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YEAR 6: SFP > SFP Acute conditions > Flashcards

SFP Acute conditions Flashcards

1
Q

What is sepsis and septic shock

A

Life-threatening organ dysfunction (defined >=2 on qSOFA) caused by a dysregulated host response to infection; ≥ 10% mortality

Septic shock: sepsis + despite adequate fluid resuscitation, hypotension requiring inotropes to maintain MAPs >65, or lactate 2

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2
Q

What is the qSOFA for poor outcome

A

GCS <15
RR>22
SBP <100

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3
Q

How would you approach a patient with sepsis

A

I’d be worried about sepsis, looking out high risk criteria and completing the SEPSIS 6

A
B: ABG (lactate), portable CXR
C: bloods + cultures Mx: fluids, IV Taz + evidence, ask for catheter
D: GCS (<15 part of qSOFA)
E: non-blanching rash, mottled skin, lines/ drains, swabs
Hx: localising signs for source of infection, immunosuppression

Definitive Ix:
Sepsis Screen: CXR, urinalysis, blood cultures, ?LP, swabs

Definitive Rx:
Microbiology guidelines
Escalation
Isolate patient/ PPE

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4
Q

How is sepsis managed

A

Sepsis 6 (3 in and 3 out)

3 In:

  • Antibiotics: broad spectrum IV (per Trust protocol) e.g. Tazocin 4.5g IV QDS (+) vancomycin if MRSA/ severe HAI
    If penicillin allergic: vancomycin + ciprofloxacin
  • Fluids: 500-1000ml of resuscitation fluids/15 minutes + reassess after each bolus; if refractory:
  • Passive leg raise
  • USS of IVC
  • ITU support: vasopressors
  • Oxygen - 15L by non-rebreather mask

3 out:
- Lactate
- Blood cultures - preferably before Abx but do not delay Abx administration
- Urine output - start fluid balance chart, consider catheterisation, hourly urine output measurements

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5
Q

How should sepsis be escalated

A

Immediate senior review (ST3+)
Rapid response team (RRT)/ critical care outreach team (CCOT)
ITU/ HDU: invasive monitoring, supporting organ dysfunction: renal replacement, inotropes, mechanical ventilation

MAP = Diastolic + 1/3 (Systolic – Diastolic)
>60 required to be needed to maintain adequate tissue perfusion
>65 recommended with severe sepsis and septic shock

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6
Q

What are other differentials for sepsis

A

Other causes of shock:
* Hypovolaemia
* Cardiogenic
* Obstructive
* Anaphylactic
Pain

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7
Q

What are features suggesting neutropenic sepsis

A

Chemo in last 30 days
Known neutrophil count
MDS (myelodysplastic syndromes)

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8
Q

How should you approach a patient suspected of having neutropenic sepsis

A

Full set of observations
FBC (but do not wait for neutrophil count)

As suspecting neutropenic sepsis —> Sepsis 6
A
B: ABG (lactate), portable CXR
C: bloods + cultures (+ fungal)
Mx: fluids, IV Taz + evidence, ask for catheter
D:
E: non-blanching rash, mottled skin, lines/ drains, swabs
Hx: localising signs for source of infection, immunosuppressed

Definitive Ix:
Sepsis Screen: CXR, urinalysis, blood cultures, ?LP, swabs

Definitive Rx:
Microbiology guidelines
Escalation: Onc review
Isolate + PPE

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9
Q

How should neutropenic sepsis be managed

A

Sepsis 6
Antibiotics (check hospital trust for Abx anti-fungals): tazocin IV 4.5g QDS, if p/a: meropenem IV,
Severe:
- vancomycin + gentamicin + metronidazole
Isolate patient + PPE

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10
Q

How should you escalate in neutropenic sepsis

A

Immediate senior review
Inform Haematology SpR
Inform Oncology SpR

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11
Q

What are features of different acute asthma severity

A

Acute severe:
- Can’t complete sentences
- SpO2 <92
- PEFR 33-50
- Pulse >110
- RR>25

Life threatening:
- Silent chest
- Cyanosis
- Poor respiratory effort
- Hypotension
- Exhaustion
- Confusion
- PEFR <33

Near fatal:
- Raised PaCO2

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12
Q

How should you approach a patient suspected of having acute asthma attack

A

Assess severity using BTS guidelines

A: Can’t complete sentences = acute severe
B: SpO2 <92 or RR>25 = acute severe,
Poor resp effort/ exhaustion —> life threatening
ABG: normal or raised PaCO2 —> escalate (in all Pts) Wheeze —> nebulisers (+) ipratropium
At this point if life threatening/ near fatal —> senior input
C: HR >110 = acute severe, ECG: salbutamol (drop K+ —> arrhythmias)
D: Confusion —> acute severe, drug chart: level of asthma care
E:
Hx: asthma exacerbations – ever been to hospital

Definitive Ix: PEFR Consider CXR

Definitive Rx: Steroids

Escalation: Mg sulphate, ITU support for IV salbutamol or intubation/ ventilation

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13
Q

How would you manage a patient with an acute asthma attack

A

Life-threatening or near fatal: immediate escalation RRT or 2222 peri-arrest

All attacks:
- Salbutamol nebulisers 5mg (repeat at 15-30 mins intervals)
- Steroids: prednisolone 50mg PO (1st day of 5-day course) or 100mg hydrocortisone IV

Acute severe or life threatening:
- Consider continuous nebulisation at 5-10mg/hour + Ipratropium nebulisers (0.5mg QDS)
- IV magnesium sulphate bolus 2g/ 20 mins

Step down:
- Nebulised salbutamol every 4- 6hr
- Prednisolone 40-50mg PO OD for 5-7 days

Discharge once: been stable, had inhaler technique checked, PEFR >75%, GP apt within 2 days, respiratory clinical apt within 4 weeks

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14
Q

How should an acute asthma attack be escalated

A

Immediate senior review
Senior anaesthetic assistance (if considering intubation/ ventilation)

ITU/HDU: ventilatory support, intensification of therapy:
- IV salbutamol bolus (15mcg/kg)
- IV aminophylline Intubation/ ventilation

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15
Q

What are some differentials for an acute asthma attack

A

Anaphylaxis
Inhaled foreign body
Pneumothorax
IE of COPD
Myocardial infarction
Pulmonary oedema
Anxiety

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16
Q

What is acute COPD

A

Acute onset worsening of a person’s symptoms from their usual stale state beyond normal day to day variations

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17
Q

How should you approach a patient with acute COPD

A

A:
B: check if known CO2 retainer, 24-28% Venturi, if hypoxic/ unstable —> high-flow
Polyphonic wheeze
ABG: type II respiratory failure
Lactate (sepsis)
Salbutamol 5mg nebulisers (+) ipratropium 0.5mg
C:
D:
E:

Hx: compare to baseline: SOB, sputum volume, sputum colour

Definitive Ix:
Repeat ABG —> guide further O2, NIV (BiPAP) if pH <7.35 despite adequate oxygen
Sputum culture
CXR

Definitive Rx:
Steroids: prednisolone 30mg PO
Antibiotics: amoxicillin 500mg/8h PO
Resp review

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18
Q

How should acute COPD be managed

A

Consider if the patient has a ceiling of care in place

Controlled O2: maintain between 88-92%
Consider NIV if pH <7.35 & PaCO2 >6
Consider doxapram if NIV not available

Salbutamol nebulisers 5mg/4hours
Ipratropium nebulisers (0.5mg 4-6 hrly)

Steroids: prednisolone 30mg/day for 7 days PO or 100mg hydrocortisone IV

Antibiotics: e.g. amoxicillin 500mg/8h PO or clarithromycin or doxycycline

Step up:
IV aminophylline
NIV (BiPAP)

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19
Q

How should acute COPD be escalated

A

Immediate senior review
Discuss with respirator SpR or consultant
Consider senior anaesthetic assistance (pH <7.26 consider invasive ventilation)

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20
Q

What are some differentials for acute COPD

A

Anaphylaxis
Inhaled foreign body
Pneumothorax
Acute asthma
Myocardial infarction
Pulmonary oedema
Anxiety

