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Year 5/6 > Medicine: AcuteMed > Flashcards

Medicine: AcuteMed Flashcards

1
Q

Three components of assessing ACS

A

Hx

ECG

Troponin

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2
Q

Classic cardiac chest pain hx

A

Retrosternal heaviness, radiates to jaw +/- arm, exertion exacerbates sx, GTN may help, a/w autonomic features

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3
Q

ACS RFs

A

HTN, hyperlipidaemia, diabetes, FHx, smoking

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4
Q

Unstable Angina (inc both at rest + crescendo angina)

A

Hx is vital, no acute ECG findings, normal troponin -> admit for ACS tx + cardio review

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5
Q

What is crescendo angina?

A

Chest pain comes on after shorter and shorter distances of exertion

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6
Q

NSTEMI vs STEMI

A

NSTEMI - mismatch of O2 demand/consumption w some myocardial damage

STEMI - complete blockage of blood flow and transmural damage

There’s an elevated troponin in both

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7
Q

NSTEMI

A

ECG: normal, subtle ST abnormalities, ST depression, inverted T waves

Mx: A-E, cardiac monitor, serial ECGs, admit for ACS tx +/- angiography

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8
Q

What is the ACS tx?

A
  1. Load w Dual AntiPl (300mg Aspirin + 300mg Clopidogrel / 180mg Ticagrelol)
  2. 2-8d AntiCoag (2.5mg Fundaparinox OD)
  3. 1y Dual AntiPl (75mg Aspirin OD + 75mg Clopidogrel OD / 90mg Ticagrelol BD)
  4. If they had PCI then after 1y stop the clopidogrel/ticagrelol and persist w lifelong aspirin
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9
Q

When should angiography be performed?

A

Fit individuals within 72hrs

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10
Q

STEMI

A

ECG: ST elevation of 2mm in chest leads/1mm in two consecutive inferior leads, new LBBB, hyperacute T waves

Mx: A-E, PCI <90mins if in capable hospital, PCI <120mins if requires transfer, thrombolysis <30mins if PCI unavailable, plus MONA w/o high flow O2 due to free radicals unless sats are low

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11
Q

Which antiemetic doesn’t cause tachycardia?

A

Metoclopramide

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12
Q

The classification of stroke

A

Ischaemic - lacunar, atherosclerotic, cardiogenic emboli, cryptogenic

Haemorrhagic - SAH + intracerebral

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13
Q

The different types of a lacunar stroke

A

Pure motor, pure sensory, mixed sensorimotor, ataxic hemiparesis, clumsy hand, silent

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14
Q

The vasc territories of the brain

A

Ant Circulation - ACA, MCA, internal carotid

Post Circulation - PCA, basilar, vertebral

Cerebellum - SCA, AICA, PICA

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15
Q

ACA Stroke Syndrome

A

Contralateral leg > arm paresis or bilateral if both ACAs involved + mild sensory defect, disinhibition, executive dysfunction

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16
Q

MCA Stroke Syndromes

A

Face -> Arm -> Leg Weakness

Left Hemisphere ie dominant - right hemiparesis, sensory loss, homonymous hemianopia + dysarthria, aphasia, apraxia

Right Hemisphere ie non-dominant - left hemiparesis, sensory loss, homonymous hemianopia + dysarthria, neglect of left side, flat affect

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17
Q

PCA Stroke Syndromes

A

Occipital Lobe - contralateral homonymous hemianopia or quadrantanopia + cortical blindness if bilateral lesions

Medial Temp Lobe - deficits in long and short term memory + behaviour alteration

Thalamic - contralateral sensory loss, executive dysfunction, aphasia, memory impairment, dec level of consciousness

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18
Q

Where must the infarct be if the patient has a quadrantanopia?

A

The occipital lobe

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19
Q

Which strokes can cause a dec level of consciousness?

A

Large MCA, thalamic, brainstem

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20
Q

Cerebellar Stroke

A 
Dysdiadochokinesis
Ataxia
Nystagmus
Intention Tremor
Scanning Dysarthria
Hypotonia

+/- nausea, vomiting, headache

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21
Q

What else can AICA ischaemia present with?

A

Deafness

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22
Q

What are you worried about if a pt following a cerebellar stroke becomes drowsy?

A

Hydrocephalus, repeat CT head, may require surgery

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23
Q

What simple test should you always do for a pt w collapse and neurology?

A

Glucose

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24
Q

Tx of ischaemic stroke following CT head

A

IV alteplase within 4.5hrs unless absolute CI of intracerebral or active bleeding

If you miss the timeframe or there’s a CI then IV thrombectomy within 6-24hrs

Plus two wks 200mg aspirin then switch to long term 75mg clopidogrel, statin, lifestyle advice

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25
Q

What further ix do you do for a pt <65yrs following a stroke?

A

Prolonged heart recorder looking for AF, bubble echo looking for patent foramen ovale, homocysteine, thrombophilia screen, vasculitic screen, LP, HIV, FHx

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26
Q

How do you dx TIA?

A

They’re having a stroke until all sx/signs revolve within 24hrs w/o tx

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27
Q

How long should a pt be assessed by a specialist following a TIA?

A

Give 300mg aspirin STAT until reviewed within 24hrs

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28
Q

What are the red flags for admission following a TIA?

A

AF, more than one event within last wk, on anticoags

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29
Q

What should you do if TIA + AF?

A

Start anticoag w NOAC on the day

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30
Q

What is SIRS?

A

Systemic inflam response syndrome w >=2: temp >38 or <36, HR >90bpm, RR >20bpm or pCO2 <4.3kPa, WCC >12 or <4 x10^9/L or >10% immature forms

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31
Q

Def of sepsis

A

Life threatening organ dysfunction caused by a dysregulated host response to infection

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32
Q

Outline how sepsis is operationalised

A

Quick sequential organ failure assessment (qSOFA) where 2/3 predicts poor outcome: RR >=22bpm, GCS <15, SBP <=100mmHg

Plus just look at the pt: position, exhausted, temp, sweaty, confused, speaking

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33
Q

Def of septic shock

A

Underlying circulatory, cellular +/or metabolic abnormalities are profound enough to substantially inc mortality

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34
Q

Outline how shock is operationalised

A

Persisting hypotenion requiring vasopressors to maintain MAP >=65mmHg

Plus lactate >2mmol/L despite adequate fluid resus

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35
Q

Each section of the GCS

A

E4V5M6

Best eye response: spontaneous, to sound, to pressure, none

Best verbal response: oriented, confused, words, sounds, none

Best motor response: obey commands, localising, withdraws, decorticate, decerebrate, none

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36
Q

What’s a quicker way of recording the level of consciousness? And it’s correlation to GCS?

A

The AVPU Scale

Alert - 15, Verbal - 12, Pain - 8, Unresponsive - 3

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37
Q

What would be the most likely source of sepsis?

