SHO Flashcards
A to E approach
General Approach
How do they look?
“How do you feel?”
Look at obs eg overall trends, request ECG?
Airway
Speaking = patent
cyanosed/ accessory breathing muscles, see-saw breathing
check mouth : forceps to remove, not fingers
high flow oxygen and maintain airway;
headtilt/chinlift or jawthrust: consider adjuvent if breathing only clear in this position
Gurgling/Burbling?: turn head to side (gurgling/burbling) and suction
airway adjunct if compromised (try guardal first to see how unconscious, then nasopharyngeal, lubricate, 6 for female and 7 for male)
Give high flow 15l non -rebreath. If bag mask then hold right behind jaw, not under. 12/min or 1/5-6s)
anaphylaxis?
Breathing
Look/listen/feel for resp distress (sweat, accessory muscles, cyanosis)
RR (>25 may deteriate suddenly)- Count for 1m
assess depth and pattern, ueven expansion?
chest deformity? abdominal distension? raised jvp?
record sats and o2 levels (does not detect hypercapnea)
breath sounds (rattle (secretions not clearing), wheeze, stridor)
percussion
Auscultate (bronchiol breathing indicates consolidation)
position of trachea
chest wall crepitas
all critically ill get a non rebreath mask 15L/min
Can step down to Venturi 28% mask (4 L min-1) or a 24% Venturi mask (4 L min-1) initially in COPD and reassess
if depth of breathing inadequate use bag mask and call for specialist help
nebs can give 6 litres max but add 5l via nasal canula
Circulation
Temp
HR - count for 1 min (weak central= poor cardiac output, bounding = sepsis
BP
are they septic?
Quick cardio exam: temp, CRT, Pulse, heart sounds, oedema
Oliguria = sign of poor cardiac output
external/internal bleeding?
cannulate
IX; All get FBC, U&E, LFTs
Major harmorhage protocol = call blood bank or 2222 . . will need trained runner
then specific:
Sepsis: CRP, lactate, blood cultures
Haemorrhage or surgical emergency: Coagulation and cross-match
Acute coronary syndrome (ACS): Cardiac enzymes
Arrhythmia: Calcium, magnesium, phosphate, TFTs, coagulation
PE: D-dimer (depending on Well’s score)
Overdose: Toxicology screen
Electrolyte imbalance: Calcium, magnesium, phosphate
Ruptured ectopic: Coagulation, cross-match, ß-HCG levels
Anaphylaxis: Consider serial mast cell tryptase levels
ECG, Cathetarisation, bladder scan, pregnancy test, swabs/cultures?
3 lead ECG = red/right, lemon/left and green/spleen
Hyovolemic? - MC . . . IVF to all cool peripheries and tachicardic
Lay patient supine and raise legs if appropriate
Give 500ml bolus Hartmann’s solution/0.9% sodium chloride (warmed if available) over 15 mins
In heart failure: Give 250ml fluid as above; check the chest for crackles after each bolus as there is a risk of fluid overload and pulmonary oedema
Repeat up to 4 times (2000ml/1000ml), monitoring response
assess BP q5mins aiming for thir normal or >100
Stop and seek help if the patient has a negative response (e.g. increased chest crackles).
Seek senior help if the patient isn’t responding adequately to repeated boluses.
ACS : ECG,po aspirin 300mg, subliguial glyceryle trinitate spray/tablet, oxygen, morphine + antimimetic,
Disability
Consciousness;
repeart AVPU (alert, responds to voice, responds to pain, uresponsive)
assess pupils (pinpoint opioids, dilated = intracranial pathology of TCA overdose)
PEARL = pupils equal and reactive to light
Check for head injury while you are here
calculate GCS (<= 8 = anaethetist or crash team)
Movement: ‘squeeze my fingers
check drug chart (opioids, sedatives, anxiolytics and antihypertensives)
Causes of decreased consciousness:
Hypovolaemia
Hypoxia
Hypercapnia
Metabolic disturbance (hypoglycaemia)
Seizure
Raised intracranial pressure/other neurological insults
Drug overdose
Iatrogenic causes (e.g. administration of opiates for pain relief)
DIABETES Blood glucose (4.0-11.0 mmols/L)
check ketones if >15
<4 give 50ml 10% dextrose - give every minute till 250ml if no response
urine dipstic?
imaging?
Exposure
Any pain?
Bleeding? - rate/ amount .. . . ax for shock
rashes? coagulopathy/infection
calves - red swollen dvt?
Lines - any concerning?
Cathetar- puss or blood?
surgical wound?
drains- pus? blood? high/low output?
Reasses . . . who can help?
Full hx from pt or collateral
r/v notes - esp vital signs and meds
lap results?
What care? HDU? ICU?
Notes and SBAR handover
keep realtivesinformed
Pneumonia
Fever and cough = CXR and Sats for everyone
ABG if low sats
FBC - neutrophilia in bacterial
U&Es for dehydration and curb 65
CRP - raised in response to infection (<20 no abx, >100 abx, 20-100 consider delay)
Blood culture should do but only returns 10% of time and does not really alter tx
Sputum culture is low yield and we tx empiracally anyway
Nothing? - bronchitis aka atypical pneumonia (CAP lite)
-PO abx
Cavity lesion?