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21
Q

How should you approach a patient with anapylaxis

A

A:
2222 peri-arrest call
Adrenaline 0.5mg IM (1:1000),
Chlorphenamine 10mg,
Hydrocortisone 200mg slow IV
B:
High flow O2
C:
IV fluids (distributive shock)
D:
Drug chart—>check allergies/ add into allergens
E:

Further Ix:
Two blood samples required to measure mast cell tryptase (first ideally w/I 30 mins, 2nd at 2 hours)

Further Rx:
Escalation to ITU

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22
Q

How should a patient with anaphylaxis be managed

A

Bring the local resuscitation equipment
Remove allergen (e.g. stop drug infusion)
Adrenaline 500ug IM, 1:1000 (0.5ml); can be repeated after 5 mins if no improvement
Consider intubation by a skilled anaesthetist early
High flow O2 via NRBM
Chlorphenamine 10mg slow IV injection
Hydrocortisone 200mg by slow IV injection
IV fluids
Add name of agent that caused reaction into allergies

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23
Q

How should anaphylaxis be escalated

A

2222 peri-arrest call

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24
Q

What are some differentials for anaphylaxis

A

Stridor:
- Foreign body
- Peritonsillar abscess
- Croup
- Epiglottitis
- Mass obstruction

Other acute dyspnoea:
- Acute asthma
- IE of COPD
- Pulmonary oedema

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25
Q

What is a massive PE

A

PE with hypotension

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26
Q

How should a massive PE be approached

A

A:
B:
Hypoxia—>high flow O2
C:
Hypotensive/ shock —>senior support/peri-arrest call (may need thrombolysis)
May need urgent echo
D:
Drug chart: anti- coagulation (thrombolysis)
E:
Calves SNT
Hx: consider features of Wells score/ RF: malignancy, immobility/ previous surgery, thrombophilia, pregnancy

PERC rule out rule for PE

Definitive Ix:
CTPA or V/Q

Definitive Rx:
LWMH

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27
Q

How should a massive PE be managed

A

High flow O2
If no shock: consider treatment dose LMWH
If shock: urgent escalation for consideration of thrombolysis

UFH may be given while discussions regarding thrombolysis: 5000 units’ bolus, with continuous infusion (target APTT ratio 2-3)

Thrombolysis: Alteplase -10mg as slow IV over 1-2 mins, infusion over 2 hours (weight dependent)
Then IV UFH if with APTT ratio of 2

In cardiac arrest: 50mg IV altepase immediately (find in resuscitation trolley)

Heparin 5000U bolus followed by heparin infusion (APTT to monitor

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28
Q

How should a massive PE be escalated

A

2222 peri-arrest call
ITU care

Absolute CI:
- Haemorrhage stroke or stroke of unknown origin at any time
- Ischaemic stroke <6 months
- CNS trauma or neoplasm
- Recent major trauma/ surgery
- GI bleed <3 months
- Known bleeding disorder
- Aortic dissection

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29
Q

What are some differentials for a massive PE

A

Tension pneumothorax
Cardiac tamponade
Myocardial infarction
Pulmonary oedema
Sepsis

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30
Q

How do you approach a patient with a tension pneumothorax

A

A:
B:
2222 peri-arrest call
Needle decompression
C:
D:
E:

Definitive Ix: CXR (check decompression)

Definitive Rx: Chest drain

Clinical diagnosis: Reduced expansion, Hyper resonant percussion, Reduced AE, Deviated trachea, Hypotension Distended neck veins

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31
Q

How is a tension pneumothorax managed

A

Needle decompression: large bore (14-16G) with a syringe into 2nd intercostal space MCL

Chest drain: small bore e.g. Seldinger, 4th or 5th intercostal space, mid to anterior axillary line

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32
Q

How should a tension pneumothorax be escalated

A

2222 peri-arrest call

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33
Q

What are some differentials for a tension pneumothorax

A

Massive pulmonary embolism
Cardiac tamponade

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34
Q

How is the severity of acute severe colitis determined

A

Using Truelove & Witts for UC

Mild:
Stools <4
HR <90
Temp <37.5
Hb >11.5
ESR <20

Moderate:
Stools 4-6
HR ≤90
Temp ≤37.8
Hb ≥10.5
ESR ≤30

Severe:
Stools >6
HR >90
Temp >37.8
Hb <10.5
ESR >30

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35
Q

How should a patient with acute severe colitis be approached

A

A:
B:
ABG for quick Hb
C:
IV fluids, consider blood products Bloods: FBC, U+E, LFT, CRP, ESR cross-match or GCS
D:
E:
Temp
Abdo: peritonism, PR?

Hx: consider Truelove & Witts criteria if Hx IBD and consider the travel Hx

Definitive Ix:
Stool cultures x3 (include C diff)
Stool chart recording
Consider infective serology (CMV, HIV) AXR (thumb-printing, toxic megacolon)
Urgent inpatient flexible sigmoidoscopy + biopsy megacolon)

Definitive Rx:
Hydrocortisone IV
Thromboprophylaxis
PPE/ infection control
Surgical work up

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36
Q

How would you manage acute severe colitis

A

IV fluids
Consider parenteral iron or blood transfusion
Hydrocortisone 100mgs IV QDS
Dalteparin
Inform charge nurse: consider isolation, PPE

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37
Q

How would you escalate acute severe colitis

A

Senior support
On call gastroenterology
On call surgery

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38
Q

What are some differentials for acute severe colitis

A

Inflammatory colitis
Ulcerative colitis
Crohn’s disease
Ischaemic colitis
Diverticulitis
Infective colitis
C difficile

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39
Q

How is acute pancreatitis severity determined

A

Glasgow-Imrie criteria for severity of acute pancreatitis:
- PaO2 <8kPa
- Age >55
- Neutrophils >15 Calcium <2
- Renal, urea >16 Enzymes, LDH >600
- AST >2000, Albumin <32
- Sugar, glucose >10

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40
Q

How would you approach a patient with acute pancreatitis

A

A:
B:
ABG, CXR (ARDS)
C:
Fluids resuscitation
Bloods (consider Glasgow score)
D:
E:
Abdo: peritonism, look for bruising around flanks

Definitive Ix:
Acute abdo work up do basics and then ring SpR

Defintive Rx: Analgesia, IV fluids
Consider: surgical SpR to exclude surgical cause
ITU support if severe ≥ 3 on Glasgow score

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41
Q

What are the components of an acute abdomen work up

A

Bedside:
- Urinalysis, pregnancy test, ABG
Bloods:
- For diagnosis: FBC, CRP, U+E, LFTs, amylase, calcium, glucose, blood cultures
- For surgery: G+S, cross match, coagulation
Imaging:
- Erect CXR, AXR, USS, CT abdomen
EscalationP
- Surgical SpR
- Surgical work-up

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42
Q

What is the management of acute pancreatitis

A

Analgesia
IV fluids
TPN/ NG as necessary (enteral feeding is gold standard)
Do not make NBM unless there is a clear reason for this

Surgical intervention:
- ERCP -> remove gallstones
- If severe: laparotomy/ lavage +/- necrosectomy

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43
Q

How should acute pancreatitis be escalated

A

PANCREAS score/ Modified Glasgow >3 requires ITU/HDU
? Surgical SpR review

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44
Q

What are some differentials for acute pancreatitis

A

MI
Dissection
AAA
Bowel perforation
Hepatitis
GORD/Ulcer
Pyelonephritis

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45
Q

How should you approach a patient with bowel obstruction

A

A:
B:
ABG (lactate/ sepsis)
C:
IV fluids
Bloods: U&Es, LFTs, FBC, CRP, cross- match, G+S
D:
E:
Abdo exam: scars, distension, absent/ twinkling bowel sounds, peritonism
Hx: bowel motions/ flatus, vomiting, colicky pain, past surgical Hx

Acute abdo work up

Definitive Ix:
AXR + erect CXR CT + oral contrast medium gastrogaffin

Definitive Rx:
‘Drip + suck’ – IV fluids, wide bore NGT Surgical SpR review
Surgical work up —> laparotomy

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46
Q

How is bowel obstruction managed

A

Wide bore NGT
IV fluids
Analgesia
Anti-emetic: IV ondansetron IV antibiotics
Prep for emergency laparotomy

