Intro week Flashcards
What type of consent for blood transfusion
verbal informed consent
Which transfusion can kill
ABO incompatible transfusions
What type of antibody is anti-A and anti-B
IgM
What happens in an ABO incompatible transfusion
Complelement activation results in lysis of antibody coated red cells. Causing haemolysis, shock and organ failure.
How do you prevent ABO transfusion
2 independent checks are required. Taking the group and save sample is the step that involves the greatest risks.
Measures implemented to reduce the risks associated with taking the G and S
2 independent G and S samples are required before blood is issued. Taken by different people at different time
Steps for taking a blood sample
Complete all requests Take all equipment Identify patient using document, verbal, wristband Label samples at bedside Handwrite samples
Absolute emergency blood
Emergency O negative red cells
Main cause of morbidity in transfusion and how its prevented
Transfusion associated circulatory overload
Avoided by limiting number of bags of authorised at the same time
Reviewing patients
Use diuretics
TACO checklist for transfusion
Heart failure LV dysfunction Diuretic Pulmonary oedema Resp symptoms Positive fluid balance
Who is at risk of fluid overload
Low weight. Everyone needs weighing
What are the 4 things of blood you can give
Red cells
Platelets
FFP
Cryoprecipitate
TACO symptomns
Dyspnoea Wheezing Tightness Cough Cyanosis Tachypnoea Raised JVP Peripheral and pulmonary oedema Biltateral infiltrates on chest x ray
How to avoid TACO
Give diuretics
Transfuse single units of red cells
How to treat TACO
Diuretic
Morphine
Nitrate
What does TACO stand for
Transfusion Associated Circulatory Overload
What is generic prescribing
Once a drug is off patent, generic prescribing is more cost effective as does not use brand names
Who has legal responsibility for the prescription
Whoever signs it
Which sizings do you write out and which do you abbreviate
Write out micrograms and nanograms
Types of prescribing
Acute prescriptions
Repeat prescriptions
Medication reviews
Fever Pain score
Fever Purulence Attend within 3 days Inflamed tonsils No cough or coryza symptoms
What antibiotic for tonsilitis
Phenoxymethylpenicillin for 10 days
How do you structure a prescription
Drug
Size of tablets (preparation)
Dose
Supply
Pen allergic tonsilitis treatment
Clarithromycin
How do you structure a controlled prescription
Name and form
Strength and dose
Total quanitity numbers (words)
How long do you prescribe for on a controlled presciption
A month
If its a dynamic/ new situation how long would you give for on a prescription
2 weeks
Measure of renal function used when prescribing DOACs
Creatinine clearance
Medication review questions
Indication
Monitoring up to date
Contraindications
Review suitability in context of patients current condition
Anticholinergic side effects
Arrythmias Blurred vision Confusion Constipation Dry eyes Dry mouth Postural hypotension Urinary retention ?Dementia
Medical generalist definition
Doctors prepared to deal with any problem presenting to them, unrestricted by particular body systems and including problems with psychological or social causes as well as physical ones
Why are medical generalists needed
Ageing population Comorbidities Medical advances Health inequalities Patient expectations
Expert generalist principles
Managing complexity and uncertainty
Person centred care
Shared decision making
Three components of a good doctor according to GMC
Skills, Knowledge, Attitudes
Two types of decisions doctor make
Diagnostic decisions
Treatment decisions
Whats bounded rationality
Concept that we work under constraints of limited information that we have a limited intellectual capacity and that we have a limited amount of time to make the decision
Biases which affect decision making
Affective state of clinician Health of doctor Workload Time of day Knowledge Clinical familiarity Tiredness
What makes a safe and legal prescription
Date Idenitifiers Name of drug Formulation Dose Administration Legible etc.
ASA status 1
Normal healthy patient
ASA status 6
Declared brain dead, organ retrieval
ASA status 2
Patient with mild systemic disease
ASA status 3
Patient with severe systemic disease
ASA status 5
Moribund patient, not expected to survive over 24 hours with/without surgery
ASA status 4
Severe systemic disease, constant threat to life
When do you add E to the ASA status
When it is an emergency
Why does surgery require muscle relaxation
For opening and closing the abdomen
What is surgical preoptimisation
HDU or POSU Invasive BP monitoring Urinary catheter Central venous access Inotropic support Cardiac output monitoring Broad aim is to maximum oxygen delivery perioperatively to supranormal levels
What is something that can be done for surgery preparation before surgical preoptimisation
Surgery school or Fit-4-Surgery. Where you improve lifestyle factors and improves long term outcomes
Preoperative measures
Oxygen
Fluids
Drugs
Types of premedication
Analgesia
Sedatives
Antiemetics
Antacids
Drugs omitted before elective
ACE and ARB
DOACs
Anti TNF (2 weeks)
Platelet inhibitors
How long should you have without aspirin before surgery
10 days
How long should you have without ACE and ARB before surgery
72 hours
Which NSAIDs are still used through surgery (COX2Inhibitor)
Parecoxib (as can be used IV)
Gastric effects of NSAIDs
Peptic ulceration. Prophylaxis with omeprazole/misoprostol.
