OSCE Stop Emergencies Flashcards
airway assessment ABCDE
if talking = patent airway
look inside the mouth
assess for secretions
airway management ABCDE
suction jaw thrust head tilt, chin lift OP, NPA intubation if GCS <8
TREAT ANY CAUSE
i.e. anaphylaxisis (adrenaline)
foreign body (remove)
breathing assessment ABCDE
including tests
pulse ox
resp rate
chest exam
calves
ABG, CXR
breathing management ABCDE
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
circulation assessment ABCDE
incl tests x4
cap refill central pulse BP temp ausc
wide bore IV cannulae
3 lead monitor
ECG
catheter + fluid balance
circulation management ABCDE
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
disability assessment ABCDE
glucose
GCS/AVPU
pupils
pain
CT brain consider
disability management ABCDE
correct glucose
give morhpine
TREAT CAUSE
exposure assessment ABCDE
look all over including underneath for bleed, rash, injury
examine abdo
further exams if relevant
investigations to find causes overview ABCDE assessment
bloods (ABG, G+S, FBC, UE, CRP, LFT +/- amylase)
urine dip, sputum culture, bHCG
CXR, CT
3 lead monitor, ECG
special tests consider
who to ask for help in acute context
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
documenting critically ill pt
ABCDE headings
brief summary
findings and mangement
review results + refer
basic stages in acute presentation assessment
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
6 key differentials for life-threatening shortness of breath
- PE
- pneumothorax
- ashtma/COPD
- pneumonia
- acute pulmonary oedema (LVF)
- acute coronary syndrome
focused Hx for acute SOB
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
focused examination for acute shortness of breath
tracheal deviation, JVP exapansion, apex, heaves percuss chestzones auscultate heart and lungs legs (pain and swelling) perform peak flow if relev
investigations in a patient with acute shortness of breath
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!
5 key differentials for life-threatening chest pain
- acute coronary syndrome
- PE
- aortic dissection
- pneumothorax
- pneumonia
(less acute: pericarditis, myocarditis, pleurisy, MSK, GORD, anxiety attack, oesophageal spasm)
focused history for acute chest pain
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
focused examination acute chest pain
cardioresp focused:
tracheal deviation, JVP exapansion, apex, heaves percuss chestzones auscultate heart and lungs legs (pain and swelling)
investigations in acute chest pain
bloods - FBC CRP U+Es, trop stat+ @12 hrs
xray/imaging - CXR, CTPA if indicated (PE), CT angio if indicated (dissection)
ECG always
4 key DDx in life-threatening abdominal pain
- peritonitis
- AAA
- ischaemic bowel (blockage, volvulus etc)
- medical causes (DKA, pneumonia, MI, Addisionian crisis)
(5. consider upper and lower abdomen causes of pain)
upper and lower abdo causes of pain
UPPER
hepatitis, cholecystitis, peptic ulcer, pancreatitis
LOWER
appendicitis, IBD, diverticulitis, UTI, pyelnonephritis, renal stones, gynae (torsion, ectopic, PID)
focused history in acute abdo pain
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
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
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
5 key DDx in life-threatening headache
- subarachnoid bleed
- meningitis
- space-occupying lesion
- temporal arteritis
- pre-eclampsia
common + rarer but important causes of headache (non life threatening)
migraine, tension headache, sinusitis
acute glaucoma, venous sinus thrombosis, dissection, hypertensive encephalopathy, CO poisoning,
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
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)
investigations in acute headache
bloods: FBC, CRP, U+Es, ESR, blood cultures if fever, meningococcal PCR
xrays/imaging: CT head
special: lumbar puncture
classic PE history
pleuritic chest pain
haemoptysis + SOB
risk factors present
classic pneumonia history
fever, SOB
productive cough
pleuritic chest pain
confusion
classic pneumothorax history
sudden onset pleuritic chest pain
SOB if large one
risk factors present (esp asthma/COPD)
classic asthma exacerbation history
dyspnoea
wheeze
known history of asthma
classic ieCOPD history
dyspnoea
wheeze
change in sputum
known COPD or lifelong smoker
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
classic pneumonia exam findings
tachypnoea, cyanosis coarse crepitations bronchial breathing dullness to percussion increased vocal resonance
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
classic exam findings asthma exacerbation
tachypnoea, accessory muscle use, polyphonic wheeze, reduced air entry, reduced peak flow
classic COPD exacerbation findings o/e
tachypnoea
use of accessory muscles
polyphonic wheeze
reduced air entry
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
classic investigation findings pneumonia
CXR consolidation and air bronchogram inflammatory markers raised sputum culture urinary pneumococcal and legionella antigens blood cultures mycoplasma serology
classic pneumothorax investigation
air in pleural space on CXR
clinical diagnosis with follow up confirmation often
