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OSCE Stop Emergencies Flashcards

1
Q

airway assessment ABCDE

A

if talking = patent airway

look inside the mouth
assess for secretions

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2
Q

airway management ABCDE

A 
suction
jaw thrust
head tilt, chin lift
OP, NPA
intubation if GCS <8

TREAT ANY CAUSE
i.e. anaphylaxisis (adrenaline)
foreign body (remove)

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3
Q

breathing assessment ABCDE

including tests

A

pulse ox
resp rate
chest exam
calves

ABG, CXR

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4
Q

breathing management ABCDE

A

15L oxygen non rebreathe mask (care if COPD)
consider NIV or intubation
bag mask if effort poor

TREAT CAUSE
pnuemothorax
asthma
COPD exacerbation 
acute pulmonary oedema
opiate OD
PE
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5
Q

circulation assessment ABCDE

incl tests x4

A 
cap refill central
pulse
BP
temp
ausc

wide bore IV cannulae
3 lead monitor
ECG
catheter + fluid balance

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6
Q

circulation management ABCDE

A

hypotensive:
elevate legs, lie back
500ml sodium chloride stat, monitor response (HF beware)

shock:
1 L sodium chloride stat
replace blood with blood + activate major haemorrhage protocol

if hypotensive and overloaded, need inotropes and ITU

TREAT CAUSE
e.g. arrhythmia

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7
Q

disability assessment ABCDE

A

glucose
GCS/AVPU
pupils
pain

CT brain consider

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8
Q

disability management ABCDE

A

correct glucose
give morhpine

TREAT CAUSE

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9
Q

exposure assessment ABCDE

A

look all over including underneath for bleed, rash, injury

examine abdo
further exams if relevant

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10
Q

investigations to find causes overview ABCDE assessment

A

bloods (ABG, G+S, FBC, UE, CRP, LFT +/- amylase)

urine dip, sputum culture, bHCG

CXR, CT

3 lead monitor, ECG

special tests consider

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11
Q

who to ask for help in acute context

A 
med reg - medical probs
on call endoscopy - upper GI bleed
surgical reg - surgical prob or bleeding
cardio reg - MI, arrhythmia
gynae reg - ruptured ectopic
ITU reg - if likely to need ITU
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12
Q

documenting critically ill pt

A

ABCDE headings
brief summary
findings and mangement
review results + refer

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13
Q

basic stages in acute presentation assessment

A

intro

focused history

check obs

focused examination (ABCDE if very unwell)

investigations to exclude DDx

management (consider: 1.oxygen 2.fluids 3.analgesia 4. disease-specific treatment)

inform patient of progress
document
chase results
discuss with seniors / refer

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14
Q

6 key differentials for life-threatening shortness of breath

A
  1. PE
  2. pneumothorax
  3. ashtma/COPD
  4. pneumonia
  5. acute pulmonary oedema (LVF)
  6. acute coronary syndrome
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15
Q

focused Hx for acute SOB

A

EXPLORE
use SOCRATES components as relevant
exercise tolerance / baseline
orthopnea/PND

SYSTEMS REVIEW

general: how do they feel, fever
cardioresp: chest pain, wheeze, cough, sputum, leg swelling

PMH:
happened before? medical conditions
baseline any chronic condition +treatment / admissions (ITU)
recent surgery

DH+allergies
check treatment compliance

SH:
smoking, alcohol, risk factors for the 6 key acute causes

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16
Q

focused examination for acute shortness of breath

A 
tracheal deviation, JVP
exapansion, apex, heaves
percuss chestzones
auscultate heart and lungs
legs (pain and swelling)
perform peak flow if relev
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17
Q

investigations in a patient with acute shortness of breath

A 
bloods: FBC, CRP, U+E
D-dimer if Well's low
ABG
BNP (if HF suspected)
troponin (if ACS suspected)
blood cultures (if pyrexial)

orifice: sputum culture

xray/imaging: CXR, CTPA if PE suspected

ECG always!

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18
Q

5 key differentials for life-threatening chest pain

A
  1. acute coronary syndrome
  2. PE
  3. aortic dissection
  4. pneumothorax
  5. pneumonia

(less acute: pericarditis, myocarditis, pleurisy, MSK, GORD, anxiety attack, oesophageal spasm)

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19
Q

focused history for acute chest pain

A

SOCRATES

SYSTEMS REVIEW:
general - how feel, fevers, clammy/sweaty
cardioresp: SOB, wheeze, cough, sputum, leg swell

PMH
happened before? other medical conditions? cardioresp risk factors

DH + allergies
cardio meds etc
FH
cardio family events
SH
smoking, relevant DDx risk factors
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20
Q

focused examination acute chest pain

A

cardioresp focused:

tracheal deviation, JVP
exapansion, apex, heaves
percuss chestzones
auscultate heart and lungs
legs (pain and swelling)
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21
Q

investigations in acute chest pain

A

bloods - FBC CRP U+Es, trop stat+ @12 hrs

xray/imaging - CXR, CTPA if indicated (PE), CT angio if indicated (dissection)