A

Pneumonia 50%

Urinary Tract 20%

Abdomen 15%

Skin + MSK 10%

Endocarditis 1%

Device Related 1%

Meningitis 1%

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38
Q

Sx that might indicate sepsis

A

Slurred speech or confusion

Extreme shivering, muscle pain, fever

Passing no urine all day

Severe breathlessness

It feels like they’re going to die

Skin mottled or discoloured

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39
Q

Sev Sepsis vs Septic Shock

A

Sev: evidence of end organ damage and hypotension responds to fluids

Shock: evidence of end organ damage w an inc lactate and hypotension refractory to fluids and inotropes requiring ITU management

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40
Q

What are the reversible causes of cardiac arrest?

A

Hypoxia
Hypovolaemia
Hypo/HyperK
Hypothermia

Toxins
Tamponade
Tension Pneumothorax
Thromboembolism

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41
Q

How do the 4H’s and 4T’s translate to the primary survey?

A

H’s: O2 sats, obvious bleeding and HR/BP, VBG, temp

T’s: known hx, examine, ECG, ultrasound, xray

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42
Q

What do pretty much all pts that come through resus get?

A

Fluids, O2, full CT

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43
Q

How do you act as a scribe?

A

Sign in sheet, pt stickers and date pages, pt wristband, age and gender, time of arrival, preload trauma booklet w obs, AMPLE

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44
Q

What does AMPLE stand for?

A 
Allergies
Medications
PMHx
Last Meal
Events
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45
Q

Which organs are most prone to ischaemia?

A

Brain
Heart
Kidneys

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46
Q

What are the two shockable and non-shockable rhythms?

A

Shockable: VF + pulseless VT -> one shock and 2mins CPR then reassess

Non-Shockable: asystole + pulseless electrical activity -> 2mins CPR then reassess

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47
Q

What does ROSC stand for?

A

Return of spontaneous circulation

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48
Q

When someone says they’re on HRT what should you inquire?

A

Reason, cyclical/continuous, SEs

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49
Q

What should you always ask about in a fall hx? (2)

A

Injury to the head and any neck/back pain

How long they were on the floor for to assess risk of rhabdomyolysis

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50
Q

How to counsel a miscarriage dx?

A

Very common 1/5 known pregnancies

It usually means the preg isn’t viable and not one you’d want to continue anyway

It doesn’t affect your fertility and chances of getting pregnant again

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51
Q

What can happen if you inject local into an artery?

A

Arrhythmias + Necrosis

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52
Q

What scoring system do nurses use for every pt?

A

Manchester Triage System where 1 is immediate resus and 5 is non-urgent

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53
Q

Chest Pain DDx

A

ACS - arm/neck/jaw, nausea, clammy, SOB, palps

PE + PT - SOB, haemoptysis, tender calves, recent surgery, long travel

Oesoph Rupture - epigastric & vomiting

Aortic Dissection - interscapular & neuro deficits

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54
Q

If they took GTN spray which helped?

A

Their own spray, when dx with IHD,

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55
Q

When is troponin measured?

A

Upon arrival and three hrs later

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56
Q

What is a good marker of re infarction?

A

CK-MB

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57
Q

Asthma Severity BTS

A

Acute Mod: inc sx + PEF 50-75%

Acute Severe: inability to complete sentences + PEF 33-50%, RR >=25, HR >=110

Life-Threat: clinical signs + PEF <33%, SpO2 <92%, T1RF

Near-Fatal: T2RF +/- requiring mechanical ventilation

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58
Q

Drugs causing pupil dilation

A

Cocaine, TCA, Atropine

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59
Q

Drugs causing pupil constriction

A

Opiates, Nicotine, Pilocarpine

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60
Q

What must you stop when reassessing the rhythm?

A

Chest compressions

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61
Q

What joules is the shock charged to?

A

150J

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62
Q

What is the definitive airway?

A

Tracheal intubation by the anaesthetists

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63
Q

How many mL/hr is an infusion rate of one drop per second?

A

180mL/hr

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64
Q

How do you categorise tachycardia’s?

A

Narrow Reg: sinus, SVT, Atrial Flutter, AVRT, AVNRT

Narrow Irr: AF

Broad Reg: VT + SVT w BBB

Broad Irr: Torsades + AF w BBB

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65
Q

How do you categorise bradycardia’s?

A

Sinus + Heart Block

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66
Q

The different types of heart block

A

AV, RBBB, LBBB, bifascicular, trifascicular

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67
Q

Def of trifascicular block

A

Presence of conducting disease in all three fascicles: right bundle branch, left anterior fascicle, left posterior fascicle

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68
Q

Def of bifascicular block

A

Combination of RBBB w either LAFB or LPFB

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69
Q

Which is more common LAFB or LPFB?

A

LAFB

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70
Q

Which part of the rhythm do you synchronise cardioversion with?

A

The R wave

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71
Q

Tx for SVT

A

Vagal Manoeuvres: carotid massage + valsalva

IV Adenosine

DC Cardioversion

NB: skip to DC cardioversion if haem unstable or others contraindicated

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72
Q

Tx for VT

A

Pulseless - defibrillation

Unstable - DC cardioversion

Stable - IV amiodarone

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73
Q

What should you have on standby when giving IV adenosine?

A

Resus equipment in case of VF or bronchospasm

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74
Q

What do you need to consider when performing a carotid massage?

A

Always auscultate for bruits first and don’t perform it on both sides simultaneously

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75
Q

Tx of Torsade de Pointes

A

IV Mg Sulfate

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76
Q

Why do pts fall?

A

CVS: arrhythmia, syncope, postural hypotension

Neuropsychiatric: vision, vestibular, cerebellar lesion, peripheral neuropathy, cognitive

MSK: instability, deconditioning, gait

Toxins: meds, polypharm, substance abuse

Environmental Hazards

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77
Q

How do you assess someone after a fall?

A

Hx + Collateral: location and activity, associated sx, drug hx, mobility aids, ADLs

O/E: CVS (HR BP HS ECG), Neuro - LL, MSK - Hip, Timed Up and Go Test (>12s), TURN180 (>4 steps)

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78
Q

Selection of adults for CT head scan

A

GCS <13 @ initial assessment

GCS <15 @ 2hrs after injury

Or: suspected skull fracture, any sign of basal skull fracture, post traumatic seizure, focal neuro deficit, >1 ep of vomiting since injury

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79
Q

Selection of children for CT head scan

A

GCS <14 @ initial assessment

GCS <15 @ 2hrs after injury

Or: suspected skull injury, tense fontanelle, any sign of basal skull fracture, focal neuro deficit, NAI

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80
Q

Signs of a basilar skull fracture

A

Raccoon eyes w tarsal plate sparing, haemotympanum, CSF otorrhea (Halo sign), postauricular ecchymosis (Battle sign)

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81
Q

What else should you enquire about if the pt complains of PV bleeding?

A

FLAWS + Anaemic Sx

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82
Q

Ddx for exertional chest pain that gets better w rest

A

CAD + AS/AR

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83
Q

What do you need to say when you put out a major haemorrhage call?

A

Paed v Adult

Med v Surg

Hosp, Ward, Bed

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84
Q

Who will be alerted following a major haem call?

A

Porter, haem, blood bank, resus team, hosp coordinator, theatre

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85
Q

What can the critical care outreach team do?

