ACC Flashcards
1
Q
anyones who’s critially ill
A
15L oxygen in non-rebreathe mask
2
Q
what does the TIMI score do
A
Assesses the risk of mortality in patients with unstable angina or NSTEMI
3
Q
management of all pt with chest pain suspected to be cardiac
A
Morphine - Oxygen – 15L non-re-breathable mask, aim for 94-98% (88-92% in COPD patients) Nitrates (GTN spray) Aspirin (300mg PO) Ticagrelor 180mg PO
4
Q
for STEMI Mx
A
Ring PRIMARY PERCUTANEOUS INTERVENTION
If PCI is unsuccessful or cannot be performed (> 120 mins after STEMI); thrombolysis can be performed
Once a STEMI has been confirmed the first step is to immediately assess eligibility for coronary reperfusion therapy. There are two types of coronary reperfusion therapy: PCI or thrombolysis
5
Q
Patients undergoing PCI should also receive
A
either an unfractioned heparin or LMWH (such as enoxaparin) as further anticoagulation.
6
Q
If PCI cannot be performed, what can be administered with the thrombolytic drug.
A
LMWH, unfractioned heparin or fondaparinux
7
Q
Non-stable angina/NSTEM Mx
A
Offer fondaparinux to patients who do not have a high bleeding risk, unless coronary angiography is planned within 24 hours of admission
Offer unfractionated heparin as an alternative to fondaparinux to patients who are likely to undergo coronary angiography within 24 hours of admission
8
Q
2d prevention of STEMI / NSTEMI
A
B blocker ACE inhibitor Aspirin – 75mg PO daily Statin e.g. Atorvastatin Clopidogrel/ticagrelor
9
Q
ACS SUMMARY:
A
ECG & CXR
If ACS confirmed: aspirin 300mg, ticagrelor 180mg and analgesia
If STEMI: PPCI + LMWH
If NSTEMI/unstable angina: calculate risk score (e.g. TIMI/HEART’GRACE)
If not for PCI in 24 hours, give fondaparinux
Secondary prevention: atorvastatin 80mg PO, aspirin 75mg PO, clopidogrel 75mg, ACEi, B blocker
10
Q
stable angina Mx - short term
A
Sublingual glyceryl trinitrate (GTN spray) - works by vasodilation
call an emergency ambulance if the pain has not gone 5 minutes after taking a second dose
11
Q
long term Mx stable angina
A
Consider aspirin 75 mg daily for people with stable angina
Consider angiotensin-converting enzyme (ACE) inhibitors for people with stable angina and diabetes
offer statin
12
Q
PE acute Mx
A
A to E;
(Oxygen 15L, monitor RR and pulse oximetry
Obtain IV access, monitor BP, HR, take ABG and bloods
Assess circulation: suspect massive PE if systolic BP is <90 mm Hg or there is a fall of 40 mm Hg, for 15 minutes
Give analgesia if necessary (e.g. morphine)
heparin or fondaparinux
13
Q
long ter Mx following OE
A
avoid dehyndartion encourage mobilisation aspirin /antiplatelet therapy compression stockings warfarin / rivaroxaban continue LMWH is malignant or pregnent
14
Q
massive PE Mx
A
Thrombolysis e.g. alteplase
Thrombolysis is only used for massive PE where there are signs/risk of cardiac arrest. Not used routinely for all PEs because 4% risk of intracranial haemorrhage.
