Red Flashcards
1
Q
Asthma ddx
A
Ddx- acute infective exacerbation of COPD, pulmonary oedema, URT obstruction, PE, anaphylaxis.
2
Q
Asthma monitoring in emergency care
A
repeat PEF 15-30mins after initiating t. Pulse ox- aim for >92%, check blood gases within 2h if PaCO2 was raised/normal or initial PaO2 was <8kPa or patient deteriorating. Record PEF before and after beta-agonist in hospital at least 4 times
3
Q
Asthma emergency management
A
- Start tx before investigating
- Sit patient up and give high dose oxygen via non-rebreathing bag.
- Salbutamol 5mg (or terbutaline 10mg) plus ipratropium bromide 0.5mg nebulised with oxygen.
- Hydrocortisone 100mgIV or prednisolone 40-50mg orally or both if v. ill
- Chest x-ray to exclude pneumothorax.
- If life threatening add magnesium sulphate (bronchodilator) 1.2-2g IV over 20mins.
- Give salbutamol nebulisers every 15minutes, or 10mg continuously per hour.
- Monitor ECG- look for arrhythmias.
- If improving- 40-60% oxygen, prednisolone 40-50mg/24h orally for at least 5 days. Nebulised salbutamol every 4h. Monitor peak flow and oxygen sats.
- If not improving after 15-30mins: continue 100% oxygen and steroids. Hydrocortisone 100mg IV or prednisolone 300mg 30mg orally if not already given. Give salbutamol nebulizers every 15mins or 10mg continuously per hour. Continue ipratropium 0.5mg every 4-6h.
- If patient still not improving: repeat nebulisers every 15mins. MgSO4 1.2-2g IV over 20mins unless already given. Consider aminophylline (bronchodilator) if not already theophylline.
- If still no improvement transfer to ITU with doctor on hand to intubate.
4
Q
COPD ddx
A
asthma, pulm oedema, URT obstruction, PE, anaphylaxis
5
Q
Ix for COPD emergency
A
PEF, ABG, chest X-ray for pneumothorax and infection, FBC, U&E, CRP, ECG, blood culture if pyrexic, sputum culture
6
Q
Emergency management of COPD
A
- Controlled oxygen therapy- start at 24-28% and vary according to ABG. Aim for PaO2 >8kPa with a rise in PaCO2<1.5kPa.
- Nebulized bronchodilators- salbutamol 5mg/4h and ipratropium 500micrograms/6h.
- Steroids- IV hydrocortisone 200mg and oral prednisolone 30-40mg (continue for 7-14d).
- Antibiotics- only if evidence of infection e.g. amoxicillin 500mg/8h oral. Can also use doxycycline or clarithromycin.
- If no response- repeat nebulisers and consider IV aminophylline. Give a loading dose (except to patients on maintenance methylxanthines e.g. aminophylline/theophylline) of 250mg over 20mins then infuse at a rate of ~500micrograms/kg/hr where kg is ideal body weight.
- If no response consider nasal intermittent positive pressure ventilation if RR>30 of pH<7. This is delivered by a nasal mask and a flow generator.
- Consider intubation and ventilation if pH<7.26 and PaCO2 is rising.
- Consider respiratory stimulant drug e.g. doxapram 1.5-4mg/min IV for patients not suitable for ventilation. Short term measure. Side effects include agitation, nausea, tachycardia and confusion. Not used as often now as NIPPV is available
7
Q
symptoms of hypoxia
A
dyspnoea, restlessness, agitation, confusion, central cyanosis. If long standing- polycythaemia, pulm HT, cor pulmonale.
8
Q
symptoms of hypercapnia
A
headache, peripheral vasodilation, tachycardia, bounding pulse, tremor/flap, papilloedema, confusion, drowsiness, coma.
9
Q
mx of type 1 resp failure
A
- Treat underlying cause
- Give oxygen (35-60%) by facemask to correct hypoxia.
- Assisted ventilation if PaO2<8kPa despite 60% oxygen.
10
Q
mx of type 2 resp failure
A
- Treat underlying cause
- Controlled oxygen therapy- start at 24% O2
- Recheck ABG after 20minutes. IOf PaCO2 steady or lower, increase O2 conc to 28%. If PaCO2 has risen >1.5kPa and pt is still hypoxic consider respiratory stimulant e.g. doxapram 1.5-4mg/min IV or assisted ventilation e.g NIPPV.
- If this fails consider intubation and ventilation if appropriate.
11
Q
signs and symptoms of PE
A
acute dyspnoea, pleuritic chest pain, haemoptysis, syncope, hypoT, tachycardia, gallop rhythm, raised JVP, right ventricular heave, pleural rub, tachypnoea, cyanosis.
12
Q
Ix for PE emergency
A
U&E, FBC, baseline clotting, ECG, chest x-ray, ABG, serum D-dimer, CT pulmonary angiography.
13
Q
Tx for PE emergency
A
- Oxygen 100%
- Morphine 10mg IV with antiemetic if patient is in pain or distressed.
- If critically ill with massive PE- immediate thrombolysis (50mg bolus alteplase) or surgery.
- IV access and start heparin either lmw heparin e.g. tinzaparin 175u/kg/24h subcut or unfractionated heparin ~10,000U IV bolus then ~18U/kg/h IV as guided by APTT.
- What is systolic? <90mmHg: start rapid colloid infusion, if BP still low after 500ml colloid, dobutamine 2.5-10micrograms/kg/min IV and aim for BP >90mmHg. If still low consider noradrenaline. If systolic BP<90mmHg after 30-60mins of standard tx, clinically definite PE and no CI, consider thrombolysis unless already given in step 3.
If BP>90mmHg start warfarin 10mg/24h orally and confirm diagnosis.
