Shorts Flashcards
Heart Failure Chest Xray
A - alveolar oedema (bat wing opacities)
B - Kerley B lines.
C - cardiomegaly.
D - dilated upper lobe vessels.
E - pleural effusion.
ACS Imediate mx
ACS : ECG,po aspirin 300mg, subliguial glyceryle trinitate spray/tablet, oxygen, morphine + antimimetic,
PE Risk Factors
Notes Mneumonic
REDCOAT
Resus Status
EDD
Drugs Chart r/v
Cannula
Oxygen
Abx
Thrombolytis
Systems R/V
Fits/Faints/Funny turns
Coughs/colds
SOB
N/V
Change in bowel habit
change in water works
Any pain anywhere
Have you lost any weight
hows your appetite been
Cardiovascular Red Flags
Chest pain
Palpitations (heart racing or thumping)
Shortness of breath (dyspnoea): tolerance
PND and Orthopnoea
Peripheral oedema
Pain in legs on walking, cold limbs (PVD)
Respiratory Red flags
Shortness of breath (dyspnoea): tolerance
Cough: duration, haemoptysis
Sputum: amount, character, blood, pink
Chest pain on breathing (pleuritic pain)
Wheeze, stridor, snoring
Gastro Red Flags
Difficulty/Pain chewing or swallowing, ulcers
Nausea, vomiting, ? blood
Indigestion or heartburn or abdo pain/mass
Change in appetite, weight loss, weight gain
Bowel habit: changes, blood, mucous, melaena, pale stools or floating (steatorrhoea)
Neurological and Psychiatric Red flags
Headache, fits, faints, dizzy, blackouts
Numbness ( or any change in sensation), weakness or clumsiness in arms or legs
Changes in vision, double vision, hearing (deafness, tinnitus), speech, taste, smell
Change in mood, stress levels, thoughts
Genito-Urinary Red Flags
Pain or discomfort urination
Difficulty starting or stopping
Are you finding you’re going more often
Noticing you’re waking up at night to go to the loo
sudden urge to pee
any accidents
Fever/rigors
N&V
weight loss
Uraemic Symptoms
Dysuria: typically associated with urinary tract infection (UTI), including sexually transmitted infections (e.g. chlamydia, gonorrhoea).
Urinary frequency: commonly associated with UTIs.
Urinary urgency: may be associated with UTIs or detrusor instability.
Nocturia: associated with UTIs and prostate enlargement (e.g. benign prostatic hypertrophy).
Haematuria: associated with UTIs, trauma (e.g. catheter insertion) and renal tract cancers (e.g. bladder cancer, renal cancer).
Urinary hesitancy, terminal dribbling and poor urinary stream: associated with enlargement of the prostate (e.g. prostate cancer, benign prostatic hypertrophy).
Urinary incontinence: associated with a wide range of pathology including UTIs, detrusor instability and spinal cord compression (e.g. cauda equina syndrome).
Fevers and rigors: typically associated with pyelonephritis.
Nausea and vomiting: typically associated with pyelonephritis.
Weight loss: associated with malignancy and uraemia.
Uraemic symptoms: nausea, vomiting, fatigue, anorexia, weight loss, muscle cramps, pruritis and confusion.
Pain or difficulty passing urine, ? dribbling
Day urination versus nocturia
? Amount ? need to drink fluids overnight
Vaginal or penile discharge, lesions
Periods: last one, changes, usual pattern,
Diabetes and Endocrinology Red flags
Polyuria, polydipsia, weight loss/gain, , blurred vision, thrush
Heat or cold intolerance, neck swelling.
Change in appearance, sweating, hirsutism, periods, energy, libido, ED
Notes Mneumonic
REDCOAT
Resus Status
EDD
Drugs Chart r/v
Cannula
Oxygen
Abx
Thrombolytis
Surgical Sieve
Sepsis
No SIRS or QSOFA
NEWS2 >= 5 or >= 3 in on parametre or pt looks sick or patient could be neutropenic or cause for concern
Could there be an infection?