A

Nurses who can support the airway and prescribe

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86
Q

When you call 2222 what call can you put out?

A

Cardiac Arrest (3mins), Peri Arrest (5mins), Major Haem, Trauma, Obs/Neo/Paeds

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87
Q

What are the clinical signs of life-threatening asthma?

A

Altered conscious level, exhaustion, arrhythmia, hypotension, cyanosis, silent chest, poor resp effort

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88
Q

Outline the CURB-65 scoring

A 
Confusion
Urea >7.0mmol/L
Resp Rate >30
sBP>90 | dBP <60
>65yrs

+1 point for each feature: 0-1 if stable discharge w PO amoxicillin 500mg/8h, 2 admit to wards, 3-5 admit to critical care unit

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89
Q

Outline the modified wells scoring: high prob of PE

A

> 4 —> CTPA

<=4 —> D-dimer

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90
Q

If the pt is tachy what ix do you need to do?

A

ECG

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91
Q

Outline the PERC rule: low prob of PE

A

If any of the below are +ve cannot rule out PE: age >50, HR >100, sats <95, unilateral leg swelling, haemoptysis, recent surgery/trauma, prior PE/DVT, hormone use

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92
Q

LOC DDx (5)

A

Reflex: vasovagal, carotid sinus hypersensitivity, situational (cough + micturition)

Cardiac: arrhythmia, WPW, outflow obstrc, stokes-adams, orthostatic

Neuro: seizure, narcolepsy, SAH/ICH

Metabolic: hypoglycaemia, hypoNa, polypharm, benzos, alcohol/drugs

Hypovolaemic: aortic dissection, AAA, ruptured ectopic

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93
Q

What is the definition of syncope?

A

A sudden transient LOC due to a reduction in blood supply to brain w spontaneous recovery: reflex, stokes-adams, orthostatic

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94
Q

Syncope vs Seizure

A

Syncope: trigger, prodrome, a/w posture/twitch, short duration, rapidly reoriented

Seizure: no trigger, deja/jamais vu, a/w jerking/tongue biting/incontinence, prolonged duration, prolonged post-ictal disorientation

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95
Q

What are the 3 P’s of syncope?

A

Provoked, Prodrome, Postural

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96
Q

Workup for TLoC

A

Hx: collateral, SOB, dizxy, fhx sudden death, RFs, risk stratify

O/E: A-E, GCS, cardio, neuro, head injury, fractures, AMTS

Ix: obs, lying+standing BP, ECG, bm, preg test, bloods, CT head

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97
Q

What is the San Francisco syncope rule?

A

Predicts risk for srs outcome at 7d if the pt has any of:

Congestive HF
Haematocrit <30%
EKG Abnormal
Short of Breath
SBP <90mmHg

Do not use if definite seizure, head trauma, alcohol/drug related, persistent altered mental status or new neuro deficits

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98
Q

What is the OESIL score?

A

Predicts risk for 12m all cause mortality:

CVD
Age >65
Syncope w/o Prodrome
EKG Abnormal

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99
Q

What is a sig change in lying and standing BP?

A

> 20 Systolic

>10 Diastolic

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100
Q

What are the RFs in the hx for falls?

A

Prev hx, injuries, immobility, afraid, meds

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101
Q

List the three broad categories of syncope

A

Reflex
Cardiac
Orthostatic

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102
Q

How do you perform lying+standing BP properly?

A

Take the BP after the pt has been lying for 5mins then again after they’ve been standing for 1min and 3mins

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103
Q

What are the ECG findings of Brugada syndrome?

A

Pseudo RBBB and persistent ST elevations in V1-2

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104
Q

What safety issues should be considered for epileptics?

A

Looking after children, driving, bathing alone, working w heights/heavy machinery

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105
Q

A-E Approach: A

A

Patent? Responsive? Added sounds?

If not responsive: look, listen, feel approach

If not breathing: check pulse, call help, start CPR

Think about airway manoeuvres/adjuncts, suction, protect c-spine

If struggling to maintain bleep the anaesthetist and only move on once happy

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106
Q

A-E Approach: B

A

Obs: RR and O2 sats

O/E: inspect chest, tracheal deviation, expansion, percuss, ausc

Ix: ABG, CXR, Covid Swab | Mx: O2

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107
Q

A-E Approach: C

A

Obs: HR and BP

O/E: inspect peripheries, CRT, JVP, HS I+II, large bore cannula in each ACF, take bloods, G+S/XM, cultures, give fluid challenge, UO

Ix: ECG, Troponin, BNP | Mx: Abx

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108
Q

A-E Approach: D

A

Work around the C: pupils, AVPU/GCS, temp, glucose, drug chart

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109
Q

A-E Approach: E

A

Examine entirety for rashes, trauma, bleeding

Plus perform crude abdo, consider urine dip and PR, NV limb exams

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110
Q

What is a definitive airway?

A

It’s cuffed + below level of the vocal cords

111
Q

What do you want to check if the pt has suspected infective endocarditis?

A

Obs: fever

Heart: murmur

Abdo: splenomegaly + microscopic haematuria

112
Q

How do you measure up a guedel?

A

Soft-to-soft: tragus of ear to lateral edge of nostril

Hard-to-hard: angle of mandible to the midpoint of incisors

113
Q

Outline the GCS

A

E4: spontaneous, verbal, pain, none

V5: oriented, confused, inappropriate, incomprehensible, none

M6: obeys, localises, withdraws, flexion/decorticate, extension/decerebate, none

114
Q

How does AVPU match GCS?

A

A - 15
V - 13
P - 8
U - 6

115
Q

How could you test if hypotension was secondary to fluid depletion?

A

Elevate the legs whilst lying down then take the BP again

116
Q

RFs for Ectopic

A

Age
Smoking
Assisted Fertility
Prev Ectopic, Abdo/Pelvic Surg, STI

117
Q

On which side is an ovarian cyst rupture or torsion more likely?

A

Right as the rectosigmoid protects the L ovary

118
Q

What are the comps of chlamydia infection?

A

Inc ectopic risk, dec fertility, PID, Fitz Hugh Curtis syndrome

119
Q

Ddx for Miscarriage w Open/Closed Os

A

Open: Inevitable + Incomplete

Closed: Threatened, Complete, Missed

120
Q

Mx of Miscarriage

A

Expectant, Misoprostol, MVA

121
Q

What are your ddx for ptosis?

A

3rd Nerve, Horners, MG: check pupil size and if uni/bilateral

122
Q

What are causes of UMN signs? (3)

A

Stroke
Multiple Sclerosis
Cord Compression

123
Q

What would you like to ask pt w spinal back pain +/- neurology?

A

Bladder + Bowel Sx

124
Q

What are the causes of small muscle wasting in the hands?

A

Spinal cord: compression, syphilis, MND

Brachial plexus: trauma, cervical rib, pancoast tumour

Peripheral nerve: median palsy, ulnar palsy, RA

125
Q

What triad identifies virtually all NFT1?

A

Neurofibroma
Lisch Nodules
Cafe Au Lait Spots >15mm >6

126
Q

What is the chromosomal involvement in NF type 1 and type 2?