14
Q
Clinical features of pneumothorax
A
: may be asymptomatic in young fit people with small pneumothorax or may be sudden onset dyspnoea and/or pleuritic chest pain. Reduced expansion, hyper-resonance on percussion, diminished breath sounds on affected side.
• With tension pneumothorax, the trachea will be deviated away from the affected side and patient will be very unwell.
15
Q
Ix for pneumothorax
A
- Shouldn’t do a chest x-ray if suspected tension pneumothorax because it will delay treatment.
- Otherwise request expiratory film and look for area devoid of lung markings peripheral to edge of collapsed lung.
- Check ABG in dyspnoeic patient with chronic lung disease.
16
Q
Tx for primary pneumothorax
A
SOB and/or rim of air>2cm on CXR? No- consider discharge, yes- aspiration. Successful? Yes- consider discharge. No- consider repeat. Successful? Yes-consider discharge. No- chest drain.
17
Q
Tx for secondary pneumothorax
A
SOB and age>50 and rim of air >2cm on CXR? Yes- chest drain. No- aspiration. Aspiration successful? No- chest drain. Yes- admit for 24h.
18
Q
Emergency management of tension pneumothorax
A
- Insert large bore (14-16G) needle with syringe, partially filled with 0.9% saline, into 2nd intercostal space in midclavicular line on side with suspected pneumothorax.
- Remove plunger to allow trapped air to bubble through the syringe until a chest tube can be placed.
- Alternately, insert large-bore venflon in the same location.
- Do this before requesting chest x-ray.
- Then insert chest drain.
19
Q
clinical signs and symptoms of acute coronary syndrome/MI
A
- Diagnosis, increased then decreased troponin and symptoms of ischaemia, development of pathological Q waves or loss of myocardium on imaging.
- Symptoms: crushing central chest pain >20mins, nausea, vomiting, sweating, dyspnoea, anxiety, distress, pallor, tachycardia, HT, decreased 4th heart sound, raised JVP.
- May get MI without pain esp in elderly. Presents as syncope, pulm oedema, epigastric pain, vomiting , confusion
20
Q
Ix for ACS
A
- Bloods: FBC, U&E, glucose, lipids.
- Cardiac enzymes: troponin (T and I are most sensitive) are used for cardiac necrosis. Serum level increased 3-12hrs post onset of chest pain, peak at 24-48h and decrease to baseline after 5-14 days. Creatinine kinase- increased CK-MB within 3-12h after onset of chest pain, peak within 24h and baseline after 48-72h. Myoglobin- rise within 1-4h from onset of pain- highly sensitive but not specific.
21
Q
DDx for ACS
A
angina, pericarditis, myocarditis, aortic dissection, PE, oesophageal reflux/spasm.
22
Q
Tx for ACS
A
- Attach ECG monitor and do 12 lead ECG
- Oxygen 2-4l aim form SaO2>95%- caution if COPD
- IV access- bloods for FBC, U&E, glucose, lipids and cardiac enzyme.
- Brief assessment- hx, risk factors, CIs to thrombolysis, vitals (BP from both arms), JVP, cardiac murmurs, upper limb pulses, look for scars from previous surgery.
- Aspirin 300mg unless already given
- Morphine 5-10mg IV and antiemetic e.g. metoclopramide 10mg IV
- GTN sublingual 2puffs or 1 tablet as required
- Primary PCI or thrombolysis?
- Beta-blocker e.g. atenolol 5mg IV unless asthma or left ventricular failure
- Chest xray- do not delay thrombolysis while waiting unless suspected aneurysm e.g. interscapular pain or BP different in each arm.
- Consider DVT prophylaxis
- Consider mediation except calcium channel antagonists.
- Bed rest for 48h
- Daily examination of chest, lungs and legs for complications, 12 lead ECG, U&E
- Consider warfarin for 3 months as prophylaxis.
- Aspirin e.g. 75mg
- Continue ACEi
- Statin e.g. simvastatub 40mg.
- Address modifiable risks
- Conduct exercise ECG
- General advice
23
Q
Signs and symptoms of acute circulatory shock
A
- General: cold and clammy suggest cardiogenic shock or fluid loss.
- Anaemia or dehydration e.g. skin turgor, hypoT.
- Warm and well perfused with bounding pulse septic shock.
- Any features of anaphylaxis
- CVS- usually tachycardic and hypoT- not always, young, fit, pregnant women.
- JVP or CVP- of raised cardiogenic shock.
24
Q
general management of acute circulatory failure
A
- ABCDE- high flow oxygen
- Raise the foot of the bed- UNLESS CARDIOGENIC SHOCK
- IV access- 2x wide bore cannulas, if this takes longer than 2 minutes get help.
- ID and treat underlying cause
- Get expert help
- Investigations: FBC, U&E, glucose, CRP, x-match blood, check clotting, blood cultures, urine cultures, ECG, lactate, echo, abdo CT
- Consider arterial line, central venous line and catheter
- Fluid replacement as indicated by BP, CVP and urine output. Don’t overload with fluids if cardiogenic shock. If persistently hypoT consider inotropes.
25
management of anaphylactic shock
1. Secure airway- 100% oxygen. Intubate if respiratory obstruction.
2. Raise feet and remove cause of obstruction
3. IM adrenaline 0.5mg- 0.5ml of 1:1000, repeat every 5mins if needed- guided by observations.
4. Secure IV access.
5. Chlorphenamine 10mg IV and hydrocortisone 200mg IV
6. IV fluids- 0.9% saline 500ml over 15minutes up to 2l. titrate against BP.
7. If wheeze- treat for asthma. May require ventilatory support
8. If still hypotensive ITU and IV adrenaline may be needed with or without aminophylline and nebulised salbutamol GET EXPERT HELP- IV adrenaline requires different doses.
