prep Flashcards
1
Q
Causes of a metabolic acidosis?
A
Normal anion gap
- Renal tubular acidosis
- Dehydration
- Addisons
Raised anion gap
- Sepsis, hypoxia (Raised lactate)
- DKA (raised ketones)
2
Q
Causes of a metabolic alkalosis?
A
Cushings Conns Diuretics Vomiting/aspiration hypokalaemia (H+ is sucked into cells, in exchange for K+ into ECF)
3
Q
Max length of QT?
A
2 big squares
4
Q
Max length of PR interval?
A
1 big square
5
Q
Max length of QRS?
A
3 small squares
6
Q
Indicators of pancreatitis severity?
A
PaO2< 7.9kPa Neutrophils (WBC > 15) Calcium < 2 mmol/L Albumin < 32g/L (serum) Sugar (blood glucose) > 10 mmol/L
7
Q
What differentiates Ascending cholangitis and Cholecystitis?
A
Jaundice
8
Q
Management of pancreatic pseudocysts?
A
If they are systemically well then conservative.
However, if not: The indications for active drainage would be signs of infection, mass effect on abdominal organs or a persisting pseudocyst beyond 12 weeks from it developing.
9
Q
Common presentation of chronic pancreatitis?
A
Abdominal pain following meals, pancreatic enzymes, steatorrhoea, and diabetes.
10
Q
Most common causative organism for ascending cholangitis?
A
E.Coli
11
Q
What is the causes of a pulmonary effusion?
A
Transudate:
- HF
- Hypoalbuminaemia
- Liver cirrhosis
Exudate:
- Pneumonia
- Malignancy
12
Q
A-E proforma?
A
A
- Patent? Are they talking, is there anything in there?
B (RESPS) RR Exertion Sats Percussion Sounds (auscultation)
C (in a c, start at hands)
- Hands warm/well perfused
- Cap refill
- Radial pulse
- Carotid
- JVP
- Central cyanosis
- Heart sounds
D (GAPSS)
- Glucose/Don’t forget glucose
- AVPU
- Pupils
- Pain
- Seizures
Expose, examine abdomen
13
Q
4 Hs and Ts of reversible causes of cardiac arrest?
A
Hypovolaemia
Hypothermia
Hypoxia
Hyperkalaemia
Tamponade
Tension Pneumothorax
Toxins
Thrombus (PE)
14
Q
General run-through of advanced life support?
A
DR ABC
- Dynamic assessment
- Response
- Shout for help
- Airway: Head tilt/chin lift, check there is nothing obstructing the airway
Breathing: Feel carotid and breath at same time, whilst maintaining head tilt/chin lift
Chest compressions
- 30:2 chest compressions to rescue breaths
- Stop compressions every 2 mins for 5 sec rhythm checks and rescue breaths (NOT ventilations)
- Switch compressor every 2 mins
Defib
- Other person attaches pads (>8cm from pacemaker, move jewellery, can do AP if needed)
- Connect pads to defib and set to monitor
- Check rhythm every 2 mins, if lines are wavy then it is shockable (VF/VT), if asystole of PEA non shockable.
Drugs/IV access
- Get access and take VBG, bloods and give fluids
- If shockable the after 3rd shock give IV adrenaline 10ml 1 in 10,000 (flush with 20ml N saline) and amiodarone (300mg), repeat adrenaline every 4 mins (every other rhythm check)
- If not shockable immediately give adrenaline
15
Q
What are the shockable/non-shockable rhythms?
A
VF/VT
- wavy lines
PEA (normal) or Asystole are non shockable
16
Q
Management of acute asthma exacerbation, and classification?