A

1 - Chr17

2 - Chr22

127
Q

What is loin to groin pain in the elderly until proven otherwise?

128
Q

What are the LT causes of epigastric pain?

A

Inferior MI, AAA, perf ulcer

129
Q

How do you distinguish clinically b/w the different causes of shock?

A

Peripheries Temp + JVP

130
Q

How do you risk stratify PE pts?

131
Q

Ddx of Atraumatic Back Pain

A 
Disc Prolapse
Muscle Spasm
Cauda Equina
Pott Disease
Metastasis

Plus: MI, AAA, perforated GU/DU, pancreatitis, renal colic

132
Q

What are the red flags of back pain?

A 
Age <20 or >55
Thoracic
Saddle Anaesthesia
Bladder/Bowel Dysfunction
Progressive Neuro Deficit
Disturbed Gait
Hx of Carcinoma
FLAWS
133
Q

O/E of Back Pain

A

Neuro (LL) + MSK (Hip)

Plus: SLR, Post Void Bladder Scan, DRE

134
Q

Selection of infant for CT head scan

A

GCS <15 @ initial assessment

Or: presence of bruise, swelling or laceration >5cm on the head

135
Q

Why is an ABG useful in the acute scenario?

A

Met Acidosis
Resp Failure
Lactate

NB: always write how much O2 pt is on and compare the gas to any prev

136
Q

What are the indications for a CXR in asthma?

A

Suspected pneumothorax/consolidation

LT

Failure to respond to initial therapy

Require ventilation

137
Q

How is hypothermia staged?

A

Mild 32-35
Mod 28-32
Sev <28

138
Q

Tx of Hypothermia

A

‘Noone is dead until warm and dead’

Withhold adrenaline until >30° and give every 6-10mins

Once above >35° every 3-5mins

Treat arrhythmias

Rewarm: passive, active, internal, external

139
Q

What toxins cause cardiac arrest?

A

Opioids
Benzos
TCAs

140
Q

What are the common iatrogenic causes of cardiac tamponade?

A

Cardiac Surgery
Pacemaker Insertion
Penetrating Trauma

141
Q

Opioid Toxidrome

A

Red RR, GCS, Pinpoint Pupils

Mx: naloxone 0.4mg if rapidly falling GCS, abnormal breathing pattern, T2RF - beware of opioid withdrawal and provoking seizures

If sx relapse within 1hr run a naloxone infusion 10mg in 50ml dextrose, partial response consider doxapram, no effect intubate

142
Q

Anticholinergic Toxidrome

A

Dry, Dilated, Delirious

Obs: tachycardic, hypotensive, pyrexic

Mx: bicarbonate 8.4% if QRS >120ms, refractory hypotension, cardiac arrest - aim for arterial pH 7.5 to promote binding of drug to plasma proteins and stabilise the myocardium

If prolonged QT give magnesium + prolonged CPR can yield favourable neuro outcomes

143
Q

Serotonin Syndrome

A

Overactive ie agitated, sweating, hyperreflexic

Obs: tachycardic, hypertensive, hyperpyrexic

Biochem: dec Na, inc CK, DIC, met acidosis

Mx: external cooling, benzos for agitation and muscle rigidity, low threshold to intubate ventilate paralyse to control temp, dantrolene, avoid fluids and paracetamol

144
Q

Benzodiazepine Toxidrome

A

Drowsy, Ataxic

Obs: bradycardic, hypotensive, hypoventilation

Mx: intubate and ventilate until the drug wears off + use flumazenil w caution only if pt develops T2RF and observe for seizures

145
Q

What is the specific antidote for methanol/ethylene glycol?

A

Fomepizole

146
Q

Salicylate OD

A

Tinnitus, N+V, Hyperventilation, Dehydration, Sweating

Mild: <150mg/kg or <300mg/L

Mod: 150-300mg/kg or 300-700mg/L

Sev: 300-500mg/kg or >700mg/L

147
Q

What is the oxygen content of the blood?

A

Hb x SaO2 x 1.3 x 10

148
Q

What is the delivery of oxygen to tissues?

A

Hb x SaO2 x 1.3 x 10 x Cardiac Output

149
Q

How can you improve DOT?

A

Inc 1. Hb 2. FiO2 3. CO

150
Q

Oxygen Dissociation Curve

A

Left Shift: dec temp, 2-3 DPG, [H+]

Right Shift: inc temp, 2-3 DPG, [H+]

151
Q

How can you tell the different causes of shock apart?

A

The JVP will be elevated if the cause is cardiogenic and the peripheries will be warm if the cause is septic or neurogenic

152
Q

Criteria making anaphylaxis likely

A

Sudden onset and rapid progression of sx

Life threatening ABC problems

Skin and/or mucosal changes (flushing, urticarial, angioedema)

Exposure to a known allergen for the pt supports the dx

Most reactions occur over several minutes and quicker if an IV trigger

The patient will look and feel unwell

There may also be GI sx such as D+V

153
Q

Mx for anaphylaxis

A

Stop offender, high flow O2, early anaesthetist intervention to I+V if required, 500microg IM adrenaline, 200mg IV hydrocortisone, 10mg IV chlorphenamine, 1L Hartmann’s solution

154
Q

What is Livedo Reticularis?

A

A normal phenomenon resembling mottling of the skin caused by red blood flow

155
Q

When is Livedo Reticularis concerning?

A

DIC plus severe sepsis

156
Q

The sepsis six

A

IN
O2, abx, fluid challenge

If remain hypotensive despite fluids then crit care review for consideration of vasopressors

OUT
Lactate, cultures, urine output

Plus FBC, U&Es, LFTs, CRP, ABG

157
Q

Mx for asystole

A

I+V, 100% O2, 0.9% saline/Hartmanns bolus, CPR w adrenaline every 3-5mins during rhythm checks

158
Q

How does sepsis cause a cardiac arrest?

A

Acute MI, hypoxia, hypovolaemia

159
Q

What is the rule of nines for working out percentage total body SA involved in a burn?

A

Wallace’s Rule of Nines:

Ant Trunk - 18%

Post Trunk - 18%

Whole Leg - 18%

Whole Arm - 9%

Whole Head - 9%

Palm/Genitals - 1%

160
Q

How do you calculate the fluid requirement for the first 24h following a burn?

A

All adults w burns >15% TBSA should receive fluids using the Parkland Formula: 4ml x Wt in kg x %Burn

161
Q

Over what time period are fluids given following a burn?

A

First half of fluids given over first 8hrs and second half given over nxt 16hrs

162
Q

When do you catheterise burn pts?

A

> 20% TBSA or if they’re intubated

Consider if 15-19% TBSA or if w perineal burns

163
Q

When titrating fluids what urine output do you wish to maintain?

A

> =0.5ml/kg/hr

164
Q

What are the indications for referral to a regional burns unit?

A

Burns >10% TBSA in an adult, >5% TBSA in a child, >5% TBSA if full thickness

Burns of face, hands, feet, perineum, genitalia or major joints

Circumferential, chemical or electrical burns

Burns in the presence of major trauma or significant co-morbidity

Burns in the very young, pregnant or elderly patient

Suspicion of NAI

165
Q

Why are burns painful?

