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Phase 3b > Intro week > Flashcards

Intro week Flashcards

1
Q

What type of consent for blood transfusion

A

verbal informed consent

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2
Q

Which transfusion can kill

A

ABO incompatible transfusions

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3
Q

What type of antibody is anti-A and anti-B

A

IgM

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4
Q

What happens in an ABO incompatible transfusion

A

Complelement activation results in lysis of antibody coated red cells. Causing haemolysis, shock and organ failure.

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5
Q

How do you prevent ABO transfusion

A

2 independent checks are required. Taking the group and save sample is the step that involves the greatest risks.

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6
Q

Measures implemented to reduce the risks associated with taking the G and S

A

2 independent G and S samples are required before blood is issued. Taken by different people at different time

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7
Q

Steps for taking a blood sample

A 
Complete all requests
Take all equipment
Identify patient using document, verbal, wristband
Label samples at bedside
Handwrite samples
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8
Q

Absolute emergency blood

A

Emergency O negative red cells

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9
Q

Main cause of morbidity in transfusion and how its prevented

A

Transfusion associated circulatory overload
Avoided by limiting number of bags of authorised at the same time
Reviewing patients
Use diuretics

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10
Q

TACO checklist for transfusion

A 
Heart failure
LV dysfunction
Diuretic
Pulmonary oedema
Resp symptoms
Positive fluid balance
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11
Q

Who is at risk of fluid overload

A

Low weight. Everyone needs weighing

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12
Q

What are the 4 things of blood you can give

A

Red cells
Platelets
FFP
Cryoprecipitate

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13
Q

TACO symptomns

A 
Dyspnoea
Wheezing
Tightness
Cough
Cyanosis
Tachypnoea
Raised JVP
Peripheral and pulmonary oedema
Biltateral infiltrates on chest x ray
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14
Q

How to avoid TACO

A

Give diuretics

Transfuse single units of red cells

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15
Q

How to treat TACO

A

Diuretic
Morphine
Nitrate

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16
Q

What does TACO stand for

A

Transfusion Associated Circulatory Overload

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17
Q

What is generic prescribing

A

Once a drug is off patent, generic prescribing is more cost effective as does not use brand names

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18
Q

Who has legal responsibility for the prescription

A

Whoever signs it

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19
Q

Which sizings do you write out and which do you abbreviate

A

Write out micrograms and nanograms

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20
Q

Types of prescribing

A

Acute prescriptions
Repeat prescriptions
Medication reviews

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21
Q

Fever Pain score

A 
Fever
Purulence
Attend within 3 days
Inflamed tonsils
No cough or coryza symptoms
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22
Q

What antibiotic for tonsilitis

A

Phenoxymethylpenicillin for 10 days

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23
Q

How do you structure a prescription

A

Drug
Size of tablets (preparation)
Dose
Supply

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24
Q

Pen allergic tonsilitis treatment

A

Clarithromycin

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25
Q

How do you structure a controlled prescription

A

Name and form
Strength and dose
Total quanitity numbers (words)

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26
Q

How long do you prescribe for on a controlled presciption

A

A month

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27
Q

If its a dynamic/ new situation how long would you give for on a prescription

A

2 weeks

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28
Q

Measure of renal function used when prescribing DOACs

A

Creatinine clearance

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29
Q

Medication review questions

A

Indication
Monitoring up to date
Contraindications
Review suitability in context of patients current condition

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30
Q

Anticholinergic side effects

A 
Arrythmias
Blurred vision
Confusion
Constipation
Dry eyes
Dry mouth
Postural hypotension
Urinary retention
?Dementia
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31
Q

Medical generalist definition

A

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

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32
Q

Why are medical generalists needed

A 
Ageing population
Comorbidities
Medical advances
Health inequalities
Patient expectations
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33
Q

Expert generalist principles

A

Managing complexity and uncertainty
Person centred care
Shared decision making

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34
Q

Three components of a good doctor according to GMC

A

Skills, Knowledge, Attitudes

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35
Q

Two types of decisions doctor make

A

Diagnostic decisions

Treatment decisions

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36
Q

Whats bounded rationality

A

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

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37
Q

Biases which affect decision making

A 
Affective state of clinician
Health of doctor
Workload
Time of day
Knowledge
Clinical familiarity
Tiredness
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38
Q

What makes a safe and legal prescription

A 
Date
Idenitifiers
Name of drug
Formulation
Dose
Administration
Legible
etc.
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39
Q

ASA status 1

A

Normal healthy patient

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40
Q

ASA status 6

A

Declared brain dead, organ retrieval

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41
Q

ASA status 2

A

Patient with mild systemic disease

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42
Q

ASA status 3

A

Patient with severe systemic disease

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43
Q

ASA status 5

A

Moribund patient, not expected to survive over 24 hours with/without surgery

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44
Q

ASA status 4

A

Severe systemic disease, constant threat to life

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45
Q

When do you add E to the ASA status

A

When it is an emergency

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46
Q

Why does surgery require muscle relaxation

A

For opening and closing the abdomen

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47
Q

What is surgical preoptimisation

A 
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
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48
Q

What is something that can be done for surgery preparation before surgical preoptimisation

A

Surgery school or Fit-4-Surgery. Where you improve lifestyle factors and improves long term outcomes

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49
Q

Preoperative measures

A

Oxygen
Fluids
Drugs

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50
Q

Types of premedication

A

Analgesia
Sedatives
Antiemetics
Antacids

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51
Q

Drugs omitted before elective

A

ACE and ARB
DOACs
Anti TNF (2 weeks)
Platelet inhibitors

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52
Q

How long should you have without aspirin before surgery

A

10 days

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53
Q

How long should you have without ACE and ARB before surgery

A

72 hours

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54
Q

Which NSAIDs are still used through surgery (COX2Inhibitor)

A

Parecoxib (as can be used IV)

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55
Q

Gastric effects of NSAIDs

A

Peptic ulceration. Prophylaxis with omeprazole/misoprostol.

