Lecture Notes COPY Flashcards
3 step Mx to high BMs in T2DM
- Review drug chart + oral hypoglycaemics
- Check ketones if BM >12 (more than 2x in 24hrs)
- Ask diabetes specialist nurse
Mx of T2DM on steroids
Causes hyperglycaemia
May have high BM pattern
Double dose oral hypoglycaemics
OR
add 2nd agent
Target BM in hospital
6-10 (4-12 acceptable)
Insulin dependent T2DM
Usually 2x daily regime Increased insulin by 10%
Monitor BMs
T1DM -Mx if hypos overnight?
Reduce basal insulin (night dose) - Decrease by 20%
Short Acting Insulin
- Examples
- Mode of Action
- Use?
Act-rapid, Humilin-S
Onset: 30mins
Peak: 2-4 hours
Lasts: 8 hours
Use: IV in variable rate insulin
Mx of DKA, high K+
Rapid Acting Insulin
- Examples
- Mode of Action
- Use?
Novarapid/humalog
Onset: 15 mins Peak: 40 mins
Lasts: 4 hours
Use: bolus insulin in T1DM (before meals/correction)
Mixed Insulin
- Examples
- Mode of Action
- Use
Rapid + Intermediate Number = percentage of rapid acting insulin e.g. Novomix 30
Used in BD dosing (e.g. T2DM)
Long Acting Insulin
- Examples
- Mode of Action
- Use?
Lantus, glargine, degludec
Onset: 2 hours Offset: 24-42 hours (brand dependent)
Often no real peak
Usually OD basal dose
Emergency Op in T1DM Mx
BM Target?
NBM
Continue basal insulin
Stop rapid acting
Start VR infusion using table
BM target = 6-10mmol
Indications for VR infusion
T1 DM - If missing 1 meal due to fasting - No background insulin
T2DM
- If missing 1 meal and BM >12
- Poor control with HbA1c >49
- Emergency surgery
What is a VR infusion?
50 units act rapid in 49.5 ml normal saline
Run alongside Dex/sal infusion
Continue basal insulin in T1DM (at 80%)
T1DM Pre-Op
Admit night before
First on list
Stop short acting insulin
Start on VR infusion
80% basal insulin (DO NOT STOP)
T2DM Pre-Op
Omit oral hypoglycaemics (day before)
VR infusion if BM >12
If insulin dependent: - Stop insulin, give VR
VR infusion? Post Op
Stop VR 30 mins after giving short acting insulin
Increase basal dose to 100% when E+D
Mnemonic for Venturi’s
Barry White Yearns for Right-wing Government
Colour, % and L of venturi’s
Blue = 24% = 2L White = 28% = 4L Yellow = 35% = 8L Red = 40% = 10L Green = 60% = 15L
Right Hemicolectomy
Ascending colon removed
Anterior Resection
Sigmoid colon removed
Proximal Rectum removed
Abdominal-Perineal resection
Sigmoid colon
Rectum and anal canal removed
Anus is closed, colostomy created
Hartmann’s
Emergency - Sigmoid and rectum removed
Colostomy made
Can be reversed at a later date
Sub-total colectomy
Asc, trans, desc and sigmoid colon removed
Anastamosis with rectal stump to create storage pouch
Good as avoids stoma
Intra Op Complications
Bleeding
Damage to tissue
Anaesthetic risk
Allergy
Post Op Complications 1-3 days
Bleeding
Atelectasis
MI/Stroke
Post Op Complications 3-7 days
Infection - Wound, chest, urine
Anastamotic Leak
VTE
Post Op Complications >1 month
Hernia
Chronic Pain
Recurrence
Requesting Scans?
- Criteria
What question are we asking?
How will that change management?
MRI Scans
- Co-morbidities to bear in mind?
MRI - pacemaker, metal fragments (eye)
Orthopaedic plates/replacements ETC ok as not magnetic material
CT/AXR
- Co-morbidities to bear in mind?
Do PT in woman of childbearing age
CT with Contrast
- Co-morbidities to bear in mind?
Check eGFR
Review Meds e.g. metformin
May need to run IV fluids.
