TO DO A&E, ANAETHETICS + PALLIATIVE Flashcards
END OF LIFE CARE
In terms of managing end of life care, what should be given for pain + dyspnoea?
MORPHINE 20-30mg modified release per day with 5mg for breakthrough pain (e.g. 15mg modified release morphine BD + 5mg oral morphine for breakthrough pain)
OXYCODONE in mild/moderate renal impairment
ALFENTANIL, BUPRENORPHINE or FENTANYL in severe renal impairment
END OF LIFE CARE
In terms of managing end of life care, what should be given for nausea and vomiting?
Haloperidol 0.5-1.5mg SC
do not repeat within 4 hrs, max dose 3mg in 24hrs
END OF LIFE CARE
In terms of managing end of life care, what should be given for agitation, anxiety, or dyspnoea?
Midazolam 2.5-5mg SC
do not repeat within 1hr, max 4 doses in 24hrs
if not in terminal phase of illness
1st line = haloperidol
other options = chlorpromazine + levomepromazine
END OF LIFE CARE
In terms of managing end of life care, what should be given for constipation?
Start with stimulant laxative (senna) as opiates decrease peristalsis or stool softener if not on opiates, if not suppositories, enemas, PR evacuation
END OF LIFE CARE
how is metastatic bone pain managed?
- strong opioids
- bisphosphonates
- radiotherapy
- denosumab
OPIOIDS
what is the typical starting dose of morphine for opioid naive patients without renal impairment?
20-30mg daily
e.g. 10-15mg oral modified release morphine every 12 hrs
MULTIPLE ORGAN DYSFUNCTION
what scoring system can be used to assess the severity?
SOFA score
END OF LIFE CARE
In terms of managing end of life care, what should be given for hiccups?
- chlorpromazine
- haloperidol + gabapentin also used
- dexamethasone if hepatic lesions
END OF LIFE CARE
In terms of managing end of life care, what should be given for haematuria?
large bleed = admission may be appropriate
non life-threatening bleeds
- encourage increased fluid intake
- exclude UTI
- etamsylate 500mg QDS
- consider referral for palliative radiotherapy
DEATH CONFIRMATION
how do you confirm lack of neurological activity?
- absence of pupillary light reflex
- absence of corneal reflex
- absence of response to painful stimuli (supraorbital pressure)
DEATH CONFIRMATION
how do you confirm death if a patient has a DNACPR?
- absence of pupillary light reflex, corneal reflex + response to pain (supraorbital pressure)
- no palpable central pulse + no heart sounds for 2 minutes
- confirmation of no chest wall movement + no audible breath sounds for 2 minutes
- no additional cardiac monitoring required in these patients
ANAPHYLAXIS
what is the management for adults?
- IM adrenaline (500 micrograms for adults) + high flow oxygen
if no response repeat IM adrenaline after 5 mins + fluid bolus
ANAPHYLAXIS
when would fast-track discharge (after 2 hours) be considered?
- good response to single dose of adrenaline
- complete resolution of symptoms
- has been given an adrenaline auto-injector and trained how to use it
- adequate supervision following discharge
ANAPHYLAXIS
when would discharge after 6 hours be considered?
- 2 doses of IM adrenaline needed, or
- previous biphasic reaction
ANAPHYLAXIS
when would discharge after a minimum of 12 hours be considered?
- severe reaction requiring > 2 doses of IM adrenaline
- patient has severe asthma
- possibility of an ongoing reaction (e.g. slow-release medication)
- patient presents late at night
- patient in areas where access to emergency access care may be difficult
- observation for at 12 hours following symptom resolution
ANIMAL BITES
what is the most common isolated organism in animal bites?
Pasteurella multocida
HUMAN BITES
what are the most common organisms?
Streptococci spp.
Staphylococcus aureus
Eikenella
Fusobacterium
Prevotella
HIV and hep C should also be considered
BED BUGS
what is the causative organism?
Cimex hemipteru
BURNS
how do you assess the extent of burns?