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56
Q

Coagulation effects of NSAIDs

A

Reduced production of thromboxane (COX2-i)

Increased bleeding time

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57
Q

Respiratory effects of NSAIDs

A

Asprin sensitive asthmatics

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58
Q

Renal effects of NSAIDs

A

Renal failure, fluid retention and hyperkalaemia

As prostaglandin release

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59
Q

Who should you avoid NSAIDs in

A

Renal
Hyperkalaemia
Hypovoloemia
…..

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60
Q

Intraoperative measures

A 
Oxygen
Fluid
Blood
Antibiotics
Anaesthesia
Analgesia
Muscle relaxation
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61
Q

Why shouldnt you give desflurane

A

Bad for the ozone

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62
Q

Whats the alternative to desflurane

A

Sevoflurane

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63
Q

What are desflurane and sevoflurane

A

Inhalational analgesia

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64
Q

Which IV analgesia is still used

A

Propofol

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65
Q

What is an alternative IV analgesia, other than Propofol

A

Ketamine

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66
Q

What are the two types of muscle relaxations

A

Depolarising and non depolarising

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67
Q

How do muscle relaxants work

A

mimic acetylcholine

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68
Q

Suxamethonium

A

Depolarising muscle relaxant

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69
Q

What is good about suxamethonium

A

Very rapidly acting

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70
Q

Non depolarising muscle relaxant

A

Rocuronium and atracurium

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71
Q

How do non depolarising muscle relaxants work

A

Competitive and therefore takes longer to work

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72
Q

What reverses neuromuscular block and muscle relaxants

A

Sugammadex

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73
Q

How does sugammadex work

A

Encapsulations relaxants and reverses

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74
Q

Post operative durgs

A

Analgesia
Blood products
Etc

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75
Q

Regional analgesia

A

Regional blocks: TAP blocks

Epidural

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76
Q

In COPD which analgesia would be preferred

A

Epidural

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77
Q

What has changed about the trauma stats

A

Has gone from young men in RTC to older patients with falls

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78
Q

Trauma PRIMARY SURVEY (different to critically ill)

A 
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
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79
Q

What is the acronym for trauma primary survey

A

C ABCDE

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80
Q

Initial assessment of trauma components

A

Preparation, triage, primary survey, resuscitation, adjuncts to primary survey

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81
Q

What happens after the primary trauma curvey

A

Next destination, definitive care, scans, surgery.
Secondary survey- life limiting
Tertiary survey- life changing (smaller things)

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82
Q

Types of trauma

A 
Blunt injury (RTC, falls, assault)
Sharp injury
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83
Q

RTC injuries

A

Cervical spine injury
Blunt thoracic and cardiac injury
Hollow viscus perforation
Pelvic, acetabular an dfemur injuries

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84
Q

Common motorcycle injuries

A

Pelvis

Everything

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85
Q

Assault injuries

A

Head injuries

Beware stamp to abdomen/ chest

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86
Q

How do stab wounds resemble

A

Follows track of the knife better outcomes

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87
Q

Gunshot wounds

A

Depends on bullets and kinetics

Bullet can tumble, cause displacement of tissues

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88
Q

Sports injuries

A

Splenic and renal injury in rugby
Open fractures motorcross
Fighting football

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89
Q

Primary injury in blast injury

A

Blast wave disrupts gas filled structures

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90
Q

Secondary injury in blast injury

A

Impact airborne debris (shrapnel)

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91
Q

Tertiary injury in blast injury

A

Trasmission of body (you are thrown)

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92
Q

Quarternary injury in blast injury

A

All other structures

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93
Q

Common preventable trauma deaths

A

Bleeding
Multiple organ dysfunction
Cardiorespiratory arrest

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94
Q

Trauma treatment key aims

A

Stop bleeding
Prevent hypoxia
Prevent acidaemia
Avoid traumatic cardiac arrest or treat

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95
Q

What pneumonic is used for handover in trauma

A

ATMIST

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96
Q

What does ATMIST stand for

A 
Age
Time of incident
Mechanism of injury
Injuries found
Signs (observations)
Treatments
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97
Q

What tool is used to decide which hospital a patient goes to for trauma car

A

Yorkshire Major Trauma Triage tool

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98
Q

what is important when doing CABCDE

A

Do everything at once

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99
Q

Where are catastrophic trauma

A

Femoral
Axillary
Neck

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100
Q

Catstrophic bleeding treatment

A 
Clear any clots
Direct pressure
More direct pressure
Indirect pressure
Tourniquet
Haeomstatic agents (ceelox)
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101
Q

How to apply tourniquet

A

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

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102
Q

According to NICE what is the expected time frame for securing an airway in major trauma

