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finals > medical and surgical emergencies and major trauma > Flashcards

medical and surgical emergencies and major trauma Flashcards

1
Q

pre-hospital mx ACS

A

MONA:
morphine (IV 5-10mg with anti-emetics)
Oxygen (only if hypoxic)
Nitrates (sublingual IV, only if SBP>90mmHg)
Aspirin 300mg STAT (then 75mg OD thereafter)

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2
Q

mx acute STEMI

A

<12h Sx onset and PPCI within 120 minutes = PPCI
Otherwise,fibrinolysis

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3
Q

mx acute NSTEMI

A

Fondaparinux 2.5mg OD
DAPT = aspirin and ticagrelor
Coronary angiogram +/- stenting (speed of which depends on GRACE score)

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4
Q

secondary prevention ACS

A

5As:
Aspirin 75mg OD
Another antiplatelet e.g., clopidogrel 75mg OD/ticagrelor 90mg BD
ACEi e.g., ramipril
Atorvastatin 80mg ON
Atenolol (aka beta-blockers, usually bisoprolol)

Echocardiogram to assess systolic function
Cardiac rehabilitation

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5
Q

specific blood test if suspect MI

A

troponin

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6
Q

scoring system for mx MI

A

GRACE

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7
Q

moderate acute asthma

A

PEFR 50-75%
RR<25
HR<110
speech normal

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8
Q

severe acute astham

A

PEFR 33-50%
RR>25
HR>/= 110
unable to complete full sentences

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9
Q

life threatening acute asthma

A

PEFR<33%
Spo2<92%
silent chest and cyanosis
haemodynamically unstable
exaustion/altered GCS
ABG=normal co2

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10
Q

ix acute asthma exacerbation

A

Routine bloods e.g., FBC, U&E, LFTs, CRP,
Viral throat swabs
ABG
CXR

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11
Q

mx acute asthma exacerbation

A

O SHIT ME) -
Oxygen (>94%)
Salbutamol 2.5-5mg nebulised (oxygen driven)
Can trial IV if B2B nebs not helping
Hydrocortisone 100mg IV or PO pred 40-50mg
Ipratropium bromide 0.5mg nebulised QDS
Theophylline IV (senior staff/ICU decision)
Magnesium sulfate IV 2g (senior staff)
Escalate early – involve ICU if not improving

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12
Q

hyperkalaemia classification

A

Mild 5.5–5.9, moderate 6.0–6.4, severe ≥ 6.5

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13
Q

ECG features hyperkalaemia

A

Flattened P waves
Tall-tented T waves
Widened QRS
Sinusoidal pattern  ventricular fibrillation

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14
Q

ix in hyperkalaemia

A

U+E
ECG

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15
Q

when to tx hyperkalaemia as an emergency

A

K+ ≥6.5 or ECG changes

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16
Q

mx hyperkalaemia

A

FIRST = calcium gluconate: Stabilises the myocardium, protects from VF
COMBINED insulin/dextrose infusion
Nebulised salbutamol
Calcium resonium
?Loop diuretics
Consider dialysis if refractory hyperkalaemia despite medical management
Suspend drugs that increase K+ e.g., ramipril, spironolactone etc.

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17
Q

A-E approach to tachycardia and bradycardia

A

O2 if <94%
IV access
monitor ECG, O2,
identify and tx reversible causes e.g. electrolyte abnormalities, hypovolaemia

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18
Q

life threatening features adult tachycardia/bradycardia

A

shock
syncope
myocardial ischaemia
severe HF

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19
Q

what to do if tachycardia with life threatening features

A

synchronised DC shock - up to 3 attempts
need sedation/anaesthesia if conscious

no success: amiodarone 300mg IV over 10-20mins

repeat shock

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20
Q

mx tachycardia with no life threatening features, broad and irregular QRS

A

consider:
-AF with bundle branch block -> control rate with BB, consider digoxin or amiodarone if HF, anticoag if duration over 48h
-polymorphic VT (torsades de pointes)-> magnesium 2g over 10 min

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21
Q

mx non life threatenin tachycardia with broad regular QRS

A

if VT or uncertain rhythm: amiodarone 300mg IV over 10-60min
if previous SVT with bundle branch block/aberant conduction: vagal manoevres, adenosine 6mg IV rapid bolus, then 12mg, then 18mg. verapamil or BB

if ineffective syncronised DC shock

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22
Q

mx non life threatening tachycardia with narrow regular QRS

A
  1. vagal manoevres
  2. adenosine 6mg IV rapid bolus, if ineffective 12mg, 18mg. need to monitor ECG
  3. if ineffective verapamil or BB
  4. syncronised DC shock
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23
Q

mx non life threatening tachcyardia with narrow irregular QRS

A

probable AF: rate control with BB, digoxin or amiodarone if HF, anticaog if duration over 48h

