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ACC > Organ failure > Flashcards

Organ failure Flashcards

1
Q

Pt has jaundice, coagulopathy and encephalopathy. Likely dx?

A

Acute liver failure

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2
Q

What is acute liver failure?

A 
Complex multi system illness after insult to liver has:
Jaundice
Coagulopathy - INR >1.5
Hepatic encephalopathy
Absence of chronic liver disease
Onset within 12 weeks
Rare but high mortality
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3
Q

How is ALF graded and what are their causes

A

O’Grady
Jaundice to encephalopathy:
Hyper acute - within 7 days (best prognosis) - cause is paracetamol, drugs, viral hepatitis
Acute - 8-28 days - cause is viral hepatitis, ischaemic hepatitis
Subacute - 29+ days (worst prog) - cause is seronegative/autoimmune hepatitis

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4
Q

Most common cause of ALF?

A

paracetamol OD
Others: viral hepatitis A and E, maybe B - common in developing countries
Also: Mushrooms (amanita phalloides)

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5
Q

Drugs which cause ALF:

A

Dose dependent & therefore predicatble - Paracetamol, alcohol, isoniazid/rifampicin, NSAIDs, sulphonamides, valproate, carbamazepine, ecstasy

Rarer: phenytoin, isoflurane, allopurinol, mono-amine oxidase inhibitors, tricyclic antidepressants, amiodarone

Not predictable: Legal highs
Anabolic steroids
Herbal meds

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6
Q

Viruses which cause ALF

A

Viral hepatitis - A, E< B

Rarely: HSV, cytomegalovirus, EBV, parvovirus

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7
Q

Rare causes of ALF?

A 
Ischaemic hepatitis
Autoimmune hepatitis
Acute fatty liver of pregnancy
Wilsons disease
Budd chiari (clot of hepatic circulation)
Mushrooms
Post hepatectomy
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8
Q

If pt has unknown cause of ALF - what might you see/how would you treat?

A 
Female 20-40
Recent jaundice + coagulopathy, previously normal LFT
?Liver biopsy
?trial of steroids
Liver transplant
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9
Q

Suspect ALF from paracetamol OD. Assessment and treatment?

A 
LFTs, FBC, U&amp;E
Paracetamol level
Blood gas
Lactate, blood gas, pH
IV N-acetylcysteine early
IV crystalloid fluids
IV broad spectrum Antibiotics (coamoxiclav) &amp; antifungals (fluconazole) in severe cases
Discuss w/ transplant centre
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10
Q

Investigation for AFL?

A 
Viral screen
Paracetamol level &amp; drug conc
Autoantibodies (IgG)
USS, platelet count (HELLP)
Ceruloplasmin, Urinary copper 24h (for Wilsons) and slit lamp (see Keiser-Fleisher rings)
USS/venography - budd Chairi
Imaging &amp; histology (malignancy)
Transaminases - ischaemic hepatitis
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11
Q

RF for paracetamol OD?

A 
Staggered OD
Excessive alcoholic consumption
malnutrition
HIV
cancer
liver enzyme inducers:(rifampicin, anti-epileptic, spironolactone)
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12
Q

What is paracetamol metabolised by?

A

CYP450 in N-acetyl-p-benzoquinoeinine toxic metabolite, detoxified by glutathione

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13
Q

Treatment of hep B ALF?

A

Inform transplant centre

Tenofovir

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14
Q

Complication of ALF?

A 
Encephalopthy - cerebral oedema
CVD 
Renal failure
Sepsis
Malnutrition
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15
Q

Big reason for hypoxia in A&E?

A

V/Q mismatch (blood is flowing through lungs but can’t get oxygen as lung isn’t ventilating properly)

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16
Q

Causes of collapsed alveoli?

A

Pneumonia, anaesthetics, lying down

17
Q

Fluid in alveoli?

A

pulmonary oedema

18
Q

Constricted terminal alveoli?/bronchiole obstruction

A

Asthma/COPD

19
Q

Types of resp failure?

A

1: pO2 <8kPa, normal PCO2 (or lowdue to hyperventilation) - failure of oxygenation.

Then pt tires and increased ventilation is not maintained. ->
2: pO2 < 8kPa, PCO2>6kPa

20
Q

T1 resp failure treatment?

A

CPAP

21
Q

T2 resp failure treatment?

A

BiPAP - EPAP (expiratory positive airway pressure for low O2)
IPAP - inspiratory PAP - when high CO2

22
Q

When to use NIV?

A

Pneumonia
post op (collapsed alveoli)
COPD
Oedema

23
Q

When not to use NIV?

A

Asthma
Pneumothorax
Agitation
Airway loss

24
Q

When is it resp failure?

A

PaO2 <8kPa

25
Q

Stage 1 AKI?

A

Creatinine 1.5X baseline

Urine output <0.5ml/kg/hr for > 6 hrs

26
Q

Stage 2 AKI?

A

Creatinine 2X baseline

Urine output <0.5ml/kg/hr for > 12 hrs

27
Q

Stage 3 AKI?

A

Creatinine 3X baseline
Urine output <0.3ml/kg/kr for >24hrs
Anurina for >12hrs
If needs renal replacement therapy

28
Q

Causes of AKI

A 
STOP
Sepsis/shock (pre)
Toxins (intra)
Obstruction (post)
Pressure optimaisation (pre)
29
Q

Pre-renal causes of AKI? +treatment

A

Poor pressure optimatisation
Sepsis/shock - hypovolaemic shock (less fluid to filter toxins), septic shock (leaking from capillaries into interstitial space -> hypovolaemia), cardiogenic shock (fluid moves through the same, but it’s less fluid, pressure remains the same)

Reduction in blood flow -> hypoxia in kidney –> acute tubular necrosis

Treat = fluids

30
Q

Intrarenal causes of AKI? +treatment

A

Toxins - acute interstitial nephritis -> from NSAIDs
Tubular toxicity - from radio-opaque contracts and gentamicin
Treat = Stop drugs

31
Q

Post-renal cause of AKI? +treatment

A

Obstruction - stones and cancer
Need nephrostomy
Treat cancer

32
Q

Complications of AKI?

A

Hyperkalaemia
Metabolic Acidosis

Due to inability to excrete K+ and H+, also sodium doesn’t get reabsorbed.

33
Q

What does high anion gap show?

A 
Normal anion gap = 4-12
High <12 eg 18 - excess H+ from somewhere
"Left total knee replacement"
Lactate
Toxins (CSP MIGE G) - cyanide, salicylates, paraldehyde, methanol, iron, CO, ethylene, glycol
Ketones (DKA)
Renal failure
- also in Addison's
34
Q

Ix for ?uretic stone?

A

CT

Ultrasound is good at looking for hydronephrosis (where there is a stone but you see the dilatation of pelvis and ureters but doesn’t see stones)

35
Q

What are the functions of the liver?

A

Synthesis: protein, clotting factors, bile, glucagon
Detoxification: alcohol, drugs, ammonia, bilirubin
Storage: energy, vitamins and minerals
Important in immune system

36
Q

In renal failure who drugs should you watch out for?

A

Ace-inhibitors

Also any ending in -pril

ACC (5 decks)

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