Acute and emergency Flashcards
(255 cards)
1
Q
What is type 1 respiratory failure ?
A
Hypoxemia without hypercapnia. Due to V/Q mismatch
2
Q
What conditions can cause type 1 respiratory failure ?
A
Reduced ventilation - Pul odema and bronchoconstriction
Reduced perfusion - PE
3
Q
What is type 2 respiratory failure ?
A
Hypoxemia and hypercapnia. Due to alveolar hypoventilation
4
Q
What conditions cause type 2 respiratory failure ?
A
COPD
Pneumonia, rib fractures
MN/Gillian barre
Opiates
5
Q
What determines metabolic vs respiratory pH values ?
A
Respiratory caused by deranged CO2
Metabolic caused by deranged HCO3-
6
Q
How do you know if there is compensation in acidosis/alkalosis ?
A
The CO2/HCO3- will both be increased or decreased at the same time.
7
Q
What does a mixed resp and metabolic alkalosis look like ?
A
Increased pH
Decreased CO2
Increased HCO3-
8
Q
What does a mixed resp and metabolic acidosis look like ?
A
Decreased pH
Increased Co2
Decreased HCO3-
9
Q
What are some of the symptoms of anaphylaxis on general inspection ?
A
- Airway obstruction due to swelling
- Skin and mucosal changes like flushing and urticaria
- Swelling of the hips
- History of atopy
10
Q
What will be present on observations in a patient with anaphylaxis ?
A
- Hypotensive due to hemodynamic shock
-Peripherally cool and thread pulse - Increased cap refill
- Tachycardia in early stages and bradycardia in arrest situations.
- Wheeze on auscultation and reduced air entry in airway compromise
11
Q
What enzyme is measured and elevated in anaphylaxis ?
A
Mast cell tryptase.
12
Q
What is the recommended treatment for a patient suffering from anaphylaxis ?
A
IM 0.50 mL - 1:1000 adrenaline ( In children 0.30 mL)
13
Q
What is the suggested management of a patient with anaphylaxis ?
A
-A - Airway. Guide or head tilt jaw thrust. Remove the trigger and administer adrenaline
- B - Obs. If a wheeze nebulized bronchodilators (Salbutamol) and 15L o2 through non rebreathe.
-C - Patients are usually hypotensive and tachycardia. Two large bore cannulas and STAT bolus of 1000,l Hartmann’s solution 0.9
- D
- E.
14
Q
Once a patient is stabilized, what should be given ?
A
Steroids and antihistamines like cetirizine to treat skin symptoms
15
Q
When performing an ABCDE assessment on a patient, what are the only two interventions that should be given ?
A
IV Hartmann’s and adrenaline
16
Q
How must a patient with burns be initially managed ?
A
A- Inhalation injury and C spine mobilization
B - High flow O2 100 percent. ABG for carboxyhemoglobin levels. (15L non rebreathe)
c - warm IV fluids due to risk of circulatory shock, catheter for fluid balance monitoring, group and save and other routine blood tests. FLUID RESUS
D - AVPU and maintain core temp
E - Assess severity using TBSA and keep patient warm as possible.
17
Q
What are the symptoms of carbon monoxide poisioning ?
A
Headache
Bright pink mucosa (Lips)
High 02 sats due to monitor not being able to tell between o2 and carboxHB. Give 15L non rebreathe
18
Q
What are the methods of estimating TBSA ?
A
- Rule of 9s
- Palmar surface area ( entire hand = 0.8 percent TBSA)
- Lund and Browder chart (Most accurate)
19
Q
What is the equation for the amount of fluid to give a burn victim ?
A
2-4ml x Body Weight (kg) x Total Body Surface Area Affected (TBSA) (%)
= Initial crystalloid fluid requirement for the first 24 hours. Only count medium and full surface burns in TBSA.
20
Q
When should fluid resuscitation be given in burns ?
A
A burn percentage of more than 15% of total body surface area in adults or more than 10% in children typically warrants formal resuscitation.
21
Q
What are some of the possible complications of burns (systemic, lung, muscles) ?
A
- ARDS
-AKI
-Rhabdomyolysis - hypothermia
-Curlings ulcers - Dehydration and shock
22
Q
What are some of the symptoms of a paracetamol overdose ?
A
- Can be asymptomatic
- Nausea and vomiting
- Loin pain and abdo pain
- Jaundice
- Severe metabolic acidosis
23
Q
What is the pathophysiology of paracetamol overdose ?
A
- Build up of toxic NAPQI. Glutathione that normally breaks this down is depleted and hence NAPQI is left unmetabolized causing liver and kidney damage
24
Q
What is the treatment of paracetamol overdose ?
(>1 hr, staggered dose, less than 4 hours )
A
Ingestion less than 1 hour and dose is greater than 150 = Activated charcoal
Staggered dose or ingestion over 5 hours = N-acetylcysteine immediately
If ingestion <4 hours ago: Wait until 4 hours to take a level and treat with N-acetylcysteine based on level
25
In what instances (not to do with timing) should NAC be administered immediately ?