A

Air moving across exposed nerve endings hence apply cling film

166
Q

What can you give if simple analgesia is not controlling the pain from a burn?

A

One off dose of intra-nasal diamorphine

167
Q

Superficial v Partial v Full

A

Superficial burns are usually dry, sometimes with minor blistering and erythema. Painful. Often due to sunburn or minor scalds. Involve the epidermis.

Partial thickness burns are moist and red, usually with broken blisters and normal capillary refill. Involve the dermis. They are usually painful unless they are deep dermal. Deep dermal burns may also have sluggish capillary refill.

Full thickness burns are dry, charred and often white. They are painless and have absent capillary return. They have destroyed the epidermis and dermis and have begun to destroy the underlying subcutaneous tissue.

168
Q

Why should you deroof the blisters following a burn?

A

To accurately assess the depth

169
Q

Mx for epistaxis

A

Pressure to ant aspect for 15-20mins

Cautery w silver nitrate to the side bleeding

Rapid rhino into both nostrils for up to 24hrs

Foley catheter nose-oropharynx and repack nose

170
Q

What is the toxic dose of paracetamol?

171
Q

What are the Toxbase guidelines following a paracetamol OD?

A

> 75mg/kg: bloods at 4h post ingestion, plot results on normogram, either NAC or referring to psych

> 150mg/kg: if unable to act on bloods within 8h post ingestion give NAC immediately

172
Q

What is immediately administered once cardiac arrest has been confirmed and pt does not have a shockable rhythm?

A

Adrenaline

173
Q

TCA OD

A

Mild-Mod: dilated pupils, tachycardia, drowsiness, dry mouth, urinary retention, confusion and agitation

Severe: hypotension, cardiac rhythm disturbance, hallucinations and seizures

174
Q

Diazepam OD

A

Drowsiness, respiratory depression, ataxia and hypothermia

175
Q

Sertraline OD

A

Vomiting, tremor, drowsiness, dizziness, tachycardia and seizures

176
Q

What are the indications for treating amitriptyline od?

A

Metabolic acidosis or wide QRS complexes

177
Q

What do you do after diagnosing an acute subdural haematoma, raised INR and stopping the warfarin?

A

Discuss w neurosurgery and give Octaplex w 5mg IV vitamin K

178
Q

What are the shockable and non-shockable rhythms?

A

Shockable: VF + pulseless VT -> one shock and 2mins CPR then reassess

Non-Shockable: asystole + pulseless electrical activity -> 2mins CPR then reassess

179
Q

What is the dosing of NAC?

A

150mg/kg over an hr

50mg/kg over nxt 4hrs

100mg/kg over nxt 16hrs

180
Q

Which bloods do you recheck after the 21h NAC infusion?

A

INR and ALT

181
Q

When should you admit a pt w burns to secondary care?

182
Q

What appearance of a burn suggests which depth?

A

Superficial epidermal: red + painful

Superficial dermal: pale pink, painful, blistered

Deep dermal: typically white but may have patches of non-blanching erythema + red sensation

Full thickness: white/brown/black, no pain, no blisters

183
Q

What NEWS score is considered significant?

A

5 or more in total or 3 or more in one domain

184
Q

How do you assess the airway?

A

Protect cervical spine if an injury is possible
Look inside the mouth and remove objects/dentures
Assess for signs of obstruction
○ Use wide-bore suction under direct vision if secretions are present
If vocalising, can assume airway is patent
Listen for stridor, snoring or gurgling
Establish a patent airway using:
○ Manoeuvres (e.g. chin lift, jaw thrust)
○ Adjuncts (e.g. oropharyngeal airway (Guedel))
If airway still impaired –> CALL ARREST TEAM (2222)

185
Q

How do you assess breathing?

A

Look for chest expansion (equal? Fogging of mask?)
Listen for air entry (equal?)
Feel for expansion and percussion (equal?)
Start 15 L oxygen via a non-rebreather
Use a bag valve mask if there is poor or absent respiratory effort
Monitor SaO2 and RR
Check for tracheal deviation and cyanosis
If NO respiratory effort –> CALL ARREST TEAM (2222)
○ Intubate and ventilate
If breathing is compromised, give 15 L oxygen through a non-rebreather mask

186
Q

How do you assess circulation?

A

Look for pallor, cyanosis and distended neck veins (JVP)
Feel for central pulse (carotid/femoral) - rate and rhythm
Monitor defibrillator ECG and BP
Gain venous access and send bloods if time allows
12-lead ECG
Treat shock
If NO cardiac output –> CALL ARREST TEAM (2222)

187
Q

How do you assess disability?

A

Consciousness (GCS/AVPU)
Pupils
Blood glucose

188
Q

What are some common causes of peri-arrest?

A 
Arrhythmia
MI
Hypovolaemia
Sepsis 
Hypoglycaemia 
Hypoxia 
Pulmonary oedema 
PE
Metabolic (hypo or hyperkalaemia)
Tension pneumothorax
189
Q

What are the components of qSOFA?

A

RR > 22
GCS < 15
SBP < 100

190
Q

What is the difference between severe sepsis and septic shock?

A

Severe sepsis: sepsis with evidence of organ hypoperfusion (e.g. hypoxaemia, oligaemia, confusion)
Septic shock: severe sepsis with hypotension despite adequate fluid resuscitation

191
Q

What are the sepsis 6?

A 
Give oxygen (15 L through NRB) 
Give IV fluids (bolus = 20 mL/kg)
Take blood cultures 
Take lactate 
Monitor urine output (aim >=0.5ml/kg/hr)
Give broad-spectrum antibiotics

ALL WITHIN 1 HOUR

192
Q

When should sepsis patients be escalated further?

A

SBP fails to reach > 90 mm Hg

Lactate remains > 4 mmol/L

193
Q

How should haemorrhagic shock be managed?

A

2 L of crystalloid
If this fails to resuscitate –> X-match
Give FFP and packed red cells (1:1) aiming for platelets > 100 and fibrinogen > 1

194
Q

Which medications are used in the management of anaphylaxis?

A 
Adrenaline 0.5 mg IM (0.5 mL of 1:1000)
Repeat every 5 mins as necessary 
Chlorphenamine 10 mg IV 
Hydrocortisone 200 mg IV
IV fluid bolus if shocked
195
Q

What should be done after the a patient with anaphylaxis has been stabilised?

A

Admit to ward
Monitor ECG
Continue chlorphenamine 4 mg per 6 hours PO if itching
Suggest MedicAlert bracelet
Prescribe autoejector
Consider skin-prick testing or specific IgE

196
Q

Outline the management of aortic dissection.

A

Fast bleep cardiothoracic surgery
Transfer to ITU
Use hypotensives (e.g. labetalol) to maintain SBP 100-110
Document and debrief

197
Q

Outline the management of a ruptured AAA.