15
Q
MSK chest pain - rib fracture Mx
A
Check for features which are suggestive of pneumothorax - if there are any CXR
Warn patient that rib may remain painful for >3 weeks and to seek medical advice if additional symptoms develop
Prescribe oral analgesia e.g. co-codamol
16
Q
MSK chest pain - costochondiasis Mx
A
Causes unknown, but are associated with URTI and excessive coughing
Assessment: ECG and CXR to exclude other diagnoses
Management: usually resolves within a few months, advise NSAIDs and paracetamol, consider physiotherapy
17
Q
fibromyalgia Mx
A
CBT
physiotherapy
pain Mx
18
Q
Aortic Dissection Mx
A
Initial assessment – high flow oxygen and IV access (2 large bore cannulas); fluid resuscitation should be done cautiously
Adequate analgesia – e.g. morphine
Refer to Cardiac-Thoracic surgeons and transfer to an intensive care unit or high dependency unit
Reduce stress on aorta by managing HTN aggressively – IV beta blockers e.g. labetalol - aim for systolic pressure of 100-120 mm Hg
19
Q
pericarditis (with effusion, and with tamponade) initial management - treat underlying cause
A
e.g. bacterial infection: blood cultures, empirical antibiotics – IV flucloxacillin and gentamicin/cefotaxime
20
Q
symptom relief for pericarditis
A
Corticosteroids and NSAIDs can be used as symptomatic relief, especially for rheumatic fever or idiopathic
Do not use NSAIDs in first few days after MI though – as they are associated with increased risk of myocardial rupture
Pericardiocentesis – consider for significant effusion or signs of cardiac tamponade
21
Q
cardiac tamponade - pericardial sac fills pressure is put on the ventricles, which compromises their pumping function. Mx
A
Airway management 15 L oxygen, pulse oximetry, ABG BP, fluids IV, pulse and HR Consider inotropes (i.e. adrenaline) Pericardiocentesis (If it keeps coming back after being drained, then it is most likely the result of malignancy - can create a window through which the fluid can drain)
22
Q
acute AF Mx - in acute setting what do you need to Be thinking about TART)
A
In acute setting, you need to be thinking about:
Treating any precipitating factors that may have triggered AF e.g. infection/sepsis, PE, thyroid disease, ischaemia/MI
Assessing the patient’s stroke risk and need for anticoagulation
Controlling the rapid heart rate
Controlling the symptoms of an irregular rhythm
Mnemonic for this: Trigger Anticoagulation Tachycardia Rhythm
23
Q
Rhythm control in haemodynamic instability AF
A
either electrical cardioversion – or pharmacological – flecainide or amiodarone
24
Q
rate control in AF
A
B blockers and diltiazem/verapamil
25
anti-coagulation in AF
LMWH
26
SVT Mx - A to E Mx;
Oxygen 15L
IV access and take bloods
BP and O2 monitoring
12 lead ECG
27
```
For SVT need to identify adverse features including; Shock (systolic BP < 90mmHg)
Syncope
Myocardial ischaemia
Heart failure
if pt has adverse features what is Mx?
```
Synchronised DC shock (cardioversion)
28
For SVT need to identify adverse features including; Shock (systolic BP < 90mmHg)
Syncope
Myocardial ischaemia
Heart failure
If patient doesn’t have adverse features:
Vagal manoeuvres – e.g. lie flat and head down, carotid sinus massage (ensure no bruits first)
Most cases are treated with ADENOSINE –
If this does not revert the SVT – call for expert help
29
If pulseless VT – cardiac arrest – ALS protocol!
| Also need to idetify adverse features including;
Identify adverse features (will inform management):
Shock – Assess BP
Syncope
Myocardial ischaemia – Assess with ECG
Heart failure – Assess with listening to chest or echocardiography
30
if adverse features present for VT what is Mx
Synchronised DC shock (cardioversion)
31
If no adverse features for SVT what is Mx
Still a medical emergency as can degenerate into unstable VT and VF
Treat with Amiodarone infusion
Cardioversion if medical therapy fails (will need sedation for this)
32
complete heart block Mx - chronic Mx
Pacemaker implantation
33
complete heart block acute Mx
Check blood pressure
Atropine IV
Isoprenaline (2nd line)
34
cardiac arrest Mx
Approach patient, checking for safety. Call for help (crash trolley – 2222).