ECG always

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22
Q

4 key DDx in life-threatening abdominal pain

A
  1. peritonitis
  2. AAA
  3. ischaemic bowel (blockage, volvulus etc)
  4. medical causes (DKA, pneumonia, MI, Addisionian crisis)
    (5. consider upper and lower abdomen causes of pain)
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23
Q

upper and lower abdo causes of pain

A

UPPER
hepatitis, cholecystitis, peptic ulcer, pancreatitis

LOWER
appendicitis, IBD, diverticulitis, UTI, pyelnonephritis, renal stones, gynae (torsion, ectopic, PID)

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24
Q

focused history in acute abdo pain

A

SOCRATES

SYSTEMS REVIEW:
- general feeling, fevers
-gastro: N+V, bowel habit, bleeding/melaena, weight loss
-gynae: LMP, PV d/c, contraception, pregnancy
PMH
happened before?med conditions
DH+allergies
any relevant meds
SH
smoking alcohol
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25
focused exam in abdo pain
``` inspect movements Grey Turner (flank bruising) Cullen sign (umb bruising) guarding, rebound tenderness Murphy's sign (deep breath, GB touches hand, catches) Rosvig's sign (LLQ pain from RLQ palpation) organomegaly+AAA screen palpate for hernias percussion tenderness bowel sounds ``` consider DRE + examining external genitalia if indicated
26
investigations for acute abdo pain
bloods: FBC, CRP, U+Es, LFTs, amylase, INR, G+S, capillary glucose, VBG for lactate orifice: urine dip, urine bHCG xray/images: erect CXR, FAST scan for AAA, USS/CT abdo, AXR if ischaemic bowel suspected ECG always
27
5 key DDx in life-threatening headache
1. subarachnoid bleed 2. meningitis 3. space-occupying lesion 4. temporal arteritis 5. pre-eclampsia
28
common + rarer but important causes of headache (non life threatening)
migraine, tension headache, sinusitis acute glaucoma, venous sinus thrombosis, dissection, hypertensive encephalopathy, CO poisoning,
29
focused Hx with acute headache
SOCRATES meningism: rash, fever, neck stiffness, photophobia temporal arteritis: visual problems, jaw claudication, scalp tenderness glaucoma: visual problems, red eyes, halos around lights ``` SYSTEMS REVIEW general: how pt feels, fever, rash neuro: fits/falls/LOC, limb weakness, altered sensation, vision changes PMH happened before, conditions DH+allergies anticoag, steroids, analgesia FH berry aneurysms SH smoking, alcohol, DDx risk factors ```
30
focused examination acute headache
GCS, signs of photophobia + rash eyes, pupils, redness, vision feel sinuses+temporal arteries for tenderness neck stiffness on passive turning Brudzinski's sign (passive flexion of neck cause leg flexion) Kernig's sign (pain on passive knee extension with hip fully flexed) motor neuro: tone, power, reflexes CN exam fundoscopy for papilloedema or haemorrhages (subarac)
31
investigations in acute headache
bloods: FBC, CRP, U+Es, ESR, blood cultures if fever, meningococcal PCR xrays/imaging: CT head special: lumbar puncture
32
classic PE history
pleuritic chest pain haemoptysis + SOB risk factors present
33
classic pneumonia history
fever, SOB productive cough pleuritic chest pain confusion
34
classic pneumothorax history
sudden onset pleuritic chest pain SOB if large one risk factors present (esp asthma/COPD)
35
classic asthma exacerbation history
dyspnoea wheeze known history of asthma
36
classic ieCOPD history
dyspnoea wheeze change in sputum known COPD or lifelong smoker
37
classic PE exam findings
tachycardia, raised JVP, loud P2, split S2 tachypnoea, chest clear, pleural rub look for DVT in calves massive PE = systolic BP<90, persistent bradycardia
38
classic pneumonia exam findings
``` tachypnoea, cyanosis coarse crepitations bronchial breathing dullness to percussion increased vocal resonance ```
39
classic pneumothorax exam findings
reduced expansion of chest absent breath sounds one side hyper-resonant if TENSION: raised JVP, hypotensive, resp distress, tracheal deviation away from affected side
40
classic exam findings asthma exacerbation
tachypnoea, accessory muscle use, polyphonic wheeze, reduced air entry, reduced peak flow
41
classic COPD exacerbation findings o/e
tachypnoea use of accessory muscles polyphonic wheeze reduced air entry
42
classic PE investigation findings
D dimer raised (only do it if low Wells score) CTPA diagnostic ECG tachycardic, RV strain (T inversion in right and inferior leads, RBBB) ABG hypoxaemic, hypocapnic, resp alkal) CXR - wedge opacity, regional oligaemia, enlarged pulmonary artery, effusion
43
classic investigation findings pneumonia
``` CXR consolidation and air bronchogram inflammatory markers raised sputum culture urinary pneumococcal and legionella antigens blood cultures mycoplasma serology ```
44
classic pneumothorax investigation
air in pleural space on CXR | clinical diagnosis with follow up confirmation often
45
