Objectives Flashcards
Causes of airway obstruc
Tongue Anaphylaxis FB Ext comp eg tum Trauma
Upper airway anatomy
Upper airway- Nose and paranasal sini Oral cavity Nasopharynx base skull to soft palate Oropharynx to superior epiglottis Hypopharnx to inferior cricoid cartilage Larynx Lower airway- Trachea Principle, secondary and segmental bronchi Terminal bronichiole Respiratory bronchiole Avleolar ducts and sacs
Identify resp failure
Hypoxia- dyspnoea, restless, agitated, confused, cyanosis. If chronic then polycythemia, pulm HTN.
Hypercapnia- headache, periph vasodilation, tachyc, bounding pulse, flap, drowsy.
Causes acute resp failure
T1- pneumonia, PO, PE, asthma, ARDS
Chronic eg COPD, fibrosis
T2- very severe asthma or COPD or pneum, end stage fibrosis, OSA, anaphylaxis
Also sedatives, CNS tum, trauma, NMDs, chest wall, compl obstruc
Resp failure
T1- paO2 under 8kPa, normal or low pCO2
Due to VQ mism
T2- pO2 under 8, pCO2 over 6kPa
Due to alv hypoventil +/- VQ mism
Resp failure mx
T1- O2, assisted ventilation
T2- controlled O2, assisted ventil, maybe intubation
O2 eg nasal under 4L, simple over 5L, venturi 24-8 for COPD, NRB
Monitoring- bloods, ABG, CXR, sputum and blood cult, spirom.
Hypoxia
Hypoxaemic- resp fail
Anaemic- low Hb or CO
Circulatory- shock, PVD
Cytotoxic- cyanide
Bradypnoea causes
Airway obstruction and exhaustion- asthma, COPD, OSA, oedema RICP Obesity Alcohol, drugs, sedation Cardiogenic shock CNS disorder Hypothyroid
tachypnoea causes
Obstructive disorders- asthma, COPD Pneumonia Fibrosis PE Pneumothorax pleural effusion HF Anxiety Arrhythmia Anaemia
Resp ix
Bloods- FBC, UE, CRP, ABG or VBG, LFT, clotting, D dimer, CA markers, a1 antiT
CXR
Sputum and blood cult
Spirometry
ABG interp
PH low and CO2 high- resp acidosis
PH low and CO2 low and HCO3 low- metab acid
PH high and CO2 low- resp alk
PH high and HCO3 high- metab alk
NIV ventil indics
BIPAP and CPAP
COPD resp acidosis pH 7.25-7.35
T2 RF
Cardiogenic PO unresp to CPAP
Tracheal intubation weaning
techs to assist ventil
CPAP- usually nasal, constant pos press, upper airways splinted open, improves VQ match
CPAP IS NOT NIV
BiPAP- 2 levs of pos press (IPAP and EPAP)
Modified wells score
3- symps eg swell, pain 3- other dx less likely than PE 1.5- HR over 100 1.5- immob over 3d, or surg in last 4wk 1.5- prev PE or DVT 1- haemoptysis 1- malig
Score over 4 means PE likely, 4 or less means unlikely
shock px
Hypot under 90 Tachyc usually over 100 Alt conciousness or syncope Poor periph perfus- cool, clammy, pallor, high CRT Oliguria under 50ml/hr Tachyp
Shock causes
Hypovol- bleed, DNV, burns, pancreatitis, sepsis
Cardiogenic-
Primary eg MI, arrhythmia, valve, myocarditis
mechanical or Secondary eg tamponade, massive PE, tens pthorax
Distributive- septic more comm in eld or v yng, DM, renal/liver fail, imm comprom. Anaphylactic
Shock mx
ABCDE High O2 IV access and take bloods Obs ABG ECG CXR Catheter and UO Fluids if req Ionot or vasoactive meds Assisted ventil Specif- lap, thrombolysis, PCI, pericardiocentesis, antidotes, abx
Acute renal failure causes
STOP most comm- sepsis, toxin, obstruc eg prostate, parenchymal eg ATN
Pre- DEHYD, shock eg sepsis, A stenosis
Intrinsic- ATN, drugs (Mb, ACEi, AG, NSAID), HTN, infec, nephritis, vasculitis
Post- obstruc eg prostate, stones, CA, stricture, fibrosis.