Open airway with head tilt/chin life manoeuvre, palpate the carotid pulse and look, listen and feel for breathing for 10 seconds
If there is a risk of a cervical spine injury, open the airway using a jaw thrust
If no pulse, or signs of life – commence cardiopulmonary resuscitation (CPR) in ratio of 30 compressions to 2 ventilations, depth of 5-6cm at rate 100bpm
35
dose of adrenaline for cardiac arrest
1mg 1:10,000 IV
36
A to E Mx ALS - A
Check airways for mechanical obstruction! Make sure ventilation is up and running with LMA or intubation.
37
A to E Mx ALS - B
Make sure chest is expanding with the ventilation and thus patient is getting oxygen.
38
A to E - ALS protocol C
IV access! 2 large bore cannulas. BP assessed; fluid bolus given if required. If IV access cannot be obtained within two minutes, use intraosseous (IO) access.
39
try to identify the reversibel causes cardiac arrest
Hypoxia – oxygen delivered via LMA and bag-valve-mask
Hypovolaemia – IV access – check BP, and then give IV 500 ml fluid bolus over 15 minutes
Hypothermia – assess temperature and if low, re-warm
Hypokalaemia – VBG and correct balance
Hyperkalaemia – VBG – correct balance with hyperkalaemia management: calcium gluconate, insulin (with dextrose) and salbutamol
Thrombosis – assess by hx of risk factors and P/C, and bedside USS (or echocardiography), treat with LMWH or thrombolysis (e.g. fibrinolytics – Alteplase)
Tension pneumothorax - auscultate the patient’s lung fields during ventilations and perform needle decompression if indicated
Toxins – look at drug chart and collateral hx
Tamponade - obtain a beside echocardiogram (echo) and perform pericardiocentesis as indicated
40
Mx hypothermia
Removing the patient from the cold environment and removing any wet/cold clothing,
Warming the body with blankets
Securing the airway and monitoring breathing,
If the patient is not responding well to passive warming, you may consider maintaining circulation using warm IV fluids or applying forced warm air directly to the patient's body
41
pneumonia Mx
Consider Pain relief: paracetamol or NSAIDs.
In patients with COPD or asthma, consider treatment with salbutamol.
Antibiotics:
Start on empirical antibiotics as soon as blood cultures have been sent.
42
ABx Tx used in CAP pneumonia
Example of antibiotics used for CAP pneumonia:
Mild/moderate: Amoxicillin plus clarithromycin or doxycycline
Severe: Co-amoxiclav plus clarithromycin
43
3 aims of the Mx of COPD
Correct hypoxaemia
Correct acidosis: by reducing hypercapnia (or preventing further hypercapnia)
Remove cause of exacerbation e.g. infection
44
Too much oxygen in someone with chronic hypoxaemia can lead to dangerous CO2 levels. In someone who retains CO2, the amount of oxygen that is given needs to be carefully balanced to optimise their pO2 whilst not increasing their pCO2. This is guided by what two things?
oxygen saturations and repeat ABGs.
45
what mask do you use in COPD
Venturi masks are designed to deliver a specific percentage concentration of oxygen
46
medical Mx COPD
Nebulised bronchodilator driven through oxygen e.g. salbutamol, ipratropium
Steroids
Antibiotics if evidence of infection e.g. amoxicillin
47
Infective exacerbation of COPD: first-line antibiotics are what?