A

45 minutes

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103
Q

Intubation absolute indications

A

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

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104
Q

Early tracheal intubation should be considered in the presence of

A

hypoxaemia or hypercapnia
Deep facial burns
Full thickness neck burns

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105
Q

Relative indications for intubation

A

Haemorrhagic shock
Agitated patient
Multiple painful injuries
Transfer to other area of the hospital

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106
Q

Airway and c spine management

A

Immobilise C spine
Give oxygen
Access airway (look, listen, feel)
Proceed to RSI/ intubation if indicated

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107
Q

Life threatening chest injuries ATOM FC

A 
Airway obstruction or disruption
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest
Cardiac tamponade
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108
Q

Tension pneumothorax signs

A 
Diminished breath sounsd
Hyperesonance
Distended neck veins
Deviated trachea
hypoxia
Tachycardia
Hypotension
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109
Q

What is the presentation of a tension pneuomthoarx

A

Air hungry, agitated
Hypoxia
Hypotensive
Tachycardic

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110
Q

Tension pneumothorax treatment

A

Needle thoracocentesis 2nd intercostal space midclavicular line

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111
Q

Massive haemothorax

A

Defined as over 1500mL blood
Reduced air sounds, hypo-resonant
Obtain IV access prior to decompression
Consider urgent thoractomy

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112
Q

Define open pneumothorax

A

Wound to chest wall communicating with pleural cavity

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113
Q

Open pneumothorax

A

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

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114
Q

Flail chest

A

Fracture of 2 or more ribs broken in 2 or more places
Floating section ribs
Moves paradoxically during respiration
Ventilatory failure

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115
Q

What are the signs of cardiac tamponade

A

Becks Triad

  • hypotension
  • diminished heart sounds
  • distended neck veins
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116
Q

Treatment for cardiac tamponade

A

Thoracotomy incise pericardium

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117
Q

Secondary survey injurieis

A 
Simple pneumothorax
Aortic injuries
Diaphragmatic injuries
Fractured ribs
Lung contusion
Cardiac contusion
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118
Q

abdo bledding

A 
Blunt force trauma
Signs can be subtle
Liver, spleen, retroperitoneal injuries
Perforation hollow viscus
CT in all but the most unstable patient
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119
Q

Indications for emergency laparotomy

A

Peritonism
Radiological evidence free air
GI haemorrhage
Resistant haemodynamic instability

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120
Q

What is a long bone

A

Bone that is longer than it is wide

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121
Q

Clinically important long bones

A

Femur
Humerus
Tibia

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122
Q

How do you treat circulation in trauma

A

Permissive hypotension. Aim for MAP 50

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123
Q

Why shouldnt you just pump them back full of fluid

A

Crystalloid doesnt carry oxygen

They will get hyperchloraemic acidosis

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124
Q

Indications for fluid administration in trauma

A

Systolic under 90
Heart rate over 130
Reduced conscious level
Obvious massive ongoing blood loss

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125
Q

How to stop the bleeding

A 
See catastrophic haemorrhage
Pelvic binder
Splint long bones
Permissive hypotension
Tranexamix acid
Emergent damage control surgery
Interventional radiology
Limit crystalloid
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126
Q

Neuro primary survey

A

AVPU
Pupillary size and response
Motor score of GCSE most predictive outcome
Sensory level if able

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127
Q

What is the primary injury

A

The incident

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128
Q

What is the secondary injury

A

Hypoxic injury/ hypoperfusion

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129
Q

What is cerebral perfusion pressure

A

mean arterial pressure - intracranial pressure

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130
Q

What is CPP

A

Cerebral perfusion pressure

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131
Q

Cushings triad in the presence of raised ICP

A

Hypertension
Bradycardia
Irregular breathing pattern

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132
Q

Head injury important things

A

Prevent secondary brain injury
Secure airway
Maintain normal ICP, glucose, oxygen and CO2

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133
Q

E assessment

A

Look for obvious limb threatening injuries
Keep patient war
Consider few bedside tests

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134
Q

How are elderly trauma patients different

A

Comorbidities

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135
Q

Respiratory differences in elederly

A 
Respiratory muscle weakness
Kyphosis thoracic spine
Chest wall rigidity
Imparied central response to hypoxia
Reduced alvelolar gas exchange surface area
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136
Q

Cardiac output

A

CO=SVxHR

Stroke volume is a product of preload, afterload and contractility

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137
Q

Cardiac differences in elderly

A 
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
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138
Q

What are the cardiac responses to small changes in elderly

A

Bigger changes to smaller stimuli as systems bad

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139
Q

Normal elderly blood pressure

A

150

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140
Q

Low blood pressure in elderly

A

Hypotensive is under 110

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141
Q

Elderly drugs that arent good for emergencies

A 
Sedatives
Anti HTN
opiates
Steroids
NSAIDs
Beta blockers
Anticoagulants
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142
Q

Spine injuries how do they differ in elderly people

A

Different normal posture

Worse prognosis and mortality

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143
Q

Why are internal organ damage from external forces more common in the elderly

A

Protective cage (ribs) are week

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144
Q

Why does it seem like lots of people have UTI when old

A

Sterile bacteriuria much more common

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145
Q

Diagnostic criteria for UTI in elderly

A 
New urinary symptoms or
Fever 
with change in urinary character 
or haematuria 
or loin tenderness
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146
Q