PRN Meds for Acute Abdo patient
Paracetamol
Weak opiate - codeine
Strong Opiate - Oramorph
Anti-emetic - cyclazine
Acute Abdo Bloods
FBC, UEs, LFTs, Clotting, G+S, VBG
CRP, Amylase
PT
ABG or cultures if indicated.
Gallbladder disease and Charcot’s Triad
Biliary Colic = RUQ pain
Cholecystitis = RUQ and fever (low grade)
Cholangitis = RUQ, high fever and jaundice
Amylase in acute Abdo
Double normal = diagnostic of pancreatitis
Raised <2x = PUD, AAA, gastritis
Glasgow Scoring
PANCREAS
PaO2 <8 Age >55 Neutrophils >15 Ca <2 Renal: urea >16 Enzymes: LDH>600, AST >2000 Albumin <32 Sugar >10
Score 3+ in first 48 hours = significant pancreatitis
Examination in Surgery
- Heart
- Lungs
- Testicular
Heart
- Murmur = need ECHO
- AF= think bowel infarct
Lungs
- Decreased air entry: effusion or infection
Testicular
- In all men with lower abdo pain: must rule out torsion!
Acute Indications for Dialysis
A = Acidosis pH <7.2
E = Electrolyte e.g. refractory high K+
I = intoxication = lithium, anti-freeze, barbituates
O = overload, fluid not responding to meds
U = Uraemia = pericarditis/encephalopathy
OR lethargy, decreased appetite, metallic taste
Acute Mx of Hyperkalaemia
30ml of 10% calcium gluconate
10U actrapid in 50ml 50% glucose
Salbutamol 5mg neb
Follow Up Mx of high K+
Treat cause
Give fluids
Review Nephrotoxics
Pre-Renal AKI
Decreased intake
Fluid loss
Renal AKI
IV Contrast
Toxins
Vasculitis
Do Urine Dip for BLOOD and PROTEIN
Post-Renal AKI
Usually urological cause
- obstruction, UTI
Urine Dip
Bladder scan
Refer urology
Fluid Status Assessment
BP, HR, CRT, JVP
Urine output
Mucous membranes and skin turgor
FLUID BALANCE CHART
STOP AKI
treat SEPSIS
avoid TOXINS
OPTIMISE BP
PREVENT harm
Haematemesis Hx
When they last ate or drank (for endoscopy)
BG sx:
Weight loss/dysphagia/change of bowel habit = cancer
Dyspepia = gastritis, GORD
Abdo pain
SHOCK: what impairs physiological response?
Age
Drugs e.g. beta blockers
CV co-morbidity
leads to organ failure as cannot increase HR or BP
Drug Hx in Haematemesis
NSAIDS? ulcer
Antiplatelets: clopidogrel, aspirin, ticagrelor, dipyridamole
Anticoagulants: warfarin, DOAC
Post GI Bleed Complications
MI
Stroke
Renal Failure
Intestinal/liver ischaemia
Glasgow Blatchford
Do they need endoscopy?
Used in A+E to discharge patients
Score 0-1 = OGD endoscopy
Rockall Score
Post endoscopy, with diagnosis
Co-morbidities = very high scoring e,g, organ failure, malignancy
Hb and Blood transfusion in GI bleed
Hb >100 = do not transfuse
Hb <70 = aim for 70-90 Hb, unless anginal sx (can give more)
Pharmacotherapy for ulcer vs variceal bleed
Ulcer:
- IV PPI post endoscopy
Varicieal
- Terlipressin, can be given in A+E
- Gastro would give to any pt with stigmata of liver disease O/E, as likely to be hepatic cause for bleed
Chronic Liver Disease Definitions
Comp vs De-Comp
Compensated
- peripheral stigmata of liver disease, functioning well, normal synthetic function
Decompensated
- Ascites, encephalopathy, jaundice, varices
Acute Liver Failure Definition
Jaundice, encephalopathy +/- ascites
NO peripheral stigmata of liver disease
Causes of Acute Liver Failure
Drugs: Paracetamol OD
Pregnancy (HELLP)
Budd-chiari (hepatic vein thrombus)
Virus
Ix in Acute Liver Failure
Pro-thrombin time
- PT MOST IMPORTANT IN LIVER FAILURE
If >30 secs, contact gastro
>50 secs = liver unit
AST may be in 1000s, irrelevant
Causes of Chronic Liver Failure
Alcohol
Fatty liver disease
Viral hepatitis (IVDU, abroad = Hep C)
Rare
Fluids in Liver failure
Avoid normal saline as will follow osmotic gradient and go straight to abdomen, increase ascites
Only give in resus scenario
Give 5% dex
Why do liver patients decompensate?