amoxicillin or clarithromycin or doxycycline
48
Options in severe infective exacerbation of COPD cases not responding to first line treatment
IV aminophylline
Non-invasive ventilation (NIV)
Intubation and ventilation with admission to intensive care
49
acute exacerbation of asthma - acute but clinically stable PEF >75%
Give Salbutamol 5mg nebuliser driven through oxygen
Consider nasal cannula if hypoxic (because nebuliser max flow rate only = 6L)
Consider ipratropium 0.5mg through nebuliser if severe/life-threatening asthma
Give Prednisolone 40-50mg orally,
50
if clinically unstable asthma PEF <75%
Repeat salbutamol (+ ipratropium) nebs after 15 minutes
Consider continuous salbutamol nebuliser 5-10mg/hr
Consider IV magnesium sulphate 1.2-2mg over 20 minutes
Correct fluid/electrolytes, especially K+ disturbances
51
after acute exaberabtion asthma Mx
observation after nebulisers
PEFR must be >75% expected prior to discharge
Check inhaler technique
Organise FU in GP
All patients should be given prednisolone orally (PO) daily, which should be continued for at least five days
52
pneumothorax Mx - standard pneumothorax do CXR before attempting to treat
If the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
Otherwise, aspiration should be attempted
If this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
53
secondary pneumothroax Mx (all pt should be admitted for 24hrs at least)
If the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted
Otherwise aspiration should be attempted if the rim of air is between 1-2cm
54
tension pneumothorax Tx
Aspiration – 2nd intercostal space, midclavicular line
| And the chest drain - to continue decompression
55
pulmonary oedema Mx
Breathing:
Sit the patient up in bed
15L O2 is critically unwell, venturi mask if COPD
If dyspnoea cannot be significantly improved, CPAP or intubation may be necessary
Fluid Management:
Diuretic e.g. furosemide
treat underlying cause
56
DVT Mx - Low risk well’s score (<2) and low D-dimer
no further investigation is required, can discharge
57
DVT Mx - High risk well’s score (≥2) OR low risk and high D-dimer
lower leg USS
| Prescribe Rivaroxaban
58
following the diagnosis of a DVT what is the Tx
Apixaban or rivaroxaban (both DOACs) should be offered first-line
Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed
59
Length of anticoagulation following a VTE
provoked - 3 months
| unprovoked - 6 months
60
cellultitis Mx - analgesia, follow up, admission if systemically unwell - what ABx
flucloxacillin
If this is unsuitable, or the person has a penicillin allergy, prescribe either:
Clarithromycin or Doxycycline
61
complicated cases of cellulitis
IV flucloxacillin
| or IV clindamycin or vancomycin if CI
62
```
acutely iscahemic leg Mx - Resuscitation:
15L oxygen
IV access – heparin infusion
Analgesia e.g. opioids
and what else?
```
surgical Mx - Re-vascularization is required within 6hr to avoid permanent muscle necrosis
63
Gout Mx
NSAIDs – c- 1st line treatment
Colchicine – is also sometimes used in conjunction with NSAIDs
Steroids – e.g. prednisone – often effective, but more likely to cause side effects than colchicine and NSAIDs.
Do not stop allopurinol or febuxostat during an acute attack of gout if the person is already established on these drugs.
analyse / remove triggers
64
septic arthritis Mx
admit pt
aspirate joint for culture
start empirical ABx - flucloxacillin or For streptococcus or gram-negative organisms - Ceftriaxone
Management typically involves a combination of surgical washout (surgical irrigation and debridement – in theatre) of the joint and IV antibiotics.
65
DKA Mx
fluids (less aggressive in Paediatrics – because at risk of cerebral oedema)
insulin actrapid
potassium (added to later bags of fluid)
66
hypoglucaemia Mx
fast acting glucose e.g jelly babies, fruit juice
| long acting carbs after
67
paracetamol overdose Mx - Less than 4 hours from ingestion of paracetamol (PCM):
wait and see the PCM level at 4 hours
68
paracetamol overdose - 4-8 hours since ingestion
see the PCM level; and using the plotted graph, either treat or don’t treat.
69
paracetamnol overdose - 8-15 hour later
PCM level and treat immediately
70
paracetamol overdose - More than 15 hours or staggered dose
Don’t bother with PCM level and treat immediately.
