Standardised Case Based Discussion Flashcards

Question

Transplant medicine

Answer 1

Typical infections **Early (0-4 weeks)** - nosocomial infections ie c diff or MRSA - donor derived infections ie candida, HIV, HB/CV, tuberculosis, CMV - Recipient dormant ie TB, HSV, EBV, CMV, HepB/C, candida, aspergillus and pseudmonoas **Intermediate (1-6 months)** - HZV, HSV, EBV, CMV, resp viruses - Pneumocystis jirovecii - Mycobacterium and fungal species **Late (>6months)** - All of the above + UTI's, community acquired infections, resp viruses Other non-infectious casues - Graft rejection - Graft vs host disease - Transplant associated malignancies - Drug toxicity - Recurrence of primary disease (ie infection or autoimmune cause etc) - Other pathology same as non-transplant patients ie pregnancy, appendicitis etc Liver complications - Most common is hepatic artery thrombosis - Portal vein thrombosis and biliary tract obctruction

Answer 2

Lights Criteria -

Answer 3

RF's - Predisposition to N/V - Multiple gestation - Previous HG - Hydatid mole - GI disorders/reflux Definition - Pregnant with ongoing N/V - >5% weight loss pre-pregnancy - Ketonuria with no other cause Evaluations - Weight, postural BP, fluid status - Foetal wellbeing/viability - U/S for foetal number and hydatiform molar pregnancy - Laboratory studies (BSL, ketones, VBG, electrolytes, UEC, LFT's, TFT's, lipase) - Urine for ketonuria, UTI and proteinuria - H. pyloria breath test DDx - N/V of pregnancy - Gastritis/h. pylori - Gastro, UTI - Pancreatitis - HELLP, Pre-eclampsia, acute fatty liver of pregnancy - DKA, thyrotoxicosis, adrenal crisis - Mechanical cause - Appendicitis - Drug overdose Complications - Severe dehydration - Starvation ketosis - Electrolyte derangement - Long QT and TdP from electrolytes - Malnutrition and Wernickes - Mallory-Weiss tear and Boerhaves - Aspiration - Premature labour, foetal distress Management - IV normal saline - Seek and treat hypoglycaemia - IV pyridoxine and Thiamine - Assess baby with CTG - Ondansetron, maxalon, cyclizine - May need NGT if vomiting severe - Seek and treat ketosis - Inpatient vs outpatient based on response to treatment and PUQE score Scoring system (PUQE 24) - >13 points is severe and likely admit, 3 questions, 1-5 points - Hours of nausea in last 24hrs (>6hrs = 5 points) - Vomiting episodes last 24hrs (>7 = 5 points) - Dry heaving episodes 24hrs (>7 = 5 points) Special Points - beware nutritional deficiency and Wernickes encephlaopthay

Answer 4

Concepts - Greatest good for greatest number Sieve: Airway patency (if not patent, considered dead) - HR, RR CRT vs Sort: Order of transportation out and where on scene interventions will be performed METHANE (communication) - Major incident declared - Exact location - Type of incident (chemical, fire etc) - Hazards present - Access/Egress - Number of casualties - EMS needed and already there CSCATT (structure) - Command (allocate and delegate) - Safety - Communication - Assessment - Triage - Treatment - Transfer **Triage** Black = Dead or unlikely to survive Red= Critical injury requiring immediate care Yellow= Significant but not immediately life threatening injuries Green= Walking wounded **Stake Holders** ED Medical + nursing director Bed co-ordinator Blood bank/Haem Heads of anaesthesia/surgery/Radiology/ICU Hospital CEO Security Media department ED Actions - Contact stakeholders - **code brown/Hospital disaster plan** - Set up **decontamination zone** if needed (ie chemical disaster) - Altered triage (trauma triage vs ATS triage system) - Call in extra staff - Ask current staff to stay late - Discharge as able current patients (allocate senior Dr) - Move other patients to the ward (Med team and bed coordinator) - Setup up a large triage bay - Minimise any investigations - Rationalise interventions - Empower nursing staff to initiate treatment without Dr oversight - Take stock of equipment/drugs Hospital Actions - No new surgical cases, activate all theatres - Call in extra staff, current stay late - Inpatient teams discharge as able - Clear outpatients, use for walking wounded - All hospital visitors leave - Establish central point of contact aka a command centre - Notify morgue (multiple bodies) 5 phases ED response *Prevention* *Mitigation* Preparedness Response Recovery

Answer 5

Always check for PACING SPIKES!!! - PMT - dysrythmias, faulty Rate - 300/big squares Rhythm - Sinus - AV dissociation Axis Intervals - PR, QRS, QT, Size - LVH, Sokolov-Lyon - Small complexes (fat, fluid, asthma, hypothyroidism) Syncope - HOCM - Brugada, long QT, Ischaemia - STEMI - Equivalents - Sgarbossa