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
classic COPD investigation findings
clinical diagnosis
CXR to exclude x2
ABG low oxygen high co2 raised bicarb
summary PE treatment
treatment dose enoxaparin
if massive, thrombolysis
summary pneumonia treatment
sepsis six if bad
otherwise just Abx
summary pneumothorax treatment
Primary >2cm or have symptoms, aspirate
Secodary > 1cm observe 24 hrs and high flow oxygen
1-2cm aspirate
2cm+ chest drain
summary asthma exacerbation treatment
salbutamol nebs ipratropium nebs steroids IV magnesium Abx if indicated
summary COPD exacerbation treatment
salbutamol nebs ipratropium nebs steroids Abx bipap if needed
classic ACS history
crushing central chest pain
radiates to neck/left arm/jaw
associated nausea/SOB/sweatiness
cardiovascular risk factors
classic ACS exam findings
may be normal
sweaty, SOB, in pain
+/- signs of HF, brady / tachycardia
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
classic treatment ACS
morphine oxygen nitrate aspirin clopidogrel
(anticoagulation, beta blocker)
classic acute LVF history
SOB, orthopnoea, PND, pink frothy sputum, peripheral oedema, cardiac Hx
classic acute LVF exam findings
tachycardia, tachypnoea raised JVP fine bibasal crepitations S3 gallop rhythm peripheral oedema
classic acute LVF investigation findings
CXR - Alveolar shadowing, B lines, Cardiomegaly, Diversion of upper lobe, Effusion
Echo
BNP
ECG - exclude MI
classic LVF treatment
position sitting up oxygen diuretics morphine anti-emetic nitrate infusion CPAP if needed
treat any cause
classic hyperventilation history
tight chest pain SOB, sweating, dizzy, palpitations, doom
anxious / psych Hx
recurrent episodes
clear stimulus
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
classic aortic dissection history
tearing chest pain of VERY sudden onset
radiating to the back
pain in other sites depending on circulation
classic aortic dissection exam findings
unequal arm pulses or blood pressures
may develop acute AR
may develop acute neurology
classic aortic dissection investigation findings
CXR - widened mediastinum
ECG signs of MI
CT angiogram crucial and must be QUICK!!
definitive aortic dissection management
type A - surgical repair immediately
type B - blood pressure control
A for ascending aorta
B is descending aorta
classic pericarditis history
retrosternal / precordial pleuritic chest pain
relieved by sitting forwards
may radiate to trapezius / shoulder / neck
viral prodrome
classic pericarditis exam findings
+/- tamponade
pericardial rub
tachycardia
tamponade:
JVP distension
pulsus paradoxus (BP drop significantly on inspiration)
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
managing pericarditis
NSAIDs
treat cause if known
classic myocarditis history
chest pain palpitations fever fatigue dyspnoea
? viral prodrome
classic myocarditis exam
signs of heart failure S3 gallop fever tachypnoea tachycardia
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
treatment myocarditis
treat cause
treat complications
bed rest
usually recover
pleurisy history
pleuritic chest pain
may have dry cough, fever, dyspnoea
pleural rub heard
diagnosing pleurisy
must exclude pneumothorax, effusion or pneumonia first
treating pleurisy
NSAIDs, treat cause
treat complications
less severe causes of acute chest pain to be considered
musculoskeletal costochondritis GORD anxiety attack oesophageal spasm (corkscrew oesophagous on barium swallow)
classic peritonitis examination findings
shock no abdo movement with respiration guarding firm abdo rebound tenderness severe pain to light palpation percussion tenderness
classic investigations for peritonism
erect CXR - air under diaphragm
CT abdo/pelvis - find perforation site
(may not have perforated yet)
urgent surgery
classic ruptured AAA summary
elderly
severe generalised abdo pain
back pain
low GCS and collapse
expansile mass
bedside USS and CTangio
treating ruptured AAA
permissive hypotension of 100
active massive bleed protocol
urgent open repair
classic appendicitis history
young
periumbilical pain moving to right iliac fossa
anorexia, nausea
fever
classic appendicitis exam findings
tender RIF
worse at McBurney’s point
guarding
Rovsing sign positive
McBurney is 2/3 from umbilicus to ASIS
classic investigations appendiciits
ultrasound abdo / pelvis to exclude gynae
CRP etc raised
bHCG to exclude ectopic
classic biliary colic history
severe intermittent RUQ / epigastric pain
worse with fatty food
classic cholecystitis history
continuous RUQ/epigastric pain
Murphy’s sign positive
tenderness
guarding
classic gallstones history
jaundice
RUQ pain
classic cholangitis history
jaundice
fever/rigours
RUQ pain
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
classic investigation findings gallstones
obstructive LFT picture if CBD stones or cholangitis
inflamm markers raised if cholangitis / cholecystitis
abdo USS
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
classic acute pancreatitis history
severe epigastric, central pain
radiates to back
vomiting
risk factors seen - alc, gallstones, high fat, trauma, surg, meds
classic pancreatitis exam
epigastric tenderness tachycarida fever shock jaundice Grey Turner Cullen signs (rare)