71
what is the Tx paracetaol overdose
acetylcysteine
72
Adverse reactions to acetylcysteine are common.
| Management of patients experiencing an adverse reaction to acetylcysteine
Temporarily stopping the acetylcysteine may be all that is required
chlorphenamine 10 mg IV) and nebulised salbutamol if bronchospasm is present
3. It is essential that the acetylcysteine infusion is restarted once the reaction has settled: consider slowing the infusion rate
73
before discahrge
ALT measurement bloods
psych r/v
FU GP
(if paracetamol liver failure - need liver transplant)
74
alcohol withdrawal - Treatment for Wernicke’s
Pabrinex IM or IV
75
seizures from alchol withdrawal Tx
benzodiazepines
| Consider antipsychotic – e.g. haloperidol
76
tricyclic overdose Mx
sodium bicarbonate
77
opiate overdose
naloxone
78
amphetamines overdose
diazepam
79
SSRIs overdose Mx
oral activated charcol
control seizures diazepam
metabolic acidosis - sodium bicarb
if severe overdose - haemolysis
80
sepsis management
```
Blood culture
urine output
fluids
ABx
Lactate
O2
```
81
shock Mx
A to E
central venous line to monitor CVP (central venous pressure) and for inotrope infusion if necessary – dopamine hydrochloride is used in cardiogenic shock
Insert arterial line for accurate assessment of BP
Catheterise bladder to monitor urine output
treat the underlying condition
82
if fluids fail in the Mx of shock
Vasopressor (vasoconstriction) e.g. noradrenaline
Inotrope (increases cardiac contractility) e.g. dobutamine
Adrenaline is both a vasopressor and an inotrope
83
Mx anaphylaxis
0.5mg 1:1000 IM, chlorphenamine (10mg IV), hydrocortisone (200mg IV)
84
ARRYTHMIAS management
adenosine for SVT, amiodarone/cardioversion for VT/AF
85
Managing haemorrhagic shock - remeber on the floor and four more
Plug the leak: direct pressure, transexamic acid, splinting
| Fill the tank: (fluid replacement) – RBC, FFP, platelets
86
supportive therapy for delirium
24 hr clock
Calendar
Hearing aids and glasses if appropriate
Avoiding unnecessary noise at night
87
what medications to Mx delirium
Consider lorazepam and haloperidol for sedation/antipsychotic, PO
Consider parenteral medication and nutrition if appropriate
Treat the cause e.g. infection
88
Haliperidol is contraindicated in what
parkinsons
89
first line sedative in delirium
heloperidol
90
Mx AKI
STOP AKI: sepsis (sepsis 6), toxins, optimise BP, prevent harm
Immediate Interventions to be completed at initial assessment (target < 4hrs)
Document Urinalysis result
Document calcium and HCO3
Prescribe IV fluids with target urine output 0.5ml/kg/hr
Stop nephrotoxic drugs and review anti-hypertensives
Alter dose of medications based on eGFR
91
metabolic acidosis Mx
Consider IV bicarbonate via central line
92
Mx hyperkalaemia
Calcium (gluconate)– stabilises the membrane – less likely to have arrythmia
Insulin (15 units) and dextrose
Consider Salbutamol nebs – makes dextrose/insulin infusion more effective
93
acuet Mx urinary retention
```
Catheterise
luids if indicated
Consider management of cause:
ABx for infections
Laxatives for constipation
Review meds
```
94
acute renal colic (acute and severe loin pain caused when a urinary stone moves from the kidney or obstructs the flow of urine through the ureter) Mx
NSAID analgesia e.g. diclofenac IM
encourage fluids
if infection treat with empiracal ABx
non contrast CT
95
Stones < 5 mm Mx
usually pass spontaneously
96
when is stone removal indicated for avute renal colic
persistent obstruction
Failure of stone progression
Infection with risk of sepsis
Increasing or unremitting colic
97
Ureteric obstruction due to stones with infection, is a surgical emergency, requiring what?
