/hr but only comes in 20/40mmol bags so give over 2hrs.
- When BM <14 give 10% glucose over 8hrs (125ml/h) as well as the fluids. Keep giving the insulin as this decreases the ketones- they take much longer to decrease.
- Ensure on VTE prophylaxis
When can euglycaemic DKA occur? Any difference in Rx?
If on SGLT2 inhibitors (as it makes them wee out glucose)
Treat as normal
What should you monitor throughout DKA Rx
Keep monitoring VBGs, BMs, ketones, U&Es (more accurate for K+). NB after 6hrs can’t use bicarb as a measure of progress as the NaCl = hyperchloraemia
What else do you need to do to assess and manage DKA
Assess for cause- ECG for MI, start Abx early if susp infection, pregnancy test.
(Infection, infarction, infant, insulin missed)
What decreases are you aiming for in DKA
Ketones- drop of 0.5mmol/L/hr until <0.6
Bicarb- rise of 3mmol/L/hr until >15
Glucose- drop of 3mmol/L/hr until <14
(if not achieving increase insulin by 1u/hr)
Retrograde/anterograde amnesia is inability to remember events before or after the injury?
Retrograde is events before the injury (inability to recall past memories)
Anterograde is events after the injury (inability to create new memories)
Signs of basilar skull fracture
CSF from nose or ear
Blood behind tympanic membrane
Immediate Mx of basilar skull fracture
CT head
Tetanus vaccine
Neurosurgeons
Criteria for C-spine CT within an hour i.e. canadian C spine rules
- age >65
- Intubated
- GCS <13
- X ray suspicious or abnormal
- Definitive answer needed eg for surgery
- FND
- Peripheral parasthesia
- High impact injury/dangerous mechanism (fall >1m or 5 stairs)
- Other imaging being done for head/multi-region trauma
Canadian C-spine rule: If they have no high risk factors what do you do?
Assess if they have factors that make them low risk:
- simple rear end motor collision
- sitting comfortably in ED
- Ambulatory since injury
- No midline C spine tenderness
- Delayed onset neck pain
If any of these apply then low risk so can assess neck movements.
If they can rotate neck 45 degrees to L and R then can r/o C spine injury
If they don’t have any low risk factors or their neck movements are impaired then do a 3 view C-spine xray in <1hr.
Criteria for CT head <1hr
- Open/depressed skull fracture or basal fracture
- Post traumatic seizure
- Battle’s sign (post auricular ecchymosis- mastoid bruising)
- Periorbital ecchymosis
- GCS <13 (or <15 at 2h)
- CSF leakage nose/ear
- Vomiting more than once
- FND
- Haemotympanum
criteria for CT head <8hrs
LOC or amnesia
AND
- > 65yo
- Retrograde amnesia >30min
- coagulopathy
- high impact injury
HHS diagnosis
Dehydration and glucose >30mmol/L
ketones and pH normal
HHS management
- Fluids 0.9% NaCl IVI over 48hr
- Potassium replacement when urine starts to flow (same as DKA)
- Insulin IF blood glucose doesn’t come down with rehydration or if ketonaemia. 0.05u/kg/hr. Keep BM at least 10-15mmol for first 24hr to avoid cerebral oedema.
VTE prophylaxis and look for cause
What type of airway adjunct do you use in a seizure
NP
Mx seizure
100% O2 reservoir mask
(Check BM)
After 5mins
1st line: BENZODIAZEPINES (midazolam 10mg buccal, diazepam 10mg rectal, lorazepam 4mg IV, diazepam 10mg IV)
10mins
2nd line- MORE BENZOS- second dose of loraz 4mg IV or diaz 10mg IV
If alcoholic give high dose IV thiamine
10 mins
3rd line: ANTICONVULSANT- PHENYTOIN loading dose over 30 mins (unless already taking) then infusion. Monitor ECG and BP as cardiac SEs.
20 mins
4th line: SEDATE AND INTUBATE (rapid sequence) if generalised seizure >30mins or recurs within 30mins without return of consciousness. ‘Status epilepticus’. >60mins=’refractory status epilepticus’ (–> ICU)
Examinations/investigations to do after seizure
Head trauma/injuries
Assess for sepsis/systemic illness e.g. meningism
Cardio (could have been anoxic jerks)
Neuro (usually normal- FND should warrant further investigation) May have Todd’s palsy- transient unilateral weakness following seizure for a few hrs. Similar to a TIA/stroke
BM
ECG
FBC/U&E/Calcium
Anticonvulsant levels if taking
Prolactin (increases 10-20 mins after seizure if Dx unclear)
CT if first seizure or abnormal neurology.
Discharge of seizure pt
Known epileptic, normal for them fit- discharge
First fit- observe 4h, nil findings = discharge. Avoid driving, machinery, ladders, swimming etc unsupervised until specialist r/v. (document this!) OP f/u after ECG and CT.