IF increased risk of toxicity
Long term enzyme inducers
Alcoholism
Preexisting liver disease
Anorexia, malnutrition and HIV
26
What are the symptoms of amitriptyline overdose ? (TCA/SALCYLATE overdose ) - pupils ?
- Drowsiness
- Confusion
- Headache
- Flushing
- Dilated pupils
- Arrhythmias
27
What are the key investigations needed to be undertaken in amitriptyline overdose ?
- VBG for signs of acidosis
-ECG
28
What would be present in an ECG of a patient presenting with amitriptyline overdose ?
- QT prolongation
- QRS prolongation
Can cause arrhythmias and heart block.
29
What is the mainstay of treatment for a patient presenting with an amitriptyline overdose ?
- Supportive and is based on patients symptoms
- Severe metabolic acidosis may need renal replacement therapy.
30
What is the definitive symptoms of aspirin overdose ?
- Tinnitus
- Initial resp alkalosis
- Later metabolic acidosis
31
What are the symptoms of aspirin (salicylate overdose) overdose ?
- including the one key symptom
- Nausea and vomiting
- Tinnitus
- Tachycardia
- Fever and confusion
32
What is the mainstay of treatment for salycate overdose ?
- IV fluids - Sodium bicarbonate and potassium chloride to alkalize the urine in order to increase excretion.
Dialysis may be needed if levels remain high
33
What are the signs of opiate overdose ?
- Reduced consciousness
- Resp depression
- Miosis
- Nausea and vomiting
- Type 2 resp depression
- Pruritis
- Acidosis
34
What are the differences in pupils in Opioid vs TCA overdose ?
- Opioid = Miosis
- TCA = dilation
35
What is the mainstay of treatment for opiate overdose ?
- Remove the source
- Naloxone
36
What are the symptoms of benzodiazepine overdose ?
- Reduced consciousness and can result in coma
- Resp depression
- Dilated pupils
- Hypotension and tachycardia
- Rhabdomyolysis
- HYPOTHERMIA
37
What is the mainstay of treatment for benzodiazepine overdose ?
Supportive care
Flumazenil is an option. Used in cases where CNS depression is severe enough the patient needs ventilation
38
What is the antidote for antifreeze ?
Fomepizole
39
When does DKA occur ?
In type 1 diabetics, Hyperglycemic ketosis occurs and results in life threatening acidosis.
HYPOGLYCAEMIC ketoacidosis
40
Why does DKA occur?
The patient is not producing (new diagnosis) or injecting enough insulin.
41
What are the main issues that occur in DKA ?
-Ketoacidosis
- Dehydration
- K imbalance
42
What are the main symptoms of a patient in DKA ?
- Polyuria and polydipsia
- Nausea and vomiting
- Weight loss
- Acetone breath
- Dehydration
HYPOTENSION
- Altered consciousness
- Abdo pains
43
What three measurementS are used to confirm a diagnosis of DKA ?
- Hyperglycemia
- Ketosis
- Raised anion gap acidosis
44
What is the FIRST initial management of DKA ?
- Fluid resus (Over 48 hours to correct the hyperglycemia)
- and fixed rate insulin infusion
45
What are some of the other management methods in DKA ?
- Hypoglycemia treatment (IV dextrose)
- Potassium to IV fluid
- Avoid boluses to minimize risk of cerebral odema
- Treat the underlying trigger
46
What dose of IV solution should be given in fluid resus of patients with DKA ?
0.9% Sodium Chloride 1L over 1 hour
47
What complication to children with DKA have the risk of developing ?
- Cerebral edema
Symptoms include confusion, bradycardia, altered behavior.
48
What is the treatment of a patient with cerebral odema ?
- Slowing of IV fluids
- Mannitol (Used in dieresis)
- Hypertonic saline
49
When should you be suspicious of DKA ?
- High anion gap
- Acute abdominal pain, acidosis
- Hyperglycemia
- Child may have a history of new bedwetting and weight loss
50
Random raised plasma glucose is indicative of .....
Diabetes
51
What is HHS and in what condition is it found ?
- Type 2 diabetes
- Endogenous insulin production and hence enough to switch of insulin production and prevent DKA
52
How do DKA and HHS differ ?
HHS, unlike in DKA, is not accompanied by significant acidosis or ketosis.
Both have hyperglycemia.
53
What are the symptoms of HHS ?
- Dehydration (Dry mucus membranes and decreased UO)
- Coma and seizures
- Weakness and confusion
- Nausea and vomiting
- Hypovolemia
- Hypotension
- Tachycardia
- Polyuria and polydipsia
54
What are the diagnostic criteria for HHS ?
Severe hyperglycemia (Greater than 30mmol/L)
Hypotension ( In absence if ketoacidosis so bicarb will be normal)
Hyperosmolality (Greater than 320 mosmol/kg)
55
What is the mainstay of treatment for HHS ?
- Correction of hypotension and electrolyte abnormalities. 0.9 percent saline (1L) over 1,2 hours. Every 2 hours, + 1L KCL. A bolus of 0.9 percent saline is required if the patient is hemodynamically unstable.
- Correction of hyperglycemia. 0.05 units/kg/hour if ketones
56
Why is VTE prophylaxis required in HHS ?