- usually malodorous sputum
differentiate with CT chest
Tx 3rd gen + G+ve and anaerobic coverage (clindomycin)
Consolidation?
Pneumonia
Differentiate with Time relation to hospital building
Empiric tx depending on category
Low severity community = amoxicillin (macrolide/tetracyclin if pen allergy)
more severe = Amoxacilin + macrolide (7-10d)
- consider co amoxiclav/ ceftriaxone / piperacillin with tazobactam and a macrolide
Admit?
-CURB 65 score
Confusion (AMT <=8)
Urea >7 mmol/L
RR>30/min
BP <90/60
>65yo
0 mx in community
1 - SATS and community CXR
2- MX in hospital
4 = 30% mortality by 30days
CRB65 in community - 2 = go to hospital
PCP
HIV+ve (immunosuppressed)
not solid consolidation but patchy diffue infiltrates
longer subacute presentation
ix silver sputum stain (not culture)
Tx with co trimoxazole
Give steroids if hypoxaemic
FLU
Myalgia giveaway
confirm with swab
prevent with vaccine
presdisposes to S.Aureus pneumonia
AND
Klebsiella ax with aspiration (MC righ lower lobe)
H.flu = COPD or smokers
3RD gen cephalosporin = ceftriaxone
Imaging
- Pneumonia
- PCP
- Abscess
Mycoplasma Pneumonia
Associated erythema multiforme
tx: doxycycline or a macrolide
Allergic Bronchopulmonary Aspergillosis
IX: po glucocorticoids + itraconazole
Legionella Pneumophilia
flu-like symptoms including fever (present in > 95% of patients)
dry cough
relative bradycardia
confusion
lymphopaenia
hyponatraemia
deranged liver function tests
pleural effusion: seen in around 30% of patients
Dx: Urinary Antigen
MX: erythromycin/clarithromycin
AKI full
Pre
PUMP = mi and chf
Leaky - also a bit CHF but think OSI
Hole : diuresis, dehydration, diarhoea and haemorhage
FMD (fibromuscular dysplasia) = young woman with secondary htn and renal failure
RAS (renal artery stenosis) = old man with atherosclerosis
Renal
RBC casts = glomerulonephritis - BUT r/o nephrotic syndrome (triad)
AIN - itis . .. look for infections. Look for WBC casts or eosiophils
but also some drugs (TMX-SMP, penicillins, cephalosporins)
ATN - muddy brown casts (not sensitive or specific)
Things in tubules coming into contact and damaging them
two main types (ischamia and toxins) prevent with IVF
Three main phases
Post
hydroureter/hydronephrosis
depends on level of obstruction (both kidneys = urethra. . only one dialted = ureter)
more causes the lower down you go
neurogenic = nerve damage or medications
foley kink
Approach
PRE
first rule this out
U:Cr >100 / Urins sodium <10 = pre-renal
give IVF if hypovolaemic
give diuresis if hypervolaemic
Post
Then rule out this
US or CT scan (CT better for stones)
then relieve obstruction
intra
hx/physical/UA usually enoght
eg DM with glucose and protein = diabetic nephropathy
Might need bx occosionally to prove dx
AEIOU = indications for dialysis
Staging
AKI is staged according to the serum creatinine changes, and/or the production of urine.
1 = Increase 1.5-1.9x baseline or < 0.5ml/kg/h for >6 consecutive hours
2 = Increase 2.0-2.9x baselinem or < 0.5ml/kg/h for >12 consecutive hours
3 = Increase > 3x baseline or >354 µmol/L or < 0.3ml/kg/h for > 24h or anuric for 12h
Extra
Stop NSAIDs in AKI as can worsen
Renal replacement therapy indications: (i) fluid overload that is refractory to diuresis, (ii) hyperkalaemia refractory to medical therapy, (iii) metabolic acidosis (pH <7.1) and (iv) complications arising from uraemia (e.g. encephalopathy, pericarditis).