Run through the red false (if ane ONE then red flag sepsis)
if no assess for moderate risk (look up formula and send bloods)
Sepsis 6:
aim >94%
give abx as per guidelines
take blood cultures (and think of any other cultures you could take)
Fluids: 500ml sytat hartmann’s if hypotensive or lactate >2mmol/l
check lactate if >4mmol check after each fluid bolus and call critical outreach
measure urine output
Bundle Branch Block
WILLIAM and MARROW
if RBBB w/o QRS widening, it is not significant
Cannot interpret rest of ecg with LBBB
the ‘W’ pattern may not always be present in LBBB
remember any deflection however small counts . .. . someimes slow sloping W in LBBB at begining
can be associated with T wave inversion
The most important causes of
LBBB are ischaemia (?pain), aortic stenosis(?echo) and cardiomyopathy(?echo)
PE risk factors
ECG Intervals
RR interval: 0.6-1.2 seconds.
P wave: 80 milliseconds.
PR interval: 120-200 milliseconds. 3-5 squares
PR segment: 50-120 milliseconds.
QRS complex: 80-100 milliseconds. 2- 2.5 squares
ST segment: 80-120 milliseconds.
T wave: 160 milliseconds.
Delirium Tremens Scale
SHOT protocol scale is a quick assessment.
NICE recommends CIWA-AR scale (closely correlated to above)
Can find on MDCALC
Sweating
Hallucinations
Orientation
Tremor
Paeds Traffic Light System
NSAIDs SEs and contraindication
No urine (renal failure)
Systolic dysfunction (hear failure)
Asthma
Indigestion (any cause)
Dyscrasia (clotting abnormality)
BUT Aspirin is not contraindicated in renal or heart failure or in Asthma
Enzyme Inducers
Griseoflavin - antifungal
Carbamazapine
Rifampin
Phenytoin
Chronic Alcohol Use
Barbituates
Cyclophosphamine
Suphonylureas
St John’s Wort
PC BRAS
Phenytoin
Carbamazapine
Barbituates
Rifampin
Alcohol (chronic excess)
Sulphonylureas
Enzyme Inhibiters
CP450
Quinidine
Metronidazole
Omeprazole
Isoniazid - TB tx
Grapefruit Juice
Ethanol (acute useage) - saturated by toxins
Erythromycin
Cimetidine - histamine H2 receptor antagonist
Sulfonamides
Indinavir (HIV protease inhibitor)
Valporic acid aka valorate (vault pro lemon)
Verapamil
Amiodarone
Ketocanazole
AODEVICES
Allopurinol
Omeprazole
Disulfaram
Erythromycin
Valporate
Isoniazid
Ciprofloxacin
Eethanol
Sulphonamides
Antihypertensive SEs
Common causes of K+ and Na+ imbalances
High K, low Na -> spironolactone, ACEi, NSAIDs
Low K, high Na (or low Na) -> loop and thiazide diuretics, steroids
What to consider when prescribing IV fluids to replace
Which one - 0.9% NaCl (crystalloid)
UNLESS-> ascites= HAS
hypernatramia or hypoglycaemia = 5% dex
bleeding = blood or colloid ( gelofusine) first
How much/how fast - if hypotensive or tachycardic = 500ml stat (250ml if heart failure) - then reasses
if only oliguric give 1L over 2-4 hrs - then reasses
Steroid SE/ contraindications
Stomach Ulcers
Thin Skin
oEdema
Right and left heart failure
Osteoporosis
Infection (including candida)
Diabetes ( commonly causes hyperglycaemia and uncommonly pregresses to diabetes)
Cushing’s Syndrome
Extra
Proximal myopathy (weakness) in longer term use
Antiemetics
Cyclazine good firt line treatmet except cardiac cases
Metoclopramide is contraindicated in PD (worsenign of sx) and young women (dyskinesia)
Pain relief
Oxycodonoe MR 10mg BD (can titrate up to max of 400mg per day)
PRN oxynorm 5mg q4-6hrs
po Morphine breakthrough dose, do 1/6 of total daily dose
conversion of weak opiods to morphine you divide by 10
never increase background by more than 50%
po morphine to po oxycodone = divide by 2
po morphine to sc morphine = divide by 2