Infection
- UTI, chest, SBP
Medications
- opiates, diuretics
AKI
- Hepato-renal syndrome
Disease progression
- Increased alcohol intake, do not cease drinking
GI bleed
Child Pugh Score
Albumin
PT
Bilirubin
Ascites
Encephalopathy
Grade A, B, C (most serious)
Viral causes Acute LF
Serology for Hep B and C
USS and Dopplers in Acute LF
Rule out hepatic vein thrombus (budd chiari)
Immune Causes Acute LF
IgA
- Alcohol
IgG
- Autoimmune hepatitis
- ASMA
IgM (M disease)
- Primary biliary cirrhosis
- Anti- mitochondrial antibody
Genetic Causes Acute LF
Wilson’s disease
Haemochromotosis
Alpha a1 antitrypsin
Causes of Metabolic Acidosis
- Lactic = tissue hypoxia
- Keto = DKA
- Renal = high urea and creatinine
BTS Oxygen Guidelines
- Critically ill?
15L NRB Mask, 60% 02
BTS O2
- Seriously ill
Mod O2 if hypoxic
2-6L via Nasal canula/face mask
BTS O2
- COPD/scholiosis/obesity hypoventilation
- Risk of loss of resp drive if oxygen toxicity
CONTROLLED O2 THERAPY
Venturi mask and titrate
Judgement of PaO2
Below 8 = RESP FAILURE
Work out if low
% of oxgen inspired -10
Therefore:
if patient on 15L NRB mask (60%)
- PaO2 should be at least 50
PE: ECG
Sinus tachy, fast af
RBBB (right heart strain)
S1Q3T3
PE: ABG
Low PaO2
Low CO2
- due to increased work of breathing
PE: CXR
May be normal
May have small pleural effusion
Causes of COPD in a young person?
Heroin smoking
Alpha A1 anti tripsin
Secondary pneumothorax
Known resp. disease
> 50 with smoking hx
What is the Management?
COPD patient on 15L NRB Mask
ph 7.29 PaCO2 7.1 PaO2 8.9 HCO3 28 Base Excess +1
Oxygen toxicity
TRY ON CONTROLLED O2 Therapy
e.g. venturi mask
What is the management?
COPD patient on 28% venturi mask
ph 7.29 PaCO2 7.1 PaO2 8.9 HCO3 28 Base Excess +1
Need NIV!
Indication for NIV = resp acidosis NOT hypoxia
NIV Principles
Biphasic pressure
Inspiratory (IPAP) and expiratory (EPAP)
Difference between IPAP and EPAP
= increase tidal volume and decreased CO2
Indications for NIV
Resp Acidosis
On controlled O2 therapy
Recieved medical rx
Contraindications for NIV
Pneumothorax
- Will cause tension
CPAP
Continuous Positive airway pressure
Used to splint open upper airway in
Obstructive sleep apnoea
Life-Threatening Asthma
33 92 CHEST
<33 Peak flow
<92 O2 sats
Cyanosis Hypotension Exhaustion Silent Chest Tachycardia
Near Fatal Asthma
33 92 CHEST
+++ HIGH CO2 LEVELS
Need ICU involvement and potentially ventilation
Criteria for Asthma discharge
Off Nebs
Peak flow >75% best
Check
- Inhaler technique
- PEFR meter and diary
- Self management plan
RED FLAGS Headache
Thunderclap - SAH
Positional = raised ICP
Malaise = meningitis
Weight loss = Cancer
SNOOP 4Ps
Systemic features
Neuro: arm weakness
Onset? sudden - bleed
Older: >50 years
Pattern
- Getting worse
- Precipitated by valsalver
- Papilloedema
Migraine Criteria
> 5 episodes with 2 of:
- unilateral
- pulsating
- worsened by moving
- N+V
- photophobia
Seizures? What medications cause?