UTI
General
Typically ascending infectino from urethra to kidneys (higher = worse)
MC young woman with contraception (having sex) and men who penetrate the anus
Uncomlicated must be a non pregnant female
Comlicated = the Ps
E.coli 85% of the time
klebsiella and proteus = other enteric GNR
Cloudy offensive urine
U/A and urine culture = the go to tsts
(>10 WBC/ high powered field)
CT/ US to ix more serious
(>10 to the 5 colonies)
Urethritis
Not really UTI but STD
gonorrhea = chlamydia (ie if you find one then you tx the other)
test urine sample now (first void urine sample NAAT test)
Gonnorhoea = IM ceftriaxone (ciprofloxacin if its known to be sesnitive)
Chlamydia = 7d Doxycycline (azithromycin if not tolerated)
HIV screen
Asx Bacteriuria
should only really be for regant or prepp for urologic procedure ( no-one else should be tx)
Tx with nitrofurentoin (amoxacillin/cefalexin 2nd line) - 7days
repeat to see if tx (only one that you repeat test)
nitrofurentoin can cause neonatal haemolysis near to term so use amoxacillin instead
Cystitis
MC young women
U/F/D (urgency, frequency and dysuria) w/o systemic symptoms (in life you can of course get sepsis from this)
Can choose the abx (TMP-SMX if CKD) but decide how long for
complicated - 7day in uk
Men get abx straight away, woman have back up prescription if not improved in 48hrs
Pyelonephritis
U/F/D but with systemic sx
CVA = costrovertebral angle
WBC casts = give away
urine culture here as long course of abx
Can give PO ciprofloxacin if ambulatory (young and still getting around but still all the sx)
want to admit them to see if perinephritic abscess
Perinephric abscess
(walled off or in parenchyma itself)
suspect if don’t improve after 72hrs confirm with US/CT
Children
Maybe more generalised sx
<3months refer to paediatrician and admit if upper UTI
>3month then usual 3 day
Gall Bladder
Cholelithiasis
means gallstones in gallbladder
stones in two forms: cholesterol = green and haemolysis = black
does’t really matter as present the same
Fat makes GB squeeze out bile but squeezes stones
US great as solid against liquid
Ursodoxycholic acid if not surgical candidate
Cholecystitis
inflammation
US to look for 1,2,3
Murphy’s sign (hand on ribs and thumb on GB . . . big breath in and out and then put thumb in. . . will stop breathing out in positive)
HIDA san if US not all 1,2,3 (gallbladder won’t fill with ijected isotope)
tx with urgent (<72hrs) cholecystectomy as could perforate
Cholecystotomy in non surgical candidate
Boas sign refers to this hyperaesthesia (increased sensitivity). It occurs because the abdominal wall innervation of this region is from the spinal roots that lie at this level. (beneath right scapula)
Choledocolithiasis
Gallstones in CBD presents with painful jaundice (consider everyting else a maybe)
might have gallstone pancreatitis or hepatitis too
US looks for dilated CBD
Want ERCP (but ok to NP,E VF, IVabx as don’t know if infective and can progress to cholangitis)
tx with urgent ERCP and can do cholecystectomy at a later date (can do straight away but ERCP quicker)
Ball-valve . . . .painful and deranged LFTs correct then come back as its acting as a valve
Cholangitis
Dilated ducts with stagnant fluid is ready for infection . . .. SAS
GNR = gram -ve rods
Don’t bother with MRCP and ERCP as this is emergency tx (ERCP diagnostic)
can give IVF, IV abx and NPO when prepping for surgery
Cholecystectiomy still urgent after
ABX p cipro (GNR) and metronidazole (anaerobe) - pip tazo wastes the +ve coverage
Extra
Pigmented Stones associated with Sickel Cell Anaemia
AKI Guidelines
Prevention
At risk = elderly, diabetic, hypotensive and septic pt
Keep well hydrated
Recognition
Cr = 1.5x baseline
1 = Increase 1.5-1.9x baseline or < 0.5ml/kg/h for >6 consecutive hours
2 = Increase 2.0-2.9x baselinem or < 0.5ml/kg/h for >12 consecutive hours
3 = Increase > 3x baseline or >354 µmol/L or < 0.3ml/kg/h for > 24h or anuric for 12h
clarify what type and reasoning
presence or absence of immune sx (rashe, new arthritis, nasal crusting/bleeding, haemoptysis, bew deafness, mouth ulcers, alopecia, iritis/episcleritis, mononeuritis or neuropathy)
Obstructive sx? FUD, poor stream, hesitancy,, nocturia, PV bleeding, stones
Examination and Observations
Fluid status exam (inc autoimmune)
Urine Dipstick (all AKI, non dialysis CKD, DVT &PE , oedematous pt and suspected UTI)
fluid input/output (cathetarise if this is hard)
send MSU if urinalysis abnormal
send urine protein creatinine ration if protein >2+
Investigations
daily U&Es, bone profile and bicarbonate until fxn improving
autoimmune screen if glommerulonephritis/vasculitis suspected
urine sodium if oliguric (<20 implies pre-renal)
Renal US:
- urgent if >3x or > 400 or obstructions suspected
- non-urgent if 1.5-3x or suspected GN
- may not reed if recovering function or US in last 6 months
Management
Stop nephrotoxic drugs (NSAIDs, ACEi, ARB, pottassium sparing diuretics)
Diuretics should only be suspended if hypovolemic
Stop metformin if eGFR <30
optimise fluids
treat infection promptly
suspected vasculitis/ renal syndromes are a renal emergency (call nephrologist)
30% increase in Cr acceptable on starting RAAS inhibitor (ARBs/ACEi)
HF approach
Left HF - backs up to lungs
Right HF- backs up to body
often mixed
SX - RHF - peripheral oedema, hepatosplenomegally, raised JVP . . . dyspnoeea etc from hypoperfusion
- liver = firm, smooth, tender and pulsatile liver edge
LHF - Dyspnea, orthopnea, paroxysmal nocturnal dyspnoea, crackles, S3
IX - BNP>TTECHO>Left heart cath (ischaemic or not)
1st line N-terminal pro-B-type natriuretic peptide (NT‑proBNP)
High = > 2000 pg/ml (236 pmol/litre) = TTE <2w and specialist assessment
Raised = 400-2000 pg/ml (47-236 pmol/litre) = TTE <6w and specialist assessment
Normal = < 400 pg/ml (47 pmol/litre)
BNP levels different (H= >400, R = 100=400 and N<100)
TX
Annual influenza vaccination
One off pneumococcal vaccine
check U and Es 2 weeks after ACEi or Spironolactomne started
1st line ACEi and Beta blockers (bisoprolol, carvedilol, and nebivolol)
If still symptomatic and LVEF <35%:
second line ARBs and aldosterone antagonist (spironolactone/eplerenone) - cause hyperkalaemia along with ACEi
If still symptomatic and LVEF <35%:
Third line ;
ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy
Diuretics for managing fluid overload but no change in mortality
Aspirin and statin if know ischaemic cause
Pacemaker if <35% but not stage class IV
Class IV- bridge to transplant
Acute bloods for anaemia, infection, electrolyte imbalance . . . . BNP >1mg/L supports diagnosis
NYHA classification
Stage I - No limitation on ordinary physical activity (incorrect)
Stage II - Normal at rest. Ordinary physical activity causes breathlessness (correct)
Stage III - Normal at rest. Less-than-ordinary activity causes breathlessness (incorrect)
Stage IV - Symptoms at rest. (incorrect)
Extra
Measure digoxin levels 6hrs post dose
XRAY:
A - alveolar oedema (bat wing opacities)
B - Kerley B lines.
