VIVA Flashcards
PV Bleed + abdominal pain —- approach + Tx of ectopic pregnancy
approach
impression —- DDx
ectopic pregnancy
miscarriage
menorrhagia
acute abdomen
gynae malignancy
resus ABCDEs
focused Hx
symptoms:
abdo pain — SOCRATES
PV bleed — vol, assoc symptoms
r/o symptoms of ectopic rupture: sudden onset lower abdo pain/shoulder tip pain, rectal pressure, fainting, PV bleeding
gynae
last menstrual period
usually get menorrhagia? — whats diff this time
kardex
anticoagulants
COCP — compliance?
physical exam:
signs of rupture:
vitals: hypotension
abdo distension
rebound tenderness
bimanual exam: cervical motion or adnexal tenderness
Ensure bleeding is truly PV
Ix
bedside: beta hCG
bloods: FBC, U&E, grp & hold 2 units, coag profile
abdo or transvaginal US — findings:
homogenous adnexal mass separate from ovary
empty extra-uterine gestational sac
foetal pole
free fluid
pseudosac
diagnostic laparoscopy
Tx of ectopic pregnancy
conservative = rare
impt to safety net for red flags — severe abdo pain, PV bleeding
monitor until hCG <15
medical Tx = methotrexate 50 mg/m2 single IM dose
indication: small + low hCG + no complications
monitor hCG day 4 & 7 — until hCG <15
if needed = give 2nd dose
surgical Tx = laparoscopy w salpingectomy or salpingostomy
post-op = give anti-D
counsel patient
ToDo:
stop smoking
attend EPAU (early pregnancy assessment unit) at 6-8 wks in future pregnancies — to confirm intrauterine pregnancy
prognosis
7-10% recurrence rate
65% will achieve successful pregnancy within 18 months of an ectopic
female + reproductive age + acute LIF pain — approach + Tx of ovarian cyst
approach
impression
acute abdomen — appendicitis, diverticulitis, bowel obstruction
ectopic pregnancy
ovarian cyst +/- rupture
resus ABCDEs
focused Hx
symptoms:
pain — SOCRATES
precipitant: physical activity, sexual intercourse
symptoms of rupture
pre-rupture = intermittent unilateral abdo pain
post-rupture = severe unilateral abdo pain
gynae
last menstrual period
sexually active
DDx cause
physical exam
signs of rupture
vitals — hypotension
abdo distension
rebound tenderness
bimanual exam: cervical motion or adnexal tenderness
Ix
bedside: beta hCG
bloods: FBC, U&E, coag profile, grp & hold 2 units, CA125
trans-abdominal or transvaginal US
calculate RMI risk of malignancy index
Tx of ovarian cyst
no rupture = conservative — analgesia, antiemetic
rupture = laparoscopy — cystectomy or salpingo-oophorectomy
28 wks gestation pregnant woman + headache + blurred vision + epigastric pain —- approach + Tx of severe pre-eclampsia vs eclampsia
approach
impression
severe pre-eclampsia or imminent eclampsia
migraine
cortical venous thrombosis
resus ABCDEs
focused Hx
symptoms — signs of imminent eclampsia
headache
aura
visual disturbance
epigastric pain
hyperreflexia/clonus
vomiting
DDx
migraines
pre-eclampsia
official diagnosed
how well controlled
usual BP + when was last visit
cortical venous thrombosis
kardex
meds for pre-eclampsia
physical exam
maternal
neuro — hyperreflexia/clonus
foetal
wellbeing – HR, movements
Ix
vitals – BP >140/90
bloods: U&E
r/o HELLP — FBC, LFTs, LDH
US foetus
CTG
Tx
severe pre-eclampsia:
admit to HDU
lower HTN carefully — IV labetalol + hydralazine
fluid restriction
LMWH
monitor regularly: vitals, physical exam, U/O, continuous CTG
if still uncontrolled = primary prevention of eclampsia: MgSO4 4g loading dose + 1g per hr IV infusion
continue up to 24 hrs post delivery
if 24-34 wks gestation = dexamethasone
arrange for delivery
eclampsia:
resus ABCDEs
suction any foam or secretions
dont attempt to insert airway when actively seizing
position: left lateral
seizure control + secondary prevention = 4g loading dose + 2g per hr IV infusion
NOT diazepam or phenytoin!!!