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24
Q

mx adult bradycardia with life threatening signs

A

atropine 500mcg IV

response and no risk asystole then observe

no response: interim measures = atropine 500mcg IV repeat to max 3mg, isoprenaline 5mcg/min IV, adrenaline 2-10 mcg/min IV
OR transcutaneous pacing

transvenous pacing

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25
Q

mx bradycardia with no life threatening signs and no risk asystole

A

observe

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26
Q

features in bradycardia at risk of asysteole

A

recent asystole
mobitz II block
complete heart block with broad QRS
ventricular pause >3s

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27
Q

most common causes pancreatitis

A

alcohol, gallstones and ERCP

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28
Q

presentation pancreatitis

A

Acute severe abdominal pain, vomiting, nausea, fever, tachycardia, shock, peritonitis.

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29
Q

ix pancreatitis

A

Obs, routine bloods, LFTs inc Amylase (or lipase), Calcium, ABG if requiring O2, USS/CT depending on clinical picture.

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30
Q

what is the imrie-glascow score

A

for pancreatitis
Reflects severity of inflammation alongside assess involvement/failure of other organs

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31
Q

factors in the imrie-glascow score

A

P–Pa02< 8 KPa
A–Age > 55
N–Neutrophils (WBC > 15)
C–Calcium < 2
R– uRea >16
E–Enzymes (LDH > 600 or AST/ALT >200)
A–Albumin < 32
S–Sugar (Glucose >10)

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32
Q

Interpretation of the imrie-glascow score

A

0-1 is mild, 2 is moderate and >3 is severe

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33
Q

atlanta classification pancreatitis

A

Mild: No organ failure or systemic complications

Moderate: Transient organ failure (<48 hrs) and /or local or systemic complications (sterile or infected) without organ failure

Severe: Persistent organ failure (>48 hours): single organ or multiple organ failure

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34
Q

mx pancreatitis

A

IV fluid resuscitation
Analgesia
Eat as able
Cholecystectomy ~ 6/52
CT if unwell 7-10 days after presentation

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35
Q

complications pancreatitis

A

NECROSIS IS BAD
Interstitial oedematous pancreatitis: Acute inflammation of pancreatic parenchyma and peripancreatic tissues, but without recognisable tissue necrosis

Necrotising pancreatitis: Pancreatic parenchymal necrosis or peripancreatic necrosis, or both

Acute peripancreatic fluid collection: Peripancreatic fluid with interstitial edematous pancreatitis but no necrosis (this term applies only within the first 4 weeks after onset of interstitial edematous pancreatitis and without features of a pseudocyst)

Pancreatic pseudocyst: Encapsulated collection of fluid with a well defined inflammatory wall usually outside pancreas with minimal or no necrosis (usually occurs > 4 weeks after onset of pancreatitis)

Acute necrotic collection: Fluid and necrosis associated with necrotising pancreatitis affecting pancreas or peripancreatic tissues, or both

Walled-off necrosis: Mature, encapsulated collection of pancreatic or peripancreatic necrosis with an inflammatory wall, or both (walled-off necrosis usually occurs >4 weeks after onset of necrotising pancreatitis)

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36
Q

cholelithiasis

A

Stones in gallbladder

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37
Q

features cholelithiasis

A

Asymptomatic (90%)
Biliary colic (10%)

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38
Q

mx cholelithiasis

A

USS to confirm gallstones, LFTs, add to (very long) elective list

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39
Q

cholecystitis

A

Inflammation of gallbladder

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40
Q

features cholecystitis

A

Pain – Murphy’s
Fever
N&V

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41
Q

mx cholecystitis

A

Confirm via USS - >4mm
10% may have obstructive jaundice picture
IVI + Abx – observe/operate

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42
Q

choledocholithiasis

A

Stone in CBD

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43
Q

presentation choledocholithiasis

A

Pain
Obstructive jaundice

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44
Q

mx choledocholithiasis

A

USS/MRCP
ERCP (usually pre-elective cholecystectomy)

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45
Q

cholangitis

A

Infection of the bile duct

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46
Q

presentation cholangitis

A

Pain
Fever/Septic
Obstructive jaundice

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47
Q

mx cholangitis

A

Septic screen and start IV Abx early. ERCP as above to treat the blockage.