C - cardiomegaly.
D - dilated upper lobe vessels.
E - pleural effusion.
COPD MEDED
If they have Asthma too it should have already been diagnosed
Bronchitis - low o2 leads to hypertension and RHF
Emphysema - damaged aveoli and co2 retension - cachexic and prolonged forced expiration
Diagnose - Spirometry. .. . . the other stuff is for acute
Asthma: raised eosinophil count +/- diurnal variation +/- peak flow varition over time (at least 400ml)
FEV1/FVC = <0.7
FEV1 of predicted for severity
->80% =mild stage 1
50-79 = moderate stage 2
30-49 = stage 3 severe
<30% = stage 4 very severe
Simplified drugs
beclometasone, formoterol and glycopyrronium (Trimbow) - triple therapy in one for better compliance
Non asthmatic = SAMA + LABA + LAMA
Asthmatic = LABA + ICS (can add in LAMA if refractory
Mucolytics for productive cough
SABA = Albuterol (can also use SAMA first line in uk but need to switch to SABA for second line)
LAMA = ibatropium (2ND line ICS+LABA instead if asthmatic features)
LABA- ending in -alol
COPDER - long term management
O2 and smoking cessation = only things that prelong life (and colume reduction surgery in some patients
O2 - 88-92%
- -long term - IX if FEV1 <30%/cyanosis/raised JVP*
- 2 ABG 3w apart offer if <7.3 kPa or 7.2-8 and peripheral/pulmonart oedema or polycythamia*
Exacerbation
ECG, ABC, CXR important to see if anything else causing
Add ABX if sputum looks infected. Cycle between doxycycline (ruin teeth) and azithromycin (QT prolongation so check ECG first)
- azithromycin used for prophylaxis in UK
- amoxicillin, doxycycline or clarithromycin for acute in UK
Causative organisms
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
IX
The following investigations are recommended in patients with suspected COPD:
post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%
chest x-ray: hyperinflation, bullae, flat hemidiaphragm. Also important to exclude lung cancer
full blood count: exclude secondary polycythaemia
body mass index (BMI) calculation
Ventilation
Non invasive ventilation benefits pts with pH 7.25-7.35
also indicated if respiratory acidosis persists despite maximal standard medical therapy for 1 hour or more
Invasive ventilation if pH <7.25
PE
Common, high mortality, extensive topic
Continuous with DVT
Need Vircow’s Triad to get DVT
1-
2- eg central lines or smoking
3- COCP, coagulopathy, malignacy
CALF SIGNS = NO DIAGNOSTIC VALUE
- unilateral odema >2cm
Retinal haemorrhages and intra-arterial fat globules on fundoscopy can be assoicated with fat embolsim
2 Level DVT wells score
=>2 = DVT likely
<=1 do D-dimer to rule out
Post Thrombotic Syndrome
Complication following DVT
painful, heavy calves, pruritus, swelling, varicose veins, venous ulceration
tx with compression stockings
Wedge Infarct
can see on CXR
Ischaemia - pleuritic chest pain
- Pulmonary hypertension from pushing against clot
Hypoxaemia from decreased perfusion
S1Q3T3 - indicates rs heart strain (also new RBBB associated with PE)
Haemodynamically unstable + Right Heart straign indicates massive PE (thrombolyse them)
Body’s response (why PE size not important)
- platelet mediators spread over lungs leading to vasodilation and fluid to leak out
- O2 diffusion limited so hypoxaemia develops
- hypoxaemia leads to tachyC/P
- co2 perfussion limited so decreases with rachypnoea
-hypocapnaeia/alkalaemia develop
therefore Blood gas = hypoxaemia with respiratory alkalosis
IX (NICE)
ABG, ECG, CXR
Blood: fbc, u+es, clotting screen and G+S
Use well’s criteria to
>4 CTPA (ie >=5)
-V/Q scan if renaly impared and CXR clear (needs to be able to visualose ventilation)
=<4 = D-dimer to rule out (>50yo you need to age adjust)
tPA - massive PE eg drop in BP (can give IVF also). if haemodynamically unstahble after fluid challenge can consider POC echocardiogram ix right ventricular strain or to visualise thrombus. tPA (eg alteplase) also considered for haemodynamically stable patients with severe right ventricular dysfunction, extensive clot burden and cardiopulmonary arrest due to PE
if cont. haemodynamically unstable after tPA can consider cathetar directed or surgical embelectomy.