continue for up to 24 hrs post delivery
HTN: IV labetalol + hydralazine
fluid restriction
LMWH
stabilise for delivery
if 24-34 wks gestation = dexamethasone
post-delivery:
monitor BP acutely + for the next 2 months (shld normalise)
monitor for seizures – esp 1st 24 hrs
continue antihypertensives
counsel for future pregnancies
ToDo
stop smoking
target CVS risk factors
daily low dose 75mg aspirin OD from 12 wks gestation
PPH post partum haemorrhage — approach + Tx
approach
impression = PPH
resus ABCDEs + IMEWS
insert 2 wide bore 14-16G IV Cannulas
500ml warmed normal saline over 10-15 mins
activate massive transfusion protocol if needed
insert foley catheter to decompress bladder
Call for senior help
focused Hx
symptoms
quantity of blood loss
time of delivery —- ie pri vs sec
pri = within 24 hrs of delivery
sec = 24 hrs to 6 wks
Has placenta been delivered
DDx cause — 4 Ts
tone
tissue
trauma
thrombus
physical exam
Ix
bloods: FBC, U&E, Coag profile, GXM 4 units
Tx
prevention
oxytocin during the 3rd stage of labour
careful delivery of placenta
PPH triangle — scribe
monitoring — vitals, ECG, U/O
resuscitation team
Tx — acc to cause
Tx of uterine atony
medical
ergometrine
prostaglandin F2 alpha
misoprostol
tranexamic acid
oxytocin
surgical — if medical fails
bimanual massage
balloon tamponade
B lynch suture
uterine A ligation
hysterectomy
Tx of retained products of conception
if placenta has separated from uterine wall = controlled cord traction
if placenta hasnt separated from uterine wall = manual removal
if small section or lobe of placenta left behind = ERPC evacuation of retained products of conception
post-acute phase
debrief family & team
monitor for complications
pregnant woman + IMEWS >2 — ?obstetric sepsis — approach + Tx
approach
impression = obstetric sepsis
resus ABCDEs
call for senior help
focused Hx
symptoms:
tender abdomen
respi symptoms: SOB, chest pain
pregnancy:
preterm or at term
any recent interventions — cerclage, amniocentesis
physical exam:
abdo: tenderness
vaginal: offensive vaginal discharge
respi: crepitations
Ix
bedside: urine dipstick
bloods: FBC, U&E, C&S
if ? UTI = MSU
if ?PID = high vaginal swab + cervical swab + 1st void urine
sepsis 6
take 3
bloods
blood C&S
insert urinary catheter — monitor U/O
give 3
supplementary O2
IV fluids
empirical Abx: gentamicin (1 dose immediately) + cefotaxime + metronidazole
+1 = CTG — assess foetal wellbeing
monitor patient
if severe = xfer to HDU/ICU + change empirical Abx
monitor for signs of maternal end organ dysfunction
If CTG non-reassuring = consider antenatal steriods + emergency caesarean section
maternal cardiac arrest —- approach + Tx
impression = maternal cardiac arrest
check for response
no response = call for help — crash cart, AED, call for obstetric resuscitation team, if >22 wks = call neonatal team
commence CPR
position: wedge under spine or manual left displacement of uterus
CPR compressions higher on sternum
once help arrives
connect AED machine to patient
insert 2 wide bore IV cannulas
supplementary O2 (15L O2 via non-rebreather mask) + head tilt & chin lift —- consider intubation if experienced anaesthetist present
if shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia) = provide shock
ensure foetal monitoring detached prior to shocking
give adrenaline 1mg 1:10000 ASAP — rhythm check every 2 mins, adrenaline every 4 mins
after 4 mins of effective attempt to resus + mother still unresponsive = emergency delivery or perimortem caesarean section
sick child — approach + Tx
impression = sick child
impt to detect red flags — children compensate well v.initially but decompensate v.rapidly
resus — paediatric ABCDES
circulation — cap refill time of sternum
focused Hx
symptoms
DDx cause
physical exam = paediatric assessment triangle
general appearance:
abnormal tone
reduced interactiveness
reduced consolability
abnormal look or gaze
abnormal speech or cry
work of breathing:
abnormal sounds
abnormal position
retraction
nasal flaring
apnoea or gasping
circulation to skin:
pallor
mottling
cyanosis
impt to r/o pre-terminal signs — ECHOS
E: exhaustion
C: central cyanosis