Due to hyperviscosity, there is a risk of thrombosis and hence VTE prophylaxis is required
57
What are the RF for HHS ?
Infection
Medications like diuretics or lower glucose tolerance
Surgery
Impaired renal function
58
Define hypothermia
Defined as a core body temperature of less than 35 degrees
59
What are the sub categories of hypothermia ?
Mild (32-35) - Tachycardia, tachypnoea, vasoconstriction and shivering.
Moderate (28 –32) - Cardiac arrhythmias, hypotension, respiratory depression, reduced consciousness and may cease to shiver
Severe ( less than 28) - Reduced consciousness, coma, apnea, arrhythmia and fixed/dilated pupils.
60
What are the symptoms of hypothermia ?
Tachypnoea and tachycardia
Hypotension
Resp depression
Vasoconstriction
Arrhythmias.
Reduced consciousness in severe cases
61
What are some of the ECG changes present in hypothermia ?
- Sinus brady
- Prolonged PR, QRS, QT intervals
- Shivering artefacts
- Cardiac arrest
- New onset AF
- J waves ( Wave at the end of the QRS complex)
62
How is hypothermia managed ?
Warm the patient with blankets and warm drinks
Internal and external re-warming.
IV administration of warmed fluids and application of warm air
Monitoring as at a high risk of cardiac arrest
63
What is the main risk of hypothermia ?
Cardiac arrest
64
Briefly, how do hemorrhoids present ?
- Usually in younger patients
- Superficial bleeding on wiping
- No pain on passing stool
- Mucus and itching
65
Briefly, how do anal fissures present ?
- Patients are usually constipated and have hard stool
- Pain on passing stool
- SE of opiate analgesia
66
Briefly, how does a rectal prolapse present ?
- Mass that extrudes during defecation
- Rectal mucus discharge
- Perianal pain
- Bleeding
- Incontinence
67
Briefly, how does an anal carcinoma present ?
- Fecal incontinence, perianal pain, bleeding and itching
68
What is neutropenic sepsis ?
- Sepsis in a patient with a low neutrophil count
- Patient usually have a history of anticancer treatments or immunosuppressants
- It should be investigated in all immunocompromised patients that have a fever
- Methotrexate use
69
What is the most common causative organism of neutropenic sepsis /line infections ?
Staphylococcus epidermitis
70
What is the treatment of neutropenic sepsis ?
- BSA like piperacillin with taxobactam.
71
What is the most common cause of late onset neonatal sepsis ?
Staphylococcus aureus
72
What are the symptoms of sepsis ?
Hypoxia
Oliguria
AKI
Thrombocytopenia
Coag dysfunction
Hypotension
Hyperlactatemia
Reduced urine output
73
What is the cause of a non blanching rash in suspected meningitis
Meningococcal septicemia.
74
What is the fist sign of sepsis ?
Tachypnoea is usually the first sign of sepsis.
Elderly patients with confusion or drowsiness
Neutropenic or immunocompromised may have normal obs and a temp.
75
What score is used to assess potential sepsis ?
NEWS
76
What are the risk factors for developing sepsis ?
Very young or old patients
Chronic conditions like COPD/DIABETES
Chemotherapy immunosuppressants or steroids
Surgery/burns/trauma
Pregnancy
Catheters or central lines
77
What is TAKEN in sepsis 6
Blood lactate level
Blood cultures
Urine output
78
What is given in sepsis 6 ?
O2 to maintain O2 sats 94-98
Empirical broad spectrum antibiotics (Cephalexin)
IV fluids - Three boluses should be given before looking at other treatment options.
79
What BSA is commonly given in sepsis ?
Cephalexin
80
What increases the risk of an AKI in sepsis ?
Antihypertensive like ramipril.
81
What is a common cause of early onset sepsis ?
GBS
82
What should be withheld in diabetics with sepsis ?
Metformin is associated with lactic acidosis and particularly in conditions that also raise lactate like sepsis and renal impairment. In diabetics and sepsis, it should be withheld and consideration of alternate antibiotic activity should be considered.
83
What is a common cause of pneumonia in immunocompromised (Alcoholics, diabetes ect)
Klebsiella pneumonia
84
If a patient with sepsis is not recovering after fluid resus, what is indicated ?
na INFUSION (VASOPRESSOR)
85
What would be identified on testing for sepsis (on obsevation)
-Thrombocytopenia, hemorrhages and DIC ( Low platelets and fibrinogen, high PT/APTT and D dimer). OOZING from cannula site is a classic presentation of DIC.
- Increased lactate levels
- Oedema
- Resp distress
- Hypotension
- Hypoxia
- Tachycardia
86
What is feltys syndrome ?
Triad of
Neutropenia
Splenomegaly
Rheumatoid arthritis
87
What is hypovolemic shock ?
Due to blood loss
88
What is disruptive shock ?
Can be septic shock. Usually a sudden or surprising event or experience that stops the body processes from running as normal.
89
What is the only type of shock that causes warm peripheries ?
Disruptive shock/septic shock
90
What is cardiogenic shock ?
As a result of poor CO.
91
What are the symptoms of cardiogenic shock (heart cannot pump enough oxygen to the organs ) ?