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47
Q

How should bowel obstruction be escalated

A

Senior review
Surgical SpR review

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48
Q

How should you approach a patient with an acute abdomen

A

A:
B:
ABG: lactate
(erect CXR)
C:
Bloods - FBC, CRP, U+E, LFTs, blood cultures, ßHCG Surgery: G&S, cross match
IV fluids, blood products/ ? MHP
D:
Analgesia
E:
Abdo exam:
Look: distension, bruising around flank (retroperitoneal haemorrhage) peritonism, focal tenderness, bowel sounds
FAST scan (USS: hepatorenal, spleen, bladder etc.)
Hx:
Symptoms, PMH, last oral intake

Unstable:
FAST scan: intra- abdominal bleeding Surgical SpR review/ Make Pt NBM

Definitive Ix:
Bedside: urinalysis + pregnancy test
Bloods:
Diagnosis: FBC, CRP, U+E, LFTs, blood cultures, ßHCG Surgery: G&S, cross match
Imaging: erect CXR, AXR, CT, USS/ TVUS

Definitive Rx - depends on cause of acute abdomen

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49
Q

What scoring systems can be used for upper GI bleeds

A

Blatchford bleeding score
Components:
- Blood urea nitrogen
- Hb
- SBP
- HR
- Melena
- Syncope
- Hepatic disease
- Cardiac failure
Score >0 suggests high risk GIB that is likelyto require intervention

Rockall score - pre-endoscopy - determines mortality w/o endoscopy:
Age
Comorbidities
Shock
Rockall score - post-endoscopy to determine mortality and re-bleeding risk:
Source of bleeding
Stigmata of recent bleeding

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50
Q

What are the stages of shock

A

1: up to 750ml, BP normal, HR <100
2: 750-1500ml, BP normal, HR>100
3: 1500-2000ml, SBP <100, HR >120
4: >2000ml, SBP <100, HR >140

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51
Q

How do you approach a patient with suspected upper GI bleed

A

A: airway, blood
B: high flow O2, ABG (PaO2, Hb, lactate)
C: IV access (FBC, clotting, U+E, LFTs, cross-match, G+S); resuscitate: 500ml crystalloid, blood*** (àmajor haemorrhage)
D: AVPU (encephalopathy), glucose, drug chart (anti- coagulation?)
E: hidden injuries/ bruising, PR, CLD signs (jaundice, ascites)

Definitive: from history+ background or blood picture – determine likelihood of variceal

Variceal:
Pre-endoscopy:
Terlipressin 2mg 6hrly as IV bolus, continue for 5 days; GTN patch if Hx of IHD
(Octreotide is an alternative)
Prophylactic antibiotics (e.g. Tazocin)
Urgent endoscopy: band ligation or sclerotherapy or glue infection (band ligation is preferred as sclerotherapy makes subsequent banding difficult)

Post endoscopy:
PPI
Prevention: ß blockers

Rescue therapy: Balloon tamponade (if immediate endoscopy unavailable)
TIPS (need urgent US of portal vein prior)

Peptic ulcer:
Urgent endoscopy
PPIs may be used post- endoscopy
Rescue therapy: Laparotomy

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52
Q

How should upper GI bleed be escalated

A

Major haemorrhage protocol
Contact for urgent endoscopy
Contact on-call surgical team
ITU/HDU

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53
Q

What are some differentials for upper GI bleed

A

Oesophageal varices
Peptic ulcer disease
Mallory-Weiss tear
Boerhaave syndrome

Why has liver disease decompensated?
- Infection (chest/urine, SBP)
- GI bleed

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54
Q

How should you approach a patient with major haemorrhage

A

C spine immobilisation
Catastrophic bleed – apply pressures/ splint fractures
A:
B:
ABG: quick Hb (may be normal)
RO ATOM FC (airway obstruction, tension pneumothorax, open pneumothorax, massive haemothorax, flail chest, cardiac tamponade)
C:
Fluid resuscitation
Major haemorrhage protocol
Bloods: cross match, FBC, coagulation, biochemistry
? tranexamic acid (CRASH-2 study said to do it)
D:
E:
External bleeding Internal bleeding (? FAST scan)

Definitive Ix:
Trauma CT
Full skeletal survey

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55
Q

How should a patient with major haemorrhage be managed

A

ABCDE + major haemorrhage protocol
Stop active bleeding: apply pressure, splint fractures
Resuscitate with warm IV fluids until blood arrives
? Tranexamic acid

Blood: (aim for Hb >80)
1) Primary Pack
5 unit’s RBC (O if immediate need and/or group unknown) FFP 4 units
Alternative RBC and FFP, ratio 2:1 (or 1:1 in trauma)
2) Secondary Pack
RBC 5 units FFP 4 units

Platelets (if <50) Cyroprecipitate (if fibrinogen <1.5
Correct hypothermia
Correct hypocalcaemia (aim ionised >1.13)

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56
Q

How should you escalate major haemorrhage

A

2222 peri-arrest call
Contact transfusion: major haemorrhage protocol
Contact surgeons on call
Contact haematologist

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57
Q

What are some differentials for major haemorrhage

A

GI bleed: variceal vs peptic ulcer
Rupture AAA
Ectopic pregnancy
? DIC
Haemolytic anaemia

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58
Q

How can acute MI’s be diagnosed on ECG

A

STEMI:
ST elevation >1mm in contiguous limb leads
>2mm in contiguous chest leads
>1mm ST depression + dominant R wave in V1-3
New LBBB

Need 2 of: ECG changes, chest pain or troponin

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59
Q

How should a patient with suspected acute MI be approached

A

12 lead ECG
Troponin T (time: presentation, 3, 6), U+E, lipids, LFT, glucose, CRP, FBC, coagulation screen
Echocardiogram: all patients after STEMI to assess LV function

A:
B: O2 if <94%
C: BP in both arms, Bloods
ECG —> STEMI/MI (alert senior + PCI, analgesia, aspirin)
D:
E: ? calves
Hx: RFs MI, PE, PMH

Blood:
Troponin T (time: presentation, 3, 6), U+E, lipids, LFT, glucose, CRP, FBC, coagulation screen
Further Ix: NSTEMI: risk tools e.g. GRACE
Echo
Organise PCI

Definitive Rx: 2nd anti- platelet

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60
Q

How should an acute MI be managed

A

All:
O2 if <94%
Analgesia:
GTN: 2 puffs sublingual, infusion if persistent pain, SBP maintained >100
Morphine 5-10mg slow IV + anti-emetic e.g. metoclopramide 10mg IV Aspirin 300mg PO (check if given pre-hospital)

If STEMI:
STEMI:
2nd anti-platelet i.e. Prasugrel 60mg PO or clopidogrel 600mg or Ticagrelor 180mg
PCI (target <120 mins) - if undergoing this then give IV unfractionated heparin

If NSTEMI
2nd anti-platelet i.e. Clopidogrel 600mg or Ticagrelor 180mg
Antithrombin:
Fondaparinux 2.5mg OD SC if angiography >24 hours
If <24 hours, UFH
Assess risk: ECG, trops, scoring systems e.g. GRACE Consider glycoprotein IIb/IIIa inhibitors
Angiography (+/-) PCI (<96 hours)

Long term:
Education conservative methods
Anti-platelet: aspirin 75mg OD lifelong + clopidogrel 75mg Od (for 1 year)
ß blocker e.g. bisoprolol ACE inhibitor e.g. ramipril Statin e.g. atorvastatin 80mg PO
Consider aldosterone antagonists

GRACE: estimates admission 6-month mortality for patients with ACS

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61
Q

How should an acute MI be escalated

A

2222 peri-arrest call
Alert PPCI team
Cardiology SpR on call
Evidence shows effective PCI critical

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62
Q

What are the differentials for an acute MI

A

Aortic dissection
Pulmonary embolism
Pneumothorax
Acute asthma
Pericarditis

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63
Q

How should you approach a patient with pulmonary oedema

A

ABG
Bloods: FBC, U+E, LFT, CRP, Troponin
12 lead ECG Portable CXR
Urgent echocardiogram