Coagulation effects of NSAIDs
Reduced production of thromboxane (COX2-i)
Increased bleeding time
Respiratory effects of NSAIDs
Asprin sensitive asthmatics
Renal effects of NSAIDs
Renal failure, fluid retention and hyperkalaemia
As prostaglandin release
Who should you avoid NSAIDs in
Renal
Hyperkalaemia
Hypovoloemia
…..
Intraoperative measures
Oxygen Fluid Blood Antibiotics Anaesthesia Analgesia Muscle relaxation
Why shouldnt you give desflurane
Bad for the ozone
Whats the alternative to desflurane
Sevoflurane
What are desflurane and sevoflurane
Inhalational analgesia
Which IV analgesia is still used
Propofol
What is an alternative IV analgesia, other than Propofol
Ketamine
What are the two types of muscle relaxations
Depolarising and non depolarising
How do muscle relaxants work
mimic acetylcholine
Suxamethonium
Depolarising muscle relaxant
What is good about suxamethonium
Very rapidly acting
Non depolarising muscle relaxant
Rocuronium and atracurium
How do non depolarising muscle relaxants work
Competitive and therefore takes longer to work
What reverses neuromuscular block and muscle relaxants
Sugammadex
How does sugammadex work
Encapsulations relaxants and reverses
Post operative durgs
Analgesia
Blood products
Etc
Regional analgesia
Regional blocks: TAP blocks
Epidural
In COPD which analgesia would be preferred
Epidural
What has changed about the trauma stats
Has gone from young men in RTC to older patients with falls
Trauma PRIMARY SURVEY (different to critically ill)
C= control catastrophic haemorrhage A=airway with C spine protection B= breathing with ventilation C= circulation with haemorrhage control D= disability: neurological status E= exposure/environment
What is the acronym for trauma primary survey
C ABCDE
Initial assessment of trauma components
Preparation, triage, primary survey, resuscitation, adjuncts to primary survey
What happens after the primary trauma curvey
Next destination, definitive care, scans, surgery.
Secondary survey- life limiting
Tertiary survey- life changing (smaller things)
Types of trauma
Blunt injury (RTC, falls, assault) Sharp injury
RTC injuries
Cervical spine injury
Blunt thoracic and cardiac injury
Hollow viscus perforation
Pelvic, acetabular an dfemur injuries
Common motorcycle injuries
Pelvis
Everything
Assault injuries
Head injuries
Beware stamp to abdomen/ chest
How do stab wounds resemble
Follows track of the knife better outcomes
Gunshot wounds
Depends on bullets and kinetics
Bullet can tumble, cause displacement of tissues
Sports injuries
Splenic and renal injury in rugby
Open fractures motorcross
Fighting football
Primary injury in blast injury
Blast wave disrupts gas filled structures
Secondary injury in blast injury
Impact airborne debris (shrapnel)
Tertiary injury in blast injury
Trasmission of body (you are thrown)
Quarternary injury in blast injury
All other structures
Common preventable trauma deaths
Bleeding
Multiple organ dysfunction
Cardiorespiratory arrest
Trauma treatment key aims
Stop bleeding
Prevent hypoxia
Prevent acidaemia
Avoid traumatic cardiac arrest or treat
What pneumonic is used for handover in trauma
ATMIST
What does ATMIST stand for
Age Time of incident Mechanism of injury Injuries found Signs (observations) Treatments
What tool is used to decide which hospital a patient goes to for trauma car
Yorkshire Major Trauma Triage tool
what is important when doing CABCDE
Do everything at once
Where are catastrophic trauma
Femoral
Axillary
Neck
Catstrophic bleeding treatment
Clear any clots Direct pressure More direct pressure Indirect pressure Tourniquet Haeomstatic agents (ceelox)
How to apply tourniquet
Open band fully and place around limb, 2 to 3 inches above bleeding source. Twist rod until bleeding stops. Ensure bleeding stopped and no distal pulse.