Typical symptoms of an MI
- Hypotension and tachycardia
-Weak thready pulse
- Low urine output
- Pul crackles due to flash pulmonary edema.
92
What is anaphylactic shock ?
Often due to anaphylaxis
93
What is neurogenic shock ?
Caused by irregular blood circulation in the body
Often caused by trauma or injury to the spine.
It is dangerous as it can cause a rapid and drastic drop in BP.
94
What is obstructive shock ?
Due to a physical obstruction to the vessels of the heart
- PE, cardiac tamponade and tension pneumothorax.
95
What is the treatment of hypovolemic shock ?
- 1.5-2L of warm IV crystalloid and assess the patients response.
- If inadequate O - until cross matched blood is available
- If there is massive bleeding - massive hemorrhage protocol is activated.
96
How is septic shock managed ?
Sepsis 6
Take 3 - Lactate, blood cultures and Urine output.
Give 3 - BS antibiotics, Oxygen and fluid resus
97
What is the classic triad for the presentation of spinal cord compression ?
- Lower back pain
- Urinary incontinence
- Loss of perianal sensation
98
What are some of the other features of spinal cord compression ?
- UMN signs and sensory disturbance below the lesion
- Radiation down the legs and loss of sensory function
- deep and localized back pain.
- Stabbing radicular sensory disturbance at the level of the lesion.
Bladder and bowel involvement also common. Loss of perianal sensation and incontinence.
History of malignancy and compression could be due to possible metastasis.
99
What are some of the causes of spinal cord compression ?
- Trauma
- Metastasis
- Infection like TB
- Disk prolapse
- Epidural hematoma
- Neoplasia (Tumor growth in cancer patients)
100
What is the FIRST line investigation for suspected Spinal cord compression and cauda equina ?
URGENT WHOLE SPINE MRI
Then surgical decompression within 48 hours.
101
In a patient with Small cell carcinoma and malignancy, what else should be administered alongside surgical decompression ?
Dexamethasone 16mg daily.
102
What is the definition of major hemorrhage ?
- 50 percent blood loss within 3 hours with a rate of over 150ml/min
- Loss of more than one blood volume over 24 hours.
103
What meningitis is the most common cause of non blanching rash ?
Neisseria meningitidis
104
What are the most common causes of meningitis in adults and children ?
Neisseria meningitidis and streptococcus pneumonia.
105
What is the most common cause of neonatal meningitis ?
GBS
106
What are the most common causes of viral meningitis ?
- HSV
- VZV
- Enterovirus (Coxsackie virus A)
107
What is THE most common cause of viral meningitis ?
Enterovirus (Coxsackie virus A)
108
What are the common symptoms of meningitis ?
- Fever
- Neck stiffness
- Photophobia
- Headache
- Altered consciousness
- In meningococcal septicemia, children can present with non blanching rash
109
How do neonates with meningitis present ?
Non specific symptoms
Sometimes have bulging fontanelle.
Resp distress
Poor feeding
Any signs of sepsis
110
What is one of the Key complications of meningitis ?
Hearing loss
111
When is LP indicated in children ?
- Any child under 1 month with fever
- 1-3 months with fever and unwell
- Under 1 year with unexplained fever and features of serious illness.
112
What tests can be used in detecting meningeal irritation ?
Kernigs and brudzinskis
113
How to carry out kernigs test ?
(Knee)
- Place the hip at 90 degrees and straighten the knee
- This will cause irritation and hence spinal pain or resistance
114
How to carry out Budinski's test ?
(B - On back)
- Lie the patient flat on back and gently use the hands to lift the patients neck off the bed and flat to the chest. This will cause involuntary flexion of the hips and knees
115
If a patient presents in the community with suspected bacterial meningitis, what is the immediate management ?
- IM benzylpenicillin 1.2g if not allergic to penicillin. Don't let this delay transfer to hospital.
116
When are antibiotics given in meningitis ?
After LP unless very unwell
117
What is the first line treatment for bacterial meningitis ?
Ceftriaxone
118
What is the treatment for children under 3 months with bacterial meningitis ?
- Cefotaxime and amoxicillin
119
What is given alongside antibiotics in meningitis ?
Dexamethasone qds for four days to reduce hearing loss and neuro damage
120
What is first line of treatment in meningitis in patients that are penicillin resistant ?
Vancomycin
121
Meningitis is a notifiable disease. What should given to all close contacts ?
Single dose of ciprofloxacin
122
What is the empiric antibiotic therapy for patients with bacterial meningitis ?
2g IV ceftriaxone twice daily.
123
What is the treatment of viral meningitis ?
Usually supportive as symptoms are milder but patients with HSV or VZV infection can be treated with aciclovir.
124
When is acyclovir given in meningitis ?
In HSV OR VSV infection
125
What are the symptoms of encephalitis ?
- Neurological disturbances like seizures, hallucinations or confusion, speech or hearing difficulties. Loss of sensation
- Weakness and fatigue
126
If a patient shows signs of encephalitis alongside meningitis, what is the recommended treatment ?
Alongside ceftriaxone IV add Acyclovir IV
127
What level is a LP inserted ?
L3/L4
128
What does a typical Bacterial CSF culture look like ?