po oxycodone to sc oxycodone = divide by 1.5
Patches if they don’t want to be hooked up (buprenorphine or fentanyl - convert using NICE chart)
NSAID - any stage
Neuropathic: Amytriptyline 10mg nightly or pregabalin 75mg 12 hrly
Diabetic Neuropathy: Duloxetine 60mg PO daily
An NSAID (e.g, ibuprofen 400 mg 8-hourly may be introduced at any stage regularly or ‘as required’ if not contraindicated (as discussed earlier under Contraindications). With neuropathic pain (t.e. pain arising from nerve damage or disease and usually described as ‘shooting’, stabbing’ or ‘burning) the first line of treatment is amitriptyline (10mg oral nightly) or pregabalin (75 mg oral 12-hourly): duloxetine (60 mg oral daily) is indicated in painful diabetic neuropathy
WBC interpretation
Eosinophils = allergic reaction, paracites or coxi,
Monocytes think TB(and lymphocytes)
Infection vs Steroids
infection = increase in band neutrophils (steroids you don’t get this shift as its not new WCC but WCC moving more into the bloods)
Very High Increase in WCC think CDIFF
Hyponatraemia Causes + tx
Hypovolemic tx = stop relevent drugs, IV nacl, 100mg IV hydrocortison if clincial suspician of adrenal insufficiency
euvolemic tx= stop relevent drugs, water restric 1 L/day, oral sodium chloride (slow sodium) +/- low dose furesemide, consider demeclocycline
hypervolemic tx = tx underlying cause, sodium restrict, fluid restrict 1l/day
Monitoring: CNS observations and reassess every 6 hrs till stablised?
SIADH
Small cell lung tumours
Infection
Abscess
Drugs (esp. carbamazepine and antipsychotics)
Head Injury
Predict fluid depletion
Oliguric =500ml
Oliguric + tachycardia = 1L
Oliguric + Tachycardia + shocked = >2L
- reduced urine output (oliguric if <30 mL/h; anuric if 0 mL/h) indicates 500 mL of fluid depletion
- reduced urine output plus tachycardia indicates 1 L of fluid depletion reduced
- urine output plus tachycardia plus shocked indicates >2L of fluid depletion.
As a general rule never prescribe more than 2L of IV fluid for a sick patient. The effect on the patient and thus the rate of subsequent fluids should be reviewed regularly.
Hyper/okalaemia Causes
Intrinsic AKI
Maintenance fluids: which and how much
Maintenance: which fluids and how much?
Adults: 1 salty, 2 sweet over 24hrs
Elderly : 2 litres over 24hrs
K+ determined by U&Es
• As a general rule, adults require 3 L IV fluid per 24 hours and the elderly require 2L
Adequate electrolytes are provided by 1 of 0.9% saline and 2L of 5% dextrose (1 salty and 2 sweet).
To provide potassium, bags of 5% dextrose or 0.9% saline containing potassium chloride (KCL) can be used but this should be guided by urea and electrolyte (U&E) results, with a normal potassium level, patients require roughly 40 mmol KCI per day (so put 20 mmol KCL in two bags)
BUN and Cr
Urea better marker for dehydration than Cr
Urea to Creatine ratio
Urea:Cr = Urea/ (creatine/1000)
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.
GCS
Glasgow coma scale (GCS) scores are generally expressed in the following format ‘GCS = 13, M5 V4 E4 at 21:30’.7
Intubate if GCS <8 (eg cuffed endotracheal tube)
Basal Bolus Regimen
Which antiemetic
Higher centres = GABA + H1
comitting centre = ach, h1, nk1
chemotactic trigger zone = d2, 5ht3, nk1
vestibular apparatus = ach, h1
GI tracT = 5HT3, 5HT4, d2
all feed into vomitting centre
regular > prn
syringe drive = xcellent
not po if comitting
dont give cyclazine and metoclopramide togetheer
levomepromazine a good choice in last days of life as broad-spectrum.