Submassive PE = RHS (ix with trop, bnp and echo) but haremodynamically stable
Massive = RHS + Haemodynamically unstable
-sit up, give 15L o2
IVC filter (eg DVT likely to kill and GI bleed)
The warfarin bridge is 5d/ when INR 2-3 (whichever longest)
NICE - GIVE DOAC straight off if PE likely its not contraindicated as can just cont. after - apixaban, rivaroxaban
ROH Process
Gestalt assessment = unlikely then rule out with PERC assessment
if not then Wells score (d-dimer to rule out if negative (adjust if >50))
CTPA unless <35 or pregnant/breast feeding
if can do within 4 hours then wait for treatment, if not then tx straight away
provoked? main =surgery, major trauma, pregnant or puperium, Hormone treatment (pill or HRT), immobility (bedbound, unable to walk or proprtionate part of day in bed/chair)
all unprovoked should be offered cancer screening
DOAC for most unprovoked
LMWH in Ca, pregnancy, breast feeding, eGFR <15
Lifelong = warfarin
egfr <5 = unfractionated
Small Bowel Surgery
Peritoneal Pain
Straight to OR
rebound tenderness and involuntary guarding (tap area that does not hurt and radiates to site that hurts)
pain worse on coughing or moving
Often fever and leukocytosis but not necessarily
increased amylase and lactate
upright CXR to look for free air (don’t see in appenix peforation as fecolith blocks it
2 large bore cannulas and sepsis 6
perforated duodenal ulcer can look like appendicits (drops down to RIF)
analgesia - morphine 5mg
SBO
Adhesions MC if pervious surgery, hernias if not
adhesions = drip and suck
hernias = surgery
paralytic ileus = silent bowel
gallstone ileus = from fistula, pneumobilia
Obstipation = complete constimation
earlier N&V and later constipation
colicky pain (pain constant with these pangs)
Borborygmi = high pithed crescendo sounds after 5m of auscultaiton as peristalsis approaches obstrucion = complete obstruction
silent ominous sign
increased amylase +/- acidosis
UK AXR, do upright CXR to r/o perforation, now often contast CT
analgesia, antiemeitcs, fluids, electolyte correction,
TX
Icomplete = conservativly =NPO + NGT decompression + IVF . . .. make sure K+ levels ok
Hernia
Femoral = inferior and lateral to pubic tubercle
Inguinal = superior and medial to pubic tubercle
Direct = direct through muscle (transversalis in inguinal region)
Indirect = through inguinal ring ( often to scrotum)
Femoral = femal = groin lump
Ventral = iatrogenic failure to close fascia post op
DX (hx and exam)
Irreducible = muscle constricts = urgent as could incarcerate
Strangulated = muscle contraction cuts of intestinal blood supply
Appendicitis
In large bowel obvs
infection behind fecolith
PR tender on right
guarding/rebound/rigidity
neurophilia, increased CRP, blood culture, US/CON CT
increased amylase (can test urine also as it lasts longer there)
in practice might get CT while preparing OR
surgery (NBM, IVF, analgesia, IV Abx (co amoxiclav)
Carcinoid
Only symptoms if mets as liver and lungs break it down
CT scan to ID lesions for resection.
Mesenteric Ischaemia
HIGH lactate
metabolic acidosis
leukocytosis (>20)
Pseudoobstruciton
more largebowel
from low K+ as NPO and not replacing K+ (othopaedics)
GI bleed Approach
Can’t rely on sx as some variation
- even upper can present as haematocetzia
Call GI when stabalised
- minimal : FBC, U&Es, LFTs, clotting, obs, crossmatch
Give Terlippressin before OGD in varicies
OGD all suspected upper GI within 24hrs of admission (first gastrographin/ barium in borhaeves)
NICE says you don’t need to do IV PPI but conflicting evidence so many still do
Mallory weiss = weekend warrier. does not usually vommit
Boorhaeves = professional vomitter
Lower GI you want to find source of bleed. . .. based on rate of bleed (hypotension?). rapidly decreasing HB?
Mesenteric Ishcaemia = ‘gut attack’ POOP (pain out of proportion to examination) - pain after meals is like angina to the heart. colonoscopy looking for ischarmic tissue.
Colonic ischaemia = watershed areas in hypotensive patient. This would be a painful bleed after someone becomes hypotensive for another reason. colonoscopy
Haemorhoids - Internal = painless + blood (not mixed in)
external = painful - blood
glasgow-blatchford bleeding score
assess upper GI bleed severity
1-6 each graded on points
>8 ICU admission
Score is “0”only if all the following are present :
- Hemoglobin level > 12.9 g/dL (men) or > 11.9 g/dL (women)
- Systolic blood pressure > 109 mm Hg 3. Pulse < 100/minute
- Blood urea nitrogen level < 39 mg/dL
- No melena or syncope
- No past or present liver disease or heart failure.