- bacteria use glucose and release proteins and neutrophils so
- High protein
- High WCC (Neutrophils_
- Low glucose
- Cloudy appearance
129
What does a typical viral CSF culture look like ?
Viruses release small amount of proteins but DO NOT use up glucose. They also cause the release of lymphocytes
- Glucose will be normal
-Proteins will be normal or mildly raised
- WCC will be high with lymphocytes
- Clear
130
What causes malignant hypothermia (medications) ?
- Inhaled anesthetics ( Sevoflurane and isoflurane)
- Suxamethonium (Muscle relaxant)
131
What are the symptoms of malignant hypothermia ?
- Usually at the induction of general anesthesia
- Increased body temp
- Rigid muscles
- Metabolic acidosis and tachycardia
- PP of exhaled CO2 will increase
- Mandible muscle rigidity
- Rhabdomyolysis and myoglobinuria (red or brown urine)
132
What type of anesthetics cause malignant hypothermia ?
- Volatile agents like - Sevoflurane and isoflurane
133
What is the most common cause of malignant hypothermia ?
- Autosomal dominant mutation by ryanodine receptor 1
- This increases the amount of calcium in the SR and hence increased metabolic rate
Hence genetic with genetic testing
134
What is the pharmacological management of malignant hypothermia ?
IV dantrolene (200MG IV)
135
What is the management of malignant hyperthermia ?
Stopping the triggering agent
IV dantrolene (200mg IV)
Restore normothermia
136
What is pancytopenia ?
Low RBC, ECC and platelets
137
What are the symptoms of pancytopenia ?
- Anemia like symptoms - Fatigue, pallor ect
Neutropenia - Fever and signs of infection
- Thrombocytopenia symptoms like easy bruising and heavy bleeding.
138
What are some cause of pancytopenia ?
- Chemotherapy
-HIV/Sepsis
---------------------- ( Most common causes)
- Hypersplenism
- Leukemia
- Aplastic anemia/megaloblastic anemia.
139
Describe the typical exam presentation of a pneumothorax.
Tall, thin young pan presenting with sudden SOB and pleuritic chest pain when playing sports
140
What are the physical symptoms of a pneumothorax ?
- Breathlessness
- Pleuritic chest pain
- Tightness
- Cyanosis
- Chest ache
- Use of accessory muscles on inspiration
141
What are the signs OE of a pneumothorax ?
- Hyper-resonance on percussion
- Decreased air entry
- Decreased chest expansion.
- Tachycardia
142
If a patient develops a pneumothorax when intubated, what is a sign ?
Acute increase in ventilation pressure
143
Signs of pneumothorax on CXR ?
- Absence of lung markings
- Line demarcating the area
If too small to see, a CT can be used
144
What guidelines are used to measure the size of a pneumothorax ?
BTS guidelines.
145
What is the treatment for an asymptomatic, <2cm pneumothorax ?
No treatment and will spontaneously resolve
146
What is the treatment for a symptomatic or <2cm pneumothorax ?
Aspiration and reassessment. If aspiration fails twice = Chest drain. Chest drain is also indicated in patients that are unstable or have multiple reoccurrences of pneumothorax. If the pneumothorax is less than 2cm but the patient is still symptomatic, aspiration with a 16G cannula is still advised.
147
When is surgical management indicated in a pneumothorax ?
when chest drain fails to correct the pneumothorax, persistent air leaks into the drain and recurrent pneumothorax. VATS.
148
What is the treatment for secondary spontaneous pneumothorax due to COPD ?
- Chest drain if symptomatic
- Aspiration if asymptomatic
149
What is rhabdomyolysis ?
Skeletal muscle breakdown causing the release of myoglobin and K into the blood
150
What can rhabdomyolysis cause in the kidneys (x3) ?
- Renal obstruction
- AKI
- Direct nephrotoxicity
151
What are the symptoms of rhabdomyolysis ?
- Muscle pain and swelling
- Red/brown urine
- AKI
152
What is released into the bloodstream in rhabdomyolysis ?
Myoglobin and potassium
153
What are the clinical signs of rhabdomyolysis (Blood tests)
- Hyperkalemia/Uricemia/phosphoremia
- Hypocalcemia
- False positive for Hb on urine dip
- 5x fold increase of CK
- Raised LDH
154
What is the treatment of Rhabdomyolysis ?
- Supportive IV fluids
- Treatment/management of hyperkaliemia (Furosemide)
155
What are the signs on CXR of tension pneumothorax ?
- Tracheal deviation
- Reduced air entry
- Hyper-resonance
- Hypotension and tachycardia (Hemodynamically unstable)
156
What is the DEFINATIVE treatment for tension pneumothorax ?
- Insertion of large bore cannula into the second intercostal space in the midclavicular line.
Do not waste any time if suspected.
157
What is TACO
Transfusion associated circulatory overload. Can occur in patients with pre-existing cardiac disease
158
What is the treatment for TACO ?
IV furosemide
159
What are the symptoms of TACO ?
- Dyspnea
- Peripheral odema
- Rapid hypertension
- Orthopnea
160
What is TRALI ?
- Transfusion related acute lung injury.