A
Classify it:
1. Do PEFR
PEFR <33% (33, 92 CHEST) - life threatening 33: PEFR <33% predicted 92: sats <92 Cyanosis Hypotension Exhaustion Silent chest Tachycardia
PEFR: <50%: severe
PEFR: <75%: Moderate
PEFR: >75% Mild
Treatment (O SHIT ME) Give all together: - Oxygen, 15L, non-rebreathe - Salbutamol Nebs, 2.5mg, back to back initially - Hydrocortisone 100mg IV - Ipratropium 500mcg Neb
If needed with senior input:
- Theophylline (aminophylline infusion)
- Magnesium Sulphate 2g IV over 2 mins
- Escalate
17
Q
Management of COPD exacerbation?
A
- O SHIT (as in asthma, but give o2 24-28% via venturi)
- Abx as per local guidelines
- Chest physio
- Consider BiPAP
18
Q
PE management?
A
A-E if critically unwell
Confirm/exclude:
- Wells score
Investigate severity:
ECG changes (Sinus tachy or Rv strain) CXR (infarcts), echo (R strain)
Wells 4 or less, then D-Dimer
Wells 5 or more then LMWH (1.5mg/kg OD), CTPA when poss then therapeutic anticoag for 6 months (DOAC)
Thrombolysis if haemodynamic instability
19
Q
ACS acute Management?
A
A-E
MONAC
- Morphine 10mg in 10ml slow IV (& 10mg metaclopramide IV)
- Oxygen (IF sats <98%)
- Nitrates: Sublingual GTN
- Aspirin 300mg loading dose (75mg OD after)
- Clopidogrel 300mg loading dose (then 75mg OD)
20
Q
Acute management of Pulmonary oedema?
A
A-E:
To include:
- ECG, CXR, Echo, Catheterise (strict fluid balance), serial weights, BNP, ABG
POD MAN
Position upwards
Oxygen high flow
Diuretics (furosemide IV, 40mg initially)
Morphine (5-10mg, 2mg/min, 5 if elderly or frail)
Anti-emetic (metoclopramide 10mg IV)
Nitrates if severe (>110 BP then infusion >90 then 2 puffs spray)
21
Q
Acute management of arrhythmia?
A
A-E if critically ill
- No pulse: ALS
- Adverse signs (Sys <90, Syncope, chest pain or ischaemia on ECG, HF)
- Tachy: DC cardioversion
- Brady: Atropine & pacing
If no adverse signs (call cardio reg?)
- 3 lead telemetery,
- Treat reversible causes (e.g. electrolyte disturbance)
Narrow complex tachy:
- Paroxysmal SVT:
1. vagal maneuvers
2. Adenosine (not in asthma) - use verapamil
3. B Blocker - AF: Rate/rhythm control
Broad complex tachy:
VT - amiodarone, torsades - Mag sulf
Brady:
- treat cause (sinus/sick sinus/Heart block type 2)
22
Q
Upper GI bleed acute management?
A
Usual A-E to include:
- Look for chronic/decompensated liver disease
- Melaena (PR)
- Bloods: G&S/Crossmatch, FBC. U&Es (urea), LFTs, Clotting, glucose
- Catheterise
- IV fluid resuscitation aiming for SBP 100
- If massive blood loss do local major haemorrhage protocol, FFP, platelets and blood.
- If Hb <7 or 8 then transfuse blood
Investigations once stable:
- CXR, AXR, OGD once stable
If varcieal bleed (signs of chronic liver disease)
- Terlipressin
- Prophylactic IV abx
- Endoscopic intervention
If non-variceal
- Straight to endoscopy
- After endoscopy IV PPI
23
Q
Causes of Upper GI bleed?
A
Variceal bleed
Ruptured peptic ulcer
Oesophagitis
Mallory weiss tear
24
Q
Acute management of DKA?