If hasnt worked, add another tourniquet above
According to NICE what is the expected time frame for securing an airway in major trauma
45 minutes
Intubation absolute indications
Inability to maintain and protect own airway
Inability to maintain adequate oxygenation with less invasive manouevres
Inability to maintain normocapnia
Significant facial injuries
Detiorating conscious level
Seizures
Early tracheal intubation should be considered in the presence of
hypoxaemia or hypercapnia
Deep facial burns
Full thickness neck burns
Relative indications for intubation
Haemorrhagic shock
Agitated patient
Multiple painful injuries
Transfer to other area of the hospital
Airway and c spine management
Immobilise C spine
Give oxygen
Access airway (look, listen, feel)
Proceed to RSI/ intubation if indicated
Life threatening chest injuries ATOM FC
Airway obstruction or disruption Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Cardiac tamponade
Tension pneumothorax signs
Diminished breath sounsd Hyperesonance Distended neck veins Deviated trachea hypoxia Tachycardia Hypotension
What is the presentation of a tension pneuomthoarx
Air hungry, agitated
Hypoxia
Hypotensive
Tachycardic
Tension pneumothorax treatment
Needle thoracocentesis 2nd intercostal space midclavicular line
Massive haemothorax
Defined as over 1500mL blood
Reduced air sounds, hypo-resonant
Obtain IV access prior to decompression
Consider urgent thoractomy
Define open pneumothorax
Wound to chest wall communicating with pleural cavity
Open pneumothorax
More than 2/3 aperture of trachea
Air moves down pressure gradient into pleural space
Wound seals on expiration
Three sided occlusive dressing is the treatment
Flail chest
Fracture of 2 or more ribs broken in 2 or more places
Floating section ribs
Moves paradoxically during respiration
Ventilatory failure
What are the signs of cardiac tamponade
Becks Triad
- hypotension
- diminished heart sounds
- distended neck veins
Treatment for cardiac tamponade
Thoracotomy incise pericardium
Secondary survey injurieis
Simple pneumothorax Aortic injuries Diaphragmatic injuries Fractured ribs Lung contusion Cardiac contusion
abdo bledding
Blunt force trauma Signs can be subtle Liver, spleen, retroperitoneal injuries Perforation hollow viscus CT in all but the most unstable patient
Indications for emergency laparotomy
Peritonism
Radiological evidence free air
GI haemorrhage
Resistant haemodynamic instability
What is a long bone
Bone that is longer than it is wide
Clinically important long bones
Femur
Humerus
Tibia
How do you treat circulation in trauma
Permissive hypotension. Aim for MAP 50
Why shouldnt you just pump them back full of fluid
Crystalloid doesnt carry oxygen
They will get hyperchloraemic acidosis
Indications for fluid administration in trauma
Systolic under 90
Heart rate over 130
Reduced conscious level
Obvious massive ongoing blood loss
How to stop the bleeding
See catastrophic haemorrhage Pelvic binder Splint long bones Permissive hypotension Tranexamix acid Emergent damage control surgery Interventional radiology Limit crystalloid
Neuro primary survey
AVPU
Pupillary size and response
Motor score of GCSE most predictive outcome
Sensory level if able
What is the primary injury
The incident
What is the secondary injury
Hypoxic injury/ hypoperfusion
What is cerebral perfusion pressure
mean arterial pressure - intracranial pressure
What is CPP
Cerebral perfusion pressure
Cushings triad in the presence of raised ICP
Hypertension
Bradycardia
Irregular breathing pattern
Head injury important things
Prevent secondary brain injury
Secure airway
Maintain normal ICP, glucose, oxygen and CO2
E assessment
Look for obvious limb threatening injuries
Keep patient war
Consider few bedside tests
How are elderly trauma patients different
Comorbidities
Respiratory differences in elederly
Respiratory muscle weakness Kyphosis thoracic spine Chest wall rigidity Imparied central response to hypoxia Reduced alvelolar gas exchange surface area
Cardiac output
CO=SVxHR
Stroke volume is a product of preload, afterload and contractility
Cardiac differences in elderly
Total body water declines with age Peripheral vasculature becomes rigid and non compliant Myocardium replaced by fat and collagen Autonomic and baroreceptor dysfunction Atrial pacemaker atrophy
What are the cardiac responses to small changes in elderly
Bigger changes to smaller stimuli as systems bad
Normal elderly blood pressure
150
Low blood pressure in elderly
Hypotensive is under 110
Elderly drugs that arent good for emergencies
Sedatives Anti HTN opiates Steroids NSAIDs Beta blockers Anticoagulants
Spine injuries how do they differ in elderly people
Different normal posture
Worse prognosis and mortality
Why are internal organ damage from external forces more common in the elderly
Protective cage (ribs) are week
Why does it seem like lots of people have UTI when old
Sterile bacteriuria much more common
Diagnostic criteria for UTI in elderly
New urinary symptoms or Fever with change in urinary character or haematuria or loin tenderness
Why is abuse common in elderly
Averbal
Dependent
vulnerable
Elder abuse definition
A single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person
Why wouldnt you an MRI of a trauma patient
Takes 30 mins and you cant do anything when theyre in
FAST scan
Foccussed assessment with sonography in trauma
Pericardium, RUQ, LUQ, bladder
Looking for free fluid
But can only see more than 250ml and cant see retroperitoneal
Do you normally FAST scan or CT scan
Always CT unless too many patients
If you cant see lung markings and its dark whats going on on x ray
Pneumothorax
What is surgical emphysema
Air within the soft tissues
What causes a flat line on a chest xray
Fluid level
What is flail chest normally associated with
Pulmonary contusion (brusiing) Pneumothorax or haemothorax
Widened mediastinum treatment
CT angio and transfer
Do you ever get just one pelvic fracture
No normally get two fractures as its a disk
What fracture is caused by AP compression to the pelvis
Open book fracture
Vertical shear force to the pelvis causes what fracture
Malgaigne or bucket handle fracture