ROH Approach
A to and oxygen
2 large bore cannulas : FBC, U+Es, LFRs, Clotting, VBG, crossmatch 6 units
arrange blood transfusion/ give crystalloid vs major haemorhage protocol
correct coagulopathy (plts \> 50, vit/ffp, reverse anti-coags) Varicell bleed + 2mg IV terlipressin, 4.5g pip-tazo, metoclopromide 10mg
escalate to med reg or GI consultant
discontinue NSAIDs, aspirin and antiplatelets
Asthma
Not all wheezing asthma but should always consider
Ominous = lots of air trapping and not much room for air movement
PFTS = spirometry
ach agonist = Methacholine
Negavite Spirometry does not exclude asthma: ix further with fractional exhaled nitric oxide (FeNO) testing
Tx
Bronchoconstricion with bronchodilators
Inflammation with anti-inflammatories
Stabalisers can be used for athletic asthma as you can take pre-emptivly (cromolyn/ nedocromil)
short course of prednisolone for acute episodes (eg 5day hx of wheeze and cough and already on medicaiton)
Adult Tx
2- jump in here if Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking
Salmeterol = LABA aka a ‘controller’
Child 5-16 tx
The same as adult but stop LRTA at 4
Jump to 2 if Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking
8 week trial:
After 8-weeks stop the ICS and monitor the child’s symptoms:
if symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely
if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy
if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8‑week trial of a paediatric moderate dose of ICS
Exacerbation
Life threatening:
SpO2 <92%
PEF <33% best or predicted
Silent chest
Poor respiratory effort
Agitation
Altered consciousness
Cyanosis
Nebs = Ipratropium (muscarinic antagonist)/ salbutamol
PEFR = peak espiratory flow rate ( they should know their best)
All patients to receive PO prednisolone
Oxygen through non rebreath
MDI = metered dose inhalors
Rescue medication :
Racemic adrenaline neb, subq adrenaline, IV magnesium all used to try and prevent intubation
Grades
1 - intermitent
2/3/4 = intermittent
- mild
- moderate
- severe
Refractory = tx not working
Adult Corticosteroid Doses
<= 400 micrograms budesonide or equivalent = low dose
400 micrograms - 800 micrograms budesonide or equivalent = moderate dose
> 800 micrograms budesonide or equivalent= high dose.
Paeds Corticosteroid Doses
<= 200 micrograms budesonide or equivalent = paediatric low dose
200 micrograms - 400 micrograms budesonide or equivalent = paediatric moderate dose
> 400 micrograms budesonide or equivalent= paediatric high dose.
Maintenance and reliever therapy (MART)
a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)
Criteria for discharge
been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
inhaler technique checked and recorded
PEF >75% of best or predicted
ABG interpretation
Normal Ranges
pH: 7.35 – 7.45
PaCO2: 4.7 – 6.0 kPa || 35.2 – 45 mmHg
PaO2: 11 – 13 kPa || 82.5 – 97.5 mmHg
HCO3–: 22 – 26 mEq/L
Base excess (BE): -2 to +2 mmol/L
Hypoxic?
<10 kPa on air = hypoxaemic
<8 kPa on air = severely hypoxaemic
Type 1 or 2?
Type 1 respiratory failure involves hypoxaemia (PaO2 <8 kPa) with normocapnia (PaCO2 <6.0 kPa).
V/Q (ventilation/perfusion) mismatch>hypoxia + hypercapnaei > increased RR then blows off CO2
causes: alveolar hypoventilation (pneumonia, ARDS, pulmonary oedema), distribution/diffusion) (pulmonary fibrosis), perfusion (pulmonary embolism)
Type 2 respiratory failure involves hypoxaemia (PaO2 <8 kPa) with hypercapnia (PaCO2 >6.0 kPa).
Alveolar hypoventilation:
Central (coma, intracerebral haemorhage), Neuromuscular (muscular dystrophy), obstruction (COPD/ Asthma), restriction (pulmonary fibroisis, pneumothorax)
-airway obstruction (COPD) -reduced compliance (pneumonia/rib fracturs/ obesity - reduced respiratory muscle strength (Guilian-barre/MND) -Drugs reducing resp rate (opiates)
pH?
Acidotic: pH <7.35
Normal: pH 7.35 – 7.45
Alkalotic: pH >7.45
imbalance in the CO2 (respiratory) or HCO3– (metabolic).
PaCO2?
Does it correlate or not>
Bicarbonate?
Does this correlate?
(Base Excess)
High base excess = > +2mmol/L = high HCO3- = primary metabolic alkalosis or compensated respiratory alkalosis
Low base excess = < -2mmol/L = low HCO3- =
primary metabolic acidosis or compensated respiratory alkalosis
respiratory compensation is quicker than metabolic (days)
Compensation?
Assess compared to primary disturbance
Anion Gap?
Normal = 4-12 mmol/L
Anion gap formula: Anion gap = Na+ – (Cl- + HCO3-)
An increased anion gap indicates increased acid production or ingestion:
Diabetic ketoacidosis (↑ production)
Lactic acidosis (↑ production)
Aspirin overdose (ingestion of acid)
A decreased anion gap indicates decreased acid excretion or loss of HCO3–:
Gastrointestinal loss of HCO3– (e.g. diarrhoea, ileostomy, proximal colostomy)
Renal tubular acidosis (retaining H+)
Addison’s disease (retaining H+)
Mixed acidosis/alkalsosis
CO2 and HCO3- will be moving in oppositie directions
tx each primary acid/base disturbance
Context
A ‘normal’ PaO2 in a patient on high flow oxygen: this is abnormal as you would expect the patient to have a PaO2 well above the normal range with this level of oxygen therapy.
A ‘normal’ PaCO2 in a hypoxic asthmatic patient: a sign they are tiring and need ITU intervention.
