Peer Teaching Flashcards
How can CXR interpretation be structured?
- Details
- RIPE-> rotation, inspiration, picture, exposure
- Soft tissues + bones
- Airways + mediastinum
- Breathing
- Circulation
- Diaphragm
- Extras-> PICC lines, NG tubes etc
Why might someone be given clarithromycin as well as IV co-amoxiclav in severe CAP?
To cover for atypical pathogens
What are patients allergic to penicillin given in pneumonia?
Doxycycline
What are some features of moderate asthma?
-PEFR 50-75% of predicted
What are some features of acute severe asthma?
- PEFR 33-50% of predicted
- Pulse 110+
- Inability to complete sentences in 1 breath
- Oxygen sats >92%
What are some features of life threatening asthma?
- PEFR <33%
- Sats <92%
- Reduced consciousness
- Arrythmias
- Poor resp effort
- Silent chest
- Confusion
How is acute asthma managed?
- Oxygen-> aim for 94-98%
- Neb’d salbutamol
- Neb’d ipratropium bromide
- Prednisolone (PO) or hydrocortisone (IV)
- IV magnesium
- Antibiotics
What should be monitored when treating acute asthma?
U+Es-> salbutamol can cause hypokalaemia
What can trigger an asthma attach?
- Infection
- Smoking
- Poor asthma control
- Poor inhaler technique
How is primary spontaneous PTX managed?
Needle aspiration (if >2cm)
How is secondary spontaneous PTX managed?
Chest drain
How does tension PTX present?
Hypotension, hypoxia reduced breath sounds, tracheal deviation
How is tension PTX managed>
- Large bore cannula into pleural space
- Then chest drain
- 2nd anterior intercostal space mid-clavicular line
What can cause transudate pleural effusion?
- CCF
- Liver cirrhosis
- Liver failure
- Nephrotic syndrome
- Renal failure
- Due to oncotic/hydrostatic pressures
What can cause exudate pleural effusion?
- Local factors cause changed in pleural fluid movement
- Infection
- Local malignancy
- Local trauma
Which type of pleural effusion contains lots of protein (>30g/L)
Exudative
What is the pathophysiology of transudative pleural effusion?
- Increased hydrostatic pressure due to venous outflow obstruction
- Decreased colloid osmotic pressure due to decreased protein synthesis
- Fluid leaks out of vessels
What is the pathophysiology of exudative pleural effusion?
- Vasodilation and stasis
- Increased interendothelial space
- Both due to inflammation
- Fluid and proteins leak out of vessels
What can be used to diagnose exudative pleural effusion?
Lights criteria
What can be used to quantify the severity of breathlessness?
MRC dyspnoea scale
- 1-> not troubled except on strenuous exercise
- 2-> SOB when hurrying or walking up slight hill
- 3-> walk slow on level ground or has to stop for breath when walking at own pace
- 4-> stop for breath after walking 100m or few mins on level
- 5-> too breathless to leave house or SOB when dressing
How can COPD be diagnosed?
- Spirometry
- CXR-> hyperinflation
- High resolution CT scan-> emphysema/chronic airway disease signs
What extra bits should be done/given in COPD?
- Smoking cessation support
- Pneumococcal and flu vaccines
- Pulmonary rehab if indicated
- Personalised self-management plan
- Co-morbidity management
How should someone with COPD (without asthmatic/steroid responsive features) be managed?
- SABA or SAMA PRN
- Then LABA + LAMA
- Then LABA + LAMA + ICS 3 months trial
- Then revert back to LABA + LAMA if no improvement
How should someone with COPD (with asthmatic/steroid responsive features) be managed?
- SABA or SAMA PRN
- Then LABA + ICS
- Then LABA + LAMA + ICS
How is acute exacerbation of COPD managed?
- Nebulisers or inhalers
- 30mg oral prednisolone 5 days
- Antibiotics-> amoxicillin 5 days (but depends on sputum culture)
- Theophylline
- O2/NIVs-> target 88-92%
- ‘Rescue pack’-> pred + amoxicillin
When is CPAP used?
Type 1 resp failure-> hypoxia
When is BiPAP used?
Type 2 resp failure
What can cause acute heart failure?
CHAMPS
- ACS
- Hypertensive crisis
- Arrhythmia
- Mechanical/metabolic
- PE
- Sepsis
How can acute heart failure be managed?
- IV furosemide
- High flow oxygen
- Digoxin or beta blocker if AF
- If not improving-> IV GTN, CPAP, dobutamine
What are some potential CXR findings in acute heart failure?
- Alveolar oedema-> bats wings
- Kerley B lines
- Cardiomegaly
- Dilated upper lobe veins
- Effusions
What can cause raised BNP?