161
What are the symptoms of TRALI ?
Symptoms within 6 hours of transfusion or during.
-ARDS
-Pul edema
- White out on CXR
- Fever
- Red urine
- Hypotension
162
What is the treatment for TRALI ?
Stop transfusion, saline and treat ARDS.
163
What is febrile non hemolytic transfusion reaction ?
Abnormal vital signs but the patient is generally well
164
What are the symptoms of FNHTR ?
- Asymptomatic
- Sometimes can have fever, chills ect
- Abnormal vital signs
165
What is the treatment of FNHTR ?
- IV paracetamol
- Slow the infusion
166
What are the symptoms of acute hemolytic transfusion reaction ?
Early signs – Fever, hypotension and anxiety
Late signs – Generalized bleeding secondary to DIC
167
What is the treatment for AHTR ?
Stop transfusion, saline and treat DIC
168
What are the symptoms of an allergic reaction during a transfusion ?
Mild allergic transfusion reaction is associated with a urticarial rash soon after the transfusion in the absence of anaphylaxis or hemodynamic compromise.
169
If a patient is having a mild allergic reaction to a blood transfusion, what do you do ?
Stop the transfusion due to risk of anaphylaxis
170
What is the treatment for anaphylaxis bc of a blood transfusion ?
- Stop transfusion
- Oxygen
- Call for help
- ABCDE
- Adrenaline
- Chlorphenamine (Antihistamine)
- Hydrocortisone
171
What is delayed hemolytic transfusion reaction and what is the triad of
symptoms ?
Exaggerated response to foreign body patient has previously been exposed to
Jaundice, anemia and fever.
Usually 5 days post transfusion
172
What organisms usually cause TSS ?
- Strep A
- MRSA
- Staphylococcus aureus
173
What are the symptoms of TSS ?
- Flu like prodrome like nausea, vomiting and diarrhea
- Rapid progression to HIGH fever and widespread macular rash.
- erythrodermic>90that blanches with pression
- Hypotension and confusion (Multiorgan involvement)
- Usually have pre existing wound
174
What rash is present in TSS ?
Widespread macular rash
175
What are the risk factors for TSS ?
- Tampon use
- Infection
- Diabetics
- Alcoholics and IV drug use
- HIV
- Wounds
176
What causes TSS ?
Exotoxin acts as a super antigen causing polyclonal T cell activation, IL-1 and TNF-a cytokine release leading to shock and multiorgan failure.
177
What is the management of TSS ?
- ABCDE
- Aggressive fluid and electrolyte resus
- Vasopressors to manage shock
- Antibiotics (Clindamycin + Vancomycin)
- Corticosteroids
178
What antibiotics are used in TSS ?
Clindamycin and vancomycin
179
What are the symptoms of Upper GI bleeding?
Hematemesis (Coffee ground like appearance)
Altered bowel habit (Dark tarry stools or fresh rectal bleeding)
Abdominal pain – Typically epigastric but can be diffuse
Pre syncope/syncope due to hypovolemia and 2nd cerebral hypoperfusion
180
What are the clinical signs of Upper GI bleeding ?
Tachycardia
Hypotension
Abdo tenderness
Malaena
Hematochezia (Passage of fresh red blood pr)
Postural syncope
181
What are the causes of upper GI bleeding ?
Esophageal/gastric varices
Peptic ulcer disease
Malignancy
Aorto-enteric fistula
Mallory weiss tear
182
What is the initial management of upper GI bleeding ?
A-E assessment
IV fluid resus and blood transfusion (if Hb is under 7)
NBM and supplemental oxygen
IV PPI maybe
Once stable = Upper GI endoscopy for cause of bleeding
183
What is used to treat variceal bleeding
IV terlipressin (vasopressor - used to narrow blood vessels) and antibiotics
184
What scoring system is used to assess mortality in patients with GI bleeding ?
Rockhall
185
What are the rf for esophageal varices ?
A- Alcoholism
Splenomegaly
Thrombocytopenia
186
Where does a SAH occur (layers) ?
arachnoid and pia mater meningeal layers.
187
What is the main cause of SAH ?
Trauma
188
What are some of the causes of spontaneous SAH ?
- Intracranial aneurysm
- AVM
- hypertension, PKD, smoking, female and FHx
189
What type of aneurysm are patients with PKD at a higher risk of ?
Berry aneurysm
190
What are the clinical features of SAH ?
- Aneurysms are often asymptomatic until rupture
- SUDDEN onset severe headache - Thunderclap
- Nausea and vomiting
- Commonly occipital area
- Photophobia
191
What are common clinical findings of SAH ?
- Reduced level of consciousness
- Neck stiffness (due to meningeal irritation)
- Positive kerning's sign (non specific and other pathology can be occurring like meningitis as it is caused by irritation of motor never roots)
- Mya have hyponatremia
192
When is a LP indicated in SAH ?
LP is indicated in SAH id suspected by CT scan shows no evidence of bleeding of raised ICP.
193
When should a LP be performed in suspected SAH (time frame) ?
At least 12 hours after the onset of symptoms
194
What will be present on LP in patients with SAH ?