A 
Fast bleep vascular surgery and anaesthetics 
Take the patient straight to theatre 
Gain IV access 
Administer O- if necessary 
Keep SBP < 100 mm Hg
198
Q

Outline the initial management of a STEMI.

A

Morphine 5-10 mg IV (repeat after 5 mins if necessary)
Metoclopramide 10 mg IV
Oxygen 15 L via non-rebreather
Nitrates
Aspiring 300 mg PO (with clopidogrel or ticagrelor)

199
Q

What doses of second antiplatelet agents are used with aspirin in the prevention of atherothrombotic events in ACS?

A

Clopidogrel 300 mg followed by 75 mg

Ticagrelor 180 mg STAT followed by 90 mg BD

200
Q

Which medications should patients who have had an MI take home?

A 
Dual antiplatelet therapy (continue for 12 months)
GTN spray 
Beta-blocker 
ACE inhibitor 
Statin
201
Q

Outline the management of acute heart failure.

A

Diamorphine 1.25-5 mg IV (caution in liver failure or COPD)
Furosemide 40-80 mg IV
GTN spray 2 puffs sublingual (consider isosorbide mononitrate infusion 2-10 mg/hour)

202
Q

What should be considered if a patient in acute heart failure deteriorates?

A

Further dose of 40-80 mg furosemide
Consider CPAP
Increase nitrate infusion
Refer to ITU

203
Q

How should a patient with acute heart failure be managed once they have been stabilised?

A

Monitor daily weight and observations
Repeat CXR
Switch to oral furosemide or bumetanide
ACE inhibitor if LVEF < 40%
Consider beta-blocker and spironolactone
Consider biventricular pacing or transplantation
Consider digoxin and warfarin

204
Q

Outline the management of broad complex tachycardia in a haemodynamically UNSTABLE patient.

A
  • DC cardioversion
  • Hypokalaemia and hypomagnesaemia
  • Amiodarone 300 mg IV over 10-20 mins through a central line
  • Procainamide and sotalol in refractory cases
205
Q

Outline the management of broad complex tachycardia in haemodynamically STABLE patients.

A

Correct electrolyte abnormalities
Amiodarone 300 mg IV over 10-20 mins
If it fails –> DC cardioversion

NOTE: after correction of VT, patients should be given maintenance antiarrhythmic therapy (e.g. sotalol)

206
Q

Outline the management of torsades des pointes.

A

Stop predisposing drugs (e.g. TCAs)
Correct hypokalaemia
Give magnesium sulphate 2 g over 10 mins

207
Q

Outline the management of narrow complex tachycardia.

A

Vagal manoeuvres
Adenosine 6 mg IV bolus (followed by 0.9% saline flush)
If unsuccessful –> after 2 mins give 12 mg bolus
If unsuccessful –> after 2 mins give 12 mg bolus
Alternative: verapamil 2.5-5 mg over 2 mins

208
Q

How should AF in an unstable patient be treated?

A

Emergency cardioversion
If unavailable –> IV amiodarone
Control ventricular rate: verapamil 40-120 mg/8 hrs PO or bisoprolol 2.5-5 mg/day PO
Start anticoagulation with LMWH

NOTE: cardioversion is only recommended if it can be done within 48 hours of the onset of symptoms

209
Q

Which medications should patients with AF be given to take away?

A 
Use CHADS-Vasc to calculate need for anticoagulation (1 or more requires warfarin) 
Rate control (beta-blocker or CCB) 
Rhythm control (flecainide if no structural heart disease, otherwise amiodarone)
210
Q

Outline the investigations that you would request for a suspected acute asthma attack.

A

Bedside: PEFR, ECG, ABG, SaO2
Bloods: FBC, U&E
Imaging: CXR?

211
Q

Outline the management of severe acute asthma.

A

Nebulised salbutamol 5 mg with oxygen
IV hydrocortisone 100 mg (or PO prednisolone 40-50 mg)
If it worsens
- add ipratropium bromide nebuliser 0.5 mg
- stat dose of magnesium sulphate 1.2-2 g IV over 20 mins

212
Q

If a patient with a severe asthma is showing signs of improvement, how should they be cared for?

A

Nebulised salbutamol every 4 hours
Prednisolone 40-50 mg OD for 5-7 days
Monitor PEFR and oxygen saturations

213
Q

How should a patient with life-threatening acute asthma be escalated if initial treatment fails to cause an improvement?

A

Refer to ICU
May need ventilatory support (e.g. intubation)
May need intensified treatment (e.g. IV aminophylline, IV salbutamol)

214
Q

Outline the management of an infective exacerbation of COPD.

A

BRONCHODILATOR: nebulised salbutamol 5 mg/4 hr + nebulised ipratropium 0.5 mg/6 hr
OXYGEN: at 24-28% via venturi mask aiming for 88-92%
STEROIDS: IV hydrocortisone 200 mg (or oral prednisolone)
ANTIBIOTICS: trust guidelines (e.g. amoxicillin or doxycycline)

215
Q

How should the treatment of a patient with an infective exacerbation of COPD be escalated if they fail to respond to initial treatment?

A

Consider IV aminophylline
Consider NIV
Consider intubation and ventilation
Consider respiratory stimulant (e.g. doxapram)

216
Q

Which investigations may be useful in patients with acute pancreatitis?

A

Bedside: glucose
Bloods: amylase, lipase, FBC, U&E (calcium), LFTs, ABG, glucose
Imaging: USS, erect CXR, AXR (rule out other causes of acute abdomen), ERCP

217
Q

Outline the management of acute pancreatitis.

A

Assess severity using Modified Glasgow Criteria
NBM
IV fluids to achieve normal vital signs (3rd spacing)
Insert catheter to monitor urine output
Analgesia (IM pethidine 75-100 mg/4 hr or morphine)
If worsening –> ITU (may need ERCP)

218
Q

Outline the management of a primary pneumothorax.

A

No SOB + < 2 cm rim of air on CXR –> consider discharge and repeat CXR in a few weeks
SOB + > 2 cm rim of air on CXR –> aspiration
- if unsuccessful –> repeat aspiration
- if unsuccessful –> insert chest drain

219
Q

Outline the management of a secondary pneumothorax.

A

No SOB, age < 50 yrs + < 2 cm rim of air –> aspiration
- if successful –> admit for 24 hours
- if unsuccessful –> insert chest drain
SOB, age > 50 yrs and > 2 cm rim of air –> insert chest drain

220
Q

Outline the management of tension pneumothorax.

A

Insert a large-bore needle that is partially filled with saline into the 2nd intercostal space in the MCL on the side of the suspected pneumothorax - remove plunger to allow air to bubble through the syringe
OR: into the safe triangle

221
Q

Outline the management of PE in a stable patient.

A

Oxygen
Morphine 5-10 mg IV with 10 mg metaclopramide
SC tinzaparin 175 U/kg/24 hrs (or UFH 10,000 IV bolus)

222
Q

How does the systolic BP affect the management of PE?

A

SBP > 90 mm Hg –> warfarin loading regimen (e.g. 5-10 mg warfarin PO)
SBP < 90 mm Hg –> IV colloid infusion + contact ICU –> dobutamine 2.5-10 µg/kg/min IV –> IV noradrenaline infusion –> consider thrombolysis

223
Q

Describe the ongoing management of PE after the immediate situation has been dealt with.