A ‘very low’ PaO2 in a patient who looks completely well, is not short of breath and has normal O2 saturations: this is likely a venous sample.
ECG take 2
What it represents
P wave = depolorisation of atrial muscle
PR interval = time for electricle impulse to spread from atria to ventricles (3-5 small squares)
QRS = depolorisation of the ventricles (<3 squares)
ST segment = period when ventricles are completely activated
T wave = repolorisation of ventricular muscle
U wave = repolorisation of pappilary muscles (abnormal if after flattened T wave)
Context
note BP/HR consciouness when taking ECG
RRPWQST
RATE: 300, 150, 100, 75, 60, 50 (small = 4ms and large = 200ms
RHYTHM: regular = equal distance between QRS complexes
P WAVES: P wave before every QRS = sinus (impulse from SAN to ventricles) - no P = abnormal rhythm. >1 P = heart block (abnormal coduction to the ventricles)
WIDTH: QRS >3 squares = slow ventricle conduction (abnormal conduction or eronously starting in ventricular tissue)
Q WAVE: if QRS starts with deep downward deflection could be old MI
ST segment: should be level with baseline. elevated = MI and depressed = MC Ischaemia
T wave: normally upside down in VR and V1 .. in other leads could be ischamie or ventricular hyertrohy
QT interval: varies with heart rate, prolonged with some drugs (>12 small squares)
Calibration: 1 square wide and two high . . .. . should be included on every record (25mm/s)
AXIS
serves to alert of other pathology eg PE/ conudction abnormality
Normal = +ve I and II
Left leaving = positive in I and Negative in II
Right reaching = -ve in 1 and +ve in 2
90 degrees from isoelectric lead, see if +ve at +90 or -90
RAD ax Right ventricluar hypertrophy (2ary pulmoary conditions causeing right heart strain)
LAD ax wtih conduction abnormalities
V leads
V1,V2 look at right ventricle
V3/V4 look at septum
V5/V6 look at left ventricle
V leads QRS - first septal depolorisation from left to right (intial R wave in V1/V2 but q wave in V5/V6) then ventricular depolorisation
RS trasition point represents the position of interventricular septum (normal V3/V4), right ventricle hypertrophy pushes to V4/V5/V6
Reporting ECG
Always:
- rhythm
- conduction intervals
- cardiac axis
- description of QRS complexes
- description of ST segments and T waves
eg:
- Simus rhythm, rate 50bpm
- normal PR interval (100ms)
- Normal QRS complex duration (120ms)
- Normal Cardiac Axis
- Normal QRS complexes
- Normal T waves (inverted in VR is normal)
Setup
attache electrodes to correct limbs
ensure ggod elecrical contact
check the calibrationand speed settings
make patient comfortable and relaxed
Paeds Hx
Systems Review
Head – History of injury, headaches or infection?
Eyes – Visual acuity/glasses? History of injury, headaches or surgery?
Nervous system – Fits, faints, or funny turns? History of hearing concerns, seizures (febrile or afebrile), abnormal or impaired movements, tremors or change in behaviour? School performance? History of hyperactivity?
ENT – Earache, throat infections, snoring or noisy breathing (stridor)?
Chest – Cough, wheeze, breathing problems? Smokers in the family? Exposure to smoke?
Heart – Cyanosis, exercise tolerance, chest pain, fainting episodes? History of heart murmurs or rheumatic fever in the child or the family?
GIT – Vomiting, diarrhoea/constipation, abdominal pain? Rectal bleeding?
Genitourinary – Dysuria, frequency, wetting/accidents, toilet training?
Joints/Limbs – Gait, limb pain or swelling, other functional abnormalities?
Skin – General rashes? Birthmarks or unusual marks?
Pubertal development – Age of menarche?
HEEADSSS
Home and relationships
Who lives at home with you?
Do you have your own room?
Who do you get on with best and/or fight with most?
Who do you turn to when you’re feeling down?
Education and employment
Are you in school/college at the moment?
Which year are you in?
What do you like the best/least at school/college?
How are you doing at school?
What do you want to do when you finish?
Do you have friends at school?
How do you get along with others at school?
Do you work? How much?
Eating
Are you worried about your weight or body shape?
Have you noticed any change in your weight recently?
Have you been on a diet? Do you mind telling me, how?
Activities and hobbies
How do you spend your spare time?
What do you do to relax?
What kind of physical activities do you do?
Drugs, alcohol and tobacco
At this stage – reassure about confidentiality
Does anyone smoke at home?
Lots of people your age smoke. Have you been offered cigarettes? How many do you smoke each day?
Many people start drinking alcohol around your age. Have you tried or been offered alcohol? How much/how often?
Some young people use cannabis. Have you tried it? How much/how often?
What about other drugs, such as ecstasy and cocaine?
Sex and relationships
Are you seeing anyone at the moment?
Are they a boy or a girl?
Young people are often starting to develop intimate relationships? How have you handled that part of your relationship?
Have you ever had sex?
What contraception do you use?
Self-harm, depression and self-image
How is life going in general?
Are you worried about your weight?
What do you do when you feel stressed?
Do you ever feel sad and tearful?
Have you ever felt so sad that life isn’t worth living?
Do you think about hurting or killing yourself?
Have you ever tried to harm yourself?