A
- A-E
- Confirm DKA with VBG, Urine Ketones and Glucose
- Acidosis pH <7.3
- Glucose >11 or known diabetic
- Ketones ++ urine
3. Fluids 1L over 1 hr - No KCl 1L over 2 hr 1L over 2 hr 1L over 4 hr 1L over 4 hr 1L over 6 hr 1L over 6 hr
After first litre add KCl dependent on VBG results
- IV insulin at 0.1 units per kg per hour in 50ml of N saline, when you get Glucose below 14 start to also give 10% glucose at 125ml/hr and reduce saline rate in the insulin infusion.
Investigate to find cause
- Hx
- Examination
- Notes
- Bloods, culture, MSU CXR
Consider ITU if GCS<12, ketones > 6, SBP <90, Sats <92.
Check VBGs 2 hrly
Continue Long acting insulin throughout, if new presentation start long acting insulin
25
HHS acute management?`
Conform diagnosis
- >30 glucose, no ketones
- >320 serum osmolarity
- Hypovolaemia
```
Management
1. rehydrate with normal saline (same as DKA):
1L over 1 hr - No KCl
1L over 2 hr
1L over 2 hr
1L over 4 hr
1L over 4 hr
1L over 6 hr
1L over 6 hr
```
2. VTE prophylaxis
3. IV insulin at 0.05 units/kg/hour
Look for cause and hold metformin for 2 days (metabolic acidosis)
26
Acute mangement of hyperglycaemia (No DKA/HHS)?
Rehydrate if necessary
STAT dose of actrapid:
In T1DM aim for <12 glucose, one unit decreases by 3
In T2DM give 0.1unit/kg, aim for <14 glucose.
Identify and correct cause (are they taking their insulin correctly?)
Reasses in 1 hr
27
Acute management of Hypoglycaemia?
Unconscious
- 150ml 10% glucose/ 75ml 20%
- Glucagon 1mg IM if no IV access
- check glucose 10min later, give long acting carbs when conscious
Conscious, no swallow
- 2 tubes of glucose gel around teeth
- Check glucose 10min later
Can swallow
- 150ml fruit juice, 5 glucose tabs
- Long acting carbs
Correct cause and consider reducing insulin dose (do not omit.
28
Stroke acute management? inc hx and ex
Hx
- exact time of onset
- Progression of symptoms
- r/fs
Ex
- Full neuro exam
- Pulse, HS, bruising/bleeding, carotid bruits
Management
1. CT head within 1 hr
2. If intracranial bleed excluded:
- Alteplase if within 4.5 hrs & not contraindicated.
- If contraindicated aspirin 300mg PO OD for 2 weeks or Clopi 300mg stat followed by 2 weeks 75mg
Consider endovascular clot retrieval & transfer to stroke ward.
29
TIA acute management? inc hx and ex
Hx
- exact time of onset
- Progression of symptoms
- r/fs
Ex
- Full neuro exam
- Pulse, HS, bruising/bleeding, carotid bruits
1. Aspirin 300mg PO OD for 2 weeks or Clopi 300mg stat followed by 2 weeks 75mg
- If already on anti-platelet then continue
- If in AF start anticoagulation
Specialist r/v within 24 hrs
30
How long can't you drive after stroke?
4 weeks
31
Acute seizure management?
A-E, including:
- Recovery position
- Jaw thrust
- Consider nasopharyngeal airway
- 15L O2 by non-rebreathe
- IV access
- Ob
- Cap glucose, VBG
- ECG
If seizure not stopping after 5 mins consider 4mg lorazepam IV with9in 10 mins, repeat within 20 mins
at 30 mins give phenytoin 18mg/kg IV max 2g
at 60 General anaesthesia andf ITU
IF hypoglycaemia 50mls 50% glucose
IF alcohol abuse give pabrinex 2 pairs IV
32
Septic screen?
Bloods:
- Hb
- WCC/Neutrophils
- Plts
- INR
- Bilirubin
- VBG for lactate
- Cultures
Orifices
- Urine dip, other cultures
CXR
ECG?
Special
- Other imaging if necessary
33
Post op early complications?