9. Admit to ward- monitor ECG, continue chlorphenamine 4mg/6h, suggest medic alert bracelet, epipen, allergy testing.
26
mx of cardiogenic shock
1. Oxygen- titrate to maintain levels
2. Diamorphine 2.5-5mg IV for pain and anxiety
3. Investigations and close monitoring GET SENIOR AT BEDSIDE. Pericardiocentesis, x-match blood.
4. Correct arrhythmias, U&E abnormalities or acid-base disturbance.
5. Optimise filling pressure- if available measure pulmonary capillary wedge pressure (PCWP)
• If PCWP<15mmHg fluid load- give plasma expander, 100ml every 15mins IV, aim for PCWP 15-20mmHg.
• If PCWP>15mmHg, inotropic support e,g. Dobutamine 2.5-10micrograms/Kg/minute IV. Aim for systolic BP >80mmHg.
6. Consider renal dose dopamine- 2-5 micrograms/kg/min IV initially via central line only.
7. Consider intra-aortic balloon pump if you expect the underlying condition to improve, or you need time before surgery.
8. Look for and tx any reversible cause e.g MI or PE.
27
mx of septic shock
1. See general management
2. Give antibiotics within 1h (preferably after blood cultures). If source unknown give co-amoxiclav 1.2g/8h IV or meropenem 1g/8h IV.
3. Give colloid or crystalloid by IV
4. Aim for CVP 8-12mmHg, mean arterial pressure >65mmHg, urine >35ml/h.
5. Low dose steroids may help continuous hypoT despite fluids and vasopressors.
28
Ix for AF
Tests: absent p wave on ECG, irregular QRS, blood tests- U&E, cardiac enzymes, thyroid function. Echo for L atrial enlargement, mitral valve disease.
29
symptoms of AF
May be asymptomatic, chest pain palpitations, dyspnoea, faintness, irregularly irregular pulse, apical pulse>radial rate.
30
Mx of acute AF
1. If very ill or haemodynamically unstable o2, U&E, cardioversion (shock), if unavailable try IV amiodarone. Don’t delay treatment to start anticoagulation
2. Treat associated illnesses
3. Control ventricular rate- good first choice is diltiazem 60-120mg/8h PO. 2nd line- digoxin and amiodarone.
4. Start full coagulation with low molecular weight heparin.
31
Mx of chronic AF
1. Main goals are rate control and anti-coagulation.
2. Beta-blocker or rate limiting calcium channel blocker.
3. If this fails- digoxin as monotherapy is acceptable but only in sedentary patients.
4. Rhythm control- cardioversion, do echo first. Pretreat with 4wks amiodarone
5. Anticoagulation
32
ddx for ventricular tachycardia
SVT, pre-excited tachycardia e.g. atrial flutter
33
Mx of ventricular tachycardia
1. Pulse? No- arrest protocol, yes oxygen and IV access
2. Adverse signs? Systolic BP<90mmHg, chest pain, heart failure, HR>150.
3. YES: get expert help, sedation, synchronised DC shock- 200J300J360J, amiodarone (potassium channel blocker) 300mg IV over 20minutes, then 900mg over 24h, ensure K and Mg are correct, cardioversion if necessary.
4. No: correct electrolyte problems esp low K, assess rhythm. If regular- amiodarone 300mg IV over 20-60minutes, then 900mg over 24h OR lidocaine IV 50mg over 2mins, repeat every 5 mins to a total of 200mg. If irregular- diagnosis is usually AF with bundle branch block, pre-excited AF or polymorphic VT.
34
ddx for acute pulmonary oedema
asthma, COPD, pneumonia and pulmonary oedema are hard to distinguish. Do not treat all simultaneously.
35
symptoms of acute pulmonary oedema
dyspnoea, orthopnoea, pink frothy sputum.
36
signs of acute pulmonary oedema
- distressed, pale, sweaty, tachycardia, raised JVP, fine lung crackles, wheeze, usually sitting up leaning forwards.
37
Ix for acute pulmonary oedema
CXR: cardiomegaly, shadowing, small effusions at costophrenic angles, ECG, U&E, cardiac enzymes, ABG, consider an echo, plasma BNP.
38
emergency management of acute pulmonary oedema
1. Sit patient upright
2. Oxygen 100% if no existing lung disease
3. IV access, ECG, treat arrhythmias
4. Investigations while continuing treatment
5. Diamorphine 2.5-5mg IV slowly- caution in liver failure and COPD
6. Furosemide 40-80mg IV slowly- larger doses required in renal failure
7. GTN spray 2 puffs S/L or 2x0.3mg tablets S/L- don’t give if systolic BP<90mmHg
8. Necessary investigations, examination, hx
9. If systolic BP>100mmHg start nitrate infusion e.g. isosorbide dinitrate 2-10mg/h IV and keep systolic >90mmHg
10. If the patient is worsening further dose of furosemide 40-80mg. consider ventilation or increasing nitrate infusion. Alternately venesect 500ml blood- rarely done
11. If systolic <100mmHg, treat as cardiogenic shock.
39
Mx of cardiorespiratory arrest
1. Airway: head tilt if no spine injury and chin lift/jaw thrust. Clear the mouth.
2. Breathing: check breathing and give 2 breaths after 1st set of compressions for 1s. Use specialised equipment if available and two resuscitators present, if not give mouth to mouth.
3. Chest compression: 30 compressions to 2 breaths. Uninterrupted unless shocking or intubating. Use heel of hand with straight elbows centrally over lower third of sternum, aim for 5-6cm depression at 100-120/min.
4. Place defibrillator pads on ASAP and assess rhythm
• VF/VT- defibrillation must occur without delay 360J
• Asystole and electromechanical dissociation: poorer prognosis. Obtain IV access and intubate. Look for reversible causes and treat.