classic asthma investigations
clinical diagnosis! ABG - normal oxygen, low CO2 (very bad if oxygen falling as getting tired) inv to exclude causes CXR - infection, pneumothorax exclude blood/sputum cultures - exclude septic trigger
46
classic COPD investigation findings
clinical diagnosis CXR to exclude x2 ABG low oxygen high co2 raised bicarb
47
summary PE treatment
treatment dose enoxaparin if massive, thrombolysis
48
summary pneumonia treatment
sepsis six if bad otherwise just Abx
49
summary pneumothorax treatment
Primary >2cm or have symptoms, aspirate Secodary > 1cm observe 24 hrs and high flow oxygen 1-2cm aspirate 2cm+ chest drain
50
summary asthma exacerbation treatment
``` salbutamol nebs ipratropium nebs steroids IV magnesium Abx if indicated ```
51
summary COPD exacerbation treatment
``` salbutamol nebs ipratropium nebs steroids Abx bipap if needed ```
52
classic ACS history
crushing central chest pain radiates to neck/left arm/jaw associated nausea/SOB/sweatiness cardiovascular risk factors
53
classic ACS exam findings
may be normal sweaty, SOB, in pain +/- signs of HF, brady / tachycardia
54
classic investigation findings in ACS
ECG - ST elevation / depression, new LBBB, inverted T waves, Q waves troponin - increased (unless unstable angina) CXR - normal or signs of HF coronary angio
55
classic treatment ACS
``` morphine oxygen nitrate aspirin clopidogrel ``` (anticoagulation, beta blocker)
56
classic acute LVF history
SOB, orthopnoea, PND, pink frothy sputum, peripheral oedema, cardiac Hx
57
classic acute LVF exam findings
``` tachycardia, tachypnoea raised JVP fine bibasal crepitations S3 gallop rhythm peripheral oedema ```
58
classic acute LVF investigation findings
CXR - Alveolar shadowing, B lines, Cardiomegaly, Diversion of upper lobe, Effusion Echo BNP ECG - exclude MI
59
classic LVF treatment
``` position sitting up oxygen diuretics morphine anti-emetic nitrate infusion CPAP if needed ``` treat any cause
60
classic hyperventilation history
tight chest pain SOB, sweating, dizzy, palpitations, doom anxious / psych Hx recurrent episodes clear stimulus
61
investigation findings in hyperventilation history
diagnosis of exclusion! ``` ECG - exclude MI trop - exclude MI D-dimer - exclude PE CXR - exclude infection ABG will show resp alkalosis ``` normal obs
62
classic aortic dissection history
tearing chest pain of VERY sudden onset radiating to the back pain in other sites depending on circulation
63
classic aortic dissection exam findings
unequal arm pulses or blood pressures may develop acute AR may develop acute neurology
64
classic aortic dissection investigation findings
CXR - widened mediastinum ECG signs of MI CT angiogram crucial and must be QUICK!!
65
definitive aortic dissection management
type A - surgical repair immediately type B - blood pressure control A for ascending aorta B is descending aorta
66
classic pericarditis history
retrosternal / precordial pleuritic chest pain relieved by sitting forwards may radiate to trapezius / shoulder / neck viral prodrome
67
classic pericarditis exam findings +/- tamponade
pericardial rub tachycardia tamponade: JVP distension pulsus paradoxus (BP drop significantly on inspiration)
68
classic pericarditis investigation findings
clinical diagnosis! ECG - PR depression, widespread saddle-shaped ST elevation CXR - globular heart IF effusion present echo - done if suspect effusion around pericardium
69
managing pericarditis
NSAIDs | treat cause if known
70
classic myocarditis history
``` chest pain palpitations fever fatigue dyspnoea ``` ? viral prodrome
71
classic myocarditis exam
``` signs of heart failure S3 gallop fever tachypnoea tachycardia ```
72
classic investigation findings myocarditis
ECG - diffuse T wave inversions, ST depressions/elevations raised inflammatory markers raised troponin serology to identify cause myocardial biopsy if required
73
treatment myocarditis
treat cause treat complications bed rest usually recover
74
pleurisy history
pleuritic chest pain may have dry cough, fever, dyspnoea pleural rub heard
75
diagnosing pleurisy
must exclude pneumothorax, effusion or pneumonia first
76
treating pleurisy
NSAIDs, treat cause | treat complications
77
less severe causes of acute chest pain to be considered
``` musculoskeletal costochondritis GORD anxiety attack oesophageal spasm (corkscrew oesophagous on barium swallow) ```
78
classic peritonitis examination findings
``` shock no abdo movement with respiration guarding firm abdo rebound tenderness severe pain to light palpation percussion tenderness ```
79
classic investigations for peritonism
erect CXR - air under diaphragm CT abdo/pelvis - find perforation site (may not have perforated yet) urgent surgery
80
classic ruptured AAA summary
elderly severe generalised abdo pain back pain low GCS and collapse expansile mass bedside USS and CTangio
81