Why is abuse common in elderly

A

Averbal
Dependent
vulnerable

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147
Q

Elder abuse definition

A

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

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148
Q

Why wouldnt you an MRI of a trauma patient

A

Takes 30 mins and you cant do anything when theyre in

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149
Q

FAST scan

A

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

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150
Q

Do you normally FAST scan or CT scan

A

Always CT unless too many patients

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151
Q

If you cant see lung markings and its dark whats going on on x ray

A

Pneumothorax

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152
Q

What is surgical emphysema

A

Air within the soft tissues

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153
Q

What causes a flat line on a chest xray

A

Fluid level

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154
Q

What is flail chest normally associated with

A 
Pulmonary contusion (brusiing)
Pneumothorax or haemothorax
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155
Q

Widened mediastinum treatment

A

CT angio and transfer

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156
Q

Do you ever get just one pelvic fracture

A

No normally get two fractures as its a disk

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157
Q

What fracture is caused by AP compression to the pelvis

A

Open book fracture

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158
Q

Vertical shear force to the pelvis causes what fracture

A

Malgaigne or bucket handle fracture

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159
Q

Lateral compression causes what fracture

A

Lateral compression frature

160
Q

What are the three C spine views

A

Lateral
Anterior posterior
Odonotoid peg

161
Q

Whatre the 4 lines in the spine

A

Anterior vertebral line (straight)
Posterior vertebral line (straight)
Spino laminar line (straight)
Posterior spinous line (curved)

162
Q

C1 fracture

A

Jefferson fracture

163
Q

C2 fracture

A

Hangman fracture

164
Q

Hyperextension flexure C345

A

Flexion teardrop fracture

165
Q

Burst fracture

A

Dived into a swimming pool

166
Q

Why does blood go dark then grey on CT

A

Acute and then when chronic and becomes fibrinated and changes colour

167
Q

Subarachnoid bleed

A

Space between arachnoid and pia mater. Can cause hydrocephalus, midline shift and raised intracranial pressure

168
Q

Subdural haematoma

A

Blood in space between the dura and arachnoid mater
Caused by traumatic tear to bridging veins
Crescent shaped
Crosses sutures

169
Q

Extradural haemorrhage

A

Outer layer of dura and inner surface of skull. Biconvex.

Middle meningeal artery

170
Q

When is CT indicated

A

Haemodynamically instable
Mechanism of injury
Findings on Fast
Obvious severe injury

171
Q

VQ mismatch causes

A 
Pneumonia
Heart failure
COPD
Asthma
Lying down
Post Operative
172
Q

Respiratory failure definition

A

pO2 less than 8

173
Q

Normal partial pressure of oxygen

A

13

174
Q

Normal partial pressure of carbon dioxide

A

5

175
Q

Type 1 respiratory failure

A

Oxygen delivery is impaired. Breathe harder. Lower partial pressure of oxygen. Failure of ventilation but not oxygenation

176
Q

If you breathe hard what happens to partial pressure of carbon dioxide

A

Partial pressure of carbon dioxide falls and then after you tire it goes back up

177
Q

Type 2 respiratory failure

A

Obesity hypoventilation syndrome and COPD.

Ventilation and perfusion are both impaired

178
Q

What is high CO2 a sign of

A

Poor ventilation

179
Q

What is the CO2 in Type 2 respiratory failure

A

High

180
Q

What is the CO2 in Type 1 respiratory failure

A

Low/normal

181
Q

Non invasive ventilation what can it be used for

A

Increasing expiratory pressure to prevent collapse of alveoli

182
Q

When does gas exchange take place

A

During expiration

183
Q

If you have a low oxygen and VQ mismatch what do you need

A

Expiratory positive airway pressure

184
Q

If you have inadequate ventilation what do you need

A

Inspiratory positive airway pressuer

185
Q

What is BIPAP made up of

A

Expiratory and inspiratory positive airway pressure

186
Q

What is EPAP alone known as

A

CPAP

187
Q

Type 1 respiratory failure (oxygen only problem) ventilation

A

BIPAP

188
Q

Type 2 respiratory failure (oxygen and carbon dioxide problem) ventilation

A

CPAP)

189
Q

When not to use Non Invasive Ventilation

A

Asthma (as gas trapping)
PTX
Agitation
Airway loss

190
Q

Stage 1 AKI

A

Creatinine 1.5x baseline

Urine output less than 0.5ml/kg/hr for more than 6 hours

191
Q

Stage 2 AKI

A

2x baseline creatinine

Urine output less than 0.5ml/kg/hr for more than 12 hours

192
Q

Stage 3 AKI

A

3x baseline creatinine
Anuric 12 hours
Renal replacement therapy
urine output less than 0.3ml/kg/hr

193
Q

Pre renal AKI causes

A

Sepsis shock

Pressure optimisation

194
Q

Renal AKI causes

A

Toxins

195
Q

Post renal AKI causes

A

Obstruction

196
Q

3 causes of shock which cause AKI

A

Hypovolaemic shock
Septic shock (leaky capillaries)
Cardiogenic shock

197
Q

Treatment of hypovolaemic or septic shock

A

Fluid

198
Q

How does pre renal failure affect ultrafiltration

A

K+ and H+ ions dont leave blood at the glomerulus causing acidosis and hyperkalaemia

199
Q

How does septic shock affect the tubules

A

Acute tubular necrosis occurs

200
Q

which toxin can cause acute interstitial nephritis

A

NSAIDs

201
Q

Which drugs cause tubular toxicity

A

CT contrast

Gentimicin

202
Q

At the tubule whats happening to sodium

A

Moving into blood

203
Q

At the tubule whats happening to potassium and hydrogen ions

A

Absorbed into tubule

204
Q

How to treat the renal failure caused by a toxin

A

Stop the toxin

205
Q

Causes of obstruction post renal

A

Stones and cancer

206
Q

What is a CVVH machine

A

Renal replacement therapy on intensive care unit. Put heparin or citrate in to prevent clots.