5. Find patients notes to look for cause.
6. If IV access fails can give intraosseous route
7. If spontaneous circulation occurs consider therapeutic hypothermia.
40
Causes of cardiopulmonary arrest
* MI
* PE
* Tension pneumothorax
* Electrocution
* Shock
* Hypoxia
* Hypercapnia
* Hypothermia
* U&E imbalance
* Drugs e.g. digoxin
41
what is an acute abdomen?
sudden onset severe abdo pain
42
Ix for acute abdomen
* Urine dipstick: infection or haematuria
* ABG- sepsis, lactate indicates hypoperfusion
* Routine bloods- FBC, U&E, LFT, CRP, amylase, serum calcium in suspected pancreatitis
* Imaging- ultrasound of kidneys, ureters and bladder, biliary tree and liver, ovaries, fallopian tubes and uterus.
* Radiological- CXR, CT
43
Basic management of acute abdomen
* A- Give oxygen
* B
* C- IV- start fluids and monitor fluid balance
* D- analgesics, antiemetics
44
Causes of GI bleeding
* Peptic ulcer
* Mallory-Weiss tears
* Gastroduodenal erosions
* Oesophagitis
* Varices
* Malignancy
* Vascular malformations
* Facial trauma
45
Mx of GI bleeding- if shocked
1. Protect airway and keep nil by mouth.
2. Insert 2 large bore cannulas
3. Bloods- FBC, U&E, LFT, glucose, clotting screen, cross match 6 units
4. Give high flow O2
5. Rapid IV crystalline infusion up to 1l
6. If remains shocked, give blood
7. Otherwise give slow saline infusion to keep lines open
8. Transfuse as dictated by haemodynamics
9. Correct clotting abnormalities- vitamin K, FFP, platelets
10. Set up CVP line to guide fluid replacement.
11. Catheterise and monitor urine output. Aim for 30ml/h
12. Monitor vitals every 15mins until stable
13. Notify surgeons
14. Urgent endoscopy for diagnosis +/- control of bleeding
46
Mx of GI bleeding- not shocked
1. Insert 2 big cannulas
2. Start slow saline IV to keep lines patent
3. Check bloods and monitor vitals + urine output
47
MOA of DKA
* Lack of insulin+ decreased glucose uptake into cells
* Decreased production of pyruvate by glycolysis.
* Acetyl CoA is generated by fat breakdown to make up the deficit.
* Excess of 2C acetyl CoA which is converted to ketone bodies.
48
presentation of DKA
* Gradual drowsiness
* Hyperglycaemia
* Ketosis
49
complications of DKA
* Cerebral oedema
* Aspiration pneumonia
* Hypokalaemia
* Hypomagnesaemia
* Hypophosphatemia
* Thromboembolism
50
emergency management of DKA
1. Check plasma glucose: usually >20mmol/L. if so give 4-8U soluble insulin IV
2. Tests: bloodsglucose, U&E, bicarbonate, osmolality, ABG, FBC, blood culture. Urine ketones. CXR.
3. NG tube if nauseated/vomiting/unconscious
4. Insulin: give via a pump dilute to 1unit/ml, start at 6U/H for an average adult. Expect blood glucose to drop by ~5mmol/L per hour, if poor response double or quadruple rate. When blood glucose is <10mmol/L slow the rate to 3U/hand continue food by mouth. Don’t stop the pump before routine subcut insulin has been started. If no pump then load with 20U IM, then give 4-6U/h IM while glucose is >10mmol/L then decrease to 2U hourly.
5. Check glucose, U&E and bicarb regularly (hourly initially)
6. Continue fluid and K+ replacement. Fluid replacement: give 1l of 0.9% saline stat, then typically 1l over the next hour, 1l over 2h, 1l over 4h, 1l over 6h and adjust according to urine output. Use 5% dextrose when glucose <10mmol/l.
7. Find out cause of DKA
51
signs and symptoms of hypoglycaemia
```
Usually rapid onset
May be preceded by odd behaviour
Sweating
Tachycardia
Seizures
```
52
Mx of hypoglycaemia
1. Give 20-30g dextrose IV e.g. 200-300ml 10% dextrose- preferable to 50-100ml 50% dextrose as this harms veins.
2. Glucagon 1mg IV/IM is as rapid as dextrose but won’t work in drunk patients.
3. Once conscious, give sugary drinks and a meal
53
signs and symptoms of addisonian crisis
* Shock
* Tachycardia
* Vasoconstriction
* Postural hypotension
* Oliguria
* Weak
* Confused
* Comatose
54
precipitating factors for addisonian crisis
* Infection
* Trauma
* Surgery
55
emergency tx for addisonian crisis
1. If suspected treat before biochemical results
2. Take blood for cortisol and ACTH
3. Hydrocortisone sodium succinate 100mg IV stat
4. IV fluids e.g. 0.9% saline
5. Monitor blood glucose- danger is hypoglycaemia
6. Blood, urine, sputum for culture, then antibiotics e.g. cefuroxime 1.5g/8h IV
56
Ongoing tx for addisonian crisis
1. Iv glucose if needed
2. Continue IV fluids more slowly- guided by clinical state. Correct U&E balance
3. Continue hydrocortisone sodium succinate
4. Change to oral steroids after 72h if patients condition is good.
5. Fludrocortisone may be needed if cause is adrenal gland- ask an expert
6. Found out cause.
57
signs and symptoms of AKI
* HypoT
* Risk factors
* Kidney insults
* Reduced urine production
* Lower urinary tract infection symptoms
* Symptoms of volume overload/pulmonary oedema
* Vomiting/nausea
* Fever, rash and/or arthralgia
* Haematuria
* Palpable bladder and/or enlarged prostate and/or abdominal distension
* Abdominal bruit
58
RFs for AKI
* Age
* Underlying kidney disease
* DM
* Sepsis
* Iodinated contrast
* Exposure to nephrotoxins e.g. aminoglycosides
* Excess fluid loss
* Surgery
59
Ix for AKI
* U&E
* LFT
* FBC
* Serum K
* Bicarbonate
* CRP
* Blood culture
* Urinalysis
* Urine output monitoring
* Fluid challenge
* Venous blood gases
* CXR
* ECG
* Renal ultrasound
60
Emergency management of AKI
Mnemonic: STOP AKI!