nephrostomy tube placement, or a ureteric catheter/stent
98
testicular tortion Mx
note: Testicular torsion is a surgical emergency with a 4-6hrs window from the onset of symptoms to salvage the testis before significant ischaemic damage occurs
surgical Mx - cord and testis will be untwisted and both testicles fixed to the scrotum, known as bilateral orchidopexy
99
UTI Mx - first line
Nitrofurantoin for 3 days
OR
Trimethoprim for 3 days
100
lower & complicated UTI 1st line
Trimethoprim for 7 days OR
| Nitrofurantoin for 7 days
101
pyelonephritis Mx
Cefalexin for 7-10 day OR
Co-amoxiclav for 7-10 days OR
Trimethoprim for 14 days OR
Ciprofloxacin for 7 days
102
for pregnant women pyelonephiritis
Cefalexin
103
AAA Mx rupture
A to E
Refer to vascular surgery, anaesthesia and ICU
ECG, take blood for amylase (exclude pancreatitis), Hb, Group & save and crossmatch
Catheterise the bladder
IV access – 2 large bore cannulae – treat shock with O Rh- blood
take pt straight away to theatre
104
incidental asymptomatic AAA - urgency depends on size
<3cm diameter is normal
3-5.5 cm diameter and asymptomatic requires follow up with regular ultrasound
what size requires immediate CT scan then surgery - reguardless of no Sx
5.5cm
105
appendictis - management
IV opioids
refer to surgical team
prescribe pre-op ABx e.g. cefuroxime and metronidazole
106
if rupture of appendix is suspected what do you do
gentamicin 5mg/kg IV, ampicillin 1g IV QDS and metronidazole
107
biliary tract infections Mx
1st line - amoxicillin AND gentamicin
If unresponsive to initial therapy: piperacillin/tazobactam OR ticarcillin/clavulanate
Refer to surgical team for urgent relief of biliary obstruction e.g.
ERCP, sphincterotomy +- biliary stone removal / USS guided drainage / Open surgical decompression / Lithotripsy
108
bowel obstruction - sigmoid volvulus Mx
inserting flatus tube or sigmoidoscopy
Sigmoid colectomy is sometimes required
109
for bowel obstruction prescribe - analgesia and anti-emetics. when to refer to medical / surgical team?
When gastrointestinal obstruction results in ischaemia, perforation or peritonitis, then emergency surgery is required
110
Diverticulitis Mx
A to E management - focus on fluids
Prescribe antibiotics – usually metronidazole
Prescribe analgesia – but not a constipating one! (i.e. no opioids)
Consider referral to surgical team e.g. Perforation / Sepsis / Abscess rupture or haemorrhage
111
acute pancreatitis Mx
Resuscitation with IV fluids (Hartmann’s)
Catheterisation to monitor urine output
Supplemental oxygen
Analgesia
Regular monitoring (e.g. bloods, VBG/ABGs)
Escalate care according to Glasgow score
Early nutritional support
112
If the person has acute pancreatitis caused by suspected or proven gallstones (biliary onstruction), management may include:
Endoscopic retrograde cholangiopancreatography (ERCP) to relieve the obstruction
Cholecystectomy can be considered during the same admission
113
peptic ulcer disease Mx
Review medication (e.g. NSAIDs and Steroids)
Prescribe PPI – e.g. omeprazole, lansoprazole
Assess social Hx e.g. smoking, alcohol use, stress, diet
lifestyle advice
114
peptic ulcer disease - casue H.pylori Mx
A PPI twice daily and amoxicillin 1 g twice daily AND
| Either clarithromycin 500 mg twice-daily or metronidazole 400 mg twice-daily
115
what score is used to assess upper GI bleeds
Glasgow Blatchford score
116
upper GI bleeds Mx
A to E
Vital sign monitoring
Consider O2
Consider fluids and/or cross match (2 units) – packed RBCs
Review medication e.g. anticoagulants, NSAIDs
Nil by mouth
117
upper GI blleds consider for different causes
PPI and antibiotics (H-pylori)
118
for varicelar bleeds what to do
terlipressin 2mg IV bolus (4 x a day) and antibiotics (hospital guidelines – in leeds Tazozin), vitamin K
119
Mx massive GI bleed
senior involvement
Consider massive transfusion pathway
Sengstaken tube – essentially inflating gastric balloon to stop bleeding
The definitive treatment of upper GI bleeds is endoscopy:
Provides confirmation of diagnosis
Biopsies can be taken to eliminate malignancy is appropriate
Provides interventions that can stop the bleeding e.g.