H: hypotension
O: O2 sat <85% on RA
S: silent chest
also consult the NICE guidelines traffic light system — ensure no serious illness present
if need be = consult WETFLAG algorithm for emergency calculations in paediatrics
acute onset chest pain + palpitations —- approach + Tx of afib
approach
impression
arrhythmia
MI
PE
resus ABCDEs
check vitals, GCS, blood sugar levels
focused Hx
HOPC:
palpitations
syncope/pre-syncope
reduced exercise capacity
SOB
chest pain
peripheral oedema, orthopnoea, PND
DDx causes — ARITHMETIC
A: alcogol
R: rheumatic heart disease
I: ischaemia — MI
T: thyrotoxicosis
H: HTN
M: mitral valve disease
E: endocarditis
T: toxins — cocaine, steroids
I: infections
C: cardiomyopathy
kardex
anticoagulation
notes: check old ECGs for comparison
physical exam
irregularly irregular pulse or no palpable pulse
signs of HF: raised JVP, parasternal heave, peripheral cyanosis
murmurs
Ix
bedside = ECG —- findings
irregularly irregular pulse
absent p waves
narrow QRS complex
absent isoelectric baseline
variable ventricular rate
bloods: FBC, U&E, d-dimers, troponins, TFTs, BNP
imaging: CXR, ECHO
Tx of afib
conservative Tx
stop smoking
reduced alcohol intake
lifestyle: increased exercise, reduced fat & salt in diet, maintain healthy BMI
strict glycaemic control if DM
acute Tx
rhythm control
if unstable = emergent DC conversion
if stable
afib onset <48 hrs = give heparin then cardiovert — either DC or medical cardioversion
afib onset >48 hrs = give anticoagulation for at least 3 wks before cardioverting
or: do TOE to r/o left atrial appendage thrombus — then heparin and cardiovert
medical cardioversion — acc to amt of structural damage to heart
mild: oral flecainide
moderate: IV flecainide
severe: IV amiodarone
rate control — until successful cardioversion
beta blockers —- initially metoprolol, then longer acting bisoprolol/nebivolol
non-dihydropyridine CCB — diltiazem or verapamil
anticoagulation
if new onset <48 hrs + cardioverted = acc to CHA2DS2Vasc
if new onset >48 hrs = 3 wks before cardioversion + at least 4 wks post cardioversion
drug choice
non-valvular afib = DOAC
valvular afib = warfarin
long term
CVS risk factors
hyperlipidaemia
CHA2DS2-Vasc score
criteria
CHF — 1
HTN – 1
Age 65-74 — 1; >75 y/o — 2
DM – 1
Sex female — 1
stroke/TIA — 2
Vascular disease —- 1
anaphylaxis — definition + approach & Tx
anaphylaxis: sudden, rapidly progressive, systemic type I hypersensitivity reaction — that is potentially life-threatening due to airway compromise & hypotension
approach & Tx
resus ABCDEs
airway = early endotracheal intubation
breathing = 15L O2 via non-rebreather mask
if respi distress persists + adrenaline has been administered = 5mg salbutamol nebulised
circulation = 500ml bolus normal saline if hypotensive
assess severity
mild: urticaria +/- angioedema (swelling around face, etc)
moderate: above + bronchospasm
severe: above + respi or haemodynamic compromise
adrenaline 0.5mg 1:1000 —- ie 0.5ml
inject into anterolateral aspect of the middle 1/3 of thigh
repeat dose every 5-15 mins if life-threatening symptoms remain
after 2 IM doses = IV adrenaline attempted by specialist
+/- antihistamines (chlorphenamine 10mg IV)
+/- steroids (125mg IV methylprednisolone)
only if severe
monitor for 6-12 hrs post-onset
bi-phasic rxns can occur in up to 20%
amend allergies box in kardex
follow up
detailed Hx of allergies & triggers
refer for allergen testing
safety net for discharge
adrenaline autoinjector
emergency action plan
avoid triggers
ED: fever + photophobia + neck stiffness — approach + Tx of meningitis
approach
impression = CNS infection (meningitis, encephalitis)
or migraine
resus ABCDEs
focused hx + potentially collateral Hx
symptoms:
classic triad of meningitis = fever + neck stiffness + AMS
signs of meningism = photophobia
N&V
focal neuro deficits
seizures
reduced GCS
close contacts — similar symptoms
vaccinations — esp Hib, Men B/C
physical exam
kernig’s sign
brudzinski’s sign
focal neuro signs
Ix
vitals
bloods: FBC, CRP, coag profile, U&E, glucose, C&S, viral PCR
LP — ensure no raised ICP + no decreased in consciousness!!