Sepsis screen
Toxins- identify and stop any source of toxins e.g. nephrotoxic drugs (NSAIDs, aminoglycosides)
Optimise volume status and BP. If hypovolemic give immediate IV crystalloid bolus (500ml over 15mins). Withhold drugs that may exacerbate e.g. ACEi or angiotensin 2 receptor antagonists. Consider withholding diuretics and other anti-hypertensives.
Prevent harm- identify and treat cause, treat life threatening complications e.g. hyperK- immediate cardiac protection with IV calcium chloride ot calcium gluconate. Adjunctive therapy to drive K intracellularly- IV insulin/glucose and nebulised salbutamol. Review doses of medications.
61
symptoms of polymyalgia rheumatica
* Subacute onset (<2 weeks) of symmetrical aching, tenderness and morning stiffness in the shoulders and proximal limb muscles
* +/- mild polyarthritis, tenosynovitis and carpal tunnel syndrome
* Fatigue
* Fever
* Weight loss
* Anorexia
* Depression
62
Ix for polymyalgia rheumatica
* CRP
* Plasma viscosity
* ESR (will be high)
* Creatinine kinase
* Alkaline phosphatase (may be raised)
63
ddx for polymyalgia rheumatica
* Recent onset rheumatoid arthritis
* Polymyositis
* Hypothyroidism
* Primary muscle disease
* Occult malignancy
* Infection
* Osteoarthritis
64
Management of polymyalgia rheumatica
1. Prednisolone 10-15mg/d po
2. Expect a dramatic response within 4 days
3. Decrease dose slowly e.g. 1mg/month (according to symptoms and ESR
4. Most people will need steroids for >2 years so give gastric and bone protection e.g. PPI and alendronate
65
signs and symptoms of giant cell arteritis
* Headache
* Temporal artery and scalp tenderness
* Jaw symptoms
* Dyspnoea
* Morning stiffness
* Unequal or weak pulses
66
Ix for giant cell arteritis
* Raised CRP and ESR
* Raised platelets
* Raised alkaline phosphatase
* Low Hb
* Temporal artery biopsy within 3 days of starting steroids
67
what is giant cell arteritis
an inflammatory disease affecting the large blood vessels of the scalp, neck and arms. Inflammation causes a narrowing or blockage of the blood vessels, which interrupts blood flow. The disease is commonly associated with polymyalgia rheumatica.
68
what is polymyalgia rheumatica
Polymyalgia rheumatica (PMR) is a condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips
69
treatment for giant cell arteritis
1. Prednisolone 40-60mg/d po immediately
70
describe the approach to the infected patient
```
Rule out sepsis
• Temp >38 or <36
• Pulse >90bpm
• Resp rate >20/min
• Leucocyte count >12 or <4 x109/litre
```
```
Rule out severe sepsis
• HypoT
• Confusion
• Oliguria
• Hypoxia
• Acidosis
• DIC
Rule out septic shock
Severe sepsis with hypoT despite fluid resuscitation (One litre of saline given over 30 min, and repeated if the pulse rate does not fall, is an appropriate prescription for an adult in this situation.)
```
Take a history
• Travel
• Sexually active?- HIV and syphilis
• Been around crowds of people e.g. uni freshers- increased chance of meningococcal or pneumonia infection
• Hospitalised or had medical attention recently- C diff, dental work predisposes to endocarditis, splenectomy predisposes to pneumococcal septicaemia, infected surgical wounds, new drugs- drug fever.
• Is the illness remittent?
```
Clinical exam
• Head to toe
• Obs
• Examination of the perineum is necessary in febrile neutropenic patients- septic necrosis spreading from the rectum.
Imaging
• CXR- consolidation (white on CXR)
```
Investigations
• Bloods- FBC, U&E, LFT, CRP, malaria test if indicated
• Blood cultures
• Urinalysis- midstream or clean catch sample
• LP
Second phase investigations – if initial investigations don’t lead to a particular focus
• Abdominal imaging- US for liquefied liver abscesses and hydronephrosis.
• If US negative do a CT.
Consider therapeutic trials
• If a pt reports improved symptoms after a previous course, consider giving antibiotics.
• Consider the spectrum of the antibiotic
71
symptoms of sepsis
* Slurred speech or confusion
* Extreme shivering or muscle pain
* Passing no urine (in a day)
* Severe breathlessness
* It feels like you’re going to die
* Skin mottled or discoloured
72
management of sepsis
Give 3 Take 3
1. Establish early venous access
2. Within 1 hour give broad spec antibiotics (after taking blood cultures x2- however this should not delay antibiotic administration)
3. IV fluids
4. Oxygen
5. Take lactate level (>4mmol/L is associated with worse outcomes)
6. Hourly urine output
7. Consider vasopressors if pt is hypoT during or after fluid resuscitation
8. Other blood tests: FBC, WCC, U&E, serum glucose, CRP, LFT, clotting tests
73
signs and symptoms of allergy and anaphylaxis
* SOB
* Wheeze
* Urticaria
* Swelling
* Laryngeal obstruction
* Sweating
* Diarrhoea
* Vomiting
* Tachycardia
* HypoT
* Cyanosis
74
mechanism of anaphylaxis
* Type 1 IgE mediated hypersensitivity reaction
* IgE binds to receptors on mast cells causing massive degranulation
* Release of histamine and other inflammatory mediators
75
emergency management of anaphylaxis
1. Secure airway and give 100% O2
2. Intubate if resp obstruction
3. Remove cause
4. Raise feet- may help with circulation
5. Give IM adrenaline 0.5mg (0.5ml of 1:1000), repeat every 5 mins if needed- guided by BP, pulse and resp function, until better