- Heart failure
- ACS
- PE
- Myocarditis
- CKD
- Liver cirrhosis
- Sepsis
How does BNP correlate to symptoms + prognosis in HF?
Higher levels-> worse mortality but not necessarily symptoms
What symptoms might be described in heart failure?
- SOB
- Fatigue
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
- Wheeze
- Leg swelling
- Abdominal swelling
What signs may be elicited in heart failure?
- Raised JVP
- Creps in lungs
- 3rd heart sound
- Pedal oedema
- +ve hepatojugular reflex
How does furosemide work in heart failure?
- Loop diuretic
- Inhibits Na/K/Cl transporter in loop of Henle
- Stops electrolyte reabsorption-> diuretic
- Dilated veins to reduce preload
What medicines can improve prognosis in heart failure?
- ACE-i
- Beta blocker
- Spironolactone
- Sacubitril-Valsartan
- SGLT2-inhibitor
- Ivabradine
- Isosorbide mononitrate
- Hydralazine
Is troponin needed to diagnose STEMI when seen on ECG?
No
If STEMI is present in leads II, III and aVF, which artery is affected?
RCA
What meds are given in immediate management of STEMI?
- Aspirin
- 2nd antiplatelet-> ticagrelor, clopidogrel, prasugrel
- Sublingual GTN
- IV morphine
- IV metaclopramide
A patient develops bradycardia + irregularly irregular pulse after being treated for inferior STEMI. What is this?
Heart block-> secondary to inferior MI
What meds should be prescribed to patients post-MI?
- Atorvastatin
- Ramipril
- Bisoprolol
What lifestyle advice should be given to patients post-MI?
- Cardiac rehab
- Stop smoking
- Healthy diet
- Lower alcohol intake
What can cause irregular narrow complex tachycardia?
- AF
- Atrial flutter with variable block
- Frequent atrial ectopics
- Multifocal atrial tachycardia
What investigations would be suitable to perform in AF?
- ECG
- Observations
- TFTs
- FBC
- U+E
- Mg
- LFT
- Clotting screen
- Echo
What anticoagulant should be used in AF if a patient has mitral stenosis?
Warfarin
What anticoagulant should be used in AF if a patient has a metal heart valve?
Warfarin
How does warfarin work?
- Vitamin K antagonist
- Inhibits vitK epoxide reductase-> needed to activate vitamin K
- Stops vitK dependent clotting factor synthesis-> 2, 7, 9, 10
What drugs can be used to control heart rate in AF?
- Bisoprolol
- Verapamil
- Diltiazem
- Digoxin
How should patients who are haemodynamically unstable with AF be managed?
Electrical cardioversion
What organisms can cause infective endocarditis?
- Staph aureus
- Strep viridans
- Coagulase negative staph
- Enterococcus
- HACEK
Which valve is most affected in endocarditis?
Tricuspid-> injecting (IVDU) + bacteria hits this valve first
What signs of immune complex depositions can be present in endocarditis?
- Haematuria
- Osler nodes-> painful
- Splinter haemorrhages
- Roth spots
What affect can septic emboli have in endocarditis?
- Abscesses
- From left heart to brain, kidneys, spleen, gut, bone, skin (Janeway lesions)
- From right heart to lung
Why are serial ECGs done in aortic valve endocarditis?
PR prolongation can indicate aortic root abscess (press on AVN)
Why are antibiotics given empirically in endocarditis?
- Bactericidal-> immune system not good at getting to heart valves (poor blood supply)
- Gentamicin-> can’t usually get into streptococci
- Benpen-> breaks down strep walls + allows gentamicin in to kill bacteria
- Both-> gram +ve and gram -ve cover
What antibiotics are used in endocarditis and how long for?
Amoxicillin + Gentamicin for 4-6 weeks
When is surgery indicated in endocarditis?
- Abscess formation
- Acute heart failure
- Prosthetic valve dehiscence
- Recurrent emboli
- Infection spreads past valve
What is the definition of a stroke?
Acute neurological deficit of vascular origin lasting 24+ hours or causing death
What can cause stroke?
ASCOD grading
- Atherosclerosis
- Small vessel disease-> lipohyalinosis (due to age/HTN) causing lacunar infarcts or microhaemorrhages
- Cardiac pathology-> AF, MI, valvular, endocarditis
- Other-> SLE, anti-phospholipid syndrome, sickle cell, moyamoya disease, vasculitis
- Dissections
What causes cerebral small vessel disease?
- HTN or atherosclerosis
- BVs can’t dilate in response to reduced flow
- Blocked by atherosclerotic plaque
- Bleeds
What is a lacunar infarct?
- Small vessel stroke
- Can cause basal ganglia + internal capsule damage
What is an incomplete infarct?
