prep Flashcards
Causes of a metabolic acidosis?
Normal anion gap
- Renal tubular acidosis
- Dehydration
- Addisons
Raised anion gap
- Sepsis, hypoxia (Raised lactate)
- DKA (raised ketones)
Causes of a metabolic alkalosis?
Cushings Conns Diuretics Vomiting/aspiration hypokalaemia (H+ is sucked into cells, in exchange for K+ into ECF)
Max length of QT?
2 big squares
Max length of PR interval?
1 big square
Max length of QRS?
3 small squares
Indicators of pancreatitis severity?
PaO2< 7.9kPa Neutrophils (WBC > 15) Calcium < 2 mmol/L Albumin < 32g/L (serum) Sugar (blood glucose) > 10 mmol/L
What differentiates Ascending cholangitis and Cholecystitis?
Jaundice
Management of pancreatic pseudocysts?
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.
Common presentation of chronic pancreatitis?
Abdominal pain following meals, pancreatic enzymes, steatorrhoea, and diabetes.
Most common causative organism for ascending cholangitis?
E.Coli
What is the causes of a pulmonary effusion?
Transudate:
- HF
- Hypoalbuminaemia
- Liver cirrhosis
Exudate:
- Pneumonia
- Malignancy
A-E proforma?
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
4 Hs and Ts of reversible causes of cardiac arrest?
Hypovolaemia
Hypothermia
Hypoxia
Hyperkalaemia
Tamponade
Tension Pneumothorax
Toxins
Thrombus (PE)
General run-through of advanced life support?
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
What are the shockable/non-shockable rhythms?
VF/VT
- wavy lines
PEA (normal) or Asystole are non shockable
Management of acute asthma exacerbation, and classification?
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
Management of COPD exacerbation?
- O SHIT (as in asthma, but give o2 24-28% via venturi)
- Abx as per local guidelines
- Chest physio
- Consider BiPAP
PE management?
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
ACS acute Management?
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)
Acute management of Pulmonary oedema?
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)
Acute management of arrhythmia?
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)
Upper GI bleed acute management?
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
Causes of Upper GI bleed?
Variceal bleed
Ruptured peptic ulcer
Oesophagitis
Mallory weiss tear
Acute management of DKA?
- 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
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
- VTE prophylaxis
- IV insulin at 0.05 units/kg/hour
Look for cause and hold metformin for 2 days (metabolic acidosis)
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
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.
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
- CT head within 1 hr
- 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.
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
- 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
How long can’t you drive after stroke?
4 weeks
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
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