6. Secure IV
7. Chlorphenamine 10mg IV and hydrocortisone 200mg IV
8. IV (0.9% saline e.g. 500ml over 15mins up to 2l). Titrate against BP
9. If wheeze- give bronchodilators
10. If still hypoT admit to ITU where an IV adrenaline may be required +/- aminophylline and nebulised salbutamol.
76
management of bleeding in emergencies
1. Know and use local procedures
2. Take blood for crossmatching
3. When giving blood monitor TPR and BP every 30mins
4. Do not use giving sets that have contained dextrose of Gelofusine.
5. What to use and when: whole blood (use x matched if able)- exchange transfusion, grave exsanguination. Red cells- to correct anaemia or blood loss (1 unit will increase Hb by 1-1.5g/dL), in anaemia transfuse until Hb ~8g/dL. Platelets- not usually needed if not bleeding or count is >20x109/L (1unit should raise platelets by >20x109/L. FFP- use to correct clotting defects e.g. DIC, warfarin overdose where vitamin K would be too slow, liver disease, do not use as a volume expander. Human albumin solution- used as protein replacement and can be used temporarily in the hypoproteinaemic patient who is fluid overloaded.
6. Transfusing patients with heart failure: if Hb <5g/dL with heart failure transfusion with packed RBCs is vital to restore Hb. Give each unit over 4h with frusemide with alternative units. Check for JVP and lung crackles.
77
complications of transfusion
* Early (within 24h): acute haemolytic reactions, anaphylaxis, bacterial contamination, febrile reactions, allergic reactions, fluid overload, transfusion-related acute lung injury.
* Late (after 24h): infection, iron overload, GVHD, post transfusion purpura
78
approach to bleeding
* Is there an emergency? Exsanguination, hypovolemia, CNS bleeding, minor bleeding evolving into a major bleed.
* Why is the patient bleeding? Is it normal e.g. trauma, unexplained- purpura, bruising, family Hx
* In cases of bleeding disorders, what is the mechanism? Conduct PT, APTT, TT, D-dimer, bleeding time.
* Interpretation: platelets- if low do FBC, film, clotting. PT: if long look for liver disease or anticoagulant use. APTT: if long consider liver disease, haemophilia or heparin. Bleeding time- raised in von Willebrand disease, platelet disorders and if on low dose aspirin
79
ddx for blackouts
vasovagal syncope
situation syncope e.g. cough syncope, effort syncope
carotid sinus syncope
80
tx for vasovagal faints
1. 1st line- patient education plus avoiding triggering factors. Recognising symptoms. Education on manoeuvres to abort attacks and reduce susceptibility to future episodes e.g. hydration with electrolyte rich fluids. Withdraw medications that can cause hypoT
2. Plus physical techniques e.g. tilt training to prevent faints when warning symptoms. Measures such as squatting, arm tensing, leg crossing and uncrossing, tensing lower limb muscles can reduce the chance of syncope.
3. Plus volume expansion- conventional methods are increased dietary salt and electrolyte rich sports drinks.
4. Adjunct- fludrocortisone 0.1 to 0.2mg orally once daily
5. Adjunct- midodrine 2.5 to 10mg three times a day.
81
mx of carotid sinus syndrome
1. 1st line: patient education plus avoiding triggers
| 2. Plus cardiac pacing
82
mx of epilepsy
1. Drug therapy: usually not given after only 1 fit, unless the risk of recurrence is high, but would start after a second.
2. Generalised tonic-clonic seizures: sodium valproate or iamotrigine are first line, then carbamezapine or topiramate
3. Absent seizures: sodium valproate, iamotrigine or ethosuximide
4. Tonic, atonic and myoclonic seizures: same as generalised tonic-clonic but avoiding carbamazepine.
5. Partial seizures +/- secondary generalisation: carbamazepine is 1st line, then sodium valproate.
83
mx of status epilepticus
1. Open and maintain airway, lay in recovery position. Remove false teeth if poorly fitting. Insert oral/nasal airway, intubate if necessary.
2. 100% oxygen and suction as required
3. IV access and take blood: U&E, LFT, FBC, glucose, Ca2+, toxicology, anticonvulsant levels.
4. Thiamine 250mg IV over 10mins if alcoholism or malnourishment suspected. Glucose 50ml 50% IV unless glucose known to be normal.
5. Correct hypotension with fluids
6. Slow IV bolus phase- to stop seizures e.g. lorazepam 2-4mg. Give 2nd dose of lorazepam if no response in 2 minutes.
7. IV infusion phase: if seizures continue, start phenytoin 18mg/kg IVI at a rate of <50mg/min. Monitor ECG and BP. 100mg/6-8h is a maintenance dose. Alternative: diazepam infusion 100mg in 500ml of 5% dextrose and infuse at 40ml/h as opposite
8. General anaesthesia phase: continuing seizures require expert help with paralysis and ventilation with continuous EEG monitoring in ITU.
84
Ix for Status epilepticus
bedside glucose, blood gases, U&E, Ca2+, FBC, ECG
• Consider anticonvulsant levels, toxicology screen, LP, blood and urine culture, EEG, CT, carbon monoxide level
• Pulse ox and cardiac monitor
85
Ix for intervertebral disc prolapse
* MRI spine
* Plain spine Xray
* Gadolinium enhanced MRI
* CT spine
* FBC with differential
* ESR and CRP
* Blood or CSF cultures
* Tumour biopsy and histpathology
86
management of non-traumatic intervertebral disc compression- cauda equina syndrome
1. Decompressive laminectomy- emergency decompression of spinal cord within 48h of symptoms showing. Urodynamic studies should be completed to show bladder and sphincter function.