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
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
classic diverticulitis history
old, LIF pain
fever
diarrhoea
diverticulitis on examinaton
tender LIF
guarding
need PR to exclude cancers or abscesses
inv findings and management diverticulitis
raised CRP etc
CT abdo pelvis confirms
clear fluids
Abx
classic renal colic histry
spasms of excruciating loin to groin pain
nausea and vom
never comfortable on bed
renal colic inv
renal angle tenderness and abdo soft ussually
urine dip - micro blood
US KUB
CT KUB
treatment renal colic
strong pain relief
IV fluids
abx if infection signs
if <1cm tamsulosin to aid excretion of stone
if >2cm need nephrolithotomy
classic bowel obstruction history and exam
vomiting (feculent possibly)
colicky abdopain
no bowel motions or flatus
distended, tender
tinkling bowel sounds
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
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
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
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
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
classic pyelonephritis history and exam
fever, rigours
loin pain
frequency and dysuria
loin tenderness
renal angle tenderness
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
classic ectopic pregnancy history
severe unilateral pelvic pain 6-8 weeks, missed period contraception lacking shoulder tip pain spotting
classic ectopic examination
tenderness RIF/LIF
guarding
adnexal tenderness +/- mass palpated
cervical exciation
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
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
investigation and management ovarian cyst rupture or torsion
TVUSS
bHCG to exclude ectopic
laparoscopy for torsion
cyst conservative management
pelvic inflammatory disease classic history
bilateral pelvic pain of gradual onset vaginal discharge DPU and dysmen PCB, IMB discharge may be purulent
classic PID examination
suprapubic tenderness vaginal discharge cervicitis bilateral adnexal tenderness cervical excitation fever
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
classic tension headache story and treatment
bilateral tight band sensation recurrent late in day stressed muscular tenderness
simple pain relief
destress
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
treating cluster headaches
100% oxygen
triptan
verapamil prophylaxis
classic migraine history
unilateral pulsating trigeminal nerve distribution hoursto days aura photophobia
exam usually normal
migraine treatments split into two categories
abortive
NSAID, aspirin, triptan
preventative
propanolol, amitriptyline, antiepileptics
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
trigeminal neuralgia workup and treatment
MRI to find cause if any
antiepileptics
treat cause if found
group the DDx of headache into 3 categories
primary headache
secondary - intracranial
secondary - extracranial
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
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
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
investigation findings and mnagement temporal arterits
raised ESR
+ve temporal artery biopsy
doppler of temp artery shows reduced flow
high dose pred
classic subarachnoid history and exam
very sudden very severe smacked on the back of the head doctor meningism thunderclap!
reduced GCS
meningism
subarac inv and manage
CT head - blood in circle of Willis
LP if normal CT - shows xanthochromia (yellow CSF)
nimodipine
coiling, clipping
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
inv findings and manage high ICP
CT head to find cause
monitoring of ICP
mannitol +/-hyperventilate them if severe
drain CSF
treat cause
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
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
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
raised ICP from bleed with midline shift on CT
craniotomy and clot evac
endoscopic evac
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
acute closed angle glaucoma inv and manage
tonometry >24mmHg IOP
acetazolamide
timolol
laser peripheral iridectomy
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
inv findings and treatment sinusitis
clinical diagnosis
abx
warm face packs
saline nasal drops
analgesia
classic hx and exam hypertensive encephalopathy
headache
visual blurring
vomiting
severe HTN measured
bilateral retinal bleeds
papilloedema
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
classic pre eclampsia hx and exam
3rd trimester headache visual disturbance epigastric pain vomiting
HTN
brisk reflexes
oedema
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
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
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
group the differentials for collapse / fall
neurological
vascular
metabolic / drugs
infection
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
investigate seizures
EEG if needed
find trigger: CT head - intracranial electrolytes cap glucose drug levels
management seizures
IV lorazepam or PR diazepam to terminate acutely
treat cause
start on anti-epileptics if 2+ instances of seizures
don’t drive!