A
B: sit patient up, coarse crackles, ABG, CXR
C: explain caution fluid resus
D: drug chart (fluids)
E: leg oedema

Definitive Ix: Inpatient echo

Definitive Rx:
IV furosemide
Consider nitrates if normotensive
? Diamphorine (evidence base)
Inotropes
CPAP

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64
Q

How should pulmonary oedema be managed

A

Sit patient up
High flow oxygen 15L NRBM

Diuretics: Furosemide 50mg IV

Nitrates:
If BP >100 SBP give 0.5mg GTN S/L, consider GTN infusion (aim for BP >100)

If BP low:
Escalation: (cardiogenic shock)
Inotropes: Dobutamine or intra-aortic balloon pumping CPAP: with a PEEP of 5- 10mmHg

Address cause: treat arrhythmias

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65
Q

How should pulmonary oedema be escalated

A

Immediate senior support
Call cardiology SpR on call
Contact ICU/HDU

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66
Q

What are differentials and triggers for pulmonary oedema

A

Pneumonia
PE

Triggers:
MI
Arrhythmia

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67
Q

What is the definition of hypertensive urgency/emergency/malignant HTN

A

Hypertensive urgency:
SBP >180, DBP >110 and no target end organ damage

Hypertensive emergency:
SBP >180, DBP >110 and target end organ damage

Malignant HTN: papilloedema present

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68
Q

How should you approach a patient presenting with hypertensive emergency

A

A:
B:
C:
BP (in both arms)
ECG
Bloods: U+ES, troponin
D:
Altered mental status
Drug chart
E:

Hx: symptoms (headache, visual problems, CP), drugs, flushing, (pregnancy)

Definitive Ix:
Target end organ: ECG, urinalysis, fundoscopy

Bloods:
Plasma renin, aldosterone
TFTs
Plasma metanephrines/ 24 hr urinary collection

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69
Q

How should a patient with a hypertensive urgency/emergency be managed

A

Hypertensive urgency:
1. Oral labetalol or CaV blocker e.g. amlodipine 5mg, nifedipine (Never use an ACEi due to rapid BP lowering)

Hypertensive emergency - escalate
1) IV labetalol (CI asthma, heart failure) or hydralazine or sodium nitroprusside
If myocardial ischaemia then GTN

Rapidly lowering BP is dangerous - aim to lower MAP by 25% over first 24 hours

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70
Q

How should hypertensive emergency be escalated

A

Seek senior support/cardiology SpR
HDU/ITU

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71
Q

What are some differentials of hypertensive emergency

A

Uncontrolled essential hypertension
Pain: anxiety Endo: Conns, phaeo, hyperthyroid
Drugs: ciclosporin, post-surgical vasopressors
Renal: Acute glomerulonephritis

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72
Q

How should you approach a patient with cardiac tamponade

A

A:
B: high flow, ABG (lactate; organ perfusion)
C: Beck’s triad (hypotension, raised JVP, muffled HS)
IV access
ECG (low voltages) —> If concerned: PERI- ARREST CALL: need senior for urgent pericardiocentesis, in mean time get urgent Echo
D:
E:
Hx: symptoms, last oral intake
Bloods: surgical work- up, FBC, crossmatch + G&S, baseline U+Es, LFTs

Fix: Echocardiogram (FICE)

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73
Q

How is cardiac tamponade managed

A

Urgent pericardiocentesis by senior

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74
Q

Who should cardiac tamponade be escalated to

A

Cardiothoracic surgeons
ITU

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75
Q

What are some differentials for cardiac tamponade

A

Obstructive - PE
Hypovalaemia - Graft failure
Cardiogenic - MI, acute HF

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76
Q

What are some differentials for cardiac tamponade

A

Obstructive - PE
Hypovalaemia - Graft failure
Cardiogenic - MI, acute HF

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77
Q

What are adverse features of bradyarrhythmias

A

Shock
Syncope
MI
Heart failure

78
Q

What are features of high risk of asystole in bradyarrythmias

A

Recent asystole
Mobitz II AV block
Complete HB with broad QRS
Ventricular pause >3s

79
Q

How should you approach a patient with a bradyarrhythmia

A

A:
B: ABG (electrolytes, lactate)
C:
ECG, if adverse features —> escalate —> atropine 500mcg IV
D:
Drug chart
E:
Hx: onset symptoms, drug chart

80
Q

How should a bradyarrhythmia be managed

A

If adverse features/ high risk of asystole: 2222 call
Atropine 500mcg IV

If no satisfactory response:
Atropine 500mcg IV up to max of 3mg
Isoprenaline 5mcg/min IV
Adrenaline 2-10mcg/min IV

Seek senior expert help: Consideration of transcutaneous pacing (will need sedation)

81
Q

How should bradyarrhythmias be escalated

A

Seek senior input

Alert on-call cardiology SpR

Alert anaesthetic team

82
Q

What are the causes of bradyarrhythmias

A

Post-MI
Infective endocarditis
Myocarditis
Endocrine/metabolic
Hypothermia etc

83
Q

What are the causes of bradyarrhythmias

A

Post-MI
Infective endocarditis
Myocarditis
Endocrine/metabolic
Hypothermia etc

84
Q

What are adverse features in tachyarrhythmias

A

Shock
Syncope
MI
Heart failure

85
Q

How should you approach a patient with a tachyarrhythmia

A

A:
B: ABG (electrolytes, lactate)
C: ECG monitoring —> adverse features —> 2222 —>DC shock
If wide-complex + regular —> 2222
D:
E:

Hx:
Bloods: FBC, U&Es (includes Mg and K+), bone profile, TFTs, CRP, blood cultures?)

Definitive Ix: Echo

86
Q

How should a patient with a tachyarrhythmia be managed

A

If adverse features: 2222 call
Synchronised DC shock up to 3 attempts (need sedation) Subsequent:
- Amiodarone 300mg IV/ 10-30 min
- Repeat shock
- Amiodarone 900mg/ 24 hours

If stable:
Wide QRS + regular + no BBB: (likely VT —> RRT/ 2222) Amiodarone 300mg IV/ 20-60 mins
Irregular: MgSO4

Wide QRS + irregular: Escalate to RRT/ cardio SpR - treat as AF

Narrow QRS + regular:
Escalate to senior reg/ cardio SpR
Vagal manoeuvres
Adenosine 6mg IV bolus
Adenosine 12mg IV bolus
Further 18 mg IV bolus

Narrow QRS + irregular (AF):
Escalate to senior reg/ cardio SpR

87
Q

How should you escalate a tachyarrhythmia

A

Seek senior input
Alert cardiology SpR on-call
Alert anaesthetic team

88
Q

What are precipitants for AF

A

Infection
Dehydration
Hypovolaemia
Electrolyte disturbances
Thyroid
Hypoxia e.g. PE

89
Q

How do you approach a patient with AF

A

Look for signs of adverse features: shock, syncope, MI, heart failure

A:
B:
Chest: HF v Pneumonia
ABG: lactate, electrolytes
C:
12 lead ECG/ monitoring
If Adverse featuresà 2222/ Rx
Bloods: FBC, CRP, U+Es, TFTs
D:
E:

Hx: onset, known AF,

RFs: syncope, PMH

Definitive Ix: ? CXR
? Echo

Definitive Rx:
Treat any obvious causes – see if settles
<48h: rate or rhythm >48h: rate

90
Q

How do you manage a patient with AF

A

If adverse features:
2222 call
Synchronised DC shock at 200J up to 3 attempts (sedation prior)
Subsequent:
- Amiodarone 300mg/ 20 mins
- Reattempt shock

No adverse features:
Is there an obvious precipitant to be corrected
<48 hours: rate or rhythm
>48 hours: rate

Rate:
Oral bisoprolol 2.5mg OD Diltiazem 60mg TDS

Rhythm:
If the atrial fibrillation (AF) is definitely of less than 48 hours onset patients should be heparinised. Patients who have risk factors for ischaemic stroke should be put on lifelong oral anticoagulation. Otherwise, patients may be cardioverted using either:
electrical - ‘DC cardioversion’
pharmacology - amiodarone if structural heart disease, flecainide or amiodarone in those without structural heart disease