Xanthochromia ( CSF is stained yellow due to the infiltration of blood from the hemorrhage ). There also mat be increase in bilirubin and oxyhemoglobin due to the hemolysis of RBC.
195
What is xanthochromia ?
CSF is stained yellow due to the infiltration of blood from the SAH.
196
What two imaging modalities are used when investigating SAH ?
- Plain CT head
- CT angiogram
197
What will be present on a CT head of a patient with SAH ?
- Hyperdense (Light grey) in the SA space indicating the presence of blood.
198
What is the initial management of patients with SAH ?
- ABCDE assessment
- Urgent referral to neurosurgery team
199
What medication is it important to give to patients with a SAH ?
- Ca channel blockers like nimodipine to reduce risk of cerebral artery spasm and secondary cerebral ischemia.
200
What are some of the common complications of SAH ?
- Obstructive hydrocephalus - Due to blood pooling and can lead to obstruction in CSF drainage. Ventricles will appear enlarged on a CT scan
- **Arterial vasospasm - Ca channel blockers**
- Re bleeding
- Long term neurological deficits
201
What is a subdural hematoma ?
Caused by the rupture of bridging veins in the outermost meningeal layer. Between the dura mater and the arachnoid mater
202
How does a subdural hematoma present ?
- headache
- Increasing confusion and consciousness
- Recent history of falls
- Nausea and vomiting
RF
- Diminished eye/verbal/motor response
203
Risk factors of subdural hematoma ?
- Elderly
- Alcoholic patients
- Bleeding disorders or anticoagulant therapy
- Recent trauma
- Due to increased brain atrophy.
204
What is present on a CT in a patient with a subdural hemorrhage ?
- Crescent shape on CT
- Not limited by cranial sutures
205
What should be prescribed in acute alcohol withdrawal ?
Reducing regime of chlordiazepoxide and parbrinex (thiamine) to reduce ridk of wenikes encephalopathy
206
What are the symptoms of a migraine ?
- Recurrent and severe
- Usually **unilateral** and **throbbing** in nature
- Can be associated with - Aura, nausea and photo-sensitivity.
- Nausea/may be vomiting
- Women, may be associated with menstruation.
- Aggravated by activities of daily living (tiredness/stress, alcohol, COCP, lack of food ot dehydration ect)
207
What is the acute management of migraines (1st and second line) ?
- **Oral triptan and oral NSAID/paracetamol.** If the patient is between 12 and 17, consider a nasal triptan.
- If not effective or tolerated, offer non oral prep of **metoclopramide/p**rochlorperazine and consider non oral preps of triptans/NSAIDS.
208
What is used in migraine prophylaxis ?
Should be given if attacks are having a significant effect on quality of life and daily function. More than once a week and are prolonged despite treatment.
- **Propanolol**
- **Topiramate** (avoided in women of child bearing age as tetarogenic and reduces effectiveness of the pill)
- **Amitriptyline.**
209
What is absolutley CI in patients with migrane with aura ?
COCP
210
What is the general treatment of migraine during pregnancy ?
Paracetamol 1g is first line. NSAIDS is second like in the first and second trimester.
211
What is the general management of migrane and menstruration ?
Metfanamic acid or aspirin/paracetamol and caffeine. Triptans in acute situations.
212
What are the general symptoms of a tension headache ?
- Recurrent, non disabling, **bilateral** headache.
- Described as a tight band or pressure sensation in the head
- Not aggravated by the routine activities of daily living
- Lower intensity than a migrane
- May be related to stress.
- Chronic - headache on more than 15 days of a month.
213
What is the acute treatment of a tension headache ?
Aspirin, paracetamol or an NSAID 1st line.
214
What is the prophylaxis for a tension headache ?
up to 10 sessions of acupuncture over 5-8 weeks. Prophylaxis is not commonly used.
215
What are the symptoms of a cluster headache ?
- Pain occurs **1 to 2 times a day**
- Sudden onset unilateral.
- Episodes last **15 mins** up to two hours
- Clusters lasting **4-12 weeks, clusters usually once a year.**
- Intense pain around one eye and always effect the same eye
- Pain is restless during an attack
- Redness, lacrimation and lid swelling.
- Nasal stuffiness
- More common in **men and smokers**
216
What is the gold standard of investigation in cluster headaches and why is it carried out ?
Most patients will have neuroimaging due to risk of underling brain lesions. MRI with gadolinium contrast is the investigation of choice.
217
What is the acute management of a cluster headache ?
- SC triptan and 100 percent oxygen
218
What is used in the prophylaxis of cluster headaches ?
Veramapril
219
What are the symptoms of a medication overuse headache ?
- 15 or more days per month present
- Developed or made worse whilst taking regular symptomatic medication
- Patients using opiods/triptans at the highest risk
- May be a psychiatric co-morbidity.
220
What is the management of MOH ?
Simple analgesics and triptans should be withdrawn abruptly. Opioids should be gradually withdrawn.
221
GCA has a strong association with ????
PMR
222
What is one of the more serious complication of GCA ?
Vision loss.
223
What are the features of GCA ?
- Typically, patients are above 60 years old.