Wallace’s Rule of Nines:
- head + neck = 9%,
- each arm = 9%,
- each anterior part of leg = 9%,
- each posterior part of leg = 9%,
- anterior chest = 9%,
- posterior chest = 9%,
- anterior abdomen = 9%,
- posterior abdomen = 9%
Lund and Browder chart: the most accurate method
- the palmar surface is roughly equivalent to 1% of total body surface area (TBSA).
- Not accurate for burns > 15% TBSA
BURNS
what is a superficial epidermal (1st degree burn)?
- red and painful
- dry
- no blisters
BURNS
what is a Partial thickness (superficial dermal) (2nd degree burn)?
- pale pink
- painful
- blistered
- slow CRT
BURNS
what is a Partial thickness (deep dermal) (2nd degree burn)?
- white
- may have patched of non-blanching erythema
- reduced sensation
- painful to deep pressure
BURNS
what is a full thickness (3rd degree burn)?
- white (waxy) / brown (leathery) / black in colour
- no blisters
- no pain
BURNS
when do patients require fluids?
children = >10% burns
adults = >15% burns
BURNS
how do you calculate the fluids required for burns?
parkland formula
volume = %SA burnt x weight (kg) x 4
half of fluid should be administered within first 8 hours
ADVANCED LIFE SUPPORT
when is adrenaline used?
- non-shockable rhythms = 1mg ASAP
- shockable rhythms = 1mg after 3rd shock
repeat adrenaline 1mg every 3-5 minutes
ADVANCED LIFE SUPPORT
when is amiodarone used?
- shockable rhythm: 300mg after 3 shocks
- further 150mg after 5 shocks
lidocaine can be used as alternative
ADVANCED LIFE SUPPORT
when should thrombolytic drugs be considered?
- if PE is suspected
if given, CPR should be extended for 60-90 mins
ADVANCED LIFE SUPPORT
what are the reversible causes of cardiac arrest?
Hs + Ts
- hypoxia
- Hypovolaemia
- Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
- Hypothermia
- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Tamponade - cardiac
- Toxins
ACID-BASE ABNORMALITY
what are the different causes of metabolic acidosis?
NORMAL ANION GAP
- GI bicarbonate loss (diarrhoea, ureterosigmoidstomy, fistula
- renal tubular acidosis
- drugs (acetazolamide)
- ammonium chloride injection
- addisons disease
RAISED ANION GAP
- lactate (shock, hypoxia)
- ketones (DKA, alcohol)
- urate (renal failure)
- acid poisoning (salicylates, methanol)
ACID-BASE ABNORMALITY
what are the causes of metabolic alkalosis?
usually GI/renal
- vomiting/aspiration
- diuretics
- liquorice, carbenoxolone
- hypokalaemia
- primary hyperaldosteronism
- cushings syndrome
- Bartter’s syndrome
- congenital adrenal hyperplasia
ACID-BASE ABNORMALITY
what are the causes of respiratory acidosis?
Caused by inadequate alveolar ventilation, leading to CO2 retention
- COPD
- decompensation in other respiratory conditions (life-threatening asthma/pulmonary oedema)
- sedative drugs (benzodiazepines, opiate overdose)
- GBS
ACID-BASE ABNORMALITY
what are the causes of respiratory alkalosis?
caused by excessive alveolar ventilation, resulting in more CO2 than normal being exhaled.
- anxiety leading to hyperventilation
- PE
- salicylate poisoning
- CNS disorders (stroke, SAH, encephalitis)
- altitude
- pregnancy
ACID-BASE ABNORMALITY
what are the causes of mixed respiratory and metabolic acidosis?
cardiac arrest
multi-organ failure
ACID-BASE ABNORMALITY
what are the causes of mixed respiratory and metabolic alkalosis?
- liver cirrhosis in addition to diuretic use
- hyperemesis gravidarum
- excessive ventilation in COPD
BURNS
how are circumferential burns to limbs managed?
escharotomy to divide burnt tissue to allow better blood flow + relieve compartment syndrome
FLUIDS THERAPY IN ADULTS
who requires resuscitation fluids?
- hypotension (systolic BP<100mmHg)
- NEWS <5
- oliguria (urine output <0.5ml/kg/hr)
- prolonged CRT (>2s)
- raised lactate (>2mmol/L)
- tachycardia
- tachypnoea
CARBON MONOXIDE POISONING
what are the clinical features?