```
Fluid depletion
Electrolyte imbalances
Local infection
Atelectasis
DVT/PE
Wound break down
Anastomotic leak
Bed sores
```
34
Gastrectomy post-op complications?
```
Dumping syndrome
Malabsorption
Anastomotic ulcer
Peptic ulcer
Small intestine bacterial overgrowth
```
35
What is dumping syndrome?
Rapid gastric emptying, with the delivery to the small intestine of a significant proportion of solid food as large particles that are difficult to digest. Intravascular fluid moves into the intestinal lumen, causing cardiac difficulties.
- Desire to lie down
- Palpitations.
- Headache.
- Flushing.
- Epigastric fullness.
- Nausea, vomiting and diarrhoea.
- Abdominal cramps and borborygmi (rumbling/gurgling)
Late dumping syndrome (1-3hrs)
- Sweating and tremor.
- Hunger.
- Difficulty concentrating
36
Small/large bowel operation complications?
```
Postoperative ileus
Anastomotic leaks (5-10 days post op)
Stoma retraction
Intra-abdominal collection
Pre-sacral plexus damage
Adhesions/intestinal obstruction
Damage to local structures (kidney, bladder)
```
37
Cholecystectomy most common complication?
CBD damage/bile leak
38
How would CBD damage/bile leak present?
Abdo pain
Nausea
Pyrexia
Abdominal swelling
39
Common complications following biliary operations?
```
CBD damage/bile leak
CBD stricture
Anastomotic leak
Bleeding into biliary tree (jaundice)
Pancreatitis
```
40
Approach to assessing a pyrexic post-op patient? (include 5 Ws)
A-E
Think about specific risks of operation
Most at risk of sepsis from chest infection (2nd to atelectasis)
5 Ws
- Wind, 2 days, atelectasis, pneumonia
- Water, 2-4 days, UTI
- Wound, 5-7 days Wound infection
- Walking 8-10 days, VTE
- Wonder drugs, any time, Transfusion/drug reactions.
41
Maintenance fluid requirements per kg per day?
30 mls/kg/day
42
Requirements (in mmols of sodium, potassium and chloride)?
1 mmol/kg/day
43
Healthy urine output? minimum urine output in fluid replacement?
1ml/kg/hour
0.5ml/kg/hour in replacement
44
What conditions can cause increased fluid loss?
Vomiting/diarrhoea
Stoma/drains/fistulae
Skin lesion/Burns
Bleeding
45
Roughly how much do you lose via insensible losses (gut/lungs/skin)?
If someone is tachypnoeic/pyrexic/sweating how can these change?
800mls
Can double if pt is sweating, tachypnoeic or febrile
46
What electrolytes are lost in vomiting, diarrhoeal(/stoma) and sweating?
Sweating - sodium
Diarrhoeal/stoma - Sodium, potassium, bicarb
Vomiting - potassium, chloride, hydrogen (hypochloraemic metabolic alkalosis)
47
What volume of N saline is needed to replace a 1000ml loss of blood?
4 Litres as only 25% remains intravascularly
48
When assessing a post-op patient for hypotension what should you do?
1. Try to find cause
2. Assess for organ dysfunction
```
1:
Causes:
- Decreased intravascular volume
- Pump failure (cardiogenic shock): MI, Fluid overload and HF
- Sepsis and anaphylaxis
- Sympathetic shock (neurogenic shock)
```
2:
- ABG for lactate
- Urine output assessment (>0.5ml/kg/hr)
- Confusion
49
Post op Respiratory difficulties causes and assessments?
RTI
PE
Pulmonary oedema (from large fluid shifts, hypoalbuminaemia, cardiac dysfunction)
Assess:
- Fluid status
- Calves for DVT
- Bloods/CXR for infection
- ABG
50
Anaphylaxis management?