Following electrical cardioversion if AF is confirmed as being less than 48 hours duration then further anticoagulation is unnecessary

If the patient has been in AF for more than 48 hours then anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded patients may be heparinised and cardioverted immediately.
NICE recommend electrical cardioversion in this case

Following electrical cardioversion patients should be anticoagulated for at least 4 weeks. After this time decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence

All:
Treatment dose LMWH: dalteparin 200U/kg OD; until full assessment by CHAD2DS2VASC

91
Q

What is status epilepticus

A

Seizure >5 minutes

92
Q

How should you approach a patient with status epilepticus

A

Start time/ consider safety: avoid moving/ put pillows around

A:
Suction: blood, vomit Airway (nasopharyngeal: trismus, avoid putting things in mouth)
B:
High flow O2
Ventilation (can be low due to benzos)
C:
Establish IV access —> lorazepam 0.1mg/kg
D:
Check reversible: Pabrinex, glucose
E:
Injuries
Rashes

Bloods: FBC, U+Es, CRP, VBG (lactate),glucose, toxicology, drug levels

Toxicology

Post seizure: CXR for possible aspiration

93
Q

How do you manage a patient with status epilepticus

A

Note the time

Early status: Benzodiazepines:
IV lorazepam 0.1mg/kg (usually 4mg) slow bolus, if no response after 10-20min, give 2nd dose +
—> ESCALATE
IM/buccal midazolam
Rectal diazepam

Consider reversible causes:
thiamine 250mg IV or glucose 50% 50ml

Established status:
IV anticonvulsant: Phenytoin infusion 15- 18mg/kg at rate 50mg/min (requires BP + ECG monitoring)
Others:
- Valproate
- Levetiracetam
- Phenobarbital

Refractory status: general anaesthesia (rapid sequence induction)
- Propofol
- Midazolam
- Thiopental

94
Q

How should you escalate status epilepticus

A

Contact on call anaesthetist

Contact ICU

95
Q

What are some causes of status epilepticus

A

Provoked:
1) Infection:
meningitis,
sepsis
2) Metabolic:
hypoglycaemia
3) Toxins:
alcohol
withdrawal,
overdose

Non-seizure:
Non-epileptic attack disorder (NEAD)

96
Q

How do you approach a patient with an overdose

A

Airway

Breathing: RR,
SpO2, ABG

Circulation: BP, 12 lead ECG, bloods: paracetamol levels, salicylate levels, LFTs, U+Es, clotting studies, glucose

Disability: glucose, GCS, pupils*, limbs: tone, body temperature

Exposure: feel skin*, needle track marks

Fluids: urinary toxicology screen

History: find out when medications available: paramedics, GP, friends/ family

97
Q

How do you manage an overdose

A

ABCDE:
Consult ToxBase or UK National Poisons Information Service

Consider enhanced GI elimination of drug:
- Activated charcoal if present <1hr
If require haemodialysis —> escalate

Paracetamol:
Depending on time post ingestion – give NAC infusion
Kings College Criteria for Transplant:
- Acidosis pH <7.35
- INR >6.5 or PT >100
- Creatinine >300
- Grade III or IV
encephalopathy

Opioid: treat in B
B: 400mcg Naloxone IV/IM
Stop opioid administration
Continue and come back + reassess at 1 minute
Consider: bag-valve mask Then continue ABCDE

Definitive:
1st: naloxone 400mcg
2nd: 800mcg for up to 2 doses at 1 min intervals
3rd: 2mg for 1 dose
Infusion: set at 60%of initial resuscitative IV injection per hour

98
Q

How should you escalate an overdose

A

2222 call/ RRT
ITU/HDU
If lack capacity can treat under MCA 2005
If capacity but refuse
—> Psychiatry
If psychiatric illness may be detained under MHA and treatment given (as a consequence of mental disorder)- It must be done by psychiatrist in charge of care

Consider specialities i.e. hepatology SpR

99
Q

How do you approach a patient with a stroke

A

ECG: AF

Bloods: FBC, LFT, U+E, CRP, glucose, coagulation screen

Urgent non-contrast CT

Consider: carotid USS (if carotid territory ischaemic stroke)

A ? bulbar function
B: ? aspiration
C: carotid bruit, 12 lead ECG - AF
D: Neuro exam (spasticity, weakness, hyperreflexia, speech, visual fields), anti- coagulation drug chart
E: ? head trauma

History: onset of symptoms, CI for thrombolysis

Bloods: FBC, LFT, U+E, CRP, glucose, coagulation screen

Definitive Ix: Urgent non-contrast head
SALT assessment

Definitive Rx: Thrombolysis

100
Q

How do you manage a patient with a stroke

A

ABCDE

Ischaemic stroke:
Once CT excluded haemorrhage —>
Consider thrombolysis (<4.5 hours) with alteplase [If patient thrombolyse avoid anti-platelets for first 24 hours, then repeat CT to exclude haemorrhage]

Aspirin 300mg (orally [only if safe swallow], rectally or via NGT) to all patients once a haemorrhagic stroke has been excluded
Continue for 2 weeks

LT anti-thrombotic: Clopidogrel lifelong: 300mg loading dose, 75mg OD
If, AF: warfarin or DOAC

Haemorrhagic stroke: Reverse any anti-coagulation e.g. warfarin using Vit K and PTC, dabigatran call haematologist for Idarucizumab
Control BP: if SBP >150 give labetalol IV

TIA:
Aspirin 300mg, followed by 2 weeks of aspirin and then clopidogrel LT
Specialist assessment and Ix within 24 hours (if high risk), 1 week (if low risk)

101
Q

How should you escalate a stroke

A

Inform radiology
Contact stroke team
SALT assessment
Alert neurosurgery if GCS low / evidence of raised ICP
Depending on centre consider Thrombectomy

102
Q

What are some differentials for a stroke

A

Hypoglycaemia
Todd’s paraesis Hemiplegic migraine Functional

103
Q

How should you approach a patient with a SAH

A

ABCDE

CT scan/ CT angiogram (call radiology)

LP only if CT negative and Hx suggestive

104
Q

How should you manage a patient with an SAH

A

ABCDE

Definitive: GCS <9
Intubate + ventilate
BP: aim for SBP 120-160, —> if low support using IV fluids, caution if high, consider labetalol

Nimodipine 60mg 4 hrly via NGT

Neurological observations: pupil checks every 20 minutes

GCS >=9:
BP, nimodipine as above Analgesia
Anti-emetics
Neurological observations

105
Q

How should you escalate a patient with an SAH

A

Alert radiology
Contact anaesthetics
Contact neurosurgery
Contact ITU

106
Q

How would you approach a patient with a reduced GCS/raised ICP

A

ATLS principles:
C spine immobilisation

A:
Vocalising/ help V of GCS
RRT / anaesthetic support → intubation?
B:
If low —> bag valve mask
Aspiration? Portable CXR
ABG for electrolytes
C: fluid resus Sepsis? (qSOFA, link reduced GCS)
D: GCS, pupils (unequal 3rd nerve, pinpoint opiate), neuro exam, glucose, drug chart (? Opioid —> 400mcg naloxone)
E: temp (hypothermia) full skeletal survey, head trauma

Definitive Ix:
Urinalysis + toxicology
Bloods: FBC, CRP, cultures, U+Es, LFTs, glucose, toxicology
CT head and/or cervical spine/ full trauma CT
LP

Definitive Rx
Reversal agents: naloxone, alcohol withdrawal?