treating ruptured AAA
permissive hypotension of 100 active massive bleed protocol urgent open repair
82
classic appendicitis history
young periumbilical pain moving to right iliac fossa anorexia, nausea fever
83
classic appendicitis exam findings
tender RIF worse at McBurney's point guarding Rovsing sign positive McBurney is 2/3 from umbilicus to ASIS
84
classic investigations appendiciits
ultrasound abdo / pelvis to exclude gynae CRP etc raised bHCG to exclude ectopic
85
classic biliary colic history
severe intermittent RUQ / epigastric pain | worse with fatty food
86
classic cholecystitis history
continuous RUQ/epigastric pain Murphy's sign positive tenderness guarding
87
classic gallstones history
jaundice | RUQ pain
88
classic cholangitis history
jaundice fever/rigours RUQ pain
89
differentiate biliary colic vs cholecystitis vs CBD stones vs cholangitis
biliary colic - intermittent pain cholecystitis - constant pain, peritonism gallstones - pain + jaundice cholangitis - pain + jaundice + fever
90
classic investigation findings gallstones
obstructive LFT picture if CBD stones or cholangitis inflamm markers raised if cholangitis / cholecystitis abdo USS
91
management for gallstones
biliary colic - pain relief, fat free diet, elective op cholecystitis (blocked, accumulated bile) - Abx, elective op CBD stones - cont IV fluids, ERCP cholangitis - IV abx, treat cause
92
classic acute pancreatitis history
severe epigastric, central pain radiates to back vomiting risk factors seen - alc, gallstones, high fat, trauma, surg, meds
93
classic pancreatitis exam
``` epigastric tenderness tachycarida fever shock jaundice Grey Turner Cullen signs (rare) ```
94
classic inv findings pancreatitis
raised amylase / lipase deranged LFTs CT abdo if unsure Glasgow score USS abdo to exclude gallstones triglycerides + Ig panel to find cause
95
treating acute pancraes
``` aggressive fluid resus e.g.1L 4 hourly (titrate UO) NBM until nausea and pain improve consider NG only abx if proven infection treat cause ``` ITU may be needed
96
classic diverticulitis history
old, LIF pain fever diarrhoea
97
diverticulitis on examinaton
tender LIF guarding need PR to exclude cancers or abscesses
98
inv findings and management diverticulitis
raised CRP etc CT abdo pelvis confirms clear fluids Abx
99
classic renal colic histry
spasms of excruciating loin to groin pain nausea and vom never comfortable on bed
100
renal colic inv
renal angle tenderness and abdo soft ussually urine dip - micro blood US KUB CT KUB
101
treatment renal colic
strong pain relief IV fluids abx if infection signs if <1cm tamsulosin to aid excretion of stone if >2cm need nephrolithotomy
102
classic bowel obstruction history and exam
vomiting (feculent possibly) colicky abdopain no bowel motions or flatus distended, tender tinkling bowel sounds
103
inv and management bowel obstruction
AXR - distended loops CT abd pelvis gastrograffin study if small bowel obstruction NBM + IV fluids wide bore NG free drainage laparsocopy if unresolved
104
classic acute mesenteric ischaemia history andexam
over 50years severeabdo pain dirrhoea cardiac risk factors (esp AF) hypovol / shocked soft abdo with out of proportion pain to exam findings
105
inv and management acute mesenteric ischaemic
VBG raised lactate CT shows ischaemic bowel mesenteric angiography if required aggressive IV fluids, NBM, NG decompression abx resect infarcted bowel blood thinners post op revasc if no infarct
106
big summary of abdo pain considerations
surgical - peritonitis ruptured AAA, appendicitis, gallstones, acute pancreatitis, diverticulitis, renal colic, bowel obstruction, acute mesenteric ischaemia, gonad torsion, volvulus, strangulated hernia, abscesses, mesenteric adenitis (app mimic), Meckel's diverticulum medical - peptic ulcer, pyelonephritis, gastroenteritis, IBD, DKA, Addisonian crisis, hypercalc etc etc gynae - ectopic, ovarian cyst rupture, ovarian torsion, PID, preg, fibroids
107
summarise history, inv, management peptic ulcer
epigastric pain related to meals risk factors present tender but soft abdo FBC microcytic anaemia erect CXR to exclude perf OGF if severe investiate H pylori treat - PPI and eradication therapy
108
classic pyelonephritis history and exam
fever, rigours loin pain frequency and dysuria loin tenderness renal angle tenderness
109
pyelonephritis investigations and management
urine dip and culture +ve for white cells +nitrites inflamm markers up USS to screen structural abnormalities or abscess (nephronia is intermediate phase) give abx
110
classic ectopic pregnancy history
``` severe unilateral pelvic pain 6-8 weeks, missed period contraception lacking shoulder tip pain spotting ```
111
classic ectopic examination
tenderness RIF/LIF guarding adnexal tenderness +/- mass palpated cervical exciation
112
investigation findings and management ectopic preg