if not = MUST CT brain before LP
+/- CT Brain
Tx
empirical Abx —- acc to local hospital guidelines
duration: at least 7 days
VACA
vancomycin
+/- ampicillin (if ?listeria)
cefotaxime/ceftriaxone
+/- aciclovir (if ?HSV)
if GP setting = benzylpenicillin before xfer to hospital
IV dexamethasone BEFORE or w 1st dose of Abx
CONSULT SENIOR
benefit: reduced risk of neuro complications
withhold if: septic shock, meningococcal septicaemia, IC, meningitis post surgery
prophlaxis for all household members = ciprofloxacin or rifampicin
follow up for bacterial meningitis = hearing test
prevention = vaccination against HiB, Men B & C
What are the S&S of raised ICP
symptoms
early morning headache
vomiting w/o nausea
altered consciousness
signs
Cushing’s triad
bradycardia
HTN w widening pulse P
irregular breathing — Cheyne-Stokes respirations
CN palsies
papilloedema
if child
tense/bulging fontanelle
setting sun sign
macrocephaly
what if blood in LP —– traumatic tap vs SAH
traumatic tap = 20% of LPs
r/o w “three tube test” — compare RBC in 1st & last tubes
sig less blood in 3rd than 1st = traumatic tap likely
also test for xanthochromia to r/o SAH
acute asthma attack —– approach + Tx
impression = acute asthma attack
DDx = pneumonia, pneumothorax, pulmonary oedema
resus ABCDEs
focused Hx
symptoms
features of life-threatening asthma attack
unable to speak
confused
cyanotic
poor respi effort
silent chest
SpO2 <92%
PaO2 <8 kPa
PEFR <33% predicted!!!
hypotension
bradyarrhythmia
any Hx of severe asthma attack —- since warrants admission even in absence of life-threatening features
Ix
bedside: ABG + lactate — ? respi failure
normal or raised PaCO2 = xfer to HDU/ICU
bloods: FBC, U&R, CRP, C&S
sputum C&S
PEFR
Tx
indications for hospital admission
life-threatening asthma attack
severe asthma + failure to respond to Tx
moderate asthma + pregnant or Hx of severe asthma attack
high dose (5mg) nebulised salbutamol (SABA)
repeat at 15 min intervals for 45 mins
if no improvement = repeat every 1-4 hrs
if no improvement = continuous nebuliser
if unresponsive = add ipratropium bromide 0.5mg (SAMA)
PO/IV systemic steroids —- PO prednisolone 40mg OD
if cant PO = IV hydrocortisone 100mg QDS + change to PO ASAP
duration: 5 days
consider escalating if not improving
xfer to ICU
NIV — BiPAP
IV MgSO4
IV aminophylline
IV salbutamol
other considerations
infectious cause = empirical Abx
hypoK sec to excessive salbutamol = IV fluids + KCl
criteria for discharge
stable on discharge meds (nebs or O2 discontinued) for 12-24 hrs
inhaler technique checked + recorded
emergency action plan written
PEFR >75% of best or predicted
suspected poisoning — approach + Tx
resus ABCDEs
check vitals + glucose + GCS
airway: head tilt + chin lift +/- oropharyngeal airway
if need be + expertise available = endotracheal intubation
breathing: supplementary O2 —- 4L via nasal prongs
if need = escalate to 15L via non-rebreather mask
if still cmi = call anaesthesia or ICU
circulation: insert 2 wide bore 14-16G IV Cannulas
call for senior help
focused Hx +/- collateral Hx
what did they take + when + how much
any symptoms/problems so far
physical exam
decreased LOC
opioid toxicity = pin point pupils + repsi depression –> arrest
CALL TOXBASE!!!
Ix
bloods
serum tox screen
paracetamol levels
LFTs
U&Es
+/- CT Brain —- if ? head injury
reduce absorption within 1 hr — by
activated charcoal
gastric lavage —- usually caustic/acidic contents
whole bowel irrigation — if lithium/iron
increased elimination by IV fluids +
if paracetamol at 4 hrs is over the Tx line on nomogram OR if <60 kg OR staggered OD = NAC N-acetylcysteine
if opioids OD + slowing of breathing or low GCS = naloxone 400 micrograms IM + repeat PRN
if BZD OD = flumazenil
psychiatric referral
attempted suicide or self harm — approach
what happened
details of event
method — if meds = what dose + where did you get them + do you still have any
where, when, alone
planned or impulsive
perceived lethality
precipitant? why then?
substance use
final acts
efforts to avoid discovery
actions after the act —- ie how did they end up in hospital
what did they think would happen
what led up to the episode?