Escalate: Neurosurgery ITU

107
Q

What are signs of raised ICP

A

Vomiting/ headache
Progressive reduction in
GCS
Fundal haemorrhages
Papilloedema? In acute setting
Fixed +dilated pupil/ 3rd/6th nerve palsy (evidence of Cushing’s triad: bradycardia, HTN, fixed & dilated pupil)

108
Q

How would you manage a patient with raised ICP/reduced GCS

A

GCS: Moderate (9-13)

GCS: Severe (3-8):
Immediate intubation & ventilation
Treat hypotension aggressively

Neuroprotection:
Ensure head in mid-line position, head tilted to 30 degrees
Maintain well oxygenated Maintain PaCO2 at 4.5 Maintain CPP >60 (CPP = MAP – ICP)

Raised ICP
Remove patient from ventilator & initiate manual hyperventilation
Increase noradrenaline to increase CPP
Give mannitol 0.25g/kg over 20 mins

109
Q

How should you escalate raised ICP/low GCS

A

Contact anaesthetist
Contact neurosurgery/ neurology on call
Alert ITU

110
Q

What are some differentials for raised ICP/low GCS

A

Trauma
Intracranial bleed Hypoglycaemia Electrolyte: Na+, hypercalcaemia Hypothermia Overdose (opioid + benzodiazepines) Intracranial infection Sepsis

111
Q

What are contraindications for an LP

A
  • Suspected raised ICP
  • Local superficial
    infection at the LP site
  • Coagulopathy
112
Q

How should you approach a patient with CNS infection

A

A:
B:
ABG (lactate)
C:
ECG
Bloods, cultures Empirical Abx
D: GCS, pupils, focal neurology
E: rash, temp

Hx: signs of meningism, immunosuppressed?

113
Q

How do you manage a patient with a CNS infection

A

Suspected meningitis: -
- Isolate patient
- Empiric treatment initially (then focus): Ceftriaxone 2g IV 12- hourly
If p/a: chloramphenicol
- Add vancomycin if suspecting penicillin resistant pneumococcal meningitis
- Dexamethasone base 7.6mg IV 6 hourly for 4 days on admission

Special groups:
If immunocompromised or >60 or pregnant: add ampicillin/amoxicillin to provide Listeria cover (if p/a: co-trimoxazole)

Viral encephalitis:
Aciclovir 10mg/kg IV 8 hourly for 14-21 days

114
Q

How should you escalate in a CNS infection

A

Alert senior input
Alert neurology, infectious diseases SpR
Alert PHE (Chemoprophylaxis: ciprofloxacin 500mg PO)

115
Q

What are some differentials for CNS infection

A

Meningitis
Encephalitis
Brain abscess
?SAH – generally not febrile

116
Q

How should you approach a patient with head trauma

A

Throughout my assessment I would look for signs of raised ICP + criteria for a CT head

Follow ATLS principles

C-spine immobilisation
A: ? vomit
B: Aspiration? ABG (lactate)
C: baseline surgical bloods: FBC, U&Es, LFTs, X-match
D: Assess full GCS, pupils (3rd nerve palsy)
Drug chart (anticoagulation)
E: CT head signs, full skeletal survey, temperature
H: what happened, amnesia

Fix:
Fundoscopy (papilloedema)

Organise CT head (if guidelines) +/- neck?

If no CT head: Use Canadian C-spine rules / Nexus (less sensitive/ specific) to determine if require X- ray Spine

Consider full trauma CT if other injuries

Other points:
In children ? NAI If intoxicated → consider baseline alcohol + risk of withdrawal

117
Q

How would you manage a patient with head trauma

A

Def mx:
Supportive

Raised ICP mx
Or neurosurgery for decompression

CT head guidelines: within 1 h
1. GCS<13 on initial
assessment in ED
2. GCS<15 when assessed
2h after injury in ED
3. Suspected open or
depressed skull fracture
4. Any sign of basal skull
fracture (hameotympanum – ‘panda’ eye, CSF leakage from ear or nose + Battle’s sign)
5. Post-traumatic seizure
6. Focal neurological deficit
7. More than 1 episode of
vomiting

Should be imaged within 8h of injury / immediately if present 8h or more after injury
If amnesia/ LOC since injury +
1. Age >65
2. Dangerous mech of injury
3. More than 30mins
retrograde amnesia of events immediately before
the head injury
4. Coagulopathy:
a. History of bleeding
b. Clotting disorder
c. Current treatment of
warfarin

118
Q

Who should head trauma be escalated to

A

Neurosurgical review
ITU

119
Q

How should you approach a patient with cauda equina

A

A:
B:
C:
D: Neuro –weakness, paraesthesia, anal tone PR), saddle anaesthesia
Pain relief:
E: Spinal exam for ? fracture

Emergency MRI of whole spine (call radiology)

120
Q

How should you treat a patient with cauda equina

A

If Hx of cancer: Dexamethasone 16mg PO or IV stat, followed by 8mg BD

Definitive management: Urgent radiotherapy Neurosurgical intervention

121
Q

How should you escalate a patient with suspected cauda equina

A

Alert radiology
Contact oncology SpR
Contact neurosurgery SpR

122
Q

What are some differentials for cauda equina

A

GBS
Transverse myelitis

123
Q

How should you approach a patient with spinal cord compression

A

? Ceilings of care in place ? appropriateness of aggressive ABCDE resus.

A:
B:
C: ? only wide bore access if shocked
D: Neuro – Sensory level, UMN/LMN signs
Pain relief:
E: Spinal exam for ? fracture

Fix:
Emergency MRI of whole spine

124
Q

How should you manage a patient with spinal cord compression

A

Pain relief

If Hx of cancer:
Dexamethasone 16mg PO/IV stat, followed by 8mg BD

Definitive management: Urgent radiotherapy Neurosurgical intervention

125
Q

How should you escalate a patient with spinal cord compression

A

Alert radiology
Contact oncology SpR
Contact neurosurgery SpR

126
Q

What are some differentials for spinal cord compression

A

GBS
Transverse myelitis

127
Q

How should you approach a patient with delirium

A

ABCDE

Bloods: FBC, U&E, creatinine, LFT, calcium, glucose, CRP, B12, folate, TSH

Infection screen:
Urine for MC&S CXR

Consider CT head if Hx of falls or no other reversible cause ID

Assessment tests:
4-AT

ID cause:
Constipation
Urinary retention Dehydration
Electrolyte imbalance Infection
Pain Medication SE

128
Q

What is delirium

A

Change or fluctuation in behaviour:
Cognition (poor attention, confusion)
Perception (hallucinations, paranoia)
Activity (hyper or hypoactivity)

129
Q

How should a patient with delirium be managed

A

Non-pharmacological:
De-escalation techniques (communication + environnent)
Ensure appropriate lighting (night light)
Provide continuity of care where possible
Ensure hearing aids/ spectacles worn
Maintain good fluid intake Treat constipation
Involve relatives and carers

Pharmacological: Sedation is a last resort
Use oral where possible: Otherwise IM:
Haloperidol 0.5-1mg PO/IM Risperidone 0.5mg PO Olanzapine 2.5mgPO
Don’t use anti-psychotics in LBD
2nd line: benzodiazepines e.g. lorazepam 0.5mg PO/IM

If pharmacological management:
HR, RR, temperature, BP, ECG

130
Q

How should you escalate a patient with delirium

A

If requiring repeated doses over 48 hours consider referral to liaison psychiatry or SAFE (Specialist Advice for Frail Elderly)

131
Q

What are some triggers and differentials for delirium

A

Triggers:
Constipation
Urinary retention Dehydration
Electrolyte imbalance Infection
Pain
Medication SEs

Differentials:
Ongoing dementia Depression
Alcohol intoxication
Head injury

132
Q

How should you approach a patient with an Addisonian crisis

A

A:
B: ABG
C: Resus fluids
D: ? steroids not given, IV dextrose if hypoglycaemia
E:
H: symptoms suggestive of trigger

Bloods: FBC, U+E, LFT, venous glucose, CRP, TFTs

Fix: ID & treat precipitating factors (eg septic screen)

133
Q

How should a patient with an Addisonian crisis be managed

A

Acute
IV or IM hydrocortisone 100mg stat
Hydrocortisone 50mg IV QDS maintenance
IV fluids
IV dextrose if hypoglycaemia

ID & treat precipitating factors

134
Q

How should you escalate an Addisonian crisis

A

ITU support
Consider endocrinology input

135
Q

What are triggers for an addisonian crisis

A

Triggers:
Infection
Trauma
Surgery
Stopping long-term steroids

136
Q

How does Addison’s disease/crisis present

A

Lethargy, weakness, anorexia, nausea & vomiting, weight loss, ‘salt-craving’
hyperpigmentation (especially palmar creases), vitiligo, loss of pubic hair in women, hypotension, hypoglycaemia
hyponatraemia and hyperkalaemia may be seen