Hyperkalaemia Mx
VBG AND ECG - are there ECG changes? This = more severe.
If >5.3 and ECG changes or K+ >/=7 then:
- 10ml 10% calcium gluconate slow IV injection over 2mins- do 5 times max (titrated to ECG). to stabilise cardiac membrane.
30-60mins later
- a) Insulin (10u Actrapid) in 50ml 50% dextrose IVI over 10mins
b) Nebulised salbutamol 5-20mg (caution in CVD) - Consider removing potassium with calcium resonium (15g PO QDS or 30g PR BD), loop diuretics, dialysis.
Consider cause, stop nephrotoxic meds. ABG
Mx chronic asymptomatic hyponatraemia
Fluid restriction
Mx acute/symptomatic hyponatraemia
saline ± furosemide (NB slowly)
Mx acute AF
beta blockers or digoxin if in HF (rate control)
treat cause
Acutely ill- consider DC cardioversion
Mx chronic AF
Young/first episode- consider cardioversion
Otherwise: rate control- BB or CCB
Second line- add digoxin/amiodarone
Anticoag if appropriate
Mx paroxysmal AF
Flecainide/sotolol PRN
Mx atrial flutter
Rate control (BB/verapamil)
until rhythm control - electric/pharmacological/catheter ablation.
Mx first degree and mobitz type 1 HB
conservative
Mx mobitz type 2 and third degree HB
pacemaker
What does management of bradycardia depend on?
Presence or absence of adverse features
What are the adverse features in tachy and bradycardia?
Shock
Syncope
MI
HF
What are the risks of asystole as an additional adverse feature in bradycardia?
Recent asystole
Mobitz II AV block
Complete HB with broad QRS
Ventricular pause >3 seconds
Mx bradycardia if adverse feature present?
Atropine 500mcg IV
Mx bradycardia if atropine fails
Seek expert help and arrange transvenous pacing
In the meantime:
-Repeat atropine to maximum 3mg
OR transcutaneous pacing
OR isoprenaline 5mcg min IV/adrenaline 2-10mcg/min IV
Tachycardia with pulse Mx if adverse features present
Synchronised DC shock up to 3 attempts
Amiodarone 300mg IV over 10-20mins
Repeat shock
Amoidarone 900mg over 24h
If there are no adverse features in tachycardia what do you think about?
Is the QRS narrow or broad
What are the two possibilities of a broad complex tachycardia?
Regular or irregular.
Irreg- seek expert help. Could be AF with BBB or pre-excited AF
Reg- VT (or uncertain rhythm) –> amiodarone 300mg IV over 20-60mins then 900mg over 24h
Or if known SVT with BBB- treat as narrow
What are the two possibilities in a narrow complex tachycardia?
Reg or irreg rhythm.
Narrow complex tachycardia with irregular rythm is probably what? Mx?
AF
Rate control (BB or dilitiazem)
If in HF digoxin/amiodarone
consider anticoag
Narrow complex regular rhythm tachycardia Mx?
vagal manoeuvres
Adenosine 6mg rapid bolus IV (if no effect give 12mg, then a further 12mg if needed)
continuous ECG monitoring
If sinus rhythm is restored after vagal manoeuvres/adenosine in a narrow complex regular rhythm tachycardia what is it likely to be?
Re-entry paroxysmal SVT
Record ECG and consider anti-arrhythmic prophylaxis if recurs
If sinus rhythm is NOT restored after vagal manoeuvres/adenosine in a narrow complex regular rhythm tachycardia what is it likely to be?
Possibly atrial flutter- seek expert help and control rate with BB
What might be used instead of adenosine in an asthmatic?
Verapamil
Which A drug for tachy-arrhythmias and cardiac arrest
Amiodarone
Prolongs repolarisation phase/refractory periods
Which A drug for bradycardia
Atropine
Anticholingergic (inhibits parasymp activity)
C/I acute glaucoma
Which A drug for SVT
Adenosine
Transient AV block
C/I asthma or COPD
What are the shockable rhythms
VF/ pulseless VT
What are the non shockable rhythms
PEA/asystole
What do you do as well as CPR and shocks?
After three shocks- amiodarone 300mg
Every 3-5 mins adrenaline 1mg 1:10,000
What are the 4 Hs and Ts
Hypoxia, Hypothermia, Hypovolaemia, Hyper/hypokalaemia/metabolic
Thrombosis, tension pneumothorax, tamponade, toxins
How often do you do a rhythm check
Every two mins
Mx anaphylaxis
- Call for help, lie flat and raise legs
- Adrenaline 500mcg 1:1000 IM (for >12yo) repeat after 5 min if no better
- O2, IV fluid challenge, establish airway
Chlorphenamine 10mg IM/slow IV (>12yo)
Hydrocortisone 200mg IM/slow IV (>12yo)
In which cases of paracet OD do you just start NAC
jaundice
hepatic tenderness
Ingested >150mg/kg (if in the last hour consider activated charcoal)
Staggered overdose or timing uncertain
TCA OD shows what ecg change?