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48
Q

pre-hepatic jaundice causes

A

haemolytic anaemia
gilberts
criggler-najjar syndrome

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49
Q

hepatocellular causes of jaundice

A

alcoholic liver disease
viral hepatitis
iatrogenic-medication
hereditary haemochromatosis
AI hepatitis
primary biliary cirrhosis or primary sclerosing cholangitis
hepatocellular carcinoma

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50
Q

post-hepatic causes of jaundice

A

intra-luminal e.g. gallstones
mural: cholangiocarcinoma, strictures,
extra-mural causes: pancreatic cancer

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51
Q

ALP

A

Biliary obstruction/stasis or bone turnover

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52
Q

ALT and AST

A

type of hepatic damage

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53
Q

albumin and clotting derangement

A

Liver damage ↓ synthetic ability

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54
Q

pre-hepatic jaundice bilirubin

A

cause a unconjugated hyperbilirubinemia – typically from excessive turnover of red blood cells that overwhelms the liver. This cannot be conjugated and secreted in the bile (and ultimately the urine/stool) so gets stuck on blood transport proteins and then skin/tissues.

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55
Q

hepatic jaundice bilirubin

A

Mixed jaundice of conjungated/unconjugated as cirrhosis can cause element of biliary obstruction (look at ALT/AST to work out)

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56
Q

post-hepatic jaundice bilirubin

A

Conjugated hyperbilirubinaemia

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57
Q

AST/ALT ratio

A

indicates the type of liver damage, if it’s 2 its liver damage, if roughly 1 its viral hepatitis, if it’s 0.4 it’s paracetamol

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58
Q

complications cholecystectomy

A

Gallbladder perforation is one – usually due to very inflamed/calcified gallbladder that is spiral down complications - wash out and IV Co-amox.
Bile duct injury - comes from difficult anatomy and being unable to identify calot’s triangle. Life changing injury.

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59
Q

duodenal ulcers

A

Pain when hungry eased by eating

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60
Q

gastric ulcers

A

Pain worse with eating

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61
Q

RF gastric and peptic ulcer

A

H Pylori associated with 95% of duodenal ulcers and 75% of gastric ulcers as causes increased acid secretion (increasing risk of ulceration). Also need to consider meds (NSAIDs, SSRIs, steroids, bisphosphonates). Rarely will be Zollinger-Ellison syndrome (gastrin producing tumour)

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62
Q

ix ulcers

A

FBC, Stool antigen/urea-13, OGD

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63
Q

mx gastric/duodenal ulcers

A

PPI and eradication therapy-lansoprazole + amox (metro if pen a) + clari/metro

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64
Q

features perforated peptic ulcer

A

sudden horrendous epigastric pain, looking shocked and likely peritonitis.

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65
Q

mx perforated peptic ulcer

A

Emergency – access, bloods (including ABG), erect CXR if cannot CT straight away (air-perforation). Give IVIs to maintain organ perfusion and get to theatre if unstable and evidence of unseal perforation. Lap or open, generally will need a washout

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66
Q

causes oesophageal bleed

A

Varices:
Oesophagitis:
Cancer:
Mallory-Weiss tear:

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67
Q

features oesophageal varices

A

bleed
Large volume, will likely be shocked and unstable. Will likely need intervention acutely to prevent re-bleeds

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68
Q

features oesophagitis

A

Usually small volume blood streaking vomit, preceded by GORD like symptoms

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69
Q

features oesophageal cancer

A

Will have s/s of Ca alongside a variable bleed. Can be small volume as tumour grows or a massive terminal event.

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70
Q

features mallory-weiss tear

A

bleed Will follow excessive vomit, usually self terminates

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71
Q

gastric causes GI bleed

A

ulcer
cancer

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72
Q

duodenal causes GI bleed

A

ulcer

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73
Q

what is blatchford score for

A

upper GI bleed
0=no intervention and discharge
>6 = urgent intervention

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74
Q

blatchford score

A

BUN
Hb: Men: 120-130 (1), 119-100 (2), <100 (6)
Women: 100-120 (1), <100 (6)
BP: 100-109 (1), 90-99 (2), <90 (3)
Pulse >100 (1)
Melaena (1)
Syncope (2)
Hepatic disease (2)
HF (2)

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75
Q

mx upper GI bleed

A

Resuscitate, 2x large bore cannulas, assess clotting. Assist clot formation if platelets under 50, fibrinogen is under 1 or PT/APTT is 1.5x normal with platelets/FFP
Endoscopy: Within 24 hours if severe bleed
If non-variceal: Endoscope and give PPI, if re-bleeds consider IR or laparotomy
If variceal: terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices

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76
Q

rockall score use

A

post-bleed re-bleed risk, as rises so does re-bleeding risk (and then mortality risk)

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77
Q

features splenic rupture

A

blunt trauma
epigastric/LUQ pain with peritonism that gradually spreads as the spleen bleeds

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78
Q

ix splenic rupture

A

CT

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79
Q

mx splenic rupture

A

TLDR: If unstable – diagnostic laparotomy to assess damage

Conservative management: Small subcapsular haematoma, Minimal intra-abdominal blood, No hilar disruption (grade 3 and below). Resection if hilar injury/major haemorrhage.