classic Parkinson’s histoyr
rigidity+
tremor+
bradykinesia+
postural instability
classic Parkinson’s o/e
resting tremor,
shuffling festinant gate with lack of arm swing
cogwhell rigidity
bradykinesia
Parkinson’s diagnosis
clinical
if uncertain, neuroimaging DaTscan
brief Parkinson’s treatment summary
levodopa
dopamine agonists
monoamine oxidase inhibitors
physio + OT
classic TIA/stroke history and exam
sudden onset neuro signs (limb/face weakness, slurring, vision change)
risk factors present
neuro deficits seen o/e
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
classic vasovagal history and exam
stimulus - emotion, pain, prolonged standing
preceding nausea, pallor, sweat, tunnel vision
transient LOC
normal o;e
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
summarise neuro causes of collapse
seizure Parkinson's stroke vasovagal situational syncope neuropathy (MS) intracranial bleed raised ICP
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
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
classic aortic stenosis history and exm
collapse on exertion
exertional dyspnoea
ejection systolic murmur slow rising pulse narrow pulse pressure heaving apex lung crackles
inv and treat aortic stenosis
echo
surgical open replacement
TAVI
echo follow up
classic arrhythmic syncope history and exam
sudden LOC following palpitations / feeling strange
cardiac history
FH sudden death/cardio
exam may be normal
arrhythmic syncope inv and manage
ECG
telemetry
echo
depends on cause - beta block, antiarrhythmics, ablation, pacemaker
carotid sinus hypersensitivity
precipitated by head-turning/shaving
diagnosed by carotid sinus massage triggering
vertebrobasilar insufficiency
vertigo precipitated by head extension in elderly with cervical osteoarthritis
subclavian steal syndrome
proximal subclavian artery stenosis = retrograde flow into one of vertebral arteries
summarise cardiovascular causes of collapse
postural drop arrhythmia aortic stenosis structural heart disease carotid sinus hypersensitivity subclavian steal vertebrobasilar insufficiency
summarise non cardio or neuro causes of collapse
drugs alcohol tripping bleeding out vertigo anaemia low sugar sepsis sight problems arthritis leg weakness
define acute asthma attack in words
type 1 IgE mediated hypersensitivity reaction causing airway constriction
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
summarise how to assess an acute asthma or COPD exarcerbation
focused history (as described elsewhere) regular peak flow measurements (asthma) ABG CXR core bloods
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)
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
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
indications for ITU in acute asthma /COPD
require ventilation (duh) worsening hypoxaemia / hypercapnia / acidosis exhausted delirious
someone presents with PE - what do you do initially?
ABCDE approach to assess and manage any acute issues
calculate Wells score
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
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
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
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
ACS initial assessment
12 lead ECG and continuous cardiac monitor
normal bloods + 2 x troponins, Mag, phosphate, lipids
CXR
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
short term management of ACS
morphine
oxygen to maintain sats
nitrates
aspirin + clopi loading dose
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
other medications started after loading doses with ACS
statin
beta blocker
ACEx
anticoag if NSTEMI (?)
general points on managing ACS after PCI
on ward
regular electrolytes and keep on telemetry / monitor
order echo to assess LVF
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
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
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
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
core long term heart failure treatments
ACEx beta block diuretic aldosterone antag ivabradine in HR remains 7-+ with blockers
implantable defib
arrhythmia + adverse signs
ABCDE assess
adverse signs = SBP low, syncope, MI, heart failure
tachyarrhythmia = synchronised DC cardioversion
bradycardia = atropine + pacing
first steps with ALL arrhythmias
cardiac monitoring
treat reversible causes
review ECG + determine type
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
broad complex tachycardia management
monomorphic VT - amiodarone
polymorphic VT - mag sulphate
SV origin broad complex tachy - DC cardiovert
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
differentials of bradycardias
sinus brady
SA node dysfunction (‘sick sinus syndrome’)
AV node dysfunction i.e. heart block
sinus bradycardia causes
-> drugs, carotid sinus hypersensitivity, vasovagal syncope, hypothermia, hypothyroidism, SA node dysfunction
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
bradycardias at risk of asystole
Mobitz 2 type 2 heart blok
complete heart block with broad complexes
ventricular pauses >3 secs
management overview of bradycardias
- 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
indications for permanent pacing
MObitz type 2 heart block, complte block, sympto bradys,
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
placement of cardiac monitor
red lead - anterior right shoulder
yellow - anterior left shoulder
green - left ASIS
(black would go on right ASIS if present)
placement of defib pads
right pad - along left sternal edge
left pad - left paraspinal muscles (align through body)
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
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
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
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