- headache
- nausea + vomiting
- vertigo
- confusion
- subjective weakness
severe toxicity = ‘pink’ skin + mucosa, hyperpyrexia, arrhythmias, extrapyramidal features, coma + death
CARBON MONOXIDE POISONING
what are the investigations?
- pulse oximetry (may be falsely high)
- venous/arterial blood gas
- carboxyhaemoglobin levels
- ECG
LEAD POISONING
what are the clinical features?
- abdominal pain
- peripheral neuropathy (mainly motor)
- neuropsychiatric features
- fatigue
- constipation
- blue lines on gum margin
(consider in questions giving combination of abdominal pain + neurological signs along with acute porphyria)
LEAD POISONING
what are the investigations?
- blood lead level (>10 mcg/dL)
- FBC = microcytic anaemia
- blood film = basophilic stippling + clover leaf morphology
- raised serum + urine levels of delta aminoaevulinic acid
LEAD POISONING
what is the management?
- dimercaptosuccinic acid (DMSA)
- D-penicillamine
- EDTA
- dimercaprol
LEAD POISONING
what is the pathophysiology?
lead poisoning results in defective ferrochelatase + ALA dehydratase function
ORGANOPHOSPHATE INSECTICIDE POISONING
what are the clinical features?
SLUD
- salivation
- lacrimation
- urination
- defecation/diarrhoea
- hypotension
- bradycardia
- small pupils
- muscle fasciculation
ORGANOPHOSPHATE INSECTICIDE POISONING
what is the pathophysiology?
- inhibition of acetylcholinesterase leads to upregulation of nicotinic + muscarinic cholinergic neurotransmission
ORGANOPHOSPHATE INSECTICIDE POISONING
what is the management?
- atropine
OVERDOSE
what is the management of salicylate overdose?
ASYMPTOMATIC
- discharge if asymptomatic + no acid-base disturbance
SYMPTOMATIC
- activated charcoal if ingested within 1hr
- IV fluids
- urinary alkalinization with IV bicarbonate
- haemodialysis (if severe)
OVERDOSE
what is the management of benzodiazepine overdose?
1st line = supportive (airway management, IV fluids)
2nd line = flumazenil
majority of cases are managed supportively due to risk of seizures with flumazenil
OVERDOSE
what is the management for tricyclic antidepressant (TCA) overdose?
- activated charcoal if ingested <1hr ago
- IV sodium bicarbonate
- benzodiazepines to manage seizures/agitation (diazepam or lorazepam)
- ICU support
OVERDOSE
what is the management of heparin overdose?
protamine sulphate
OVERDOSE
what is the management of beta-blocker overdose?
1st line
- activated charcoal if ingested <1hr ago
- atropine (if symptomatic + bradycardic)
- IV fluids (0.9% NaCl + dextrose)
- IV glucagon (if severe + refractory)
- airway management
2nd line
- intralipid
- high dose insulin
- benzodiazepines
OVERDOSE
what is the management for ethylene glycol overdose?
fomepizole
OVERDOSE
what is the management for methanol poisoning?
fomepizole or ethanol
haemodialysis
OVERDOSE
what is the management of cyanide poisoning?
hydroxocobalamin
SEPSIS
what tools can be used to assess sepsis?
SOFA
qSOFA (GCS<15, increased resp rate >22, reduced systolic BP <100mmHg) score >2 indicates risk of mortality
NICE have own risk stretegy tool
SEPSIS
what is the immediate management for suspected sepsis?
SEPSIS 6 (BUFFALO)
IN
- oxygen (titrate to 94-98%)
- IV fluids (crystalloid bolus 500ml over 15 mins + reassess)
- broad-spectrum antibiotics (CO-AMOXICLAV with GENTAMICIN)
OUT
- measure lactate
- blood cultures
- urine output
OVERDOSE
what are the clinical features of lithium overdose?
SYMPTOMS
- acute confusion
- N+V
- polyuria secondary to nephrogenic DI
SIGNS
- coarse tremor
- hyperreflexia
- seizures
- reduced GCS
- ataxia
OVERDOSE
when is NAC given in paracetamol overdose?