207
Q

Which drug predisposes you to renal failure

A

Linsopril (any ace inhibitor)

208
Q

What causes pain worse than giving birth

A

Ureteric stone

Gall stone

209
Q

What investigation for a ureteric stone

A

CT

210
Q

Is renal or respiratory correct of pH balances quicker

A

Resp takes hours, renal takes days

211
Q

What does pO2 tell you on blood gas

A

respiratory failure?

212
Q

What does pCO2 tell you on blood gas?

A

type 2 failure? respiratory acidosis or alkalosis

213
Q

What does base excess tell you

A

Metabolic acidosis or alkalosis

214
Q

What does pH tell you on blood gas

A

Compensated or decompensated

215
Q

What can cause a metabolic acidosis and respiratory alkalosis that cancels out

A

aspirin overdose

216
Q

If you have chronic respiratory acidosis

A

You get a chronically high HCO3 but normalish base excess.

Kidney retains bicarb

217
Q

Define sepsis

A

A life threatening organ dysfunction caused by a dysregulated host response to infection

218
Q

Indications of organ dysfunction

A 
Hypotension
Hypoperfusion (high lactate)
Hypoxia
Oliguria
Creatine high
Low platelets, high INR, high aPPT
219
Q

What is septic shock

A

Sepsis and hypotension unresponsive to fluid

220
Q

What SHEWS score should require a sepsis screen

A

SHEWS over 3

221
Q

BUFALO, sepsis 6

A 
Blood cultures
Urine output hoursly
Fluid challenge IV
Antibiotics broad spetrum
Lactate serum level
Oxygen high flow
222
Q

Causes of coma

A 
Seizure, infection, sol, cva
Low cardio output state
Hypoxia, hypercapnia, CO poisoning
Uraemia, hepatic encephalopathy, hypoglycaemia, hypo or hypernatraemia, hypothyroidism, hypothermia
Opiates, benzos, tricyclics and alcohol
223
Q

AVPU

A

Alert
Voice
pain
unresponsive (despite painful stimuli)

224
Q

GCS what order and whats it out of

A

EVM

456

225
Q

Eyes GCS

A

4spontaneous
3speech
2pressure
1none

226
Q

Verbal GCS

A 
5orientated
4confused
3inappropriate words
2incomprehensible sounds
1none
227
Q

Motor GCS

A 
6obeys commands
5localises
4normal flexion to pain
3abnormal flexion to pain
2extension to pain
1none
228
Q

What is normal flexion to pain

A

Hand goes above clavicle

229
Q

What is abnormal flexion to pain

A

Slow and bunny rabbit like flexion, below clavicle

230
Q

AVPU in GCS

A

15, 12, 8, under 8

231
Q

Whatre you looking for on neuro exam

A 
Tone 
Power
Reflexes
Coordination
Sensation
Cranial nerves
232
Q

Head injury, what scan

A

CT head and C spine

233
Q

Neuro emergency, how often neuro obs

A

At least every half hour

234
Q

Indications for intubation

A 
Failure to maintain airway
Insecure aiway (low GCS)
Poor ventilation
Impending herniation (coning)
235
Q

Why do you get 3rd nerve palsy in coning

A

Compression of occulomotor nerve

236
Q

Cushings reflex

A

High ICP leads to ischaemia of vasomotor centre which causes hypertension and bradycardic

237
Q

What does CPP =

A

MAP-ICP

238
Q

How to minimise Intracranial pressure

A

Dehydration (mannitol), hypertonic saline
Reduction of cerebral blood volume
-head up 30 degrees
-hypercabia and hypoxia

239
Q

What happens when arterial PCO2 rises to cerebral blood flow

A

Increases a lot

240
Q

Instrumental values

A

Gain value over time

241
Q

Right to die

A

Can refuse life saving treatment

242
Q

Right to be killed

A

People who physiologically cant kill themselves require help

243
Q

Paracetamol cautions

A 
Liver impairment
Severe cachexia (less than 50kg= max 500mg QDS)
244
Q

NSAIDs cautions

A

Renal impairment and platelet count
CI: GI bleed or ulcer history, asthma
Concurrent medications: warfarin, digoxin, steroids

245
Q

Weak opioids

A

Codeine
Dihydrocodeine
Tramadol

246
Q

Simple analgesia

A

Paracetamol and NSAIDs

247
Q

Problem with weak opiods

A

Ceiling effect of analgesia. So if not effective, replace with a strong opioid rather than add to weak opiods

248
Q

Strong opioids

A 
Morphine
Diamorphine
Fentanyl
Oxycodone
Buprenorphine
249
Q

Specialist palliative care opioids

A

Hydromorphone
Alfentanil
Methadone
Ketamine

250
Q

What to consider before starting a strong opioid

A 
Previous opioid experience
Previous side effects
Age and frailty
Comorbidities
Renal function
Patient concerns
Will they take them as prescribed
Are they driving
251
Q

Opioids and driving

A

Dont drive whilst changing. If safe and steady then can drive

252
Q

How many g of codeine = 1g of morphine

A

10

253
Q

Max codeine converted into morphine

A

240mg codeine= 24mg morphine= 10mg BD

254
Q

What can you use to translate opioid doses

A

Opioid conversion chart

255
Q

Define background pain

A

Pain at rest, ongoing pain

256
Q

Define breakthrough pain

A

Transient exacerbation. Can be predictable such as movement or unpredictable.