A

Reduce risk of recurrence (e.g. compression stockings)
LMWH should be continued with warfarin until INR > 2 for 24 hours or 5 days after starting warfarin (whichever is longest)
If obvious cause of VTE –> 3 months warfarin
If no obvious cause of VTE –> continue for 3-6 months

224
Q

How is a massive PE in a haemodynamically compromised patient treated?

A

10 mg alteplase followed by 90 mg infusion over 2 hours

225
Q

What crucial blood tests should be requested in patients with an acute upper GI haemorrhage?

A 
FBC 
Group and save 
X-match 6 units of blood 
Clotting screen 
LFT
226
Q

Outline the immediate management of shocked patients with an acute upper GI bleed.

A

Protect airway and keep NBM
Insert two large-bore cannulae
Rapid IV crystalloid infusion up to 1 L
If grade III-IV shock, give O- blood until X-match is complete
Correct clotting anomalies (e.g. PCC, vitamin K)
Consider ICU referral for central venous line
Catheterise to monitor urine output (aim > 30 mL/hour)
Monitor vital signs
Notify surgeons
Endoscopy within 4 hours for variceal bleed and within 12-24 hours if unstable on admission

227
Q

Outline the medical management of acute upper GI bleeds.

A

Major ulcer bleeding –> omeprazole 80 mg IV stat over 40-60 mins followed by 8 mg/hour for 72 hours
Variceal bleeding –> resuscitate then urgent endoscopy for banding or sclerotherapy + terlipressin 2 mg SC QDS

NOTE: if large bleed, Sengstaken-Blakemore tube may be used to tamponade the bleed and lactulose may be given to reduce absorption of nitrogenous products

228
Q

Outline the management of bacterial meningitis.

A

Sepsis 6
Cefotaxime 2 g IV (add ampicillin 2 g/6 hrs IV if immunocompromised or > 55 years)
Call critical care team
If meningitis only: consider adding dexamethasone 4-10 mg/6 hrs IV

229
Q

Outline the ongoing management of a patient with bacterial meningitis who has been stabilised.

A

Discuss antibiotic treatment with microbiology
Isolate in side-room for 24 hours
Treat contacts with ciprofloxacin 500 mg PO

230
Q

Which drug treatment is used for suspected encephalitis?

A

IV aciclovir (10 mg/kg/8 hrs IV)

231
Q

How much insulin should be given to patients with DKA?

A

50 u actrapid in 50 mL of 0.9% saline
Infused continuously at 0.1 u/kg/hour
Aim for a fall in ketones of 0.5 mmol/L/hour
OR rise in venous bicarbonate of 3 mmol/L/hour with a fall in glucose of 3 mmol/L/hour

NOTE: check VBG at 1 hour, 2 hours and 2 hourly thereafter

232
Q

When should glucose be added to the infusion in DKA?

A

10% glucose at 125 mL/hour alongside saline when glucose < 14 mmol//L

233
Q

Outline the management of acute abdomen.

A

Gain IV access
Catheterise and place on fluid balance chart if hypotensive
Analgesia: 100 mg diclofenac PR for renal pathology, or 5-10 mg morphine IV for intra-abdominal pathology
Send blood sample for FBC, U&E, amylase, LFT, CRP and G&S
IV antibiotics if indicated
NBM

234
Q

Outline the management of stroke.

A

15 L/min oxygen if low saturations or SOB
NBM
100 mL/hour 0.9% saline
Treat arrhythmias
Get exact timescale of symptom onset
Request urgent CT scan
Once haemorrhagic stroke ruled out: aspirin 300 mg STAT and thrombolyse with tPA of < 80 yrs and < 4.5 hours or > 80 yrs and < 3 hours

235
Q

Outline the treatment of hyperkalaemia.

A

10 mL 10% calcium gluconate IV over 2 mins (repeat every 15 mins up to 5 doses)
10 IU Actrapid with 50 mL 50% dextrose IV over 10 mins
Consider 5 mg salbutamol nebuliser
Monitor ECG and have access to crash trolley
Check ABG for acidosis

236
Q

How are pre-renal and post-renal causes of AKI treated?

A

Pre-renal: fluid resuscitation with 0.9% saline (250-500 mL bolus) followed by infusion of 20 mL + last hour’s urine output
Post-renal: catheterise

NOTE: pulmonary oedema should be treated with furosemide IV

237
Q

List the indications for dialysis in AKI.

A

Hyperkalaemia unreponsive to medical treatment in an oliguric patient
Pulmonary oedema unresponsive to medical treatment
Uraemia (e.g. encephalopathy)
Severe metabolic acidosis (pH < 7.2)

238
Q

Outline the management of hypokalaemia.

A

Monitor U&E and ECG
40 mmol/L KCl in 1 L of 0.9% saline (unless oliguric –> insert catheter to ensure accurate assessment of urine output)
Admit to ICU for insertion of a central line if > 10 mmol/hr needed
If MILD: oral K+ supplementation (SandoK)

239
Q

Which investigations would be useful in a patient with hyponatraemia?

A

Hypovolaemic –> low urine sodium
Euvolaemic –> TFT, SST, plasma and urine osmolality
Hypervolaemic –> low urine sodium

240
Q

Outline the management of hyponatraemia.

A

Do NOT correct faster than 8-10 mmol/L/24 hrs
Hypovolaemic –> 0.9% saline
Euvolaemic –> fluid restriction

241
Q

Outline the management of hypocalcaemia.

A

Mild and asymptomatic: monitor, consider vitamin D supplements and calcichew
Severe tetany: 10 mL 10% calcium gluconate IV over 10 mins

242
Q

Outline the management of hypercalcaemia.

A

Correct dehydration with 0.9% saline (3-6 L in 24 hours with the first 1 L going in over 1 hour)
Furosemide may be needed in elderly patients who are prone to pulmonary oedema
Insert catheter to monitor urine output
IV bisphosphonate for bone pain (takes 1 week to work)

243
Q

Which investigations are important to order in patients with status epilepticus?

A 
U&E
FBC 
LFT
Glucose 
Calcium
Toxicology 
AED levels 
CT/MRI head
244
Q

Outline the management of status epilepticus.

A

Secure the airway (may need adjuncts)
STEP 1: Slow IV bolus of IV lorazepam 2-4 mg
Second dose if no response within 10 mins
Thiamine if alcoholism is suspected
Glucose 50 mL 50% IV if hypoglycaemia is suspected
STEP 2: IV phenytoin infusion 15-20 mg/kg at < 50 mg/min
STEP 3: rapid sequence induction with thiopental and EEG monitoring

245
Q

Outline the management of pneumonia.

A

Treat hypoxia and hypotension if necessary
Antibiotics following local guidelines (e.g. CAP = coamoxiclav and clarithromycin; HAP = tazocin)
Analgesia if pleuritic chest pain
CPAP if no improvement

246
Q

Which investigations should be requested in suspected pneumonia?

