1st September [30th-5th] Flashcards
Differentials for chest pain
- hearstburn - chest sprain - shingles - chest infection like pneumonia - pericarditis - angina - MI - hypertrophic cardiomyopathy - pulmonary embolism - pneuothorax - asthma - COPD - oesophageal contaction disorder - epetic ulcers - pancreatiti
Causes of pancreatitis
Idiopathic Gallstones Ethanol Trauma Steroids Mumps/malignancy Autoimmune Scorpion sting Hypertriglycaemia/hypercalcaemia ERCP Drugs
Chest wall tenderness causes
- MSK problems [most common] o Injury/trauma o Costochondritis o Tietze’s syndrome o Muscle strain o Rib fracture o Nerve entrapment o Fibromyalgia o Rheumatic diseases like RA
Which tool can be used to asses risk of someone having an acute cardiac event?
History suspicious [/2] ECG [/2] Age [<65 then /2] RF [3+ then 2] Troponin [over x3 normal limit then 2] score
initial tests for MI
- FBC, U&E, glucose, HsTnT
9) Which cardiac enzyme assay is currently in use in your hospital? What is the practical difference between CK, CK-MB, Troponins and hs-Tropinins?
- Two types of troponins measured in blood: T and I - Before troponins, heart muscle damage looked at by CK-MB, now outdated - Troponin released with heart muscle damage - Can take 3-12 hrs for troponin to increase in blood after cardiac damage, will peak around 24-48 hours, damage proportional to level of troponin - Both high diagnostic accuracy I and T, I superior early presenters, T in late presenters, prognostic accuracy for all-cause mortality higher in TnT - Hs-Trop have been developed in an effort to improve detection of an MI -> can detect much lower concentrations
How long does it take for troponin to peak in the blood?
- Can take 3-12 hrs for troponin to increase in blood after cardiac damage, will peak around 24-48 hours, damage proportional to level of troponin
Is it possible to have an ECG normal in an MI?
Yes, because of a NSTEMI
Initial pain relieving drugs to give during an MI? What else should be given?
- GTN and morphine, possibly paracetamol - Can be given oxygen
Where would an anterior MI show on an ECG?
V1-V6 ST elevation, with no ST depression. LAD artery. Think minaly V3-4 in anterior.
ECG changes of an MI?
ECG changes MI [within 12 hours] 1. ST elevation in more than one consecutive leads 2. Elevation: more 2mm chest leads, more than 1mm in limb leads
What procedure does a person with an MI need?
- Coronary angioplasty [or PCI] can be done within a few hours of symptoms starting -> Primary Percutaneous Coronary Intervention
How quickly should a PCI be done?
- The 2006 Occluded Artery Trial [OAT] determined that performing angioplasty delivered no tangible benefit to people who’d had a heart attack more than 24 hours earlier and who no longer had symptoms
How does PI work?
- Opens up a narrowed artery around the heart - Surgeon inserts tube into an artery in the groin/wrist -> insert tube into affected artery -> insert balloon or stent to open artery
Which Tx should be given if procedure unavailable?
- Injection of clot-busting medicine -> given easily and quickly [thrombolise him] - Done for conditions which involve blocked arteries: stroke, PE, DVT, acute arterial thrombus in leg, blocked surgical bypasses [blocked dialysis fistulas or catheters]
Name three thrombolytic drugs
- Four thrombolytic drugs currently available in the UK o Altepase o Reteplase o Streptokinase o Tenecteplase
CI for those thrombolytic drugs
Besides risk of serious internal bleeding, other possible risks include: • Bruising or bleeding at the access site • Damage to the blood vessel • Migration of the blood clot to another part of vascular system • Kidney damage in patients with diabetes or other pre-existing kidney disease
Which patients would thrombolysis not be recommended for?
Thrombolysis may not be recommended for patients who use blood-thinning medication, herbs, or dietary supplements, or for people with certain conditions associated with an increased risk of bleeding. These conditions include: • Severe high blood pressure • Active bleeding or severe blood loss • Hemorrhagic stroke from bleeding in the brain • Severe kidney disease • Recent surgery
What other drugs should be considered during emergency Tx of ACS
Holy trinity 1. Aspirin 300mg 2. Dalteparin 3. Ticagrelor 180mg
What key information do you need with paracetamol poinsoinng?
- What time did they take the poisonous substance? - How much of the poisonous substance did they take? - Medicine in tablet/caplet/liquid/soluble form - Whether they had alcohol or not - Have they had any symptoms? How long have these been present? - What else have they taken since having the poison? - Precipitating reason for taking OD. Any suicide risk, such as whether a note was written. - Any DA? - Above 150mg/kg then toxic - Anything over 250mg can be fatal
Which organ primarily site of paracetamol toxicity?
- Liver is the principal organ affected - Brain scan also be affected with confusion and disorientation [encephalopathy] - Also, kidneys can be affected with reduction in urine, and kidney failure can occur
What is the toxic metabolite created by the ingestion of paracetamol?