Crisis: collapse, shock, pyrexia, abdominal pain, vomiting, diarrhoea, pain in lower back/legs, weakness

137
Q

How should you approach a patient with hypoglycaemia

A

<4mmol/L

A:
B:
C:
D: def mx
drug chart (? Insulin/ oral hypoglycaemics)
E:
H: ?diabetic vs non- diabetic + ? cause

Fix:
If non-diabetic ? cause

138
Q

How is hypoglycaemia defined

A

<4mmol/L

139
Q

How should you manage a patient with hypoglycaemia

A

Get hypo box on bottom shelf of resus trolley
Glucagon is in ward fridge

Patient unconscious: 2222 peri-arrest call:
100mls of 20% glucose IV Unable obtain IV access: 1mg glucagon IM or SC
Recheck BMs after 15 mins

Patient conscious/ cooperating: Carbohydrate snack: e.g. glucojuice recheck after 15 mins
If >4 follow up with a long-acting carbohydrate e.g. slice of bread, 2 digestives

If <4: repeat, senior support

140
Q

How should you escalate in hypoglycaemia

A

Seek senior support early if not responding

Refer to diabetes team and ask for help if cause of hypoglycaemia is not ID immediately

141
Q

What are causes for hypoglycaemia

A

Diabetic: chief cause insulin/ oral hypoglycaemic overdose

Non-diabetic:
Exogenous insulin Pituitary insufficiency
Liver failure
Addison’s
Islet cell tumours

142
Q

How should you approach a patient with DKA

A

A:
B: ABG – ketones, acidosis, glucose
C: bloods, ECG, resus fluids
D: insulin chart – ensure continue long- acting insulin
E:
Bloods: glucose, ketones, U&E, CRP, FBC

Fix: urinalysis – ketones, repeat VBGs to monitor glucose, K, ketones

143
Q

What are the features of DKA

A

Hyperglycameia - >11mmol/L
Ketonaemia - >3mmol/L
Acidosis - pH <7.3 and or bicarbonate <15 mmol/L

144
Q

How would you manage a patient with DKA

A

FLUIDS:
Resuscitation fluids, or
1L 0.9% saline/ 1hr then 2hrs, 2hrs, 4hrs

INSULIN:
Fixed rate IV infusion (0.1units/kg/hr)
Continue long acting insulin
POTASSIUM:
K+ >5.5: none
K+ 4-5.5: 20mmol/L of 0.9% NaCl
K+ <4: 40mmol/L of 0.9% NaCl

GLUCOSE
If glucose falls <14 and ketone remain >0.6
IV infusion of 10% dextrose at 125mls/hr

Thromboprophylaxis
(prophylaxis dose)

145
Q

How would you escalate in DKA

A

Seek senior support ITU/ HDU support
Inform diabetes/ endocrinology team

146
Q

What are some differentials for DKA

A

Diabetes related: Hypoglycaemia HHS
Lactic acidosis

Other:
Drug toxicity
Head injury
Liver failure

147
Q

What are the features of hyperglycaemic hyperosmolar state (HHS)

A

Hypovolaemia +
Hyperglycaemia (>30mmol/L) without significant ketonaemia (<3 mmol/L) or acidosis (pH >7.3)
Osmolality >320 mosmol/kg 2(Na+K) + urea + glucose

148
Q

How should you approach a patient with hyperglycaemic hyperosmolar state

A

A:
B: ABG – ketones, acidosis, glucose
C: bloods, ECG, resus fluids
D: insulin chart – E:
Bloods: glucose, ketones, U&E, CRP, FBC

Fix:
VBG:
Cap blood glucose & ketones

149
Q

How should you manage a patient with hyperosomolar hyperglycaemic state

A

FLUIDS
IV 0.9% saline over 48h, Na fall should not exceed 0.5mmol/h

INSULIN
Only used if significant ketonaemia (>1mmol/L) or plasma glucose not falling with IV fluids

Consider thromboprophylaxis (treatment dose)

150
Q

Who should you escalate hyperglycaemic hyperosmolar state to

A

Seek senior support ITU/ HDU support
Inform diabetes/ endocrinology team

151
Q

What are some differentials for hyperosmolar hyperglycaemic state

A

Diabetes related: Hypoglycaemia HHS
Lactic acidosis

Other:
Drug toxicity
Head injury
Liver failure

152
Q

What are the features of hyperkalaemia

A

> 6.5mmol/L or ECG changes (Tall tented T waves, PR prolongation, P wave flattening, bradyarrhythmias, sine waves, VF, PEA/asystole)

153
Q

How should you approach a patient with hyperkalaemia

A

A
B: ABG K+
C: ECG: tall tented T waves, small/ absent P waves, wide QRS —> Treatment
U+Es (K+, creatinine)
D: drug chart
E:

154
Q

How should you manage a patient with hyperkalaemia

A

10ml of 10% calcium gluconate IV (in the resus trolley) bolus/5 mins (improvement should be seen within 1-3 mins, repeat every 10 mins, if on digoxin bolus over 20 mins)

Actrapid 10U in 50ml of glucose 50% IV/ 15-30 mins (+) Nebulised salbutamol

Oral calcium resonium 15g TDS & regular lactulose 10ml with each dose

Stop any causative drugs e.g. ACEi, K+ sparing diuretics

Tumour lysis syndrome (TLS):
IV fluids
Rasburicase

155
Q

Who should you escalate hyperkalaemia to

A

Consider urgent referral to Nephrology (acute dialysis may be indicated)

156
Q

What are some differentials for hyperkalaemia

A

False result (lysing on draw)
Tumour lysis
AKI
Endo: Addison’s
Rhabdomyolysis
Iatrogenic: supplementation, drugs

157
Q

How should you approach a patient with burns

A

A:
Protect C spine if needed
If facial or inhalation burns —> airway support
B:
C:
Large bore IV access x2
Resuscitation using parkland formula [4ml x TBSA x body weight kg/ 24 hours]
D:
Pain assessment Morphine IV 0.1mg/kg E:
Remove rings, bracelets, jewellery
Assess TBSA
Assess burn depth
Keep patient warm Consider escharomoty (emergency surgical procedure involving incising through areas of burnt skin to release the eschar (the tough leathery skin after a full thickness burn) and its constrictive effects, restore distal circulation, and allow adequate ventilation)

158
Q

How should you manage a patient with burns

A

Analgesia: titrate morphine

Partial thickness burns >15% require IV fluid resus

Parkland’s formula: 4ml/kg/% burn Hartmann’s (give 1st 50% over 8 hours)
§
Dressing:
- Perform debridement
- Use sedation
- Use silver base creams
for burns

159
Q

How should you approach a patient with acute alcohol withdrawal

A

A
B:
C:
D: pabrinex before glucose
E:

H: last drink, calculate CIWA
Bloods: FBCs, LFTS, U&Es, creatinine, calcium, phosphate, Mg, serum glucose, clotting, PT + albumin.