257
Q

What is modified release morphine

A

For background pain. Lasts 12 hours. MST or Zomorph

258
Q

What is immediate release morphine

A

For breakthrough pain. Oramorph

259
Q

Is oxycodone or morphine stronger

A

Oxycodone is twice as potent

260
Q

How to prescribe opioids

A

Always start low
Titrate dose according to pain and PRN usage
Be ready for side effects

261
Q

What should you also prescribe for opioid side effects

A

PRN antiemetic: Haloperidol

Stimulant Laxative

262
Q

Common opioid side effects

A

Constipation
Nausea
Sedation
Dry mouth

263
Q

Less frequent opioid side effects

A

Psychomimetic effects
Confusion
Myoclonus

264
Q

Rare opioid side effects

A

Allergy
Respiratory depression
Pruritis

265
Q

When should you give fentanyl or buprenorphine patches

A

For stable opioid responsive pain.

266
Q

Indications for buprenorphine patches

A

Intolerable side effects
Oral route difficulties
Renal impairment

267
Q

How long does it take for buprenorphine patches to work

A

1-3 days

268
Q

What to be cautious of with opioid patches

A

Hairless, dry, non inflamed
Avoid heat as increases rate of absorption
Adhered fully

269
Q

Should you use fentanyl as a first strong opioid

A

Never! its too strong

270
Q

Antidepressants as analgesics

A

Amitryptilline, duloxetine

271
Q

What are used for neuropathic pain

A

Antidepressants, anti epileptics

272
Q

Are injectable or oral doses stronger

A

Injectable are twice as strong

273
Q

Renal impairment and opioids

A

Fentanyl buprenorphine more renal friendly

Reduce dose or frequency

274
Q

What to make sure is on an opioid prescription

A 
Minimum interval
Max in 24 hours
Always check allergy status
Separate prescription for PO vs SC
Is it modified release or immediate release
275
Q

General medical palliative emergencies

A 
Fits 
Cardiac arrest
DKA
Anaphylaxis
Opioid overdose
276
Q

More common palliative care emergencies

A 
Neutropenic sepsis
Superior vena cava obstruction
Stridor
Malignant hypercalcaemia
Metastatic spinal cord compression
Opioid overdose
Massive Haemorrhage
277
Q

Neutropenic sepsis, who gets it

A

Following chemotherapy
Bone marrow infiltration causing pancytopenia
Haematology patients

278
Q

Neutropenic sepsis signs and symptoms

A

High temperature

Clinical infection

279
Q

How is neutropenic sepsis diagnosed

A

Pyrexia over 38 degrees
Signs of sepsis
Low neutrophil count

280
Q

Neutropenic sepsis treatment

A 
IV access
Broad spectrum antibiotics
Close observation
Fluid resus
Investigations
281
Q

Superior vena cava obstruction who gets it

A

Lung cancer tumour, involving the right upper lobe or mediastinum

282
Q

SVC obstruction symptoms

A

Facial swelling
Conjunctival and arm oedema
Breathlessness
Distended veins in chest

283
Q

SVC obstruction investigations

A

CT chest

284
Q

Treatment of SVC obstruction

A

Dexamethasone 16mg OD (for tumour oedema)
Consider anticoagulation
Stenting
Radiotherapy

285
Q

Stridor define

A

Noisy harsh inspiratory sounds (turbulent air flow)

286
Q

Stridor who gets it

A

Head and neck tumours

Lung and upper GI tumours

287
Q

Signs and symptoms of stridor

A

Noisy breathing on inspiration
Harsh breath sounds
Breathlessness

288
Q

Diagnsois of stridor

A

ENT endoscope
Upper airway imaging
Clinically

289
Q

How is stridor managed

A 
Oxygen
Dexamethason 16mg OD
Tracheostomy
Stenting
Radiotherapy
290
Q

Who gets malignant hypercalcaemia

A 
Bone cancer mets
Breast
Lung
Kidney 
Thyroid
Prostrate
291
Q

Signs and symptoms of malignant hypercalcaemia

A

acute
-thirst, confusion, constipation, global detioration
Chronic
-depression, abdominal pain, constipation, calculi

292
Q

Diagnosis of malignant hypercalcaemia

A

Correct calcium blood test

293
Q

Malignant hypercalcaemia treatment

A

IV fluids most important
IV bisphosphonates
Denosumab

294
Q

Massive haemorrhage who gets it

A

Head and neck cancer
Lung or GI cancer with history of bleeding
Herald bleed (bleed settled)

295
Q

Signs and symptoms of massive haemorrhage

A

Sudden large volume blood

Rapidly loses consciousness

296
Q

Massive haemorrhage management

A

Stop anticoagulation

Dependent on ceiling of care

297
Q

Palliative massive haemorrhage treatment

A

Dark towels
Remain with them
Midazolam

298
Q

Opioid overdose, who gets it

A

Patient on strong opioids

Sudden improvement in condition or pain

299
Q

Opioid overdose symptoms

A 
Reduced conscious level
Reduced respiratory rate
Myoclonic jerks
Pinpoint pupils
Confusion
Hallucinations
300
Q

Opioid overdose treatment

A 
Naloxone
-400mcg stat in emergency
-smaller amounts in palliative
Close observations
Dose reduction
301
Q

What is half life of methadone

A

Long and variable

302
Q

What is half life of naloxone

A

Short

303
Q

Palliative opioid overdose

A

They get varying pain and respiratory rate so dont bother giving nalaxone

304
Q

Metastatic spinal cord compression

A

Bone mets in spine.