Safety and abuse
Do you feel safe at school/at home?
Is anyone harming you?
Is anyone making you do things that you don’t want to?
Have you ever felt unsafe when you’re online or using your phone?
CAD
Angina is Demand ischaemia - reducing load will help
ANGINA
Tx: GTN spray, BB or CCB (titrate up till max tolerated) > BB + CCB
Diagnosis
Work from STEMI back
Troponins only for initial presentation as they do not go back down
Stable chest pain : Contrast-enhanced CT coronary angiogram is the first line investigation for stable chest pain of suspected coronary artery disease aetiology
Types of MI
Type 1 = acute palaque rupture (ischaemia/infarction)
Type 2 = supply and demand (whole body problem - sepsis/hypoxia)
Cath lab
>3 or big and proximal = surgery (stents for everything else)
stop metformin 24hr (contrast media decreased renal clearance and along with metformin can cause lactic acidosis)
General ACS
Aspirin 300mg
Nitrates (sublinguinal glyceryl trinitrate - avoid if hypotensive though) and morphine to relieve pain
Anti-emetic eg metoclopromide
02 if sats <94%
STEMI
above and:
P2Y12-receptor antagonist = Prasugrel>Ticagrelor>Clopidogrel
Unfractionated heparin if PIC (LMWH is an alternative)
tPA (Alteplase/Tenecteplase) if PCI <120mins of presentation not possible (perform ECG 90 mins after and if ST elevation not reduced by 50% then rescue PCI better than repeat tPA) - give antithrombin (fonadparinux) at same time and ticagrelor after
Blood glucose < 11.0 mmol/L
NSTEMI
Unstable = immediate coronary angiography
Fondaparinux (antithrombin) - if no immediate PCI planned
Estimate 6 month mortalitly (GRACE)
if low risk (<3%) then give Ticagrelor
If intermediate/high (.3%) :
PCI immediate if unstable and within 72hrs if stable
give prasugrel/ticagrelor
give unfractionated heparin
drug elucidating stents prefered.
Ticagrelor and prasugrel antiplatelets prefered to clopidogral. continue for at least 12m Prasugrel if going to have PCI (also 12m if stented.
Complications
DARTH VADER
Death
Arrythmia/Heart block
Ruptured Aneurysm
Thrombus
Heart Failure
VSD
Another MI
Dressler’s Syndrome
Embolus
Regurgitant Valve
RIGHT SIDED INFRACTS = PRELOAD DEPENDENT
RS = V1>V2
ST eleveation in V1 and depression in V2 is highly specific to RSHF
Lead III > Lead II
Give IV fluids and do not give nitrates as they cause hypotension
Extra
Diclofenac Contraindicated
deeply inverted or biphasic waves in V2-3 in a person with the previous history of angina is characteristic of Wellen’s syndrome. This is highly specific for a critical stenosis of the left anterior descending artery
Back Pain
- Cord Compression?
- Non-specific = MSK
- can jump to others if you do not think msk (XRAY/MRI)
- If not MSK then tx is surgery based on sx and lifestyle
Thoracic back pain is a red flag symptom
acute = <6w, subacute = 6-12 and chronic >12
MSK
lower backpain first line NSAID (ibuprofen/naproxen)
+ ppi if >45
encourage exercise ( print excercise sheet) but physiotherapy only if sx no resolving or likely to become disabled.
after 2-4 weeks encourage graded return to work even if pain . . .. won’t make worse
Spinal cord compression - seems the same as cauda equina syndrome (this can be caused by massive disk herniation) - surgical emergency
- sensory loss, lowe limb weaknes
- urinary incontinence/retention
- reduced sensationin perianal area
- reduced anal tone
MRI spine WHOLE spine in 24hr
urgent oncology referal
high dose dex
Cauda Equina vs cord compression
Cauda equina = flaccid paralysis + loss of reflexes
Cord compression = spastic paralysis + brisk reflexes.
Both = sensory + power loss.
Sciatica = shooting pain from bottom down back of legs to toes
Do not offer X-ray in UK - MRI only if you suspec someting sinister - red flag symptoms
pseudoclaudication (spinal stenosins - only upper thigh and buttocks - don’t get climbing stairs or bent over on bike
- resolves on sitting down
Herniation- AKA prolapsed disk
Leg pain usually worse than back
pain worse on sitting
pain ins dermantological according to which level affected
NSAIDs/exercise/physiotherapy . . MRI if no imporovement after 4-6 weeks
nerve route compression unlikely if SLR not limited or pain does not extend below knee on slr
look for L5/S1 compression (loss of sensatino of lateral border of lower leg and foot, weakness of dorsiflexion and plantarflexion of foot or impaired ankle reflex)
Compression fracture - dont forget f/u dexa scanand osteoporosis tx
Ankylosing Spondylitis should be here:
Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)
NSAIDS - remember PPI if over 45
psoas abscess
Back/flank pain worse which is worse when the hip is flexed, with associated fever and raised inflammatory markers in an IVDU. ix CT Abdo
TX = IV abx and percutaneous drainage
EXTRAS
Previous hx of Ca? - always orthopaedic referal
Discitis
CF
backpain, fever, sepsis, lower limb neurological sx
RF: IVDU MC Staph Aureus . . . may present with endocarditis
Dx: MRI
Tx: 6-8w abx