urinary bHCG +ve serum bHCG number size suggests management transvaginal USS methotrexate or lap salpingectomy or lapartomy anti D prophylaxis if needed
113
classic ovarian cyst rupture / torsion history and exam
sudden unilateral pelvic pain(very severe if torted) light vaginal bleeding fever / vomiting tenderness RIF/LIF guarding adnexal tenderness +/- mass
114
investigation and management ovarian cyst rupture or torsion
TVUSS bHCG to exclude ectopic laparoscopy for torsion cyst conservative management
115
pelvic inflammatory disease classic history
``` bilateral pelvic pain of gradual onset vaginal discharge DPU and dysmen PCB, IMB discharge may be purulent ```
116
classic PID examination
``` suprapubic tenderness vaginal discharge cervicitis bilateral adnexal tenderness cervical excitation fever ```
117
PID inv and management
inflamm markers raised triple vaginal swabs (tests chlam, gonorrhoea + other bact/fungal) broad spectrum abx, check local guidelines usually triple therapy
118
classic tension headache story and treatment
``` bilateral tight band sensation recurrent late in day stressed muscular tenderness ``` simple pain relief destress
119
classic cluster headache story and exam
short painful attacks around one eye 30 mins to 3 hrs 1-8x daily for 1-3 months then remits lacrimation, flushing conjunctival redness, swollen eye lid can get Horner's assoc
120
treating cluster headaches
100% oxygen triptan verapamil prophylaxis
121
classic migraine history
``` unilateral pulsating trigeminal nerve distribution hoursto days aura photophobia ``` exam usually normal
122
migraine treatments split into two categories
abortive NSAID, aspirin, triptan preventative propanolol, amitriptyline, antiepileptics
123
classic trigeminal neuralgia history
2 second paroxysms of stabbing pain in UNIlateral trigeminal distribution face screws up in pain triggers - shaving, etc symptoms of underlying cause(can be MS, tumours) normal onexam
124
trigeminal neuralgia workup and treatment
MRI to find cause if any antiepileptics treat cause if found
125
group the DDx of headache into 3 categories
primary headache secondary - intracranial secondary - extracranial
126
classic meningitis hx and exam
photophobia neck stiffness systemic symptoms e.g. fever, non blanch rash (late sign) Kernig +ve Brudzinski +ve focal neurology may be NB rash
127
investigation findings and management in meningits
``` blood culture meningococcal PCR lumbar puncture throat swab CXR - pneumonia causing pneumococcal meningitis ``` IV acyclovir+ cef (+ amox if v old / young) dexamethasone cipro prophylaxis close contacts IM benpen in community f
128
classic temporal arteritis history and exam
``` unilateral throbbing pain scalp tenderness jaw claudication 55 years + visual issues ``` ipsilateral blindness tender temporal arteries optic nerve oedema
129
investigation findings and mnagement temporal arterits
raised ESR +ve temporal artery biopsy doppler of temp artery shows reduced flow high dose pred
130
classic subarachnoid history and exam
``` very sudden very severe smacked on the back of the head doctor meningism thunderclap! ``` reduced GCS meningism
131
subarac inv and manage
CT head - blood in circle of Willis LP if normal CT - shows xanthochromia (yellow CSF) nimodipine coiling, clipping
132
classic raised intracranial pressure hx + exam
``` worse in morning worse on coughing, bending vomiting, reduced GCS visual disturbance neurology +/- seizures if tumour causing ``` ``` reduced GCS papilloedema CN6 palsy ipsilateral mydriasis (pupil dilation) Cushing response in obs Cheyne-Stokes breathing ```
133
inv findings and manage high ICP
CT head to find cause monitoring of ICP mannitol +/-hyperventilate them if severe drain CSF treat cause
134
classic venous sinus thrombosis history and exam
history of high coag state e.g. pregnant gradual or sudden onset nausea, vom seizures papilloedema visual field defect CN palsies focal neurology
135
venous sinus thrombosis inv findings and manage
CT head MR venography treatment dose LMWH if in cavernous sinus need abx and any treatment for hypopituitarism
136
classic intracerebral bleed hx and exam
symptoms of stroke + headache neuro deficits CT head catheter angiography if suspect malformation in young CT at 6 weeks, MRI at 3 months to screen tumour as trigger control BP correct coag treat cause
137
raised ICP from bleed with midline shift on CT
craniotomy and clot evac | endoscopic evac
138
classic acute closed angle glaucoma history and exam
pain around one eye swollen red eye visual blurring halos reduced acuity conjunctival bleeds cloudy cornea pupil mid-dilated and irreg
139
acute closed angle glaucoma inv and manage
tonometry >24mmHg IOP acetazolamide timolol laser peripheral iridectomy
140
classic sinusitis history and exa
facial pain exacerb by leaning face forward, coughing rhinorrhoea, nasal congestion sinus tenderness pain on percussion of frontal / temporal sinuses