Banding of varices
Cauterisation of the bleeding vessel
Inject adrenaline to try to stop bleeding
120
Ideally all patients admitted with upper gastrointestinal haemorrhage should undergo Upper GI endoscopy in what period of time
within 24 hours of admission
121
The Rockall Score is used for patients that have had an endoscopy, to calculate their risk of what?
rebleeding and overall mortality
122
subarachnoid haemorrage Mx
specialist help - neurosurgery (Most intracranial aneurysms are now treated with a coil )
Aim for haemodynamic stability – Resuscitation with blood transfusion/fluids, may need benzos for seizures
123
viral meningitis Mx
Viral meningitis tends to be milder than bacterial and may only require supportive treatment.
Acyclovir can be used to treat suspected/confirmed HSV or VZV infection.
124
bacterial Mx meningitis
resusitation - BUFALO
Early antibiotics e.g ceftriaxone
Steroids e.g. dexamethasone – if signs of meningism
inform public health
125
space occupying lesions - raised ICP Mx
Avoid pyrexia - this increases ICP
Manage seizures: they contribute to raised ICP – use of benzodiazepines
CSF drainage: when an intraventricular catheter
Head of bed elevation: elevating the head of the bed to 30° improves jugular venous outflow and lowers ICP
Analgesia & sedation: usually with intravenous propofol, etomidate or midazolam for sedation
Mannitol – reduces blood viscosity
Corticosteroids: Useful to reduce oedema around lesions e.g. dexamethasone
126
temporal arteritis - who to refer to
Vascular surgeons for temporal artery biopsy (definitive diagnosis)
Ophthalmology review – SAME DAY – as emergency appointment, if they develop visual symptoms
Rheumatology follow up for specialist diagnosis and management
127
Mx temporal arteritis
Once the diagnosis is suspected, treat with high-dose corticosteroid immediately (does not need to wait until confirmation). This reduces the risk of permanent vision loss.
Start with 40-60mg prednisolone per day
128
venous sinus thrombosis Mx
Therapeutic heparin or LMWH initially
also think of ways to reduce ICP
treat underlying cause - e.g ABx, medication r/v, dehydration
129
otitis media Mx (it. Always refer for specialist assessment (and consider admission) in infants younger than 3 months with a temperature above 38ºC. For, 3 – 6 months, consideration is made if temperature higher than 39ºC) - most cases of otitis media will do what
resolve without antibiotics
advise supportive management (e.g. paracetamol, ibuprofen), and that symptoms may last up to a week. Topical analgesia (e.g. anaesthetic ear drops) can also be prescribed
130
when would you consider prescribing ABx for otitis media
Patient has significant comorbidities, or immunocompromised
Patient is systemically unwell
Children < 2years with bilateral infection
Children with otorrhoea (discharge)
131
mild crop Mx
Can be managed at home. Prescribe PO dexamethasone Paracetamol
132
moderate croup Mx
can be managed at home
PO dexamethasone OR
PO prednisolone
133
severe croup Mx
Move to RESUS
Call paediatric team to intend and inform anaesthetist
Vital sign monitoring required, particularly SPO2, O2 often required
Nebulised adrenaline
PO dexamethasone
134
life threatening croup Mx
same Mx as severe = INTUBATION
135
tonsillitis - what criteria is used as an indication of the likelihood of a sore throat being due to bacterial infection (and thus antibiotics can be used)
centor
136
what makes up the centor criteria
Absence of cough
Tonsillar exudates (ooze)