2. Prevention of VTE- enoxaparin 40mg s/c OD+ compression stockings of pneumatic intermittent compression OR heparin 5000U s/c every 8-12h and compression etc. Third option is IVC filter for pt with CI to anticoag. This tx should begin within 72h.
3. Maintenance of volume and BP- volume resus and/or dopamine (acts as a catecholamine) 1-50microg/kg/min IV and titrate according to response.
4. Prevention of gastric stress ulcers. Omeprazole 40mg po OD or cimetidine 300mg po/IV every 6h or famotidine 40mg PO OD or 20mg IV every 12h
5. Supportive therapies- nutritional support within 72h with isotonic feeds and evaluation of dysphagia. Mechanically assisted ventilation or manual assisted cough may be required. Catheter, laxatives and bowel evacuation may be needed.
87
mx of acute traumatic spinal cord injury
1. Immobilisation and decompressive/stabilisation surgery.
2. IV corticosteroids for SOME patients in selected groups. Methylprednisolone 30mg/kg IV as a bolus over 15mins followed by 5.4mg/kg/hour IV infusion for 24h if <3h post injury or for 48h if 3-8hrs since injury. Use of corticosteroids is CI in gunshot wounds to spine- no demonstrated benefit.
3. VTE prevention
4. Maintenance of volume and BP
5. Prevention of gastric stress ulcers
6. Supportive therapies
88
signs and symptoms of cauda equina syndrome
• Symptoms: saddle anaesthesia, bowel and bladder dysfunction, sexual dysfunction, spinal or root pain- dull or sharp if T3-4 or warm glows- like ice wrapped around leg, dorsal root ganglia affected= hypersensitivity and vibration feeling. SLT affected= burned bones or flesh pulled away. Weakness, absent reflexes below lesion
89
signs and symptoms of AAA
* Intermittent or continuous abdominal pain that radiates to back, iliac fossa or groins
* Collapse
* Expansile abdominal mass
* Shock
90
signs and symptoms of thoracic aortic dissection
* Sudden tearing chest pain that radiates to back
* Unequal arm pulses
* Acute limb ischaemia
91
emergency management of ruptured AAA
1. ECG and bloods for amylase, Hb, X match, catheterise
2. 2 large bore IV
3. Give blood and keep systolic <100mmHg
4. Take patient to theatre if unstable. If stable take for CT.
5. Prophylactic antibiotics e.g. cefuroxime 1.5g + metronidazole 500mg IV
92
symptoms of chronic limb ischaemia
cramping pain after walking for a fair distance, relieved by rest. Ulceration, gangrene (critical ischaemia), foot pain at rest
• Signs: absent pulses, cold, white legs, atrophic skin, punched out ulcers, postural/dependent colour change, cap refill >15s
93
Ix for chronic limb ischaemia
exclude DM, ESR, CRP, FBC, U&E, lipids, syphilis serology, ECG, platelets, clotting, ABPI, contrast arteriography, MR angiography
94
symptoms of acute limb ischaemia
• Symptoms and signs: Pale, pulseless, painful, paralysed, paraesthetic (numbness and tingling) and perishingly cold
95
mx of chronic limb ischaemia
1. Lifestyle advice- exercise, weight loss, smoking cessation
2. Percutaneous transluminal angioplasty- stenting- beneficial for iliac artery disease
3. Surgical reconstruction- bypass graft (vein or prosthetic). Aspirin helps prosthetic graft to remain patent, warfarin may be better after vein grafts in high risk patients
4. Sympathectomy
5. Amputation
96
mx of acute limb ischaemia
1. Surgical embolectomy or tPA thrombolysis
2. Anticoagulated with heparin after each procedure
3. Look for emboli source- echo, US
4. Be aware of post op reperfusion injury and subsequent compartment syndrome.
97
Ix for polyps
colonoscopy, flexi sigmoidoscopy, double contrast barium enema, CT colonoscopy.
• Consider: histology
98
mx of polyps
1. Polypectomy
2. Surveillance via colonoscopy for hyperplastic polyps <10mm and <3 in number
3. Prophylactic colectomy with ileorectal anastomosis and ongoing surveillance for large or suspicious adenomatous polyps
4. Planned surgical resection and ongoing colonoscopic surveillance for malignant polyps
5. Surgical resection
99
Ix for CRC
: FBC, liver biochemistry, renal function, colonoscopy, MRI pelvis, biopsY
100
Mx of CRC
```
1. Surgery- curative
• Right or left hemicolectomy
• Anterior resection
• Hartmann’s procedure
• Abdominal-perineal resection
• Sigmoid colectomy
2. Neoadjuvant chemorad
```
101
causes of acute pancreatitis
```
- GETSMASHED
o Gallstones
o Ethanol
o Trauma
o Steroids
o Mumps
o Autoimmune
o Scorpion venom
o Hyperlipidaemia, hypothermia, hyperCa,
o ERCP and emboli
o Drugs
```
102
symptoms of acute pancreatitis
gradual or sudden epigastric or central abdominal pain which radiates to back, sitting forward may relieve, vomiting, tachycardia, fever, jaundice, shock, ileus, rigid abdomen +/- local/general tenderness, periumbilical bruising (Cullen’s sign) or bruising on flank (Grey Turner’s sign).
103
Ix for acute pancreatitis
raised serum amylase, serum lipase (more sensitive), ABG, XRA, CTA, MRI
• On XRA- no psoas shadow due to retroperitoneal fluid.