305
Q

Metastatic spinal cord compression investigation

A

MRI

306
Q

Metastatic spinal cord compression treatment

A

Dexamethasone

Surgery

307
Q

Metastatic spinal cord compression symptoms

A

Neurological symptoms at and below that level
Paraesthesia and weakness
Change in bowel and bladder

308
Q

Approaching end of life definition

A

Advanced
Progressive
Incurable conditions
Likely to die within 12 months

309
Q

Approaching end of life caer

A

Optimise symptoms and quality of life
Plan for the future and ongoing decline
Communicating your assessment to the patient

310
Q

Advanced care planning

A

Discussion with patients and those important to them about their wishes and thoughts for the futures. Ensure Quality of Life is preserved

311
Q

Formal advance care planning

A

What they want to happen
What they dont want to happen
Who will speak for them

312
Q

What they want to happen document

A

Advanced statement of wishes

313
Q

What they dont want to happen document

A

Advance decision to refuse treatment

314
Q

Who will speak for them document

A

Lasting power of attorney for health and welfare

315
Q

DNACPR

A

CPR is a medical treatment and therefore decision

Unethical to offer futile medical treatments

316
Q

Signs and symptoms of dying

A

Oral intake
Respiratory effort
Conscious levels
Observations

317
Q

Stages of dying

A 
Disease relentless
Change underway
Recovery less likely
Dying begins
Actively dying
318
Q

Recognising dying outlook

A

Anyone on team may recognise

Senior clinician needs to be involved to assess the reversibility

319
Q

Recognising dying

A 
Recent change
Organ failure
Function decline
Treatment ineffective
Anyone recognised dying
320
Q

Signs of dying

A 
Weight loss and appetite
Fatigue and sleeping
Detiorating mobility
Social withdrawal
Changes in consciousness
Struggling with medications
Detiorating ADLs
Pulse strength, change in colour, mottled skin
Respiratory changes: noisy secretions, laboured breathing, cheyne stokes resp
321
Q

Five prioirties of care of the dying

A 
Communication
Involved
People important to the dying person
Individual compassion
Recognised dying
322
Q

What is something important to do when communicating about dying

A

Document it

323
Q

How to communicate about dying

A

Be specific and best recommendating
Use SBAR
Recommend ceilings of care and specific planning

324
Q

Symptom control in dying person

A

Daily reviews still
Keep listening and talking, meeting families
Preemptive prescribing for key symptoms

325
Q

5 key symptoms of dying

A 
Pain
Breathlessness
Respiratory secretions
Nausea/ vomiting
Distress/ agitation
326
Q

Preemptive medications

A 
Subcut injections or syringe driver
Morphine (pain and breathlessness)
Buscopan (secretions)
Midazolam (agitation)
Haloperidol (nausea)
327
Q

Preemptive for pain

A

Morphine hourly

328
Q

Preemptive for breathlessness

A

Morphine hourly

329
Q

Preemptive for secretions

A

Buscopan hourly

330
Q

Preemptive for agitation

A

Midazolam

331
Q

Preemptive for nausea

A

Haloperidol

332
Q

Non pharmacological treatment of breathelssness

A

Sit up

Open window

333
Q

Nutrition and hydration

A

Reduced intake is normal
Fundamental and instinctive nurturing act
Cultural, faith and ethical

334
Q

Nutrition and hydration things to do

A

Mouth care to prevent feeling of thirst
Support oral food enjoyment
Regularly review symptoms

335
Q

Bereavement help

A

Good communication
Discuss events following death
Following bereavement support
Counselling through GP referral

336
Q

Immediate treatment for hyponatraemia

A

3.0% normal saline 150ml bolus over 20 mins

337
Q

What can be a consequence of over quickly treatment of hyponatraemia

A

Osmotic demyelination when water rushes out.

338
Q

Max raising of sodium in a day

A

10mmol

339
Q

Hyponatraemia endocrine causes

A

Adrenal insufficiency

340
Q

Weight loss and hyponatraemia

A

Adrenal insufficiency, addisonian crisis

341
Q

How do cortisol and TSH interact

A

Cortisol inhibits TSH. So adrenal insufficiency can present as hypothyroid

342
Q

Fluid overloaded hyponatraemia causes

A

Low urine sodium
Congestive cardiac failure
Nephrotic syndrome
Cirrhosis and liver failure