If stable and grade 1-3 can closely observe and repeat CT in 1 week. Increasing tenderness has a low threshold to reimage +/- laparotomy. If contrast escapes during CT – use IR services to embolise vessel if available.

Critically: All patients who are treated conservatively should receive prophylactic vaccinations (against Strep Pneumoniae, Haemophilus Influenzae B (HIB) and Meningococcus) at discharge. If spleen comes out will need Pen-V for life as the spleen is so immunologically active in destroying Pneumococcus, Meningococcus, and H. Influenzae

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80
Q

grade 1 splenic injury

A

capsular tear <1cm parenchymal depth
subcapsular haematoma <10% SA

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81
Q

grade 2 splenic injury

A

capsular tear 1-3cm parenchymal depth
subcapsular haematoma 10-50% SA or intraparenchymal <5cm

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82
Q

grade 3 splenic injury

A

capsular tear >3cm parenchymal depth or trabecular vessels
subcapsular haematoma >50% SA or intraparenchymal >5cm

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83
Q

grade 4 splenic injury

A

laceration involving segmental or hilar vessels, devascualirsing >25% spleen

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84
Q

grade 5 splenic injur

A

completely shattered spleen or hilar vascular injury devascularising the entire spleen

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85
Q

presentation appendicitis

A

Young patient usually fit and well presents with single vomit, anorexia and generalised -> RIF pain.
Percussive and rebound tenderness -> peritonitis.
progression of generalised pain to McBurnies point,

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86
Q

ix appendicitis

A

80-90% will have neutrophil leucocytosis
Urine – rules out UTI/renal colic
USS: useful to rule out pelvic issues

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87
Q

mx appendicitis

A

Laparoscopic appendicectomy is gold-standard, if perforated will need copious washout. Conservative management with Abx works for most patients but a significant proportion will end up needing a lap appendix anway.

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88
Q

commonset causes small bowel bstruction

A

Adhesions (open > laproscopic)
Incarcerated hernia
Crohn’s
Malignancy

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89
Q

ix small bowel obstruction

A

CT

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90
Q

presentation small bowel obstruction

A

elderly with previous abdominal operations. They present, nauseous, vomiting +/- fecal, +/- distended, with episodic colicky peristaltic pain. Patient will have a period of BNO/no flatus being passed. Bowel sounds may appearing high pitched and ‘tinkling’ in early obstruction.

91
Q

mx small bowel obstruction

A

NBM
Anti-sickness
IVI and hydrate
Decompress bowel with NG (gastrograffin)
If conservative management fails, surgery

Generally simple/partial obstructions are amenable to conservative management.

Closed loop obstructions tend to compromise arterial supply or venous return. Leading to bowel oedema and perforation/ischaemia/awfulness. Will likely require resection.

92
Q

what is ileus

A

Deacceleration or arrest in intestinal motility – generally innocent

93
Q

RF for ileus

A

Patient RFs: age, electrolytes, neurological disorders and anti-cholinergics
Surgical RFs: opioids, excessive handling of bowel, resection, contamination

94
Q

ix ileus

A

Check electrolytes and inflammatory markers

95
Q

mx ileus

A

innocent in the majority of patients, it can be a sign of otherintra-abdominal pathology
Manage with NG, fluids, daily bloods, encouraging mobilisation and reducing opioids

96
Q

direct inguinal hernias

A

Bowel enters the inguinal canal “directly” through a weakness in the posterior wall of the canal, termed Hesselbach’s triangle
They occur more commonly in older patients, often secondary to abdominal wall laxity or a significant increase in intra-abdominal pressure

97
Q

indirect inguinal hernia

A

Bowel enters the inguinal canal via the deep inguinal ring
They arise from incomplete closure of the processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descent, therefore are usually deemed congenital in origin

98
Q

presentation inguinal hernia

A

lump in the groin, which (for reducible hernia) will initially disappear with minimal pressure or when the patient lies down. There may be mild to moderate discomfort, which can worsen with activity or standing. Check the cough impulse and try to reduce it yourself on examination.

99
Q

mx inguinal hernias

A

Hernia repairs can be performed via open repair (Lichtenstein technique most commonly used) or laparoscopic repair.

100
Q

femoral hernias

A

Entrance of abdominal contents into the femoral canal – much smaller with solid boundaries

101
Q

presentation femoral hernias

A

elderly woman who has lost weight/fat which allows hernia through.
lump medial to femoral pulse

102
Q

epigastric hernias

A

Abdominal contents breaches upper fibres of linae alba – low risk

103
Q

spigelian hernias

A

Small tender mass at thelower lateral edgeof the rectus abdominus – high risk

104
Q

presentation diverticular disease

A

Colicky, lower abdominal pain – relieved by defecation +/- altered bowel habit/flatulence/↕︎ bowel habit

105
Q

presentation acute diverticulitis

A

Acute, tender, stabbing lower abdominal pain + s/s of systemic upset

106
Q

classification diverticulitis

A

Complicated diverticulitis refers to abscess presence or free perforation
simple diverticulitis describes inflammation without these features.