- timed plasma paracetamol concentration on or above treatment line on normogram
- doubt over ingestion time (regardless of paracetamol concentration)
- staggered dose (all tablets not taken within 1hr)
OVERDOSE
what is the criteria for liver transplant following paracetamol overdose?
- prothrombin time >100 seconds
- creatinine >300umol/L
- grade III or IV encephalopathy
OVERDOSE
what are the clinical features of salicylate (aspirin) overdose?
SYMPTOMS
- N+V
- abdominal pain
- SOB initially
- sweating later
- tinnitus
SIGNS
- epigastric tenderness
- hyperventilation
- kussmaul breathing
- pyrexia
- severe signs (confusion, seizures, reduced GCS)
OVERDOSE
what are the investigations for salicylate (aspirin) overdose?
- salicylate levels (taken at 2hrs post-ingestion if symptomatic or 4hrs if asymptomatic)
- ABG = respiratory alkalosis followed by metabolic acidosis
- U&Es = renal failure
- LFTs + clotting
- glucose levels
- ECG
OVERDOSE
what are the clinical features of benzodiazepine overdose?
SYMPTOMS
- drowsiness (reduced GCS)
- coma
SIGNS
- ataxia
- slurred speech
- respiratory depression
OVERDOSE
what are the clinical features of TCA overdose?
SYMPTOMS
- dizziness
- dry mouth + eyes
- blurred vision
- urinary retention
- altered mental status
- seizures
SIGNS
- tachycardia
- hypotension
- mydriasis (dilated pupils)
- ataxia
- decreased bowel sounds
OVERDOSE
what are the clinical features of beta-blocker overdose?
SYMPTOMS
- dizziness
- syncope
- fatigue
- SOB
SIGNS
- bradycardia
- hypotension
- reduced GCS
- features of hypoglycaemia
OVERDOSE
what are the clinical features of iron overdose?
SYMPTOMS
- abdominal pain
- N+V
- diarrhoea
- dizziness
SIGNS
- abdominal tenderness
- haematemesis
- haematochezia
- tachycardia
- hypotension
SHOCK
what are the causes of distributive shock?
- sepsis
- anaphylaxis
- neurogenic shock (injury to CNS causing autonomic disruption)
SHOCK
what are the causes of cardiogenic shock?
- MI
- arrhythmias
- valvulopathies (e.g. acute mitral regurgitation)
- overdose of meds (e.g. beta blockers)
SHOCK
what are the causes of obstructive shock?
- pulmonary embolism
- cardiac tamponade
- tension pneumothorax
- acute superior or inferior vena cava obstruction
SHOCK
what are the clinical features?
features vary depending on cause
- cool peripheries = hypovolaemic shock
- warm peripheries = distributive shock
SIGNS
- hypotension
- tachycardia
- tachypnoea
- altered mental status (e.g. confusion)
- reduced urine output
TOXIC SHOCK SYNDROME
what is the management?
- IV antibiotics (LINEZOLID or CLINDAMYCIN) with (PENICILLIN/CEPHALOSPORIN/VANCOMYCIN)
- remove focus of infection
- IV fluid boluses
- catheterise
- correct coagulopathy or deranged glucose or electrolytes
- steroids/IVIG occasionally required
- Intensive care usually required
ANAPHYLAXIS
what is the management for children?
IM adrenaline
- <6m = 100-150 micrograms
- 6m - 6yrs = 150 micrograms
- 6-12yrs = 300 micrograms
SURGICAL SITE INFECTIONS
what are the most common causative organisms?
- orthopaedic surgery = s.aureus
- abdominal surgery = e.coli
- other = pseudomonas aeruginosa
VRIII
if VRIII is not used, what are the instructions for the following oral hypoglycaemic agents:
a. sulphonylureas (e.g. gliclazide)
b. pioglitazone
c. DPP4 inhibitors (e.g. sitagliptin)
sulphonylureas (gliclazide) = omitted on morning of surgery
pioglitazone = taken as normal on day of surgery
DPP4 inhibitors (sitagliptin) = taken as normal on day of surgery
MALIGNANT HYPERTHERMIA
what is it associated with?
gene defect on chromosome 19
it is autosomal dominant inherited
MALIGNANT HYPERTHERMIA
what are the causative agents?