-Arterial occlusion with resultant ischaemia of moderate severity
What is a watershed infarct?
- Watershed zone-> regions between vascular territories
- Vulnerable when sudden reduction in arterial BP-> CR arrest, anaphylaxis, major blood loss etc
What is a total anterior circulation stroke?
Stroke in anterior cerebral + middle cerebral arteries
What are the symptoms/criteria of total anterior circulation stroke?
All 3…
- Unilateral weakness (+/- sensory deficit) of face, arm + leg
- Homonymous hemianopia
- Higher cerebral dysfunction-> dysphagia, visuospatial disorder
What are the symptoms/criteria of partial anterior circulation stroke?
Need 2/3…
- Unilateral weakness (+/- sensory deficit) of face, arm + leg
- Homonymous hemianopia
- Higher cerebral dysfunction-> dysphagia, visuospatial disorder
What are the symptoms/criteria of posterior circulation stroke?
Need 1…
- CN palsy + contralateral motor/sensory deficit
- Bilateral motor/sensory deficit
- Cerebellar dysfunction (DANISH)
- Conjugate eye movement problems
- Isolated homomymous hemianopia
What are the symptoms/criteria of lacunar stroke?
- Pure motor
- Pure sensory
- Pure motor + sensory
- Ataxic hemiparesis
What is the ROSIER criteria?
Rule Out Stroke In ER
- LOC/syncope? (-1)
- Seizure? (-1)
- New acute asymmetrical facial weakness (+1)
- New acute asymmetrical arm weakness (+)
- New acute asymmetrical leg weakness (+1)
- New acute speech disturbance (+1)
- New acute visual field defect (+1)
What is Broca’s dysphasia?
- Expressive/non-fluent
- Understand what’s being said but can’t express self
What is Wernicke’s dysphasia?
- Receptive/fluent
- Fluent speech but doesn’t make sense
- Can’t understand what’s being said
How is stroke investigated?
- Non-contrast CT-> rule out haemorrhage
- ECG
- Bloods-> FBC, U+E, LFT, lipids, TFT, cholesterol, glucose, clotting, INR (if warfarin)
- May use-> CT angiography, perfusion weighted MRI, carotid doppler, echo
What can be seen on perfusion/diffusion weighted MRI in stroke?
- Ischaemic core
- Penumbra-> area surrounding core that could infarct
What causes brain cell death in stroke?
- Perfusion + energy failure
- Na/K+ ATPase pump failure-> Na+ stays in cell
- Release glutamate-> excitotoxic
- Ca2+ influc-> cell death
- Water influx (follows Na+)-> oedema + raised ICP-> coning-> death
How is stroke managed?
- Aspirin 300mg
- Thrombolysis-> within 4.5 hours symptom onset + CT head (rule out haemorrhage)
- Mechanical thrombectomy-> within 24 hours symptoms +/- thrombolysis if eligible
- NBM + NG tube
- Aspirin 300mg for 2 weeks then 75mg
- Clopidogrel 75mg OD if aspirin CI’d
- Statins
What would indicate neurosurgery referral in stroke?
- Dropping GCS
- Severe headaches
- N+V
- Sudden BP increase
- Large MCA or cerebellar infarct-> within 48 hours
What is transient ischaemic attack?
- Brief period of cerebral ischaemia
- Usually lasts <24 hours
What is amaurosis fugax?
- Temporary vision loss in one eye
- Can be due to TIA of retinal blood supply
How long after TIA should a patient stop driving for?
1 month
How long after stroke should a patient stop driving for?
At least 1 month
What can cause intracranial mass?
- Brain-> tumour, oedema, abscess
- Blood-> SAH, ICH, extra-dural
- CSF-> increased production, obstruction, reduced absorption
How can raised ICP be managed?
- Mannitol-> osmotic diuretic
- Hyperventilation-> to increase pO2 + decrease CO2
- Hypertension-> improve mean arterial pressure
- Head up-> improve venous drainage
- Intubation
- Thiopental
- Surgery-> Burr hole, craniectomy etc
- Monitoring-> transcranial doppler etc
What are some signs of raised ICP?
- Fixed dilated (blown) pupil-> CNIII compression due to temporal uncal herniation
- Cushing’s triad-> decreased RR + bradycardia + HTN due to CR centre compression through foramen magnum
What is Cushing’s triad and what does it indicate?
- decreased RR + bradycardia + HTN
- due to CR centre (in medulla oblongata) compression through foramen magnum
What are the different components of GCS?
- Eye opening (4)-> spontaneous, to speech, to pain, no response
- Verbal response (5)-> oriented, confused, inappropriate words, incomprehensible sounds, no response
- Motor response (6)-> obeys commands, moves to localised pain, flex to withdraw from pain, abnormal flexion, abnormal extension, no response