107
Q

RF for diverticulum

A

age, low dietary fibre intake, obesity, smoking, family history, and NSAID use.

108
Q

mx diverticular disease

A

Patients with uncomplicated diverticular disease can often be managed as an outpatient* with simple analgesia and encouraging oral fluid intake. Outpatient colonoscopy should be arranged to exclude any masked malignancies.

109
Q

mx diverticular bleed

A

conservatively as most cases will be self-limiting.
Those that fail to respond to conservative management may warrant embolisation or surgical resection. Indeed, if a second bleeding episode occurs there is a significant chance of further episodes (up to 50%)

110
Q

mx acute diverticulitis

A

with antibiotics, intravenous fluids, and analgesia

111
Q

mx perforated diverticulitis

A

Surgical intervention* is required in those with perforation with faecal peritonitis or overwhelming sepsis. This is a major procedure and usually involves a Hartmann’s procedure (a sigmoid colectomy with formation of an end colostomy. Fig. 3); an anastomosis with reversal of colostomy may be possible at a later date

112
Q

AAA

A

Dilation of aorta >3cm – pulsatile mass o/e

113
Q

mx AAA

A

3 – 4.5cm: yearly USS
4.5 – 5.4cm: 3m USS
>5.5cm/growing >1cm/yr/unstable – URGENT

114
Q

presentation ruptured AAA

A

abdominal pain, back pain, syncope, or vomiting.On examination they will typically behaemodynamically compromised, with apulsatile abdominal massand tenderness.

115
Q

mx ruptured AAA

A

Oxygen
Access
Urgent bloods including 6u crossmatched
Assess whether stable: If stable – CT angio to assess ?endovascular. If unstable get to vascular centre and laparotomy

116
Q

cause renal/ureteric colic

A

calcium stones (oxalate > phosphate) but important rarer stones (e.g. struvite

117
Q

narrowings in ureter

A

Pelviuteric junction
Pelvic brim
Vesicouteric junction

118
Q

presentation ureteric/renal colic

A

Primary symptom is pain – colicky loin to groin +/- vomiting or tenderness in flank.

119
Q

ix renal/ureteric colic

A

Check bloods and urine dip + CT KUB

120
Q

mx renal/ureteric colci

A

Hydrate
PR Diclofenac +/- opiate +/- Abx
If obstructed/significant infection
Uteric stent

definitive: Extracorporeal Shock Wave Lithotripsy(ESWL, Percutaneous nephrolithotomy(PCNL, Flexible uretero-renoscopy(URS) and laser lithotripsy

121
Q

common causes acute abdomen

A

ABDOMINAL: Appendicitis, Biliary tract, Diverticulitis, Ovarian, Malignancy, Intestinal (Obstruction), Nephritic, Acute pancreatitis, Liquor

AEIOUs: Acute (appendicitis/pancreatitis)/AAA, ectopic, IBD/intestinal, Obstruction/Ovarian, Uteric/Uterine, Stones

122
Q

ix in acute abdomen

A

Urine, ABG, Routine Bloods, ECG and imaging

123
Q

causes acute abdomen in R upper quadrant

A

cholecystitis
pyelonephritis
ureteric colic
hepatitis
pneumonia

124
Q

causes acute abdomen in L upper quadrant

A

gasrtic ulcer
pyelonephritis
ureteric clic
pneumonia

125
Q

causes acute abdomenin R lower quadrant

A

appendicits
ureteric colic
inguinal hernia
IBD
UTI
gynae/testicular torsion

126
Q

causes acute abdomen in L lower quadrant

A

diverticulitis
ureteric colic
inguinal hernia
IBD
UTI
gynae/torsion

127
Q

causes acute abdomenin epigastric region

A

peotic ulcer disease
cholecystitis
pancreatitis
MI

128
Q

causes acute abdomen in peri-umbilical region

A

small and large bowel obstriction
appendicitis
AAA

129
Q

radio opaque stones

A

Urate and xanthine

130
Q

sepsis initial mx

A

Blood cultures
Urine output
Fluids
Abx
Lactate
Oxygen

131
Q

RF sepsis

A

surgery, age, immunosuppression, diabetes, invasive lines, IVDU, open wounds

132
Q

main classes of bacteria causing intra abdo sepsis

A

Gram –ve baccili e.g. e.coli,
Gram +ve cocci e.g. staph aureus

133
Q

why is lactate measures in sepsis

A

Shows level of anaerobic respiration from hypoxic tissues

134
Q

mx anaphylaxis

A

IM adrenaline 1:1000 500mcg (0.5mls)

IM/IV Chlorphenamine 10mg

IM/IV Hydrocortisone 200mg

135
Q

common features analphylaxis

A

wheeze, urticarial rash, Tongue swelling, lip and mouth tingling, shortness of breath, fatigue, clammy, palpitations
Signs: tachypnoea, tachycardia, hypotension, drowsiness, wheeze, stridor

136
Q

what causes hypotension in anaphylaxis

A

Histamine release causes mass vasodilation and capillary leak. This vasodilation reduces TPR and thus drops blood pressure. Capillary leak moves fluid from intra to extravascular space and thus drops total circulating volume.