N-acetyl-p-benzoquinone imine [NAPQI]
Where is it formed NAPQI?
In the liver by cytochrome P450 2E1
What does the increased amount of NAPQI cause?
The small amounts of NAPQI produced after therapeutic doses are detoxified by irreversible glutathione-dependent conjugation reactions to two non-toxic metabolites.
How does NAC work?
Hence NAC works as a glutathione donor preventing NAPQI accumulation
RFs for low glutathione
anorexics, alcoholics, P450 inducing drugs so paracetamol overdose
What Ix should all patients recieeve with paracetamol OD?
- Serum paracetamol concentration - ALT/AST - Coagulation and INR
Which other Ix do they also require?
- VBG [pH and lactate] - EUC - Glucose - Coagulation - Calcium/magnesium/phosphate
Why are paracetamol levels taken 4 hours post ingestion?
The paracetamol nomogram is used to plot paracetamol concentration against time from ingestion. If the paracetamol concentration lies on or above the treatment line, NAC should be administered. This is used for patients who have ingested paracetamol over one hour or less and presented within 8 hours. As the plasma paracetamol concentration reaches its peak at 4 hours, it is important not to take a paracetamol level within 4 hours of the last ingestion. Patients who have a delayed presentation, or where the paracetamol level will not be available within 8 hours from last ingestion, NAC is started whilst awaiting investigations. Paracetamol levels can be interpreted up to 24 hours, but any detectable level of paracetamol beyond 16 hours is concerning.
When would give charcoal?
<2 hours post ingestion
2-8 hours post ingestion give what for patient?
Measure serum paracetamol concentration and ALT then plot nomongram and a treat if above line
If over 8 hours of staggered dosing Tx?
Start NAC
Which scoring system can be used to detect risk of further harm of the patient?
Sex Age Depressed Previous suicide attempts Excessive salcohol use Rational thiking loss Single Organised attempt No social support Stated future intent score: - 0-5 then may be safe to discahrge - 6-8 probab;y requires psychiatric consultation - 8+ probabaly requires hospital admission
What should all OD patients have?
Seen by mentla health practitioners
patient flushed and vomited after NAC, what’s happened?
- Anaphylactoid reactions occur anywhere between 10-50% and are more likely to occur in patients with lower paracetamol ingestions (NAPQI appears to be protective). Typically, this reaction occurs after the first bag of NAC.
What to do if patient has anaphylactoid reaction to NAC?
o Stop the infusion o Treat with loratadine 10mg (2.5mg <12kg, 5mg <30kg) PO or promethazine 12.5 mg IV (0.25mg/kg) o The NAC can then be recommenced once symptoms settle at half rate for 30 minutes and then recommenced as per normal protocol.
What is maximum daily dose of paracetamol?
4g
DDx for a PE
- Pulmonary embolism - Infection: viral [most commonly], bacterial [pneumonia or TB] - Injury or trauma [causing a fracture/bruising] - Lung Ca near the pleural surface [with smoking 20 a day] - Autoimmune disorder like RA or lupus - Pneumothorax - Pleural effusion - Pericarditis - Heart problem - GORD - Anxiety - Costochondritis
Sx of a pleural effusion
Shortness of breath Dry cough Pain Feeling of chest heaviness or tightness Inability to lie flat Inability to exercise Generally feeling unwell
Most common cause of pleural effusion?
The most common causes of transudative (watery fluid) pleural effusions include: Heart failure. Pulmonary embolism. Cirrhosis
What is normal pleural fluid?
Typical findings of normal pleural fluid are as follows: Appearance: clear pH: 7.60-7.64 Protein: < 2% (1-2 g/dL) White blood cells (WBC): < 1000/mm³ Glucose: similar to that of plasma LDH: <50% plasma concentration Amylase: 30-110 U/L Triglycerides: <2 mmol/l Cholesterol: 3.5–6.5 mmol/l
What are transudative pleural effusions?
Transudative pleural effusions are defined as effusions that are caused by factors that alter hydrostatic pressure, pleural permeability, and oncotic pressure.
Conditions associated with transudative pleural effusions?
Conditions associated with transudative pleural effusions include: Congestive heart failure Liver cirrhosis Severe hypoalbuminemia Nephrotic syndrome
What are exudative pleural effusions?
Exudative pleural effusions are caused by changes to the local factors that influence the formation and absorption of pleural fluid.
Conditions associated with exudative pleural effusions
Conditions associated with exudative pleural effusions include: Malignancy Infection (e.g. empyema due to bacterial pneumonia) Trauma Pulmonary infarction Pulmonary embolism
Diagnostic criteria for pleural effusions
Diagnostic criteria for pleural effusion Transudate Protein <30 g/L (in patients with a normal serum protein level) Exudate Protein >30 g/L (in patients with a normal serum protein level)
Which level of amylase indicates pancreatitis?
think it’s above 200U/l