Answer 6

**Thrombolysis** Inclusion - Ischaemic stroke with measurable neurological deficit (NIHSS >6) - Age >18yrs - Symptoms started <4.5hrs ago Exclusion - Typical thrombolysis contraindications - Evidence of haemorrhage - Extensive regions of irreversible injury - No ischaemic penumbra - Consistent with endocarditis as cause - Known or high possibility of dissection **Clot Retrieval** Inclusion - Ischaemic stroke with proven large vessel occlusion on CTA (ICA, M1, prox M2, basilar) - Independent pre-morbid function ie Modified Rankin score 0-2 (3 is grey zone for treatment) - Up to 24hrs post symptom onset - Accessible to clot retrieval based on anatomy - NIHSS score 5 or more - Thrombolysis started if applicable Exclusion - Modified Rankin score >3 - NIHSS score <6 - Presence of large hypodensity on CT head beyond ischaemic changes - No ischaemic penumbra present - Presence of large core infarct >50mls in patient with pre-existing severe co-morbidities - >24hrs since symptoms started (relative) Modified Rankin Scale - Score 1-6, 6 = dead - 3 = moderate disability but still able to walk independently - 4 = Moderate disability, unable to care for self or walk independently Basic Localisation Anterior - lower limb sensory/motor - Bowel and bladder dsyfunction - personality/executive function changes Middle - Upper limb and face sensory/motor - Speech centre deficits (dysphasia and dysarthria) Posterior - Visual and balance - Most common is homonomous hemianopia Lacunar - Contralateral pure sensory or motor, no effects on higher functions Brainstem - Crossed findings (some contralateral and ipsilateral changes)

Answer 7

**Resuscitation first** Compensated vs Decompensated - Asymptomatic - Still able to function but fatigued - Dissociative shock Key Differentials - Blood loss - Chronic disorders (inflammatory vs organ failure vs malignancy) - Nutritional deficiency (Fe, B12, folate and alcohol) - Haemolytic anaemia - Bone marrow failure Classification Morphology - Micro, normo, macrocytic (MCV) - Hypochromic, normochromic or hyperchromic (MCHC) Causes - Decrease production, increased destruction, increased loss Severity - Mild 130-100Hb -

Answer 8

Life Threats - Meningococcaemia - NAI/trauma - Leukaemia - SLE/Autoimmune - DIC/TTP - HUS - Bone marrow failure (aplastic anaemia ie parvovirus) More Common - Viral induced ITP (EBV and adenovirus most common) - Drug induced - Mechanical destruction (marching or jogging, valve replacements, hypersplenism) - Nutritional deficiencies (B12, folate and iron) - vW disease ITP Classification Life threatening - Large GI Haemorrhage or ICH Severe - Significant bleeding but not immediately catastrophic Moderate - Minor bleeding ie from gums, self limiting epistaxis, haematuria etc Low - Essentially no bleeding *ITP Management* - Management always in discussion with haematologist - Needs FBE film reviewed before discharge Low RIsk - Repeat FBE in 1 week, outpatient - Can forego medications unless psychosocial or safety concerns Moderate - Admission - Prednisolone 2mg/kg - IVIG 1gm/kg - +/- TXA Severe/Life threatening - All of above, Methylpred 30mg/kg - Platelet transfusion ITP restrictions - Avoid contact sports

Answer 9

Key History - Recent surgery - Previous VTE - Immobility - Malignancy Other points - Smoking - Pregnancy - Flights Wells score DVT Score 0 (5% risk) = low, score 1-2 = moderate (14% risk), score 3 or more = highr risk (50+%) - -ve 2 points if alternate diagnosis just as likely - +1 point for immobilisation, cast, recent surgery, local tenderness over deep vein system, unilateral oedema, affected leg >3cm bigger than asymptomatic leg Wells score PE - Low risk <2 (1.3% PE) - Moderate risk 2-6 (16% PE) - High risk 7 or more (40% chance PE) - 1 point Malignancy or haemoptysis - 1.5 points previous VTE, Hr >100 or immobilisation 3 days/surgery within 1 month - 3 points signs/symtpoms DVT or PE number 1 diagnsosis PERC score - 0 points = <2% risk PE - Used to rule out PE - Age >50, Hr >100, sats <95% - Unilateral leg swelling, haemoptysis - Prior VTE, oestrogen hormone use - recent surgery/trauma last month needing general anaesthesia Isolated distal (below knee) DVT - See algorithm for treatment Anticoagulation - Warfarin aiming INR 2-3 - BD Enoxaparin 1mg/kg - Rivaroxaban/Apixaban Implications of anticoagulation - High risk sporting activities - No effect on menstruation expect - Employment affected if involves physical tasks - Pregnancy (only safe one is Clexane, need to cease others) - Travel (need doses, cant miss) - Modify risks Pregnancy - Heparin and Enoxaparin safe - Warfarin contraindicated, others unclear - Usually change to clexane during pregnancy then Heparin in the peripartum period (risk of PPH) - Need to continue for at least 6 weeks post partum and 6 months in total