Acute renal failure px
Malaise, lethargy, nausea, reduc UO
High urea and cr
Elec imbal
Signs of cause eg sepsis, dehyd, vol overload, mass, renal bruit, pos dip or cult
Acute renal fail mx
Tx cause Tx fluid balance Tx elec imbal and acidosis Review meds Monitor- UE, VBG, urinalysis, USS, UO Indics for dialysis- hyperK, fluid overload, acidosis, dialysable toxin, uraemia (pericarditis, LOC, NV)
Acidosis causes
Resp- hypoventil in COPD, asthma, PO, CNS depression, obesity, GB, MG
Metab-
With normal anion gap (3-12)- reataining H (RTA, addisons) or losing HCO3 (diarr)
With high anion gap- methanol, uraemia, DKA, lactate, other poison
alkalosis causes
Resp- hyperventil eg anx, hypoxia, PE, pneumonia, asthma, PO
Metab-
Chloride responsive eg vom, diuretic, CS
Chloride resis eg cushings, hypoK
Acidosis px
Fatigue, drowsy Confusion SOB, rapid shallow breathing Headache Lack appetite Jaundice Tachyc
alkalosis px
Confusion Tremor, tetany Light headed NV Numbin and tingling
Mx of acid base disturbance
Tx cause
Oxygen if req
Tx elec imbal
Acidosis- sodium bicarb, CPAP
Tachyc causes
Arrhythmia- ST, SVT, flutter, atrial tachyc, AF, AVRT, VT, pre excited AF, torsades, VF HTN or hypot IHD Valve dis Anaemia Exercise Stress Cardiomyopathy Infection and fever Smoking Drugs eg alc, caffeine, cocaine, medications Elec imbal Hyperthyroid
Bradyc causes
Arrhythmia- SAN dis, HB AVN dis IHD Congenital heart dis Myocarditis Hypothyroid Elec imbal OSA Rheumatic dis Meds
Oliguria causes
Dehydration Obstruc Sepsis and other vasc collapse Low CO Intrinsic renal eg ATN, glom dis, vasc lesions
Hypotension causes
Dehyd eg DNV Blood loss Severe inflammation Myocarditis Valve dis PE Tamponade Bradyc
Hypernatraemia
Causes- iatrogenic, DNV, burn, DI, DKA, conns
Px-lethargy, weak, thirst, irrit, confus, coma, seiz, dehyd
Mx- hydration, maybe saline if hypovol
Tx cause
hyponatraemia
Causes- hypovol, diuretics, addisons, kidn inj, DNV, burn, SIADH, hypothyr, CCF, low alb
Px- NV, malaise, headache, irrit, confus, weak, reduc GCS, seiz, CCF, oedema
Mx- fluids, maybe hypertonic saline
Tx cause
hyperCa
Causes- thiazide, lithium, high PTH, high vit D, bone CA, myeloma, hyperthyr, sarcoid, dehyd
Px-NV, abdo pain, constip, polyU/D, dep, wl, weak, tired, HTN, confus, pyrexia, renal stones, short QT, bone pain
Mx- fluids, bisP
Tx cause
hypoCa
Causes- loops, CKD, low vit D, low PTH, bisP, alkalosis, pancreatitis
Px- spasmodic
Mx- Ca gluconate, sandocal supplems. Vit D (colecalciferol, alfacalcidol)
Tx cause
HyperK
Causes- transfusion, trauma, acidosis, addisons, K sparing diuretic, ACEi, A/CKD
Px- fast irreg pulse, CP, weak, palpit, dizziness, tall T, small P, wide QRS, VF.
Mx- Ca gluconate 10ml 10% IV 5 mins, actrapid 10U in 250ml 10% dextrose, neb salb, Ca resonium, maybe haemodialysis
Tx cause
hypoK
Causes- conns, DNV, diuretics, alkalosis, RTA, salbutamol
Px- weak, hypotonia and reflexia, cramps, tetany, palpit, dizzy, constip, arrhthmia, small or inv T, promin U, long PR, STD.