137
Q

CXR features in tension pneumothorax

A

Flattened R hemi-diaphragm, increased R intercostal spaces, total R sided collapse
Absent lung markings R side, mediastinal shift to L side, trachea deviated to L

138
Q

mx tension pneumothorax

A

High flow O2 via 15L NRB, needle thoracostomy/chest drain insertion 2nd intercostal space mid-clavicular line

139
Q

cautions following tension pneumothorax

A

Avoid flying for at least 1 month post pneumothorax. Do not fly until CXR proof that pneumothorax resolved. Never ever go scuba-diving

140
Q

how to prevent tension pneumothorax recurring

A

Pleurodesis with sterile talc (either via chest drain or laparoscopic surgery), pleurectomy, or pleural abrasion (irritating pleura)

141
Q

RF PE

A

Factors which cause hypercoagulability, venous blood stasis or vascular wall damage (Virchow’s triad)

142
Q

score determining PE prognosis

A

PESI

143
Q

interpreting wells score for PE

A

Score >4 : PE likely  CTPA
Score <4: PE unlikely D-Dimer first  CTPA if positive.

144
Q

mx PE

A

anticoag- apixaban, rivaroxaban or LMWH

145
Q

mechanism of action rivaroxaban

A

Factor Xa inhibitor

146
Q

preventing PE

A

immediate mobilisation post surgery, TED stockings, LMWH prophylaxis

147
Q

mx acute HF

A

: Furosemide and O2
daily wt and fluid balance chart

148
Q

mx chronic HF

A

ACEI +BB
Spironolactone
Specialist stuff (hydralazine, nitrates, ivabradine, sacubitril valsartan)

149
Q

CXR features HF

A

Alveolar oedema, kerley B lines, cardiomegaly, upper lobe diversion, pleural effusions

150
Q

diagnosis HF

A

Transthoracic echocardiogram
to measure Left ventricular ejection fraction

151
Q

mx bleeding varices

A

Stabilise patient with IVI, RBC, correct clotting abnormalities (platelets/FFB/Vit K)
Terlipressin 1-2mg every 4-6h until bleeding controlled
Antibiotics: broad spectrum abx cover e.g. IV co-amoxiclav 1.2g TDS
Urgent endoscopy for variceal banding or gastric sclerotherapy
TIPS (trans-jugular intrahepatic porto-systemic shunt) if varices resistant or recurrent.

152
Q

severe hypovolaemia

A

Tachycardia >100bpm, hypotension <100mmhg systolic, CRT >3s, pallor, reduced GCS, urine output <0.5ml/kg/hr

153
Q

lab ix after vomiting blood

A

FBC, U&E, LFTs, Crossmatch, clotting screen

154
Q

mechanism causing bleeding oesophageal varices

A

Cirrhosis leads to portal hypertension (high pressure in portal venous system). When this pressure exceeds 10mmHg blood flow is redirected to a lower pressure system. This develops a collateral circulation around the lower oesophagus. As portal pressure increases, pressure increases in varices. They are thin walled and fragile and can burst causing UGIB.

155
Q

diagnosing bleeding oesophageal varices

A

Upper GI endoscopy (OGD)

156
Q

Glasgow Blatchford Score

A

can identify pts at low risk
(If GBS =0, risks of endoscopy outweigh benefits.)

157
Q

Rockall Score

A

Calculates risk of re-bleeding and death
(good to know)

158
Q

ix in MI

A

ECG, troponin at 0 and 3 h
later: CXR, echo

159
Q

complications of MI

A

Arrhythmias (brady or tachy), Left ventricular failure, cardiac arrest, pericarditis/dresslers syndrome

160
Q

RF MI

A

Smoking, Diabetes, hypertension, hypercholesterolemia, obesity, sedentary lifestyle, male gender, age, family history

161
Q

medications discharged on after MI

A

B-Blocker, ACEI, aspirin, clopidogrel/ticagrelor 1 yr, Statin

162
Q

driving after MI

A

4 weeks without driving if no successful revascularisation
1 week without driving if successful revascularisation

163
Q

hyperkalaemia categories

A

Mild (5.5-6.5)
Moderate (6.5-8.0)
Severe (>8.0

164
Q

when to tx hyperkalaemia

A

Treat hyperkalaemia if moderate/severe or if ECG changes

165
Q

ECG changes mild hyperkalaemia

A

peaked T wave
prolonged PR

166
Q

ECG changes moderate hyperkalaemia

A

loss of P wave
prolonged QRS
ST elevation
ectopic beats and escape rhythms

167
Q

ECG changes in severe hyperkalaemia

A

widening QRS
sine wave
VF
asystole
axis deviation
bundle branch block
fascicular blocks

168
Q

tx hyperkalaemia

A

Calcium Gluconate (10ml of 10% over 10min)
IV Insulin (10units) in IV glucose (50mls of 50%)

Regular monitoring of BMs and hourly K+ via bloods/VBG.