- Usually rapid onset (less than 1 month)
- Headache
- Jaw claudication
- May be sudden, permanent vision loss. Vision loss can also be temp.
- May be diplopia if there is any involvement if the oculomotor system.
- Tender, palpable temporal artery
- Lethargy, low grade fever, anorexia and night sweats
- Around 50 percent have features of PMR - Aching/morning **stiffness** in the proximal limb muscles.
224
What are the key investigation findings in GCA ?
- **ESR > 50**
- CRP may also be raised
- Temporal artery biopsy may show **skip lesions.**
225
What is given in GCA with no vision loss alongside urgent ophthalmology review ?
High dose prednisolone
226
What is given in GCA with evolving vision loss ?
IV methylprenisolone.
227
What is the true definition of anaphylaxis ?
Patient needs ABC signs. Around 80/90 percent of patients will also have skin and mucosal changes like generalised pruritis and widespread erythematous/urticarial rash.
228
What is the dose of adrenaline in patients with anaphylaxis ?
IM adrenaline 500 micrograms (0.5ml 1 in 1000)
229
What is the dose of adrenaline in patients with anaphylaxis that are under 12 ?
< 6 months 100 - 150 micrograms (0.1 - 0.15 ml 1 in 1,000)
6 months - 6 years 150 micrograms (0.15 ml 1 in 1,000)
6-12 years 300 micrograms (0.3ml 1 in 1,000)
230
If a patient in anaphylactic shock has not responded to the first dose of adrenaline, in what intervals can it be given ?
Every 5 minutes
231
What is refractory anaphylaxis and how is it managed ?
- Definition - resp and or CV problems despite 2 doses of IM adrenaline.
- IV fluids should be given for shock and expert help can be sought for consideration of IV adrenaline infusion.
232
What can be measured in anaphylaxis to see if a patient has had a true reaction ?
Serum tryptase
233
What are the characteristic blood findings in a patient with an upper GI bleed ?
Raised urea and anaemia
234
On endoscopy, what region indicates an upper Gi bleed ?
Ligament of Treitz
235
When should PPIs be commenced in a case of upper GI bleed ?
After endoscopy has ruled out a varcoceal bleed.
236
When should an endoscopy be commenced in suspected upper GI bleed ?
- Should be offered immediately after resus in patients with a severe bleed and are haemodynamically unstable.
- **All patients should have one within 24 hours.**
237
What is the glasgow blatchford score ?
(used in assessing upper GI bleeds) at first assessment and sees if a patient can be managed in outpatients. Patients with a score of 0 may be considered for early discharge.
238
What is the rockhall score ?
s used after endoscopy and provides percentage risk of re-bleeding and mortality.
239
How is varciceal bleeding managed ?
- Transjugular intrahepatic porto-systemic shunts should be offered if bleeding from varices if not controlled with the above measures.
- **Terlipressin (vasopressor)** and prophylactic abx at first presentation (before endoscopy)
- Band ligation
240
What is the gold standard of management in carbon monoxide poisoning ?
Hyperbaric oxygen
241
Fungal meningitis is the most common cause of meningitis on IVDU and the immucompromised. What is the most common causative organism ?
Cryptococcus - India ink can be used to stain
242
What is used to treat human or animal bites ?
co-amoxiclav
243
What are the key symptoms of tumour lysis syndrome ?
lethargy, nausea and vomiting, diarrhoea, anorexia, muscle cramps and pruritis as well as fluid overload, paresthesia and bronchospasm
Recent chemotherapy
244
What are the electrolyte abnormalities are seen in tumour lysis syndrome ?
Hypercalaemia and hyperuricaemia
Hyperphosphataemia
Hypocalcaemia
245
How is tumour lysis syndrome managed ?
Prophylactic allopurinol and good hydration
246
How is high INR managed in a patient with major bleeding ?
- Stop anticoagulants
- Administer IV vitamin K
- Administer FFP or PT complex
247
How is high INR managed in patients with minor bleeding ?
- Stop anticoagulants
- Administer IV vitamin K
- Repeat INR after 24 hours, patient may need further vitamin K
248
How are patients with no bleeding but an INR over 8 managed ?
- Stop anticoagulants
- IV or oral vitamin K
- Repeat INR after 24 hours
249
How is INR more than 5 managed with no major bleeding ?
- Withold 1-2 doses of anticoagulant
- Review maintenence dose of anticoagulant.
250
What is refeeding syndrome ?
Rapid re-supplementation can cause a shift of electrolytes intracellularly --> extracellular.
251
What are the symptoms of re-feeding syndrome ?
Oedema, confusion and tachycardia. Hypophosphataemia
252
What is the treatment of re-feeding syndrome ?
Phosphate supplementation
253
What is the step-wise escalation of a patient having an acute asthma attack ?
- O2
- Nebs (salbutamol)
- Corticosteroid
-Ipratropium bromide
- IV mg sulphate
254
What is the most common cause of infective exacerbation of COPD ?
Haemophilus influenzae
255
What is the acute management of a COPD exacerbation ?
- O2 with aim 88-92 percent - venturi mask
- NEB bronchodilator
- steroids IV hydrocrotisone or oral pred
-NIV may be needed if pH drops below 7.25