Oxygen Titration
Aim 94%-98% in most
88%-92% in known T2 resp failure
Nasal cannula 2l-6l = 24-50% FIO2
Simple face mask for low to moderate o2 requirement . . . . hard to know how much o2 delivered. ventri adapter tells specific flow rate and associated fio2 (24- 60% fio2) usually used when specific amounts need to be delivered such as copd with t2rf
non-rebreath mask = 60-80% fio2. . . . uses 12litre-15litres . . . .. must hold valve to fill up bagmask at start
sensitivity/specificity
Stroke Basic Approach
<4 hours symptom onset?(think FAST, Rosier Score, BM)
- AtoE (ensure stable or take to resus), hx, time onset, neurological assessment,
- Fast +ve > Rosier +ve > bleep stroke team ?999 ambulance transfer
- In the meantime: NBM, 2 cannulas, stroke/tia bloods (fbc, u+e, glu, coag, lipids , G+S, ECG, no aspirin
> 4hrs, consider bm, fast, rosier and contact stroke for advice.
NIHSS (national institue of health and stroke score) - more in depth score predictive of outcomes
Image considerations are ROH specific (?avoid CT if going to send to Stroke anyway)
Assessment of neruological signs in upper limb injury
acute diarhoea causes
chronic diarhoea causes
Emergency Dept Analgesia
provide analgesia for mod-servere pain within 15 mins of arrival
Elderly and pregnant paracetamol good, avoid NSAIDs
codeine/mophine if neccessary ton pregnant
NSAIDs
ibuprophen 400mg po TDS
naproxen 500mg po initially then 250mg every 6-8hrs
Diclofenac 50mg po TDS or 100mg PR (renal colic but contraindicated in iHD, PVD, CVD and HF
avoid nhsaids in peptic ulcer disease, elderly , pregnancy and woman with fertility issues
codeine phosphate 30-60mg qds (lower in elderly)
oral morphine not generaly recomended in ED due to slow onset unless already on background.
IV morphine: 0.1- 0.2mg/kg = normal adult dose.. . . . but titrate to desired response
entonox: quick . . .in acute assessment/trauma . . . contraindicated for head/chest injuries
penthrox (methyoxyflurane): mod-severe pain in trauma setting (quick onset)
contraindicated in renal/hepatic failure, cardiac insufficiency, resp depression or malignant hyperthermia
ketamine alagesia. 0.1-0.3mg/kg iv. bolus over 5 mins (15mins to avoid sedation/neuropsychiatric SEs_
Alternatives
relaxation esp paeds
local /regional anaesthesia
immobilisation
early reduction of fracture/dislocations
stemi mx
nstemi mx
Epistaxis mx
apply pressure to soft part of nose, lean forward, ice pack to forehead or neck. only seek medical attention after 20 mins
Box 1: 1st Aid
Sit patient with upper body tilted
forward and mouth open. Pinch the soft
cartilaginous part of the nose firmly and
hold for 10-20 minutes
Box 2: History
Estimated blood loss/severity of bleeding
Recurrent bleeding?
History of trauma/surgery?
Symptoms of hypovolaemia
Symptoms of underlying causes of causes of
epistaxis
Past medical history
Drug history (esp anticoagulants)
1
st aid already received
Box 3: Cautery
Clear clots by blowing nose
Use topical LA spray with
vasoconstrictor
Wait 3-4 minutes
Identify bleeding point and lightly
apply silver nitrate stick for 3-10
seconds
Only cauterise one side of nasal
septum to avoid perforation
Avoid touching areas which do not
need treatment
Box 4: Nasal Packing
Ensure topical LA with vasoconstrictor
Wait 3-4 minutes
Insert nasal pack (eg rapid rhino) as per
manufacturers instructions
Raised ICP traid
Cushings triad