History: Calculate Clinical Institute Withdrawal Assessment (CIWA)

160
Q

How should you manage acute alcohol withdrawal

A

Use CIWA score to determine chlordiazepoxide dose + monitor symptoms with it

Treatment of Wernicke’s encephalopathy:
1. TWO pairsPabrinex (i.e. 4 ampoules) THREE times daily, usually for FIVE days

161
Q

How should you escalate in acute alcohol withdrawal

A

Escalate in line with severity

Psych liaison assessment
Addictions liaison nurse

162
Q

How should you assess a patient with hypothermia

A

A:
B: warm humidified O2, CXR: (pneumonia a cause of hypothermia in older pts)
C:
- Cardiac monitoring (J waves, prolonged QRS, ST changes, A fib).
- Bloods (U&Es, amylase, TFTs, FBC, blood cultures, clotting)
- Warm fluids
D:
E: remove wet clothes + provide blankets

Definitive: if non-invasive rewarming is ineffective → senior staff may consider warmed fluid lavage (intraperitoneal/ intravesical), dialysis or ECMO

163
Q

How should you manage a patient with hypothermia

A

ABCDE
Prepare the crash trolley (Hypothermia is a cause of arrest)

if non-invasive rewarming is ineffective → senior staff may consider warmed fluid lavage (intraperitoneal/ intravesical), dialysis or ECMO

164
Q

What are some differentials for hypothermia

A

Sepsis
Hypothyroidism Environmental
Risk —> Cardiac arrhythmia

165
Q

What are the features of compartment syndrome

A

Raised pressure within a closed myofascial compartment —> hypoperfusion, hypoxia + local tissue ischaemia

166
Q

How should you approach a patient with compartment syndrome

A

Remove all circumferential dressings
Elevate the limb
Patients should be re-evaluated w/i 30 minutes
If symptoms persist —> urgent surgical decompression

Hx: fracture/ surgery
If diagnostic uncertainty: pressure monitoring >40mmHg

167
Q

How should you manage a patient with compartment syndrome

A

Compartment syndrome is a surgical emergency and surgery should occur within an hour of the decision to operate

168
Q

How should you escalate a patient with compartment syndrome

A

Orthopaedic SpR on- call

169
Q

What are some differentials for compartment syndrome

A

DVT
Critical limb ischaemia (pulseless)
Fracture

170
Q

How should you approach a patient with acute urinary retention

A

Hx:
Symptoms: inability to void, desire to void, lower abdo pain; timing/speed of onset
Recent surgery/ anaesthesia
PMH related to urinary tract (BPH)
Medications: anti- cholinergics, TCAs, opiate analgesics

Examination:
Distension
Percuss the bladder Palpate

171
Q

How should you manage a patient with acute urinary retention

A

Def Ix:
Bladder scan

Def management:
Urgent catheterisation
- Try urethral route (14 or 16Ch) otherwise escalate for suprapubic (need urology SpR)

Further Ix:
DRE after catheterisation (size/ texture of prostate, anal tone)
Focused neurological examination
Urinalysis
Bloods: U+Es
Imaging: TRUS, cystoscopy

Further Rx:
TWOC: trial without catheter
BPH: alpha blockers, 5a reductase inhibitors

172
Q

How should you escalate acute urinary retention

A

Urology SpR

173
Q

What are contraindications to catheterisation

A

Blood at urethral meatus
High-riding prostate on rectal exam
Penile, scrotal, perineal haematoma
Radiographic evidence of urethral/bladder trauma

174
Q

What are differentials for acute urinary retention

A

Obstruction:
BPH
Malignancy

Neuropathic:
SCC compression
Multiple sclerosis

175
Q

What are the stages of an AKI

A

Stage 1: <0.5ml/kg per h/6h
Stage 2: <0.5ml/kg per hx 12h
Stage 3: <0.3 ml/kg per h x24hr, anuria / 12hrs

(normal UO = 0.5-1.5 ml/kg/hour)

Creatinine:
Stage 1: X 1.5
Stage 2: X 2
Stage 3: X3

176
Q

How should you approach a patient with an AKI

A

ABCDE
- Correct any
1. Shock
2. Hyperkalaemia
3. Pulmonary
oedema

History:
Symptoms e.g. blood, rate of onset, anuric vs oliguric —> Fluid chart
If catheter—>ask nurse to flush

Exam:
Pre-renal: dehydration Renal: rash/ vasculitis Post-renal: percuss bladder

Investigations:
Urinalysis
Bladder scan
VBG: K+, anion, gap acidosis
Bloods: FBC, U+Es
Myeloma screen
Imaging: renal tract

177
Q

How should you manage an AKI

A

Pre-renal:
Fluid management

Renal:
Drugs (e.g. stop offending drug, Abx, steroids)

Post renal:
Catheterise

Indications for dialysis:
- Refractory
hyperkalaemia
- Volume overload
- Uraemic complications:
encephalopathy, pericarditis

178
Q

What are dialysis indications in an AKI

A
  • Refractory
    hyperkalaemia
  • Volume overload
  • Uraemic complications:
    encephalopathy, pericarditis
179
Q

Who should you escalate an AKI to

A

Renal SpR

180
Q

What are risk factors for an ectopic pregnancy

A
  • PID
  • Tubal surgery
  • Previous ectopic
    pregnancy
  • IUD
181
Q

How should you approach a patient with an ectopic pregnancy

A

A
B
C
Shock (hypovolaemic) Fluid resuscitation, blood products (MHP)
D
E
Focussed abdo exam

Hx: LMP, shoulder tip pain, syncope/ dizziness, RFs

Exam: consider bimanual, speculum

Def Ix:
Urinalysis +
pregnancy test
Bloods: FBC, U+Es, serum hCG, G+S, x- match, clotting studies TVUS

182
Q

How should you manage a patient with an ectopic pregnancy

A

Contact gynaecological SpR

Def Rx
Emergency laparoscopy (salpingectomy) or laparotomy

Other:
Conservative (very rarely used due to rupture risk)
Medical (methotrexate - if small but also unlikely if presenting acutely as they will have abdo pain) Surgical (laparoscopic salpingectomy)

183
Q

Who should you escalate an ectopic pregnancy to

A

Gynacology SpR

184
Q

What are the differentials for an ectopic pregnancy

A

Gynae:
Ovarian torsion Pedunculated fibroid
PID
Miscarriage

Abdo:
Appendicitis
Renal colic

185
Q

What are the conditions you look for in a trauma survey and what scoring system can be used for determining if major trauma

A

ATOM FC:
- Airway obstruction
- Tension pneumothorax
- Open pneumothorax
- Massive haemothorax
- Flail chest
- Cardiac Tamponade

Injury severity score (ISS): 1-75, >15 defined as major trauma

186
Q

How do you approach a trauma patient

A

C spine
Catastrophic bleed
A:
Jaw thrust Airway adjuncts/ defintive airway
B:
High flow O2
ATOM FC —> decompression
C:
Simple dressings with direct pressure
Pelvic binder
Topical haemostat —> Massive haemorrhage protocol IV access & bloods
IV fluid resuscitation, blood products
IV tranexamic acid
D:
GCS
Pupils Assess pain/ analgesia (IV morphine)
E:
Minimise heat loss Fractures
?FAST scan (although don’t delay CT)

187
Q

How should you manage a trauma patient

A

Put out a hospital trauma call - team made of:
- Trauma lead consultant (ED)
- Primary survey: A (anaesthetist), BCD: general surgical SpR, T&O SpR
- ED doctor
- Airway nurse
- Circulation nurse
- Drug nurse
- Scribe

Def Ix:
Trauma CT (C spine, chest, pelvis)
Skeletal survey

Def Rx:
Open fractures
- Cover wound with saline soaked dressing
- Give IV Abx
- surgery

188
Q

How should you approach a transfusion reaction patient

A

Possible signs of acute transfusion reaction —> STOP THE TRANSFUSION

A:
Anaphylaxis: rash, angioedema, stridor —> PERI-ARREST, get crash trolley, initiate Rx
B:
High flow O2 (ABG)
C:
Fluid resuscitation
Bloods: serum tryptase
D:
Drug chart, check patient ID/ blood compatibility, other causes
E:

189
Q

How do you manage a patient with a transfusion reaction

A

Def Ix:
Second serum tryptase
Inform the hospital transfusion department and return the unit with delivery set to lab.

Def Rx:
? Repeat

Mild allergic: give chlorphenamine 10mg and restart transfusion at a slower rate, observe frequently

Febrile non-haemolytic transfusion reaction: if temp rise <1.5, observations stable, give paracetamol, restart at slower rate, observe frequently

ABO incompatibility: STOP infusion, fluid resuscitation

TACO: stop infusion, give O2, furosemide

TRALI: stop infusion, O2, treat as ARDS

190
Q

What are some differentials for transfusion reaction

A

Mild:
Mild allergic reaction Febrile non- haemolytic transfusion reaction

Major:
Anaphylaxis
ABO incompatibility
Transfusion associated circulatory overload (TACO)
Transfusion associated acute lung injury (TRALI)

191
Q

How should you escalate a patient with suspected cauda equina

A

Alert radiology
Contact oncology SpR
Contact neurosurgery SpR

YEAR 6: SFP (4 decks)

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