risk assessment
current feelings — thoughts, plan, intent
prev attempts or self harm
stressors
psych Hx
screen for other mental illness — depression, EUPD, psychosis, substance use, postnatal depression
harm to others/dependents
screening for medical comorbidities
long term planning
refer to community mental health services
refer to voluntary counselling or support services
depending on severity
admit patient
arrange for follow up soon post-discharge
COPD exacerbation — approach + Tx
approach
impression = COPD exacerbation
DDx = pneumonia, pneumothorax, etc
resus ABCDs
supplementary O2 — 4L via nasal prongs or 10L via non-rebreather mask
titrate to SpO2 88-92% —- risk of respi depression if over-oxygenated
if not improving = BiPAP
2 wide bore 14-16G IV Cannulas + resus fluids
focused Hx
features of life-threatening acute respi failure
RR >24
use of accessory muscles
acute changes in mental state hypoxaemia not improving with supplemental O2
hypercarbnia or acidosis
Ix
bedside: ABG + lactate, ECG
bloods: FBC, U&E, C&S
sputum C&S
PEFR
CXR
monitoring
serial ABG — pH & PaCO2 normalise
SpO2
Tx of acute COPD exacerbation
nebulised SABA + SAMA — salbutamol 5mg + ipratropium bromide 0.5mg (combivent)
PO prednisolone 30mg for 5 days
if ?bacterial infection = empirical Abx acc to local hospital guidelines
1st line = amoxicillin/clarithromycin/doxycycline
if v.severe or failure to improve = co-amoxiclav
chest physiotherapy — expectorate sputum
others
monitor fluid balance
VTE prophylaxis
check if xfer to HDU/ICU required
criteria for discharge
S&S resolved
meds reviewed + optimised
inhaler technique assessed
exacerbation treated
on call: nurse calls you + patient has poor urinary output — approach + Tx of AKI
approach
impression = AKI or urinary retention or UTI
ask on the nurse
trend — sudden (eg. blockage) vs gradual (eg. hypovolaemia, UTI)
vitals
resus
circulation — if hypovolaemic = fluid bolus 250ml normal saline over 15 mins
call for senior help
focused hx
symptoms
trend – sudden vs gradual
fluid balance chart
+ve balance?
adequate intake?
DDx causes of AKI (will type below )
grade severity acc to KDIGO classification
mild = serum Cr 1.5-1.9x baseline or U/O <0.5ml/kg/hr for 6-12 hrs
moderate = serum Cr 2-2.9x baseline or U/O <0.5 ml/kg/hr for >12 hrs
severe = serum Cr >3.0x baseline or U/O <0.3 ml/kg/hr for >24 hrs or RRT required
physical exam
heart, abdo, renal
r/o urinary retention — ?palpable bladder, pulmonary oedema
Ix
bedside: VBG + electrolytes, ECG (since K+ abnormal), urine dipstick
bloods: FBC, U&E
BUN/Cr >20 = pre-renal; <15 = renal
urea x 10 > Cr = pre-renal
imaging: CXR, renal US
Tx of AKI
assess need for emergency dialysis — AEIOU
(impt coz takes a few hrs to prepare)
A: acidosis (pH <7.1)
E: electrolyte imbalance (K+ >7 or refractory hyperK + ECG changes)
I: intoxication (ethylene glycol, lithium)
O: overload (severe pulmonary oedema w oliguria or diuretic R)
U: uraemic complicatons (pericarditis or encephalopathy)
4 Ms
monitor: fluid balance, BP, U/O, K+, Cr, lactate
BP esp impt for pre-renal AKI
maintain euvolaemia
pre-renal = fluid challenge +/- maintenance fluids if needed
renal = stop fluids + Tx pulmonary oedema
minimise kidney injury — hold nephrotoxins where possible
manage acute illness
long term = prevention of AKI
adequate hydration
if vascular cause = target CVS risk factors
avoid nephrotoxins where possible
appropriate prescribing for age, weight & renal function
DDx causes of AKI
pre-renal
reduced perfusion – ie shock
cardiogenic
septic
hypovolaemic
neurogenic
anaphylactic
renal vasoconstriction
NSAIDs, ACEI/ARBs
renal A stenosis
hepatorenal syndrome
renal
ATN acute tubular necrosis
acute interstitial nephritis
glomerulonephritis
rhabdomyolysis
tumour lysis syndrome
drugs — Abx (gentamicin), contrast
post-renal
BPH
kidney stones
blocked/malsited catheter
malignancy
strictures – sec to trauma (cystoscopy)
voiding dysfunction — spina bifida, atonic bladder, cauda equina syndrome