141
inv findings and treatment sinusitis
clinical diagnosis abx warm face packs saline nasal drops analgesia
142
classic hx and exam hypertensive encephalopathy
headache visual blurring vomiting severe HTN measured bilateral retinal bleeds papilloedema
143
inv findings and management classic hx and exam hypertensive encephalopathy
urine dip - micro haemat CT brain to exclude bleed in brain controlled BP reduction with IV labetalol
144
classic pre eclampsia hx and exam
``` 3rd trimester headache visual disturbance epigastric pain vomiting ``` HTN brisk reflexes oedema
145
inv findings and treatment pre eclapsia
``` urine dip - protein ! Haemolysis Elevated liver enzymes Low platelets CTG and fetal USS ``` deliver if 34 weeks + labetalol, methyldopa mag sulphate to stop seizures aspirin to prevent
146
classic carotid / vertebral artery dissection hx and exm
most common stroke cause in young adult dull pressure occip headache neck and facial pain stroke signs (transient) risk factors = trauma, neck manipulation, conn tissue disease stroke signs
147
inv findings and management carotid / vertebral artery dissectin
CT or MR angiography duplex carotids thrombolyse or antiplatelets depending on timing and CT clear of bleed antiplatelets/coag for 6 months endovasc stent
148
group the differentials for collapse / fall
neurological vascular metabolic / drugs infection
149
classic history for the following generalised seizures: ``` tonic clonic absence atonic tonic myoclonic ```
tonic clonic - sudden LOC, limbs stiffen then jerk, incontinence, tongue-biting, myalgia+confusion post-ictal absence - unresponsive, staring in to space for few seconds, typically a child atonic - all muscles relax, drops to floor tonic - all muscles become rigid myoclonic - involuntary flexion
150
investigate seizures
EEG if needed ``` find trigger: CT head - intracranial electrolytes cap glucose drug levels ```
151
management seizures
IV lorazepam or PR diazepam to terminate acutely treat cause start on anti-epileptics if 2+ instances of seizures don't drive!
152
classic Parkinson's histoyr
rigidity+ tremor+ bradykinesia+ postural instability
153
classic Parkinson's o/e
resting tremor, shuffling festinant gate with lack of arm swing cogwhell rigidity bradykinesia
154
Parkinson's diagnosis
clinical if uncertain, neuroimaging DaTscan
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brief Parkinson's treatment summary
levodopa dopamine agonists monoamine oxidase inhibitors physio + OT
156
classic TIA/stroke history and exam
sudden onset neuro signs (limb/face weakness, slurring, vision change) risk factors present neuro deficits seen o/e
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TIA / stroke inv and management
CT head ECG for AF coag screen carotid dopplers acute: antiplatelet or thrombolysis if confirmed ischaemic stroke (+/- clot retrieval) long term: clopidogrel, statin, blood pressure carotid endartectomy if >50% on same side as brain side affected
158
classic vasovagal history and exam
stimulus - emotion, pain, prolonged standing preceding nausea, pallor, sweat, tunnel vision transient LOC normal o;e
159
classic situational syncope history and exam and inv
transient syncope in specific circumstance e.g. cough, micturition, defecation normal exam tilt table if unclear exclude other causes ECG to exclude
160
summarise neuro causes of collapse
``` seizure Parkinson's stroke vasovagal situational syncope neuropathy (MS) intracranial bleed raised ICP ```
161
classic postural hypotension history and exam
dizziness +/- LOC on sudden standing +/- recent start on antiHTN drugs postural drop of 20+ on standing after 3 mins
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inv and management postural drop
find cause! ``` U+Es - dehydrated? inflamm markers - infection? FBC - anaemic? synacthen test - Addison's? fasting glucose - diabetic autonomic dysfunction? ``` treat cause BP stockings take care
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classic aortic stenosis history and exm
collapse on exertion exertional dyspnoea ``` ejection systolic murmur slow rising pulse narrow pulse pressure heaving apex lung crackles ```
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inv and treat aortic stenosis
echo surgical open replacement TAVI echo follow up
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classic arrhythmic syncope history and exam
sudden LOC following palpitations / feeling strange cardiac history FH sudden death/cardio exam may be normal
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arrhythmic syncope inv and manage
ECG telemetry echo depends on cause - beta block, antiarrhythmics, ablation, pacemaker
167
carotid sinus hypersensitivity
precipitated by head-turning/shaving | diagnosed by carotid sinus massage triggering