104
complications of acute pancreatitis
* Early complications: shock, renal failure
| * Late complications: pancreatic necrosis, abscess, bleeding, thrombosis
105
causes of chronic pancreatitis
alcohol, familial, CF, haemochromatosis, pancreatic duct obstruction, raised PTH, congenital
106
symptoms of chronic pancreatitis
: epigastric pain that radiates to back, relieved by sitting forward and heat, weight loss, brittle diabetes, bloating, steatorrhea, mottled dusky greyness
107
complications of chronic pancreatitis
pseudocyst, diabetes, biliary obstruction, local arterial aneurysm, splenic vein thrombosis, gastric varices, pancreatic carcinoma
108
mx of acute pancreatitis
1. NBM
2. IV fluids- 0.9% saline to counter third space sequestration
3. Catheter
4. Analgesia- pethidine 75-100mg/4h IM or morphine
5. Hourly obs, glucose, serum amylase and urine output.
6. ERCP + gallstone removal if progressive jaundice
109
mx of chronic pancreatitis
1. Drugs- analgesia, insulin
2. Diet- no alcohol, low fat
3. Surgery- for unremitting pain, narcotic abuse, weight loss. Such as pancreatectomy, pacreeaticojejunostomy
110
symptoms of appendicitis
* Periumbilical pain that moves to the RIF
* Anorexia
* Vomiting
* Constipation
* Sometimes diarrhoea
* Rovsing’s sign- pain>RIF than LIF when LIF pressed
* Psoas sign- pain on extension of hip if retrocaecal appendix
* Cope sign- pain on flexion and internal rotation of hip if appendix in close association with obturator internus
111
Ix for appendicitis
* Blood tests- FBC, WCC, CRP
| * Ultrasound
112
ddx appendicitis
* Ectopic pregnancy
* UTI
* Mesenteric adenitis
* Cystitis
113
mx of appendicitis
1. Appendectomy
2. Antibiotics- metronidazole 500mg/8h + cefuroxime 1.5g/8h, 1 to 3 doses IV starting 1h pre-op to reduce wound infections
114
symptoms of renal or ureteric stones
* Renal colic- excruciating spasms loin to groin pain, often with nausea/vomiting, often can’t lie still (differentiate from peritonitis)
* Renal obstruction may be felt in the loin between 12th rib and lateral edge of lumbar muscles
* Obstruction of mid-ureter may mimic appendicitis/diverticulitis
* Obstruction of lower ureter may lead to symptoms of bladder irritability and pain in scrotum, penile tip or labia majora.
* Obstruction in bladder or urethra- pelvic pain, dysuria, strangury (desire but inability to void) and interrupted flow
* UTI
* Pyelonephritis- fever, rigors, loin pain, nausea, vomiting
* Haematuria
* Proteinuria
* Anuria
115
Ix for renal/ureteric stones
* FBC, U&E, calcium, phosphate, glucose, bicarb, urate
* Urine dipstick- usually positive for blood
* Imagine- KUB XR, USS
116
mx of renal/ureteric stones
1. Analgesia e.g. diclofenac 75mg IV/IM of 100mg suppository (if CI: opioids) + fluids
2. Antibiotics e.g. cefuroxime 1.5g/8h IV if infection
3. Stones <5mm will usually pass spontaneously Increase fluid intake and sieve urine for analysis.
4. Stones >5mm/ pain not resolving- medical expulsive therapy e.g. nifedipine (anti-HT) 10mg/8h PO or alpha-blockers e.g. tamsulosin 0.4g/d +prednisolone
5. Shockwave lithotripsy
6. Percutaneous nephrolithotomy
117
signs and symptoms of testicular torsion
* Sudden onset pain in one testis
* Uncomfortable walking
* Pain in abdomen
* Nausea
* Vomiting
* Inflammation of one testis- tender, hot and swollen, testis may lie high and transversely
118
tests for testicular torsion
* Doppler USS
| * Isotope scanning
119
Mx of testicular torsion
1. Pain relief and sedation
| 2. Consent for possible orchidectomy + bilateral fixation
120
Mx of pain
No pain: no action, assessment within 20mins, re-evaluation within 60mins of initial assessment
Mild pain 1-3/10: oral analgesia e.g. paracetamol or NSAID, initial assessment within 20mins of arrival, re-evaluation within 60mins analgesia
Moderate pain 4-6/10: oral analgesia- as mild pain plus NSAID or codeine phosphate, within 20mins arrival, re-evaluate within 60mins analgesia
Severe pain 7-10/10: IV opiates or PR NSAID- plus supplemental oral analgesia, within 20mins arrival, re-evaluate within 30mins of arrival.
121
recognising the sick patient
1. Initial assessment and monitoring
2. Track and trigger systems e.g. NEWS
3. Response strategy for patients at risk of clinical deterioration
4. Venous or arterial catheter insertion
5. Transfer to ITU if indicated
122
Mx of acute poisoning
1. ABC, clear airway
2. Consider ventilation if resp rate <8/min o PaCO2 <8kPa when on 60% O2 or if airway is at risk
3. Treat shock
4. If unconscious, nurse semi-prone
5. Take a hx
6. Ix- glucose, U&E, LFT, INR, ABG, ECG, paracetamol and salicylate levels, urine/ serum toxicology, specific assays as appropriate
7. Monitor- Temp, pulse and resp rate, BP, spO2, urine output and ECG
8. Tx- supportive measures- may need catheterisation, decrease absorption- consider gastric lavage and activated charcoal
9. specific measures- antidotes, consider naloxone if reduced consciousness and pin-point pupils
10. psychiatric assessment
123
signs and symptoms of poisoning or overdose
* Fast or irregular pulse- salbutamol, antimuscarinics, tricyclins, quinine or phenothiazine poisoning
* Resp depression- opiate or benzo overdose
* Hypothermia- phenothiazines, barbiturates
* Hyperthermia- amphetamines, MAOIs, cocaine, ecstasy
* Coma- benzos, alcohol, opiates, tricyclics, barbiturates
* Seizures- recreational drugs, hypoglycaemic agents, alcohol, salicylates.