Mx- sandoK oral, K supplem IV fluid
Tx cause
bleeding diathesis causes
Susceptability to haemorrhage
warfarin liver fail vitK defic DIC haemorrhgaic virus, meningitis leukaemia AI eg antiPlipid, vasculitis Genetic eg haemophilia, VWD impaired skin heal eg scurvy and cushings Vascular malformations
bleeding diathesis mx
Tx cause Plasma exchange Pl transfusion Anticoagulants Packing an active bleed
Circulation ix
Bloods- UE, clotting, ABG, eGFR, CRP, FBC, culture, trop
Obs incl standing lying BP
Swabs sputum or urine dip if suspect sepsis
USS, CT (angio), CXR
ECG
Echo
clinical assessment of cardiac output
Signs of low CO-
BP under 90, UO under 0.5ml/kg/hr, HR under 60 or tachyc, fatigue, confusion, thready pulse, high JVP, SOB, hypoxaemia, pulm and periph oedema, metabolic acidosis
Ix-
Doppler, electromagnetic flowmeter, echo, ABG
Pathophysiology of atherosclerosis
Endothelial damage Lipop oxidation Foam macrophage Cytokines Fat and sm infilt Plaque formation
Pathophysiology of TE
Virchows triad- wall, flow, components Platelets aggregation and adhesion Cytokines, clotting cascade Localised thrombus, vasoconstriction Lodge in artery- ischaemia
Mx of epistaxis
Body forward mouth open
Pinch cartilaginous part of nose 10-15min
Naseptin cream if this works
If above doesnt work- cautery with silver nitrate stick if bleeding pt can be seen, or packing
Then naseptin aftercare (chlorhex and neomycin)
GCS score
Eyes 4, voice 5, motor 6
Eyes-
4 spont, 3 to speech, 2 to pain, 1 none
Voice-
5 orientated, 4 confused, 3 innap words, 2 sounds, 1 none
Motor-
6 obeys, 5 loc pain, 4 withdraw from pain, 3 abn flex decorticate, 2 abn ext decerebrate, 1 none
Causes of low GCS
Drugs, alc Epilepsy Hypoglycaemia CVA Brain hypoxia Dementia Head trauma Brain tumour Heart dis Liver dis Uraemia Shock Sepsis
Delirium causes
Predisp-
Eld, male, sensory impair, psych comorb eg dementia or dep, func imapir, malnutrition, other comorb eg CVS and PD
Precip-
Meds eg cholinergics, infections, metab abn (gluc, Ca, Na, thyr, liver or renal fail), hypoperfusion, hypoxia, shock, anaemia, sleep depriv, pain, surgery, neurol illness, head injury, dehydration
Seizure causes
Neuro- Epilepsy, tumour, meningitis, enceph, CVA, head trauma, congenital abn, peri natal hypoxia Metab- Hypoglycaemia, hypoNa, hypoCa, hyperuric Drugs- ODs, abuse, alc withdrawal, toxins Febrile convulsions Eclampsia
Causes of acute focal neurol deficit
Ischaemic CVA, or TIA Intracerebral of subarachnoid haemorrhage Head injury or periph nerve injury Menignitis or enceph Vascular malformation
headache causes
Tension Cluster Migraine Trigeminal neuralgia GCA Meningitis, enceph Brain haemorrhage, haematoma or abcess RICP Venous sinus thrombosis Glaucoma Sinusitis Drugs and withdrawal
Disability ix
Bloods- CRP, ESR, FBC, UE, LFT, clotting, gluc, ABG, culture Obs and neuro assess CT or MRI head Urine dip, swabs LP for mening CXR EEG ECG
delirium mx
Tx cause Early recog Mx hypoxia, usch, dehyd and elec imbal Review meds Mx sleep Geriatrician and psych input Non pharm- family inv, consis staff, avoid transfer, explain interventions, calm, large notices, adjustable lights, particip in ADLs, remove catheter, avoid restrain, correct sensory deficit Pharm- haloperidol, rarely BDZ and ACHEi
poison px
NV
R upper abdo pain liver eg paracetamol
Reduced GCS
Coma
Hypoglycaemia
Asp- hyperventil, tinnitus, deaf, vasodilat, sweat
TCA- dry mouth, seiz, arrhyth, hypothermia, hypot, hyperreflex, resp fail, urin reten, pupil dilat
SSRI- agitation, tremor, nystag, tachyc
Renal failure rarely
Lithium- GI, ataxia, tremor, weakn, dysarthria, twitch, elec imbal, dehyd, convuls, hypot, renal fail
BDZ- dysarthria, ataxia, nystag, resp dep
Amphetamines- hyper init, hallucin, paranoia, HTN, convuls, hyperthermia
Cocaine- agitation, HTN, arrhythmia, tachyc, pupil dilat, hyperthermia and tonia, CP, MI
Opioid- drowsy, coma, resp dep, pinpoint pupil
Ecstasy- delirium, coma, hyperthermia, rhabdo, renal fail, hep, DIC, ARDS, hyperreflex, hypot, IC haemorrhage, hypoNa, convuls, arrhythmia.