Call for help, get crash team on 2222. Remove allergen
Airway
- Secure airway
- Adrenaline 0.5mg IM (0.5 of 1:1000)
Breathing
- 15L non rebreathe
- If wheeze salbutamol neb
Circulation
- IV access, 2 wide bore cannulas
- IV fluid challenge
- Hydrocortisone 200mg IV
- Chlorphenamine 10mg IV
- Telemetry
Longer term:
- Admit for observation
- 5 day course of pred
- Chlorphenamine 4mg QDS if itching
- Document allergy and send for testing if appropriate.
51
How might your pain prescription differ after surgery?
Can prescribe tablets like co-codamol separately, so pt can taper off; prescribe paracetamol and codeine separately.
52
LA toxicity symptoms?
Mild toxicity
- Tingling around the mouth/extremities
- Metallic taste
- Visual disturbances
Moderate toxicity
- Altered level of consciousness
- Convulsions
Potentially fatal toxicity
- Dysrhythmias
- Cardiovascular collapse
- Respiratory arrest
53
Management of LA overdose?
1. Stop any ongoing LA infusions
2. Resuscitate the patient using the ABCDE approach
3. Start cardiopulmonary resuscitation if signs of cardiovascular collapse
4. Specific treatment of LA toxicity may be introduced in the form of an Intralipid® infusion - seek specialist advice from an anaesthetist
54
WHO pain ladder?
Paracetamol
Codeine and Paracetamol (or tramadol)
Strong opiate - morphine sulphate (liquid or tablet)
- Can prescribe immediate release at first and see if this controls pain, then convert to modified release in two separate doses, with a breakthrough immediate release dose of 1/6 - 1/10 of the 24hr dose
55
A 1% solution contains how much drug?
1g in 100ml
10mg in 1ml
56
What are the DAMNN drugs that can cause AKI?
```
Diuretics
ACEI
Metformin
Nitrofurantoin/trimethoprim
NSAIDS
```
57
Antiemetic choices?
If nauseated prescribe regular cyclizine 50mg 8hrly, unless HF (then use metoclopramide) if not nauseated prescribe as required!
58
Fluid choice of patient is oliguric (not shocked)?
1 L over 2-4 hrs then recheck.
59
What should you do with prescribing long-term drugs if patient is having surgery?
Some need to be stopped (I LACK OP)
Most should be continued
Steroids need to be increased (and given IV)
60
What drugs need to be stopped before surgery?
I LACK OP
Insulin
Lithium - day before
Anticoag/platelets
COCP/HRT - 4 weeks before
K+ sparing diuretics - Day of
Oral hypoglycaemics
Perindopril (and other ACEI) - Day of
61
1st line T2DM drug choices?
Metformin 1st line for all patients (unless contraindicated), combined with another if not working.
62
Normal drug dose for ibuprofen?
200-400mg tds
63
Normal drug dose for Codeine?
30-60mg qds
64
Normal drug dose for co-codamol?
8/500 or 30/500
2 tabs qds
65
Normal drug dose for cyclizine?
50mg tds
66
Normal drug dose for metoclopramide?
10mg tds
67
Normal drug dose for amoxicillin?
500mg tds
68
Normal drug dose for Clarithromycin?
500mg bd
69
Normal drug dose for Lansoprazole?
15-30mg od
70
Normal drug dose for Omeprazole?
20-40mg od
71
Normal drug doses for Aspirin?
75 - 300mg od
72
Normal drug doses for Clopidogrel?
75 - 300mg od
73
Normal drug doses for simvastatin?
10-80mg on
74
Normal drug doses for atenolol?
25-100mg od
75
Normal drug doses for ramipril?
1.25-10mg od
76
Normal drug dose for Bendroflumethiazide?
2.5mg od
77
Normal drug dose for Furosemide?
20mg od - 80mg bd
78
Normal drug dose for Amlodipine?
5-10mg od
79
Normal drug dose for Levothyroxine?
25-200mcg od
80
Normal drug dose for Metformin?
500mg od - 1g bd