A

Bedside: oxygen saturation, ABG, sputum sample, urine sample (Legionella)
Bloods: FBC, U&E, CRP, atypical serology
Imaging: CXR

247
Q

Which investigations would you request in a patient with delirium?

A

Bedside: glucose, ABG, ECG, urine dipstick
Bloods: FBC, U&E, LFTs, blood glucose, blood cultures
Imaging: CXR, CT/MRI

248
Q

Outline the management of bradycardia.

A

Sit the patient up (unless dizzy)
15 L/min oxygen if hypoxic
Give 0.5 mg atropine IV every 2-3 mins (up to max 6 doses)
If unsuccessful –> isoprenaline 5 µg/min
If unsuccessful –> adrenaline 2-10 µg/min
If unsuccessful –> transcutaneous pacing

249
Q

Outline the management of hyperosmolar hyperglycaemic state (HHS/HONK).

A

Rehydrate slowly with 0.9% saline over 48 hours (deficit is typically 110-220 mL/kg)
Equated to 8-15 L for 70 kg adult
First 1 L may be given quickly over 30 mins
Replace K+ when urine starts to flow
Use insulin sliding scale if glucose is NOT falling by 5 mmol/L/hr with rehydration
Keep glucose at 10-15 mmol/L for first 24 hours (avoid cerebral oedema)

250
Q

If a nurse contacts you regarding a patient who has become unconscious, what should you tell them to do?

A

Check for respiratory effort/pulse and begin CPR if absent

251
Q

How should an Addisonian crisis be treated?

A

100 mg hydrocortisone STAT
Followed by 100 mg/8 hrs hydrocortisone

NOTE: they may need fludrocortisone, glucose and fluids

252
Q

What are the components of a SOFA score?

A 
Respiratory rate 
Bloodpressure 
GCS 
Liver (bilirubin) 
Coagulation (platelets) 
Renal (creatinine and urine output)

Sepsis = infection + increase of 2 or more on SOFA

253
Q

Outline the management of NSTEMI.

A

Give oxygen if breathless or SaO2 < 90%
Morphine 5-10 mg IV + antiemetic
Nitrates (GTN spray or sublingual)
Aspirin 300 mg PO + second antiplatelet agent (clopidogrel, ticagrelor, prasugrel)
Oral beta-blocker (e.g. metaprolol) if hypertensive/tachycardic/low LV function
Fondaparinux 2.5 mg OD SC or LMWH 1 mg/kg/12 hours SC
IV nitrate if pain continues
HIGH RISK PATIENT
- Features: rise in troponin, dynamic ST or T wave changes, risk factors
- Begin infusion of tirofiban and refer for inpatient angiography (within 72 hours)
- Angiography may need to be within 24 hours if GRACE score > 140

254
Q

Which additional measures may be used during the A to E approach of a trauma patient?

A

Check for blood on the floor
Arrange FAST scan/pelvic X-ray
For unstable pelvic fractures use a pelvic band to reduce blood loss

255
Q

Outline the algorithm for the major haemorrhage protocol.

A

Take baseline blood samples (FBC, G&S, X-match, Clotting, fibrinogen)
If trauma < 3 hrs: give tranexamic acid (1 g over 10 mins, then 1 g/8 hrs infusion)
Limit use of O-negative blood and use group-specific blood as soon as possible

256
Q

What is the definition of major haemorrhage?

A

Loss of more than one blood volume in 24 hrs
Loss of 50% blood volume in 3 hours
Bleeding in excess of 150 mL/minute

257
Q

Which extra parts of an A to E would you do in a patient with suspected spinal cord compression?

A

D - palpate for spinal tenderness and perform a lower limb neurological examination to assess tone, power, reflexes and sensation
E - percuss the bladder (urinary retention), perform a rectal examination (tone and saddle anaesthesia) - important to consider cauda equina as a differential

258
Q

Outline the management of cord compression.

A

Ix: urgent MRI whole spine within 24 hours
Rx: dexamethasone 16 mg PO
Discuss with neurosurgery
Definitive: RADIOTHERAPY or decompressive surgery

259
Q

What must be done before a CTPA is performed in a patient with suspected PE?

A

Check renal function and ask about allergy to contrast

260
Q

What must always be done before thrombolysing a patient?

A

Discuss with a senior

261
Q

What is Cushing’s reflex?

A

Irregular breathing (Cheyne-Stokes)
Hypertension
Bradycardia

262
Q

Who could angry patients be directed towards?

A

PALS

NOTE: always gain consent from the patient before discussing their care with a family member

263
Q

What is the first step in managing a patient with VT?

A

Put out a peri-arrest call

264
Q

What are the 4 Hs and 4 Ts of cardiac arrest?

A 
Hypoxia 
Hypovolaemia 
Hypokalaemia/hyperkalaemia 
Hypothermia
Toxic 
Thromboembolic 
Tamponade
Tension pneumothorax
265
Q

Which medications should be continued after correction of VT?

A

Establish and treat the cause

Maintenance: amiodarone infusion for 12-24 hours followed by oral sotalol or amiodarone

266
Q

How can recurrence of VT be prevented?

A

Ablation of arrhythmogenic area OR ICD

267
Q

Outline the management of hypothermia.

A 
Prepare crash trolley
Confirm temperature with low-reading thermometer (PR) and check every 30 mins 
Set up ECG (bradycardia and J waves) 
Remove wet clothing 
Give warmed humidified oxygen 
Slowly rewarm at 0.5 degrees per hour 
CARDIAC MONITORING IS ESSENTIAL
268
Q

What is the difference between the Glasgow Blatchford and Rockall scores?

A

Blatchford - used at first presentation

Rockall - used after intervention to determine risk of re-bleed/death

269
Q

Which investigations are important to request in someone who has taken a paracetamol overdose?

A 
Paracetamol levels (4 hrs post-dose) 
LFTs 
Clotting studies 
U&E 
FBC 
Bone profile 
ABG (acidosis and lactate)
270
Q

Outline the management of bowel obstruction.

A 
IV 0.9% saline 
5-10 mg morphine IV 
NBM 
NG tube aspiration 
Correct electrolyte imbalance 
Consider giving antibiotics if septic/perforated (co-amoxiclav and gentamicin)
271
Q

Outline the management of acute limb ischaemia.

A

URGENT open surgery and angioplasty
ALERT the vascular surgeons
If embolic: surgical embolectomy or thrombolysis (tPA)
Anticoagulate with LMWH after either procedure and look for source of emboli (e.g. AF, aneurysms)
WARNING: post-op reperfusion injury can lead to compartment syndrome
Compartment syndrome is treated with fasciotomy
It is very painful so patients should be given morphine

272
Q

Who is part of the cardiac arrest team?

A 
Medical team on call (Med reg, SHO, FY1)
Anaesthetist 
Nurse 
Porters 
CCOT
273
Q

What are some contraindications for NIV?

A

Pneumothorax

Drowsiness

274
Q

For the treatment of hyperkalaemia, what do you mix the insulin in?

A

10 U Actrapid in 100 mL of 20% dextrose given over 30 mins

Year 5/6 (20 decks)

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