168
vertebrobasilar insufficiency
vertigo precipitated by head extension in elderly with cervical osteoarthritis
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subclavian steal syndrome
proximal subclavian artery stenosis = retrograde flow into one of vertebral arteries
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summarise cardiovascular causes of collapse
``` postural drop arrhythmia aortic stenosis structural heart disease carotid sinus hypersensitivity subclavian steal vertebrobasilar insufficiency ```
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summarise non cardio or neuro causes of collapse
``` drugs alcohol tripping bleeding out vertigo anaemia low sugar sepsis sight problems arthritis leg weakness ```
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define acute asthma attack in words
type 1 IgE mediated hypersensitivity reaction causing airway constriction
173
key aspects of history in an acute asthma / COPD exacerbation
``` baseline + severity history of exacerbations ITU admissions PEFR baseline inhaler compliance any home oxygen / nebs infective symptoms / trigger ```
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summarise how to assess an acute asthma or COPD exarcerbation
``` focused history (as described elsewhere) regular peak flow measurements (asthma) ABG CXR core bloods ```
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summarise the 7 aspects of acute life-threatening asthma
33, 92, CHEST ``` PEFR 33% of predicted 92% saturations Cyanosed Hypotensive Exhausted Silent chest Tachycardic ``` (severe 50, mod 75, mild more)
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treating asthma exarcerbation
``` oxygen salbutamol 2.5-5mg neb back to back hydrocortisone 100mg IV ipratropium 500mcg neb mag sulphate 2g IV over 20 minutes if poor resonse escalate care - tube/ventilate aminophylline infusion in ITU ```
177
treating COPD exacerbation
``` controlled Venturi oxygen titrated to sats 88-92% if chronic retainer salbutmol, steroid, ipratrop Abx if septic signs chest physio bipap if needed for sats ```
178
indications for ITU in acute asthma /COPD
``` require ventilation (duh) worsening hypoxaemia / hypercapnia / acidosis exhausted delirious ```
179
someone presents with PE - what do you do initially?
ABCDE approach to assess and manage any acute issues calculate Wells score
180
investigations for PE and their consequences for management (confirmatory and severity assessment)
low Wells score <4 - D dimer (if negative, reassure) high Wells score - treatment dose LMWH and CTPA CTPA confirms - 6 months anticoag severity -> ECG, CXR, echo
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severity of PE - signs on ECG, CXR and echo
ECG - tachycardia, RV strain (T wave inversion in RHS leads, RBBB, right axis) CXR - wedge infarcts, regional oligaemia, enlarged pulm artery, effusion Echo - right heart strain
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PE therapeutic anticoagulant options
DOACs - rivaroxaban or apixiban -> most people warfarin -> if renal impairment or need for quick reversal likely daily LMWH -> only option for cancer patients
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indications for thrombolysis in PE
massive PE - systolic < 90 for 15+ mins, lack of pulse, persistently low HR -> immediate alteplase sub-massive PE - myocardial necrosis or large clot burden, sig RV dysfunction -> 72hrs unfract heparin
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ACS initial assessment
12 lead ECG and continuous cardiac monitor normal bloods + 2 x troponins, Mag, phosphate, lipids CXR
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types of ACS
STEMI - ST elevation or new LBBB NSTEMI - no ST elevation but raised trop at 12 hours untable angina - no trop or ST rise
186
short term management of ACS
morphine oxygen to maintain sats nitrates aspirin + clopi loading dose
187
managing ACS after initial medical management
thrombolysis is rarely used nowadays and is only used if PCI not available within 2 hours (as many contraindications and not as good) PCI gold standard for all STEMIs, done otherwise with high Grace score or if unstable
188
other medications started after loading doses with ACS
statin beta blocker ACEx anticoag if NSTEMI (?)
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general points on managing ACS after PCI
on ward regular electrolytes and keep on telemetry / monitor order echo to assess LVF
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long term ACS managemetn
``` beta blocker 12 months ACEx GTN spray PRN eplerenone if poor LVF aspirin + clopi 12 months statin control BP alter lifestyle factors ```
191
key aspects of assessment in acute pulmonary oedema
ABCDE approach at first ``` then ECG - screen trigger of ACS or arrythmia CXR echo catheter + fluid balance chart serial weights BNP bloods troponin if necessary ABG ```