History of fever
Tender anterior cervical adenopathy
137
if giving Abx for tonsillitis
Phenoxymethylpenicillin
| rythromycin is a suitable alternative if the patient is penicillin allergic
138
if systemically unwell with tonsillitis Mx
Early resuscitation i.e. IV fluids
IV Benzylpenicillin 1g stat
Steroids – e.g. IV dexamethasone – aiming to reduce tonsillar swelling
Check for peritonsillar abscess
139
quinsy Mx
requires drainage - either by needle aspiration or incision & drainage
140
Hyperglycaemia Hyperosmolar State (HHS) -
HHS is characterised by severe hyperglycaemia with marked serum hyperosmolarity without evidence of significant ketosis
Mx
fluids NaCl 0.9%
insulin
potassium
HHS pt are at hight risk thrombosis - prophylactic LMWH
141
vasovagal syncope
general advice - avoid standing up too long, avoid missing meals, dehydration
take action on first warning collapse - lie down with legs up on chair, squat down on the heels; this can be very effective and is less noticeable in public
(These techniques help move venous blood that has pooled in the limbs, aiding circulation to the brain)
142
seizures
A to E
Ensure the patient will not hurt themselves while fitting
Give oxygen 100% by 15L non-rebreathe mask
check blood sugar
143
first line Tx seizure over 5 mins
Lorazepam (IV)
Buccal midazolam can be used if no IV access or in community setting
Failure to respond to first-line treatment requires input from critical care: phenytoin infusion
144
Mx TIA
ROSIER score
aspirin 300mg
specialist assessment clinic
secondary pevention - clopidogrel
DO NOT OFFER CT SCAN for suspected TIA unless clinical suspicion of an alternative diagnosis
145
what is ROSIER?
Recognition of stroke in the emergency room
146
stroke Mx - first of all
immediate CT scan
| bamford stroke classification
147
stroke Mx - ischaemic stroke
aspirin 300mg
given within 4.5 hours - thrombolysis with alteplase
secondary [revention - clopidogrel
definitive Mx - Carotid endarterectomy
148
haemorrhagic stroke Mx
neurosurgery help
INR measurement (reverse warfarin with vit K)
tight BP control
149
head injury & trauma
immediate CT head
TXA if intracranial bleeding
blood glucose / bloods / ABG
150
hyponatrameia Mx
hypertonic saline treatment should be reserved for those with Severe Symptoms ONLY
treat underlying casuse - e.g
Hypovolaemia, infection
Hormone deficiency e.g. Addison’s
Fluids overload e.g. HF, cirrhosis
151
hyperkalaemia Mx
calcium gluconate
insulin
salbutamol
152
hypercalcaemia Mx
fluids
consider bisphosphonates e.g zoledronic acid
153
fractures
analgesia
x-ray
immobilisation
referral to fracture clinic
154
hip fracture
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history of fall - any head injury (check pupils & consider full cranial examination)
hip exam
analgesia
immobilisation
X ray
VTE asssessment
orthopaedic referal
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155
dislocated shoulder
Shoulder examination
Check the radial pulse to assess for vascular injury
Check sensation in the regimental badge area on the lateral aspect of the shoulder over the deltoid muscle - this tests for axillary nerve damage
x ray
Analgesia e.g. codeine and NO2 gas
Closed reduction of dislocation
FU in orthopaedic clinic
156
anaphylaxis Mx
A to E
Adrenaline 0.5mg IM (0.5ml of 1/1000) repeated every 5min as required.
anterolateral aspect of the middle third of the thigh.
intubated if not responsive to adrenaline
fluids
antihistamine IM or IV
hydrocortisone IM or IV