QT prolongation (>120 toxicity, >160 imminent seizures or VF)
Antidote to TCA OD
sodium bicarbonate
Investigation thresholds for AKI
Rise in cr >/= 26 in 48hr (stage 1)
Rise in Cr >1.5x baseline in 7 days
Fall in urine output to <0.5ml/kg/hr for >6 hours
Management AKI
Optimise BP, monitor fluid balance
?septic screen
Review meds, withhold nephrotoxic medication and ?antihypertensives
Treat cause- is it pre/intra/post renal
Symptoms acute angle closure
severe pain (eye or head)
decreased visual acuity
Hard, red eye
haloes around lights
Semi-dilated non reacting pupil, may have RAPD
Corneal oedema results in dull or hazy cornea
Systemic eg N&V
Symptoms worse with mydriasis (pupil dilation)
Mx testicular torsion
6 hour window
urology review
surgery
Classic limp/hip pain cause in 0-5yo?
DDH
Classic limp/hip pain cause in 5-10yo?
Perthes
Classic limp/hip pain cause in 10-15yo?
SUFE
Classic limp/hip pain cause in 30-50yo?
Labral tear
Classic limp/hip pain cause in 50yo+?
OA
How is the pain in compartment syndrome worsened?
Passive stretching of the muscles in that compartment
Does the compartment feel swollen in compartment syndrome?
No as fascia can’t expand so it feels tense
Diagnosis of compartment synd?
Essentially clinical
Can use intra-compartmental pressure or risking CK levels
Mx compartment synd
If you suspect, it is CS until proven otherwise
Keep limb at neutral level (not elevated or lowered)
High flow O2
IV bolus transiently improves perfusion
Remove all casts/dressings etc to skin
Opioid analgesia
Definitive Mx is urgent fasciotomy
Renal monitoring
How does reperfusion cause compartment syndrome?
Reperfusion post ischaemia –> tissue oedema –> increased pressure
Does a pulse r/o compartment synd?
No
Sectioning under the MHA must be assessed by who? Who puts in the final application
2 doctors and 1 AMPH, ideally all at the same time
AMPH puts in the final application and can disagree with the docs
What are the three criteria for detention under the MHA?
- must suffer from a mental disorder to a degree that requires detention in hospital
- must be at risk to own health/safety and/or a risk to others
- must be unwilling to go to hospital voluntarily (when have capacity)
(if they don’t have capacity but are willing- still MHA)
What is a section 2 under the MHA?
For assessment and/or treatment
Up to 28 days
What is a section 3 under the MHA?
For treatment
Up to 6m
Can be appealed twice w/in the 6m then yearly.
What can be treated under MHA?
- The mental disorder
- The cause of the mental disorder
- The consequences of the mental disorder
What is a section 5(2)?
Doctor’s holding power
Inpatients only (not A&E)
Must be assessed within 72h
No right to treat- to see if further detainment necessary.
> FY2 only.
What is a section 135
Police warrant to search for and remove a patient to a place of safety for an assessment
What is a section 136
For a mentally disordered person not in a private dwelling
What is a DOLS?
Part of MCA
In someone who lacks capacity and it is in their best interests to deprive them of their liberty
Means they aren’t free to leave a place
Urgent (up to 7 days) or standard (up to 1 year)
What bloods are included in a confusion screen? What other investigations might you do?
blood cultures, b12/haematinics, calcium, coag/INR, glucose, fbc, u&es, TFT, LFT
Vital signs
CT head
CXR
Urine dip
Mx acute gout
NSAIDs or colchicine
If these are c/i consider oral or intra-articular steroids
If taking allopurinol, continue.
Offer LT urate lowering therapy (Allopurinol) after first attack.
How to confirm death
confirm ID
signs of resp effort
verbal stimuli
pain- trapezius/supraorbital pressure
pupils fixed and dilated
carotid pulse
HS 2 mins
Resp sounds 3 mins
normal co2 range in abg
4.7 – 6.0 kPa
Normal O2 range ABG
11-13
Normal bicarb range ABG
22-26
Normal base excess ABG
-2 to +2
What would you expect the O2 on a gas to be in someone on oxygen
10kpa less than the % of O2
4L O2 is around what percentage of oxygen?
36%
FiO2 % on a non rebreathe mask?
100%
If bicarb and CO2 are going in different directions in an acidosis/alkalosis what does that mean? What are the causes?
Mixed
Cardiac arrest
Multiorgan failure
Anion gap calculation includes what things?
sodium - (chloride + bicarb)
An increased anion gap indicates?
Increased acid production or ingestion