192
initial treatment protocol with acute pulmonary oedema
position SAT UP high flow oxygen IV furosemide morphine anti-emetic (metaclop 10mg IV) nitrates infusion if severe i.e. hypotensive
193
further interventions that may be needed following initial management with acute PO
look for and treat trigger - valve surgery, PCI for ACS, drugs for dodgy rhythm, BP management, drain tamponade CPAP if still hypoxic in spite of treatment ICU if cardiogenic shock
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core long term heart failure treatments
``` ACEx beta block diuretic aldosterone antag ivabradine in HR remains 7-+ with blockers ``` implantable defib
195
arrhythmia + adverse signs
ABCDE assess adverse signs = SBP low, syncope, MI, heart failure tachyarrhythmia = synchronised DC cardioversion bradycardia = atropine + pacing
196
first steps with ALL arrhythmias
cardiac monitoring treat reversible causes review ECG + determine type
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narrow complex tachycardia
sinus tachy - treat cause SVT - vagal then adenosine then beta blocker (in asthma use verapamil) AF / flutter - rate control (beta blocker, diltiazem, digoxin) and treat cause + assess for anticoag (only do rhythm control in case of acute new episode or refractory to rate control after weeks) rhythm control = DC cardiovert or flecanide/amiodarone
198
broad complex tachycardia management
monomorphic VT - amiodarone polymorphic VT - mag sulphate SV origin broad complex tachy - DC cardiovert
199
broad complex tachycardia of supraventricular origin
looks like VT but caused by conduction of pre-existing conditions like bundle branch block not supravent if very broad complexes, Left axis deviation or AV dissociation
200
differentials of bradycardias
sinus brady SA node dysfunction ('sick sinus syndrome') AV node dysfunction i.e. heart block
201
sinus bradycardia causes
-> drugs, carotid sinus hypersensitivity, vasovagal syncope, hypothermia, hypothyroidism, SA node dysfunction
202
SA node dysfunction / sick sinus syndrome
sinus brady or sinus pauses or sinoatrial arrest + escape rhythm either 1. junctional rhythm initiated from AVN (no p waves but normal QRS) or 2. from ventricles (no p waves but abnormal broad QRS v slow) can be caused by fibrosis (surg,MI), drugs
203
bradycardias at risk of asystole
Mobitz 2 type 2 heart blok complete heart block with broad complexes ventricular pauses >3 secs
204
management overview of bradycardias
1. treat cause 2a. if adverse signs -> atropine 2b. if still bad, transcutaneous pacing + adrenaline until pacemaker can be fitted if no adverse signs, observe and treat cause
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indications for permanent pacing
MObitz type 2 heart block, complte block, sympto bradys,
206
key cardiac drug doses to know adenosine amiodarone atropine mag sulphate
addnosine 6mg IV then 12mg then 12mg wide bore proximal cannula amiodarone 300mg IV over 20-60 mins then 900mg over 24 hours atropine 500mcg IV repeat up to 3mg every 5mins mag sulphate 2g IV over 10-15mins
207
placement of cardiac monitor
red lead - anterior right shoulder yellow - anterior left shoulder green - left ASIS (black would go on right ASIS if present)
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placement of defib pads
right pad - along left sternal edge left pad - left paraspinal muscles (align through body)
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synchronised DC cardioversion
need defib on synchronised mode + anaesthist present start 150J if braod complex tachy or AF start 70J if narrow complex or flutter proceed once patient sedated remove oxygen reassess ABCDE if go unstable, give 300mg amiodarone quikcly give 4 weeks anticoag
210
transcutaneous pacing
some sedation needed set to pacing setting monitor the QRS to see if follow each pacing spike - inc energy if not check pulse corresponds to QRS generated then seek definitive management
211
summarise bradycardia algorithm
ABCDE approach and asessement treat reversible causes assess for adverse features (shock, syncope, MI, HF) if adverse do atropine 500mcg x6 or t/c pacing or adrenaline also do atropione on any high risk astystole pts seek expert input for pacemaker
212
summarise tachycardia algorithm
ABCDE assess if adverse features - synchro DC shock + expert help + amiodarone if not, assess broad/narrow broad regular VT amiodarone SVT+BBB vagal + adenosine broad irregular AF+BBB vagal + adenosine pre-excited AF amiodarone narrow regular vagal, adenosine (if resolves quickly, likley re-entry paroxysmal SVT) (if not, possible atrial flutter,, give beta blocker) narrow irregular probable AF beta block + diltiazem treat other aspects

AS / OS Paces RT (11 decks)

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