- halothane
- suxamethonium
- antipsychotics (neuroleptic malignant syndrome)
MALIGNANT HYPERTHERMIA
what is the management?
dantrolene
HYPOTHERMIA
what are the potential causes?
- exposure to cold in environment
- inadequate insulation in operating room
- cardiopulmonary bypass
- newborn babies
HYPOTHERMIA
what are the risk factors?
- general anaesthetic
- substance misuse
- hypothyroidism
- impaired mental status
- homelessness
- extremes of age
AIRWAY MANAGEMENT
what are the pros and cons of laryngeal masks?
PROS
- very easy to insert
- paralysis not required
- widely used
CONS
- poor control against reflux of gastric contents
- not suitable for high pressure ventilation
AIRWAY MANAGEMENT
what are the pros and cons of tracheostomy?
PROS
- reduces work of breathing
- may be useful for slow weaning
CONS
- dries secretions so humidified air is often required
AIRWAY MANAGEMENT
what are the pros and cons of endotracheal tubes?
PROS
- provides optimal control of airway once cuff is inflated
- may be used for both short and long term ventilation
- higher ventilation pressures can be used
CONS
- errors in insertion can result in oesophageal intubation
- paralysis often required
GENERAL ANAESTHETIC
what are the adverse effects from using volatile liquid anaesthetics (isoflurane, desflurane and sevoflurane)?
- myocardial depression
- malignant hyperthermia
- halothane is hepatotoxic (not commonly used)
GENERAL ANAESTHETIC
what are the adverse effects of using nitrous oxide?
- may diffuse into gas-filled body compartments + increase pressure
- should be avoided in certain conditions e.g. pneumothorax
GENERAL ANAESTHETIC
which agents are used for intravenous anaesthetics?
- propofol
- thiopental
- etomidate
- ketamine
GENERAL ANAESTHETIC
what are the adverse effects of propofol?
- pain on injection (due to activation of pain receptor TRPA1)
- hypotension
GENERAL ANAESTHETIC
what are the adverse effects of thiopental?
laryngospasm
GENERAL ANAESTHETIC
when is etomidate used?
causes less hypotension than propofol + thiopental so used in cases of haemodynamic instability
GENERAL ANAESTHETIC
what are the adverse effects of etomidate?
primary adrenal suppression
myoclonus
GENERAL ANAESTHETIC
what are the adverse effects of ketamine?
- disorientation
- hallucinations
ASA CLASSIFICATION
what is ASA 1?
a normal healthy patient
non-smoking
no/minimal alcohol use
ASA CLASSIFICATION
what is ASA II?
- a patient with mild systemic disease
- without substantial functional limitations
examples:
- current smoker
- social alcohol drinker
- obesity (BMI 30-40)
- well-controlled DM/HTN
- mild lung disease
ASA CLASSIFICATION
what is ASA III?
- a patient with severe systemic disease
- substantive functional limitations
- one or more moderate to severe diseases
examples
- poorly controlled DM/HTN
- COPD
- morbid obesity (BMI>40)
- active hepatitis
- alcohol dependence/abuse
- implanted pacemaker
- moderate reduction of ejection fraction
- end stage renal disease (undergoing regular dialysis)
- history >3 months of MI
- cerebrovascular accidents
ASA CLASSIFICATION
what is ASA IV?
- patient with severe systemic disease that is a constant threat to life
examples
- recent (<3months) MI
- cerebrovascular accidents
- ongoing cardiac ischaemia or severe valve dysfunction
- severe reduction in ejection fraction
- sepsis
- DIC
- ARD
- end stage renal disease (not undergoing regular dialysis)
ASA CLASSIFICATION
what is ASA V?
- moribund patient not expected to survive without the operation
examples
- ruptured abdominal/thoracic aneurysm
- massive trauma
- intra-cranial bleed with mass effect
- ischaemic bowel (with cardiac pathology or multiple organ dysfunction)
ASA CLASSIFICATION
what is ASA VI?
a patient declared brain dead whose organs are being removed for donation
EPIDURAL ANAESTHESIA
where is the anaesthesia injected?
into the epidural space around L3-4 or L4-5 vertebrae