Meds that cause long QT
- Anti-histamines
- Anti-psychotics
- Anti-depressants
- Anti-microbials
- Anti-emetics
- Anti-arrhythmics
Not taking normal Anti-Epileptics
Epilepsy: Psychiatric
Ask re mental health problems
Psychogenic seizures more common
Epilepsy: Lifestyle
DRIVING, alcohol, relationships, occupation
Epilepsy: Pregnancy
DO NOT PRESCRIBE SODIUM VALPROATE
if Female <50 years
Epilepsy: Ix
DO AN ECG (look for long QT)
MRI for mesotemporal sclerosis
EEG only if primary generalised seizures (usually children)
Tests for Bradykinesia
Touch each finger to thumb in turn
Finger tapping together (slower and smaller)
Foot tapping on floor
SE Levo-dopa
Reduced efficacy
Freezing
Disinhibition - gambling etc.
Differences between Myesthenia Gravis and Guillain Barre
GB = Sensory loss, myesthenia does not
GB = progressive, Myesthenia = worse with fatigue
GB = demyelination after viral illness Myesthenia = autoimmune to Ach Receptor
Causes of Pancreatitis
I GET SMASHHHED
I - Idiopathic
G - Gallstones
E - Ethanol (alcohol)
T - Trauma
S - Steroids M - Mumps A - Autoimmune S - Scorpion/Spider bite H - High PTH H - High Lipids H - High Calcium E - ERCP D - Drugs
Ewing’s Sarcoma
Rare, 5-15 years
lytic bone lesion with periosteal rxn
‘onion skinning’
Chrondrosarcoma
Middle aged
bone destruction and calcification
rx with excision and chemo
Osteosarcoma
Young people
Comomn
Direct inguinal Hernia
Through abdo wall, not ing. canal
Medial to inguinal ligament
Alway acquired
RF: smoking, obesity, heavy lifting
Rarely strangulates
Indirect Inguinal Hernia
Through canal inyo scotum
Young active men and prem babies
Hernia above and medial to pubic tubercle
Descent into scrotum on standing or coughinh
Hydrocele
Fluid in tunica vaginalis
Tense, painless, fluctuant
Transilluminates
In adult, USS to rule out pathology
Varicocele
Left sided
Bag of worms, heavy and dragging
Harmless, supportive underwear
Hashimoto Goitre
Enlarged, firm, non-tender
MEN T1
Pituitary
pancreas
parathyroid
MEN T2 + T3
Pheochromocytoma
parathyroid
thyroid ca
Type 3 = with marfans as well
Cystic Hygroma
benign lymph proliferation in post. triangle
Transillumates brightly
Ant. Cord Syndrome
Loss of pain temp and motor
Lower and upper limbs (worse in lower)
Bad prognosis
Central Cord Syndrome
Weakness of upper limbs, not lower
Good prognosis
Older people with cervical spondylosis
Jones Fracture
5th metatarsal
Lis-Franc Fracture
2-4th metatarsal with dislocation
March Fracture
Stress/hairline fracture
Callus on Xray
Snellen Test?
Visual Acuity
Pupillary light reflex
RAPD
Damaged optic nerve e.g. optic neuritis
Ischihara Plates
Colour vision
Amsler Grid
Straight lines = curved
Sign of macular degeneration
Schirmer’s Test
Tear production
<5mm = abnormal e.g. dry eyes in sjrogens
Fluroscein Dye
Corneal ulcer,
Dendritic shows green
H Test
CN III, IV and VI
Tonometry
Raised intra-ocular pressure (IOP) in glaucoma
Daily Na2+ requirements
1-2mmol/kg
Daily K+ requirements
0.5-1mmol/kg
Daily Fluid requirements
25-30ml/kg
Daily Fluid requirements
- CCF
- Small
20-25ml/kg