169
Q

what can cause hyperkalaemia

A

medications: Spironolactone, lisinopril
AKI

170
Q

reversible causes cardiac arrest

A

4H: hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia

4T: thrombosis, tension pneumothorax, tamponade, toxins

171
Q

shockable rhythms

A

VF/Pulseless VT

172
Q

non shockable rhythms

A

Not shockable: PEA/Asystole

173
Q

Which drugs are administered during a cardiac arrest?

A

Adrenaline 1mg IV/IO every 3-5mins,
Amiodarone 300mg IV/IO after 3 shocks

174
Q

DKA definition

A

Hyperglycaemia ( >11.0mmol/L or known DM)
Acidosis (pH <7.3)
Ketonaemia ( >3.0mmol/L)

175
Q

aims of DKA tx

A

Fall in ketones 0.5mmol/L/hr and glucose 3mmol/L/hr

Continue Insulin until ketones <0.3mmol/L, pH >7.3 and pt eating and drinking

176
Q

mx DKA

A

IV 0.9% NaCl approx1L/hr

50units insulin in 50mls NaCl 0.9% at a rate of 0.1unit/kg/hr

Hourly VBG (glucose, HCO3- and K+) Add K+ to IVI as required

Add 10% glucose IV once BM <14mmol/l to run alongside NaCl

177
Q

sx DKA

A

Drowsiness, vomiting, abdo pain, polyuria, polydipsia, lethargy, ketotic breath, deep breathing

178
Q

non epileptic causes of zeizures

A

electrolyte abnormalities, alcohol withdrawal, benzodiazepine withdrawal, , hypoxia, hyponatremia, hypocalcaemia, hypoglycemia, uremia, encephalitis etc.

179
Q

mx eplileptic seizures

A

Secure airway
High flow O2 and suction if required
IV lorazepam 4mg slow bolus if cannulated (buccal midazolam 5mg or rectal diazepam if not)
Repeat after 10 mins if seizure continues.
If seizures continue or recur in 30mins = Status Epilepticus
Phenytoin infusion 1-2g slow IVI (monitor BP and ECG)
ICU for RSI if lasting >60mins

180
Q

initial approach

A

Control catastrophic haemorrhage
Airway and cspine
Breathin gwith ventilation
Circulation with haemorrhage control
Disability-neuro
Exposure/environment/everything else

181
Q

MOI in major trauma

A

blunt force: RTC, assualt, fall
penetrating: shot, stab
sports
blast

182
Q

how to handover

A

Age
Time
Mechanism
Injuries
Signs and obs
Treatment

183
Q

mx catastrophic haemorrhage

A

direct pressire
indirect pressure: exclude proximal artery
torniquet: 2-3 inches above bleeding, 2nd one moreproximal if needed
haemostatic agents - ceetox

184
Q

mx airway

A

jaw thrust
need to secure in 45m
rapid sequence indiction
c-spine
oxygen
listen and look

185
Q

indications for intubation

A

cant mantain airway
cant oxygenate
cant mantain normocapnoea
decreasing consciousness
significant facial injury
seizures
burns: hypoxaemia, hypercanoea, deep facial, full thickness neck
relative: haemorrhage, shock, agitated, multiple painful injuries, transfer

186
Q

canadian c spine high RF

A

> 65
MOI: fall >1.5m, axial load
paraesthesia

187
Q

canadian spine low RF

A

minor rear end motorcollison
comfortable sittinhg
ambulatory
no midleine tenderness
delayed onset neck pain

188
Q

when ti imobilise c spine

A

canadian c spine
any high RF
if low RF and cant rotate head 45 degrees L and R

189
Q

life threatening thoracic injuries

A

airway obstruction
tension pneumothorax
open pneumothorax
massive haemorrhage
flail chest
cardiac tamponade

190
Q

features tension pneumothorax

A

blunt or penetrating injury
tracheal deviation late sign
increased HR, decreased BP, hypoxia, agitated

191
Q

massive haemothorax

A

> 15oo ml blood or >200ml/hr

192
Q

presentation massove haemothroax

A

decreased air sounds
hyporesonant

193
Q

mx open pneumothorax

A

3 sided seal dressing or will turn to tension pneumothorax

194
Q

what is flail chest

A

fractured 2 or more ribs in 2 or more places
moves paradoxically during respiration