Poison diffs
Neuro- epilepsy, RICP, IC bleed, trauma Cardiac- arrhythmia, IHD Renal or liver dis Elec imbal Sepsis Resp dis
Poison mx
Gen- gastric lavage or bowel irrigation, activ charcoal, somet haemodialysis
Specif-
Paracetmaol- N acetylcysteine. Charcoal under 4hr
Digoxin- digibind Ab frags
BDZ- flumazenil IV 0.2mg over 15 sec, max 3mg
Insulin, BB- glucagon
Opioids- naloxone us IV ev 2-3 min
Iron salts- desferrioxamine mesilate
Ethylene glycol or methanol- fomepizole, ethanol
TCA- gastric lavage under 2hr, activ charcoal. Maybe Vasopressors, Na bicarb.
Salicylate- Na bicarb, fluids. Maybe dialysis, pressors.
CO- hyperbaric O2
Cyanide- amyl nitrate, Na nitrate, Na thuosulfate
Heparin- protamine sulfate
OrganoP- atropine, pralidoxime
SU- octreotide
Psych review
Hypothermia signs
Shiver Slurred speech Slow shallow breathing Weak pulse Lack coord Drowsy and lack energy Confusion or amnesia LOC Bright red cold skin in infants Low temp
Hypothermia RFs
Elderly and infants Cold env Mental illness Alc and drugs Exhaustion, fatigue Comorb- hypothyr, malnutr, DM, CVA, sev arth, PD, trauma, SC injury Infection Meds- antiD, antiP, sedatives, narcotics
Hypothermia init mx
Warm dry location
Heated insulating blankets
Blood removal and rewarming via haemodialysis
Warm IV fluids
Airway rewarming with humidif O2
Irrigation with warm saline- pleural and perit cavities
Comm causes of pyrexia
Virus or bact infec Heat exhaustion Rheumatoid and AI conditions, vasculitis Malig Hyperthyr Meds- abx, AED, antiHTN Some vaccines- DTP, pneumococcal Shock Collagen vasc dis Fungus and parasite Granulomatoud dis eg sarcoid, crohns, hep PE
Pyrexia ix
Sepsis 6 if indicated Bloods- FBC, ESR, CRP, LFT, ANA, RhF, TFT, culture Labeled white cell scan Cultures- urine, sputum, stool, CSF CXR, CT, MRI, PET LP Skin biop LN asp Bm asp Liver biop Lap surg
Notifiable dis
Acute enceph, acute hep Acute meningitis and mening septacaemia Acute poliomyelitis Anthrax Botulism Cholera Diptheria Thyphoid HUS Invasive grp A strep Legionnaries Leprosy Malaria Measles Mumps Plague Rabies Rubella SARS Scarlet fever Smallpox Tetanus TB Typhus Viral haemorrhgaic fever Whooping cough Yellow fever
Sepsis in kids
Later hypot Cold peripheries, CRT delay Mottled skin Hypotonia Vomit Convulsions Resp distress Oedema Rash Bulging fontanelle mening Temp instabil Lethargy Poor feeding Reduc UO