343
Q

Causes of normovolaemic hyponatraemia

A

SIADH

344
Q

Causes of dehydrated hyponatraemia

A

Vomiting and diarrhoea
Burns
Pancreatitis

345
Q

Fluid overloaded or normovolaemic hyponatraemia treatment

A

Fluid restriction

750-1000ml/24hrs

346
Q

Dehydrated hyponatraemia treatment

A

Saline replacement

347
Q

What drugs can cause high urine sodium

A

Diuretics
Addisons
Cerebral salt wasting
Salt wasting nephropathy

348
Q

What causes SIADH

A

Tumours
Respiratory
Drugs
CNS

349
Q

How do you treat adrenal insufficiency

A

Saline replacement and hydrocortisone

350
Q

How much hydrocortisone do you give to treat adrenal insufficiency

A

100mg IV/IM

351
Q

When do you do a short synacthen test

A

Testing for addisons

352
Q

If ACTH is high but cortisol is low what does this suggest

A

A primary problem as the adrenal is not responding to the high ACTH levels

353
Q

Primary causes of adrenal insufficiency

A 
Adrenalitis
Haemorrhage
Infiltration
Bilaterla adrenalectomy
Drugs
Inhertied causes
354
Q

Secondary causes of adrenal insufficiency

A

Pituitary/hypothalamic

Long term glucocorticoid usage

355
Q

Whats the treatment for phaechromocytoma

A

Alpha blocker

356
Q

What is pituitary apoplexy

A

Infarction/ haemorrhage into tumour

357
Q

Causes of hypercalcaemia

A 
Primary hyperparathyroidism
Malignancy
Lithium 
Thyrotoxicosis
High vit d
358
Q

3 roles of the liver

A

Synthesis
Detoxification
Storage

359
Q

What does the liver synthesise

A

Protein
Clotting factors
Bile
Glycogen

360
Q

What does the liver detoxify

A

alcohol
Drugs
Ammonia
Bilirubin

361
Q

What does the liver store

A

Energy
Vitamins
Minerals

362
Q

Define ALF

A

Complex multisystemic illness which occurs after an insult to the liver.

363
Q

What are the five requirements for ALF

A 
Jaundice
Coagulopathy
Hepatic encephalopathy
Absence of chronic liver
Within 12 weeks
364
Q

Hyper acute ALF defintion

A

Jaundice to encephalopathy within 7 days. Best prognosis

365
Q

Acute ALF definition

A

Jaundice to encephalopathy within 8-28 days

366
Q

Sub acute ALF definition

A

Jaundice to encephalopathy in 29days- 12 weeks (worse diagnosis)

367
Q

Most common cause of ALF in the UK

A

Paracetamol

368
Q

Most common cause of ALF in developing countries

A

Viral hepatitis

369
Q

Drugs which cause ALF

A 
Paracetamol
Rifampicin
NSAIDs
Sodium Valproate
Carbamazepine
Ectasy
370
Q

Which hepatitis’ are viral

A

A, E and B

371
Q

Rare causes of ALF

A 
Ischaemic hepatitis
AI hepatitis
Wilsons
Fatty liver of pregnancy
Budd Chairi
Amanita phalloides mushrooms
372
Q

Causes of hyperacute ALF

A

Paracetamol
Drugs
Viral hepatitis

373
Q

Causes of acute hepatitis

A

Viral hepatitis

Ischaemic hepatitis

374
Q

Causes of subacute hepatitis

A

Seronegative hepatitis

Autoimmune hepatitis

375
Q

What are the three aspects of palliative care

A

Physical
Psychological
Spiritual

376
Q

Define palliative care

A

An approach which improves the quality of life of patients and their families facing problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems

377
Q

Steps of palliative care

A

Supportive care then end of life care then terminal care then bereavement support

378
Q

Main specialties treated by palliated care

A 
Oncological
Neurological
Respiratory
Cardiac
Renal
Vascular
379
Q

Focus of palliative care

A

Patient centred goal, needs realism, honesty, hope, enablement approach

380
Q

Hospice MDT

A 
Nursing
AHP
Chaplain
Psychocologist
Physio
Social Worker
Well being therapy
Doctor
381
Q

Symptoms of cancer

A 
Fatigue and weakness
Pain
Appetite, nausea and bowel problems
Breathing problems
Sexuality and intimacy issues
Problems with body image
382
Q

Side effects of cancer treatment

A

All cancer symptoms

fatigue, weakness, pain, GI, breathing, sexual

383
Q

Common causes of nausea and vomiting in palliative patients

A

Morphine
Constipation
Hypercalcaemia
Chemotherapy

384
Q

3Bs of nausea causes

A

Bowels
Brain
Biochemical

385
Q

Bowel causes of nausea

A

Mucositis, constipation, infection, gastric stasis, bowel obstruction

386
Q

Brain causes of nausea

A

Raised intracranial pressure

Breast cancer mets

387
Q

Biochemical causes of nausea

A

Medications, hypercalcaemia, hypomagnesaemia, uraemia, infection

388
Q

Antiemetic for bowel cause

A

Odansetron

Metoclopramide

389
Q

Antiemetic for biochemical cause

A

Levomeopromazine

Haloperidol

390
Q

Antiemetic for brain cause

A

Cyclizine

Prochlorperazine

391
Q

How do metoclopramide and haloperidol work as antiemetics

A

D2 antagonist

392
Q

How does ondansetron work as an antiemetic

A

Serotonin antagonist

393
Q

How does cyclizine work as an antiemetic

A

H1 antagonist

394
Q

Name 4 supportive measures

A 
IV fluids
Lidnocaine mouthwash
Antacid
Lansoprazole fast tab
Nutrition supplement drinks
395
Q

What to do if someone cant reliably take oral antiemetics

A

Syringe driver or IV

Phase 3b (5 decks)

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