Answer 10

**Collecting evidence** *Preservation of evidence* - collection by trained personnel - Don't compromise clinical care - Use of gloves/PPE - Collect all clothing and articles, minimal cutting of clothes *Documentation* - Write in patients words, draw pictures to help with recall - Use hospital photographer to take photos if likely to be used in court - Handover to police Serious Threat to ED staff - Notify police - Notify security - If very serious then code brown/black and notify management and ED director - Keep patients, staff and visitors as safe as possible - Consider locking down department and going on bypass - Media liason if needed

Answer 11

*Initial* - Cease transfusion - Keep line patent - Support A/B/C (fluids, 02, adrenaline or noradrenaline etc) - Review the blood products and compatability - Return sample to blood bank immediately for checking and culture - Re-Xmatch in case of ongoing need for blood products *Measures to prevent* **Hospital Transfusion protocol** - Use national guidelines - Ensure clear indications before use (ie Hb <70, Hb >70 but symptomatic or comorbid etc) - Rigorous checking for cross match blood tests - Intensive initial monitoring when transfusion started - Only urgent transfusions out of hours (ie resus) **ED protocol** - Senior consultant/MO approval for transfusions - Review SSU transfusion protocols - Monitored area with visual access - Special nursing during initial part of transfusion **Education** - Inservice/CME for medical and nursing staff - Review of adverse events in M+M and RCA of events

Answer 12

Scoring Systems PSI - Most well validated, accurate and safest - Complex score with lots of factors CURB 65 - Less well validated, not preferred - Much simpler score and easier to implement SMART COP - Somewhere in between, not preferred Pneumonia Severity index - 5 classes based on points - Age and sex - Co-morbidities and nursing home - Physical findings of reduced GCS, SBP <90, tachycardia, tachypnoea, febrile - Blood tests pH, elevated urea, low Na+, high BSL, Anaemia, hypoxia - Pleural effusion on CXR

Answer 13

Mnemonic PALM COEIN P- Polyps P- PCOS A- Adenomyosis L- Leiomyomas M- Medications (blood thinners, steroids, antipsychotics, antiepileptics) C- Coagulpathy O- Ovulatory dysfunction E- Endometrial dysfunction and Endometriosis E- Endocrine I- Infection/Inflammatory (PID, SLE, vasculitis etc) **N- Neoplasm** (endometrial cancer etc)

Answer 14

Emergencies - Febrile neutropaenia - Severe neutropaenia (<0.5) - Severe anaemia - Severe thrombocytopaenia (<10) with bleeding (<50) - DIC - Acute Leukaemia - Acute aplastic anaemia - Haemophagocytic lymphohistiocytosis - Hypeuricaemia - Acute renal failure

Answer 15

Hip - usually hip fracture - Also paediatric SUFE Knee - haemarthrosis - Tibial plateau Elbow - Effusion - CRITOE - Gartland classification Chest - Basic approach - Mediastinum, lungs trauma - Lines, ETT Hand/Wrist - Carpals, subtle fractures - Scaphoid C-spine - Lines - Fracture types, stability Abdomen - Paediatric FB, volvulus, nec, pyloric stenosis and intussusception - obstruction Shoulder - Differentiating dislocations

Answer 16

DDx - Endometritis from RPOC - Wound infection from C-section or episiotomy - Septic pelvic thrombophlebitis - Epidural abscess or other spinal infection from epidural placement - Staph TSS - Mastitis - Pyelonephritis - Nosocomial infections (Hospital acquired pneumonia, C. difficile infection etc) - PE/amniotic fluid embolism - Perinatal thyrotoxicosis - Post natal depression with drug overdose Empiric cover - Pip Taz and Metronidazole +/- vanc and Gentamicin

Answer 17

1. Rule out life threats - Severe acidosis - Hyperkalaemia - Severe overload - Uraemia/Uraemic serositis 2. Assess for adequate perfusion - Shock assessment - Hx, Ex and Ix - Pocus 3. Assess for overload - Pulmonary oedema and peripheral oedema - If neither present then give a fluid challenge 4. Remember the golden rules - Measure post void residual (neurogenic bladder, BPH etc) - Urine dipstick for blood and urine (nephritic syndrome, intra-renal) - Monitor urine output (ideally catheter) - Avoid nephrotoxins (ACE, ARB, NSAID's, Gentamicin) 5. Consider renal tract imaging - Stones, tumours, strictures - Post-renal causes Classification Pre-Renal - Shock and hypovolaemia Intrarenal - Vasculitidies - Diabetes - Deposition (myoglobin, rhabo etc) Post renal - Stones, tumours, strictures - BPH, neurogenic bladder etc - Anticholinergics, alpha agonists etc