195
Q

features cardiac tamponade

A

becks triad: decreased bp, decrased heart sounds, distended neck veins

196
Q

mx cardiac tamponade

A

thoracotomy

197
Q

signs of bleeding

A

decreased consciius, pale, sweaty, agitation, anxious
increased hr, increased rr, increased crt, narrow pulse pressure

198
Q

bleeding compartments

A

thorax
abdo
pelvis
long bones

199
Q

mx bleeding

A

permissive hypotension as too much fluid moves clot and makes worse
tranexamic acid

200
Q

measuring neuro diability

A

AVPU
pupil size and response
GCS:motor best predictor

201
Q

cushings triad

A

decreased HR and increased bp due to increased icp
irregular breathing

202
Q

mx disability

A

prevent secondary brain injury
secure airway if gcs less than 8
control ventilation
normal icp, glucose and oxygen

203
Q

what to look for in everything else

A

lumbs
keep warm
pain relief

204
Q

what is major trauma

A

injury severity score (retrospective) >15

205
Q

what is silver trauma

A

> 65s
most commonly fal from standing

206
Q

why does silver trauma happen

A

osteoporosis
polypharmacy
blood thinners
decresaed muscle mass, balance, stiff joints

207
Q

radiology in trauma

A

now use CT

208
Q

mechanism anaphylaxis

A

type 1 hypersnesitivity rxn which causes mast cell degranulation and histamine release

209
Q

mx anaphylaxis

A

remove stimulus
A-E: focus on airway and 2 large bore cannulae
IM 1:1000 adrenaline to thigh (0.1mg <6m, 0.15mg 6m-6y, 0.3mg 6-12y, 0.5mg adults)

210
Q

observation post anaphylaxis

A

24-48 hrs as biphasic rxn - more common in children

211
Q

ix once stable after anaphylaxis

A

serum mast cell tryptase
also another within 6h

212
Q

options for getting blood

A

group and save: get NONE - learn type and save
cross match: takes 45m
type specific: 20m, rarely used
O negative: can get from A&E and theatres and give to anyone
major haemorrhage protocol: 2222 and say MHP=4 uits RBC, 1 platelets, 3FFP brought by porter

213
Q

what do you get in the major haemorrhage protocol

A

4 units RBC
1 platelts
3 FFP
and a porter to bring it all

214
Q

Raised pCO2 and normal pH on ABG mx

A

Compensated
Therefore no panic
Sats 88-92%
Repeat ABG IF O2 demand increases

215
Q

Raised PCO2 AND low PH mx

A

Acute T2RF
Urgent senior rev
Sats 88-92%
NIV (BiPAP)

216
Q

T2RF causes

A

Copd
Obstructive sleep apnoea
Motor neurone disease
Guillean barre
Myasthenia gravis
Scoliosis
Resp fatigue
Opiates
Sedatives

217
Q

Naloxone dose

A

IV or IM if no access
Can bolus 400mcg but usually give in smaller increments (50) unless peri arrest

218
Q

Approach to reduced urine output

A

Is it actually low: norm=0.5ml/kg/hr, is it being measured accurately
Why: pre-renal (fluid status, med rev, sepsis), renal (urine dip), post renal (retention-bladder scan)
Ix; U&E, VBG hly input output chart
Trial IV fluid or encourage to drink if compliant

219
Q

First mx low urine output

A

CHECK CATHETER
flush
Check isn’t clamped

220
Q

Mx hyperkalaemia

A

ALL AT THE SAME TIME
Cannula and repeat U&E
ask nurse to do ECG
Prescribe and ask nurses to givr calcium gluconate (1st priority) and insulin dextrose (50ml 50% Dextrose fluid with 10 units insulin in)

Senior input
Tx cause (AKI)
Other options for reducing K: salbutamol neb, sodium zirconium cyclosilicate/calcium resonium
Monitor response - need cardiac monitoring (if not on CCU/resus put on the defib Monitor), VBG within an hr
Monitor blood glucose

221
Q

Less than what level is it unlikely to have ECG changes in hyperkalaemia

A

6

222
Q

F1 role in major haemorrhage

A

FLUID BOLUS - ask nurse
2222 - major haemorrhage protocol +/- cardiac arrest
Bleep med reg
Try and limit bleeding - press artery, not much can do if GI
GET MORE ACCESS - large bore cannulas

223
Q

Falls rev

A

Stable or caused by acute event (PE, bleed, stroke)
? CT head : anticoag, neurology, HI sx NICE CRITERIA
Other injuries: c spine, hips, joints
Why: Trip, BP, ECG
prevent: physio, mobility, supervision

finals (31 decks)

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